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Routine: DVBCWVN3

DVBCWVN3.m

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  1. DVBCWVN3 ;ALB/RLC ARTERIES, VEINS AND MISCELLANEOUS WKS TEXT - 1 ; 11 FEB 1998
  1.  ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records:
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    1.  For all conditions, comment on:
  1.  ;;
  1.  ;;        a. Course, including onset of disorder, and any injury or
  1.  ;;           surgery (type and when carried out).  Past treatment.
  1.  ;;        b. Current treatment - type, effectiveness, side effects.
  1.  ;;        c. Symptoms.  
  1.  ;;        d. If surgery has been done, report effectiveness and any
  1.  ;;           residual or recurrent symptoms.
  1.  ;;
  1.  ;;    2.  For aortic aneurysm, aneurysm of any large artery, aneurysm of any
  1.  ;;        small artery, arteriovenous fistula, arteriosclerosis obliterans
  1.  ;;        and thromboangiitis obliterans, additionally comment on:
  1.  ;;
  1.  ;;        a. If lower extremities are affected, is there claudication,
  1.  ;;           and, if so, after how many yards of walking on level ground
  1.  ;;           at 2 miles per hour does it develop?  
  1.  ;;        b. Is there pain at rest?
  1.  ;;        c. Is exercise and exertion precluded by the condition?
  1.  ;;  
  1.  ;;    3.  For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia,
  1.  ;;        additionally comment on:
  1.  ;;
  1.  ;;        a. Describe a characteristic attack.
  1.  ;;        b. Record the frequency, duration, and severity of
  1.  ;;           characteristic attacks.
  1.  ;;        c. State each part of the body that is affected.  For
  1.  ;;           angioneurotic edema, state whether laryngeal edema occurs
  1.  ;;           and how frequently.
  1.  ;;
  1.  ;;    4.  For Varicose veins and Post-phlebitic syndrome of any etiology,
  1.  ;;        additionally comment on:
  1.  ;;
  1.  ;;        a. Any history of ulcers and aching, fatigue, or abnormal sensations
  1.  ;;           in the leg at rest or after prolonged standing or walking. 
  1.  ;;        b. Are symptoms or edema relieved by elevation of the extremity,
  1.  ;;           compression hosiery, or other measures?  Is edema relieved
  1.  ;;           completely or only partially by elevation of the extremity?
  1.  ;;
  1.  ;;    5.  For soft tissue sarcoma or other malignant neoplasms of vascular
  1.  ;;      origin:
  1.  ;;
  1.  ;;        a. Record date of diagnosis and pathologic diagnosis.
  1.  ;;        b. Record type and dates of treatment.  If treatment has been
  1.  ;;           completed, state date of last treatment.
  1.  ;;        c. If treatment has been completed describe residual or recurrent
  1.  ;;             symptoms.
  1.  ;;
  1.  ;;C.  Physical Examination (Objective Findings):
  1.  ;;
  1.  ;;    1.  For aortic aneurysm, aneurysm of any large artery, aneurysm of any
  1.  ;;        small artery, or arteriovenous fistula:
  1.  ;;
  1.  ;;        a.  State diameter of aneurysm, cardiac status, including heart
  1.  ;;            size and rate.  For arteriovenous fistula, state pulse
  1.  ;;            pressure and whether there is evidence of high output failure.
  1.  ;;        b.  If extremities are affected, describe temperature and color,
  1.  ;;            pulses, trophic changes, ulcers (deep or superficial?), edema,
  1.  ;;            dermatitis, cellulitis.
  1.  ;;        c.  If lower extremities are affected, record ankle/brachial
  1.  ;;            index (using Doppler).
  1.  ;;        d.  If surgery has been carried out, describe residual findings,
  1.  ;;            using appropriate worksheet for the affected body system or
  1.  ;;            organ.
  1.  ;;
  1.  ;;    2.  For arteriosclerosis obliterans and thromboangiitis obliterans:
  1.  ;;
  1.  ;;        a.  Describe each affected extremity separately.
  1.  ;;        b.  Record ankle/brachial index (using Doppler).
  1.  ;;        c.  Describe temperature and color of extremities, pulses, trophic
  1.  ;;            changes, ulcers (deep or superficial?).
  1.  ;;        d.  If surgery has been carried out, describe any residuals or
  1.  ;;            side effects of surgery.
  1.  ;;
  1.  ;;    3.  For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia:
  1.  ;;
  1.  ;;        a.  Describe ulcers, autoamputations, and any other current findings.
  1.  ;;
  1.  ;;    4.  For Varicose veins and Post-phlebitic syndrome of any etiology:
  1.  ;;
  1.  ;;        a.  Describe any visible or palpable varicose veins.
  1.  ;;        b.  Describe extent of any ulcers, edema, stasis pigmentation, and
  1.  ;;            eczema.  If edema is present, is it boardlike?  Is it massive?
  1.  ;;            Is it persistent?
  1.  ;;        c.  Describe each affected extremity separately.
  1.  ;;
  1.  ;;    5.  For soft tissue sarcoma or other malignant neoplasms of vascular
  1.  ;;        origin:
  1.  ;;
  1.  ;;        a.  Describe all current findings, whether pre- or post-treatment,
  1.  ;;            including any residuals of treatment.  Use other worksheets,
  1.  ;;            if necessary, specific to the affected body system or organs.
  1.  ;;
  1.  ;;D.  Diagnostic and Clinical Tests:
  1.  ;;
  1.  ;;    1.  Imaging studies, Doppler vascular studies, angiogram, etc., as 
  1.  ;;        appropriate, and if indicated.
  1.  ;;    2.  Include results of all diagnostic and clinical tests conducted in
  1.  ;;        the examination report.
  1.  ;;
  1.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;    1.  List all diagnoses.
  1.  ;;    2.  For each condition diagnosed, describe effects on veteran's usual
  1.  ;;        occupation and daily activities.
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;Signature:                                        Date:
  1.  ;;END