DVBCWHD1 ;ALB/CMM HEMIC DISORDERS WKS TEXT ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Frequency and duration of crisis if sickle cell disease.
;;
;;
;; 2. Fatigability and/or weakness? (Is light manual labor precluded?)
;;
;;
;; 3. Headaches?
;;
;;
;; 4. History of infections? If yes, frequency and response to therapy?
;;
;;
;; 5. Shortness of breath? If yes, with what degree of exertion?
;;
;;
;; 6. Chest pain? Symptoms of claudication?
;;
;;
;; 7. History and frequency of transfusions, phlebotomy, bone marrow
;; transplant, myelo-suppressant therapy.
;;
;;
;; 8. Symptoms of other end organ pathology?
;;
;;
;; 9. Disease activity (exacerbations/remission)? If there were
;; exacerbations, what was the state of the veteran's health
;; between exacerbations?
;;
;;
;; 10. Current and past treatment history including date and type of
;; last treatment?
;;
;;
;; 11. Syncope, lightheadedness.
;;
;;TOF
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following as appropriate to the condition
;; being examined and fully describe current findings:
;; 1. Swelling of hands and/or feet (edema)?
;;
;;
;; 2. Presence of pallor (nail beds, mucosal surfaces, and skin)?
;;
;;
;; 3. Any other significant physical exam findings?
;;
;;
;; 4. Residuals of bone or other vascular infarction.
;;
;;
;; 5. Congestive heart failure?
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Hemoglobin level, platelet count, CBC.
;; 2. X-rays of bones or joints as indicated.
;; 3. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; 1. Is the disease active?
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWHD1 2125 printed Dec 13, 2024@01:51:37 Page 2
DVBCWHD1 ;ALB/CMM HEMIC DISORDERS WKS TEXT ; 5 MARCH 1997
+1 ;;2.7;AMIE;**12**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;
+4 ;;
+5 ;;B. Medical History (Subjective Complaints):
+6 ;;
+7 ;; Comment on:
+8 ;; 1. Frequency and duration of crisis if sickle cell disease.
+9 ;;
+10 ;;
+11 ;; 2. Fatigability and/or weakness? (Is light manual labor precluded?)
+12 ;;
+13 ;;
+14 ;; 3. Headaches?
+15 ;;
+16 ;;
+17 ;; 4. History of infections? If yes, frequency and response to therapy?
+18 ;;
+19 ;;
+20 ;; 5. Shortness of breath? If yes, with what degree of exertion?
+21 ;;
+22 ;;
+23 ;; 6. Chest pain? Symptoms of claudication?
+24 ;;
+25 ;;
+26 ;; 7. History and frequency of transfusions, phlebotomy, bone marrow
+27 ;; transplant, myelo-suppressant therapy.
+28 ;;
+29 ;;
+30 ;; 8. Symptoms of other end organ pathology?
+31 ;;
+32 ;;
+33 ;; 9. Disease activity (exacerbations/remission)? If there were
+34 ;; exacerbations, what was the state of the veteran's health
+35 ;; between exacerbations?
+36 ;;
+37 ;;
+38 ;; 10. Current and past treatment history including date and type of
+39 ;; last treatment?
+40 ;;
+41 ;;
+42 ;; 11. Syncope, lightheadedness.
+43 ;;
+44 ;;TOF
+45 ;;C. Physical Examination (Objective Findings):
+46 ;;
+47 ;; Address each of the following as appropriate to the condition
+48 ;; being examined and fully describe current findings:
+49 ;; 1. Swelling of hands and/or feet (edema)?
+50 ;;
+51 ;;
+52 ;; 2. Presence of pallor (nail beds, mucosal surfaces, and skin)?
+53 ;;
+54 ;;
+55 ;; 3. Any other significant physical exam findings?
+56 ;;
+57 ;;
+58 ;; 4. Residuals of bone or other vascular infarction.
+59 ;;
+60 ;;
+61 ;; 5. Congestive heart failure?
+62 ;;
+63 ;;
+64 ;;D. Diagnostic and Clinical Tests:
+65 ;;
+66 ;; 1. Hemoglobin level, platelet count, CBC.
+67 ;; 2. X-rays of bones or joints as indicated.
+68 ;; 3. Include results of all diagnostic and clinical tests conducted
+69 ;; in the examination report.
+70 ;;
+71 ;;
+72 ;;E. Diagnosis:
+73 ;;
+74 ;; 1. Is the disease active?
+75 ;;
+76 ;;
+77 ;;Signature: Date:
+78 ;;END
