DVBCWVN3 ;ALB/RLC ARTERIES, VEINS AND MISCELLANEOUS WKS TEXT - 1 ; 11 FEB 1998
;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; 1. For all conditions, comment on:
;;
;; a. Course, including onset of disorder, and any injury or
;; surgery (type and when carried out). Past treatment.
;; b. Current treatment - type, effectiveness, side effects.
;; c. Symptoms.
;; d. If surgery has been done, report effectiveness and any
;; residual or recurrent symptoms.
;;
;; 2. For aortic aneurysm, aneurysm of any large artery, aneurysm of any
;; small artery, arteriovenous fistula, arteriosclerosis obliterans
;; and thromboangiitis obliterans, additionally comment on:
;;
;; a. 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?
;; b. Is there pain at rest?
;; c. Is exercise and exertion precluded by the condition?
;;
;; 3. For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia,
;; additionally comment on:
;;
;; a. Describe a characteristic attack.
;; b. Record the frequency, duration, and severity of
;; characteristic attacks.
;; c. State each part of the body that is affected. For
;; angioneurotic edema, state whether laryngeal edema occurs
;; and how frequently.
;;
;; 4. For Varicose veins and Post-phlebitic syndrome of any etiology,
;; additionally comment on:
;;
;; a. Any history of ulcers and aching, fatigue, or abnormal sensations
;; in the leg at rest or after prolonged standing or walking.
;; b. Are symptoms or edema relieved by elevation of the extremity,
;; compression hosiery, or other measures? Is edema relieved
;; completely or only partially by elevation of the extremity?
;;
;; 5. For soft tissue sarcoma or other malignant neoplasms of vascular
;; origin:
;;
;; a. Record date of diagnosis and pathologic diagnosis.
;; b. Record type and dates of treatment. If treatment has been
;; completed, state date of last treatment.
;; c. If treatment has been completed describe residual or recurrent
;; symptoms.
;;
;;C. Physical Examination (Objective Findings):
;;
;; 1. For aortic aneurysm, aneurysm of any large artery, aneurysm of any
;; small artery, or arteriovenous fistula:
;;
;; a. State diameter of aneurysm, cardiac status, including heart
;; size and rate. For arteriovenous fistula, state 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 massive?
;; 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. Imaging studies, 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:
;;
;; 1. List all diagnoses.
;; 2. For each condition diagnosed, describe effects on veteran's usual
;; occupation and daily activities.
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWVN3 5373 printed Nov 22, 2024@17:04:36 Page 2
DVBCWVN3 ;ALB/RLC ARTERIES, VEINS AND MISCELLANEOUS WKS TEXT - 1 ; 11 FEB 1998
+1 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; 1. For all conditions, comment on:
+6 ;;
+7 ;; a. Course, including onset of disorder, and any injury or
+8 ;; surgery (type and when carried out). Past treatment.
+9 ;; b. Current treatment - type, effectiveness, side effects.
+10 ;; c. Symptoms.
+11 ;; d. If surgery has been done, report effectiveness and any
+12 ;; residual or recurrent symptoms.
+13 ;;
+14 ;; 2. For aortic aneurysm, aneurysm of any large artery, aneurysm of any
+15 ;; small artery, arteriovenous fistula, arteriosclerosis obliterans
+16 ;; and thromboangiitis obliterans, additionally comment on:
+17 ;;
+18 ;; a. If lower extremities are affected, is there claudication,
+19 ;; and, if so, after how many yards of walking on level ground
+20 ;; at 2 miles per hour does it develop?
+21 ;; b. Is there pain at rest?
+22 ;; c. Is exercise and exertion precluded by the condition?
+23 ;;
+24 ;; 3. For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia,
+25 ;; additionally comment on:
+26 ;;
+27 ;; a. Describe a characteristic attack.
+28 ;; b. Record the frequency, duration, and severity of
+29 ;; characteristic attacks.
+30 ;; c. State each part of the body that is affected. For
+31 ;; angioneurotic edema, state whether laryngeal edema occurs
+32 ;; and how frequently.
