©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWNM1 ;ALB/CMM NEUROLOGICAL MISC. DISORDER WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Onset and course - If flare-ups exist, describe precipitating
;; factors, aggravating factors, alleviating factors, alleviating
;; medications, frequency, severity, duration, and whether the
;; flare-ups include pain, weakness, fatigue, or functional loss.
;;
;;
;; 2. Current treatment, response, side effects.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; 1. If MIGRAINE: - Obtain the history of frequency and duration of
;; attacks and description of level of activity the veteran can
;; maintain during the attacks. For example, state if the attacks
;; are prostrating in nature or if ordinary activity is possible.
;;
;;
;; 2. If TICS AND PARAMYOCLONUS Complex: - Ascertain the muscle
;; group(s) involved and obtain the best possible history of
;; frequency and severity of attacks. State the effects on daily
;; activities.
;;
;;
;; 3. If CHOREA, CHOREIFORM DISORDERS, ETC.: - Describe manifestations
;; by impairment of strength, coordination, tremor, etc., with
;; particular attention to the effects of the performance of
;; ordinary activities of daily living.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;TOF
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END