DVBCWHI3 ;ALB/RLC HIV-RELATED ILLNESS WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment On:
;;
;; 1. Recurrent opportunistic infections - type.
;; 2. Constitutional symptoms - recurrent, refractory, any currently present.
;; 3. Diarrhea.
;; 4. Debility.
;; 5. Progressive weight loss.
;; 6. Other symptoms - lymphadenopathy, fever, cough, dyspnea, headaches,
;; difficult or painful swallowing, vision loss, etc.
;; 7. Periods of remissions in symptomatology - frequency, average duration,
;; date of last remission.
;; 8. Depression or memory loss.
;; 9. Treatment, type duration, response, side effects. Is this an approved
;; medication?
;; 10. Describe the effects of the condition on the veteran's usual
;; occupation and daily activities.
;; 11. History of hospitalizations or surgery, reason or type of surgery,
;; dates and location, if known.
;; 12. History of malignant neoplasm.
;;
;; a. Date of diagnosis.
;; b. Diagnosis.
;; c. Type of treatment, dates.
;; d. Last date of treatment.
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe, follow additional
;; worksheets as appropriate:
;;
;; 1. Secondary diseases affecting multiple body systems. Describe.
;; 2. HIV-related illnesses. Describe.
;; 3. Neoplasm related to HIV-related illness. Describe.
;; 4. T4 cell counts.
;; 5. Hairy cell leukoplakia.
;; 6. Oral candidiasis.
;; 7. Side effects from the use of HIV-related medications. Describe.
;; 8. Lymphadenopathy.
;; 9. Hepatomegaly.
;; 10. Splenomegaly.
;; 11. If evidence of memory loss or depression (refer for examination by
;; mental health provider).
;;
;;D. Diagnostic and Clinical Tests:
;;
;; Provide:
;;
;; 1. T4 Cell counts.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; 1. Definitive diagnosis of AIDS. (Use CDC Definition).
;; 2. Active opportunistic infection or neoplasm.
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWHI3 2472 printed Oct 16, 2024@17:52:35 Page 2
DVBCWHI3 ;ALB/RLC HIV-RELATED ILLNESS WKS TEXT - 1 ; 12 FEB 2007
+1 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment On:
+6 ;;
+7 ;; 1. Recurrent opportunistic infections - type.
+8 ;; 2. Constitutional symptoms - recurrent, refractory, any currently present.
+9 ;; 3. Diarrhea.
+10 ;; 4. Debility.
+11 ;; 5. Progressive weight loss.
+12 ;; 6. Other symptoms - lymphadenopathy, fever, cough, dyspnea, headaches,
+13 ;; difficult or painful swallowing, vision loss, etc.
+14 ;; 7. Periods of remissions in symptomatology - frequency, average duration,
+15 ;; date of last remission.
+16 ;; 8. Depression or memory loss.
+17 ;; 9. Treatment, type duration, response, side effects. Is this an approved
+18 ;; medication?
+19 ;; 10. Describe the effects of the condition on the veteran's usual
+20 ;; occupation and daily activities.
+21 ;; 11. History of hospitalizations or surgery, reason or type of surgery,
+22 ;; dates and location, if known.
+23 ;; 12. History of malignant neoplasm.
+24 ;;
+25 ;; a. Date of diagnosis.
+26 ;; b. Diagnosis.
+27 ;; c. Type of treatment, dates.
+28 ;; d. Last date of treatment.
+29 ;;
+30 ;;C. Physical Examination (Objective Findings):
+31 ;;
+32 ;; Address each of the following and fully describe, follow additional
+33 ;; worksheets as appropriate:
+34 ;;
+35 ;; 1. Secondary diseases affecting multiple body systems. Describe.
+36 ;; 2. HIV-related illnesses. Describe.
+37 ;; 3. Neoplasm related to HIV-related illness. Describe.
+38 ;; 4. T4 cell counts.
+39 ;; 5. Hairy cell leukoplakia.
+40 ;; 6. Oral candidiasis.
+41 ;; 7. Side effects from the use of HIV-related medications. Describe.
+42 ;; 8. Lymphadenopathy.
+43 ;; 9. Hepatomegaly.
+44 ;; 10. Splenomegaly.
+45 ;; 11. If evidence of memory loss or depression (refer for examination by
+46 ;; mental health provider).
+47 ;;
+48 ;;D. Diagnostic and Clinical Tests:
+49 ;;
+50 ;; Provide:
+51 ;;
+52 ;; 1. T4 Cell counts.
+53 ;; 2. Include results of all diagnostic and clinical tests conducted
+54 ;; in the examination report.
+55 ;;
+56 ;;
+57 ;;E. Diagnosis:
+58 ;;
+59 ;; 1. Definitive diagnosis of AIDS. (Use CDC Definition).
+60 ;; 2. Active opportunistic infection or neoplasm.
+61 ;;
+62 ;;
+63 ;;
+64 ;;Signature: Date:
+65 ;;END