+33 ;;
+34 ;; 4. For Varicose veins and Post-phlebitic syndrome of any etiology,
+35 ;; additionally comment on:
+36 ;;
+37 ;; a. Any history of ulcers and aching, fatigue, or abnormal sensations
+38 ;; in the leg at rest or after prolonged standing or walking.
+39 ;; b. Are symptoms or edema relieved by elevation of the extremity,
+40 ;; compression hosiery, or other measures? Is edema relieved
+41 ;; completely or only partially by elevation of the extremity?
+42 ;;
+43 ;; 5. For soft tissue sarcoma or other malignant neoplasms of vascular
+44 ;; origin:
+45 ;;
+46 ;; a. Record date of diagnosis and pathologic diagnosis.
+47 ;; b. Record type and dates of treatment. If treatment has been
+48 ;; completed, state date of last treatment.
+49 ;; c. If treatment has been completed describe residual or recurrent
+50 ;; symptoms.
+51 ;;
+52 ;;C. Physical Examination (Objective Findings):
+53 ;;
+54 ;; 1. For aortic aneurysm, aneurysm of any large artery, aneurysm of any
+55 ;; small artery, or arteriovenous fistula:
+56 ;;
+57 ;; a. State diameter of aneurysm, cardiac status, including heart
+58 ;; size and rate. For arteriovenous fistula, state pulse
+59 ;; pressure and whether there is evidence of high output failure.
+60 ;; b. If extremities are affected, describe temperature and color,
+61 ;; pulses, trophic changes, ulcers (deep or superficial?), edema,
+62 ;; dermatitis, cellulitis.
+63 ;; c. If lower extremities are affected, record ankle/brachial
+64 ;; index (using Doppler).
+65 ;; d. If surgery has been carried out, describe residual findings,
+66 ;; using appropriate worksheet for the affected body system or
+67 ;; organ.
+68 ;;
+69 ;; 2. For arteriosclerosis obliterans and thromboangiitis obliterans:
+70 ;;
+71 ;; a. Describe each affected extremity separately.
+72 ;; b. Record ankle/brachial index (using Doppler).
+73 ;; c. Describe temperature and color of extremities, pulses, trophic
+74 ;; changes, ulcers (deep or superficial?).
+75 ;; d. If surgery has been carried out, describe any residuals or
+76 ;; side effects of surgery.
+77 ;;
+78 ;; 3. For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia:
+79 ;;
+80 ;; a. Describe ulcers, autoamputations, and any other current findings.
+81 ;;
+82 ;; 4. For Varicose veins and Post-phlebitic syndrome of any etiology:
+83 ;;
+84 ;; a. Describe any visible or palpable varicose veins.
+85 ;; b. Describe extent of any ulcers, edema, stasis pigmentation, and
+86 ;; eczema. If edema is present, is it boardlike? Is it massive?
+87 ;; Is it persistent?
+88 ;; c. Describe each affected extremity separately.
+89 ;;
+90 ;; 5. For soft tissue sarcoma or other malignant neoplasms of vascular
+91 ;; origin:
+92 ;;
+93 ;; a. Describe all current findings, whether pre- or post-treatment,
+94 ;; including any residuals of treatment. Use other worksheets,
+95 ;; if necessary, specific to the affected body system or organs.
+96 ;;
+97 ;;D. Diagnostic and Clinical Tests:
+98 ;;
+99 ;; 1. Imaging studies, Doppler vascular studies, angiogram, etc., as
+100 ;; appropriate, and if indicated.
+101 ;; 2. Include results of all diagnostic and clinical tests conducted in
+102 ;; the examination report.
+103 ;;
+104 ;;E. Diagnosis:
+105 ;;
+106 ;; 1. List all diagnoses.
+107 ;; 2. For each condition diagnosed, describe effects on veteran's usual
+108 ;; occupation and daily activities.
+109 ;;
+110 ;;
+111 ;;
+112 ;;Signature: Date:
+113 ;;END
