Lymphatic Disorders

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. If there are exacerbations/remissions, what is the state of the veteran's health during remissions?
2. Current and past treatment history including date and type of last treatment, response, side effects.
3. If malignant neoplasm, need diagnosis, date of diagnosis, dates of treatment, or if treatment ended, date of last treatment.
4. Current symptoms - lymphadenopathy, bleeding tendency, gastrointestinal symptoms, constitutional symptoms.
5. History of hospitalizations or surgery, reason or type of surgery, location and dates, if known.
6. Effects of condition on occupational functioning and daily activities.

C. Physical Examination (Objective Findings):

Describe the residuals of each body system affected and follow additional worksheets as appropriate. Comment on the following:

1. Lymphadenopathy.
2. Splenomegaly.
3. Hepatomegaly, jaundice.
4. Signs of bleeding.
5. Signs of anemia - Presence of Pallor (nail beds, mucosal surfaces and skin), tachycardia, systolic murmur.
6. Evidence of superior vena cava syndrome.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Is the disease active?

Signature:

Date: