source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWVN1.m@ 1036

DVBCWVN1 ;ALB/JFP ARTERIES, VEINS AND MISCELLANEOUS WKS TEXT - 1 ; 11 FEB 1998
 ;;2.7;AMIE;**16**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;    For all conditions, comment on:
 ;;      1. Course, including onset of disorder, and any treatment,
 ;;         including surgery (type and when carried out).
 ;;      2. Symptoms.  
 ;;      3. Is exercise and exertion precluded by the condition?
 ;;      4. Current treatment - type, effectiveness, side effects.
 ;;      5. If surgery has been done, report effectiveness and any
 ;;         residual or recurrent symptoms.  
 ;;      6. Describe the effects of the condition on the veteran's usual
 ;;         occupation and daily activities.
 ;;
 ;;    For aortic aneurysm, aneurysm of any large artery, aneurysm of any
 ;;    small artery, arteriovenous fistula, arteriosclerosis obliterans
 ;;    and thromboangiitis obliterans, additionally comment on:
 ;;      1.  If lower extremities are affected, is there claudication,
 ;;          and, if so, after how many yards of walking on level ground
 ;;          at 2 miles per hour does it develop?  
 ;;      2.  Is there pain at rest?
 ;;  
 ;;    For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia,
 ;;    additionally comment on:
 ;;      1.  Describe a characteristic attack.
 ;;      2.  Record the frequency, duration, and severity of
 ;;          characteristic attacks.
 ;;      3.  Describe which parts of the body are affected.  For
 ;;          angioneurotic edema, state whether laryngeal edema occurs
 ;;          and how frequently.
 ;;      4.  What is the current treatment - type, dose, effectiveness,
 ;;          side effects?
 ;;      5.  Describe the effects of the condition on the veteran's usual
 ;;          occupation and daily activities.
 ;;
 ;;    For Varicose veins and Post-phlebitic syndrome of any etiology,
 ;;    additionally comment on:
 ;;      1.  Describe symptoms, noting particularly whether aching,
 ;;          fatigue or abnormal sensations are present in the leg at
 ;;          rest or after prolonged standing or walking.  
 ;;      2.  Are symptoms or edema relieved by elevation of the extremity 
 ;;          compression hosiery, or other measures?
 ;;      3.  What is the current treatment - type, dose, effectiveness,
 ;;          side effects.
 ;;      4.  What are the effects of the condition on the veteran's usual
 ;;          occupation and daily activities?
 ;;
 ;;      For soft tissue sarcoma or other malignant neoplasms of vascular
 ;;      origin:
 ;;        1. Record date of diagnosis and pathologic diagnosis.
 ;;        2. Record type and dates of treatment.  If treatment has been
 ;;           completed, state date of last treatment.
 ;;        3. Describe current symptoms.  If treatment has been completed
 ;;           describe residual or recurrent symptoms.
 ;;        4. What are the effects of the condition on the veteran's
 ;;           usual occupation and daily activities?
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;      1.  For aortic aneurysm, aneurysm of any large artery, aneurysm
 ;;          of any small artery, or arteriovenous fistula:
 ;;            a.  State size of aneurysm, cardiac status, including
 ;;                heart size and rate, pulse pressure, and whether there
 ;;                is evidence of high output failure.
 ;;            b.  If extremities are affected, describe temperature and
 ;;                color, pulses, trophic changes, ulcers (deep or
 ;;                superficial?), edema, dermatitis, cellulitis.
 ;;            c.  If lower extremities are affected, record
 ;;                ankle/brachial index (using Doppler).
 ;;            d.  If surgery has been carried out, describe residual
 ;;                findings, using appropriate worksheet for the affected
 ;;                body system or organ.
 ;;      2. For arteriosclerosis obliterans and thromboangiitis
 ;;         obliterans:
 ;;            a.  Describe each affected extremity separately.
 ;;            b.  Record ankle/brachial index (using Doppler).
 ;;            c.  Describe temperature and color of extremities, pulses,
 ;;                trophic changes, ulcers (deep or superficial?).
 ;;            d.  If surgery has been carried out, describe any
 ;;                residuals or side effects of surgery.
 ;;      3.  For Raynaud's phenomenon, angioneurotic edema, and 
 ;;          erythromelalgia:
 ;;            a.  Describe ulcers, autoamputations, and any other
 ;;                current findings.
 ;;      4.  For Varicose veins and Post-phlebitic syndrome of any
 ;;          etiology:
 ;;            a.  Describe any visible or palpable varicose veins.
 ;;            b.  Describe extent of any ulcers, edema, stasis
 ;;                pigmentation, and eczema.  If edema is present, is it
 ;;                boardlike?  Is it persistent?
 ;;            c.  Describe each affected extremity separately.
 ;;      5.  For soft tissue sarcoma or other malignant neoplasms of
 ;;          vascular origin:
 ;;            a.  Describe all current findings, whether pre- or 
 ;;                post-treatment, including any residuals of treatment.
 ;;                Use other worksheets, if necessary, specific to the
 ;;                affected body system or organs.
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;       1.  X-rays, Doppler vascular studies, angiogram, etc., as 
 ;;           appropriate, and if indicated.
 ;;       2.  Include results of all diagnostic and clinical tests 
 ;;           conducted in the examination report.
 ;;
 ;;E.  Diagnosis:
 ;;  
 ;;
 ;;Signature:                                        Date:
 ;;END