VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWAV1.m

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DVBCWAV1 ;ALB/CMM ARTERIES AND VEINS WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Symptoms due to aortic aneurysm, other large or small artery
;; aneurysm, or arteriovenous aneurysm.
;;
;;
;; 2. Current and past treatment, including surgery - e.g., aortic
;; aneurysm grafting, varicose vein stripping, angioplasty of
;; peripheral vessels, etc. Date and response, side effects.
;;
;;
;; 3. Pain, cramping, claudication on exertion? standing? pain at
;; rest? Give frequency, severity, level of exercise that
;; precipitates pain, duration.
;;
;;
;; 4. Paresthesias or other abnormal sensations.
;;
;;
;; 5. Attacks of angioneurotic edema - severity, location, frequency,
;; duration?
;;
;;
;; 6. Cold sensitivity.
;;
;;
;; 7. If treated for malignancy, state type of treatment and dates,
;; including date of last treatment. Describe any residual
;; or recurrent symptoms if treated has been completed.
;;
;;
;; 8. Is exercise and exertion precluded by the condition?
;;
;;
;; 9. Is veteran confined to house or bed because of the condition?
;;
;;
;; 10. Describe the effects of the condition(s) on the veteran's
;; usual occupation and daily activities.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Nutrition, general state of health.
;;
;;
;; 2. Renal, cardiac, or cerebral arteriosclerotic foci.
;;
;;
;; 3. Cardiac status - size, function.
;;
;;
;; 4. Evidence and size of aneurysm.
;;
;;
;; 5. Extremities:
;; a. Temperature.
;;
;;
;;
;; b. Evidence of superficial phlebitis.
;;
;;
;;
;; c. Ulceration or tissue loss.
;;
;;
;;
;; d. Edema (constant or intermittent, relieved by elevation?).
;;
;;
;; e. Scar.
;;
;;
;;
;; f. Color.
;;
;;
;; g. Eczema.
;;
;;
;; h. Tenderness.
;;
;;
;; 6. If there are attacks of blanching or flushing, or blanching,
;; rubor, and cyanosis, indicate their frequency and duration.
;;
;;
;; 7. If evidence or history of erythromelalgia - severity, frequency,
;; duration?
;;
;;
;; 8. If varicosities are present, indicate their size (diameter?),
;; location, appearance, and if deep circulation is involved.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. X-rays, 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:
;;
;;
;;Signature: Date:
;;END