<noteTO>
                  <id>43296940</id>
                  <timestamp>3160113.0835</timestamp>
                  <localTitle>C&amp;P GENERAL MEDICAL</localTitle>
                  <standardTitle>C &amp; P EXAMINATION NOTE</standardTitle>
                  <author>
                    <id>2926</id>
                    <name>DOUGLAS,DAVID M</name>
                  </author>
                  <location>
                    <id>648</id>
                    <name>PORTLAND VA MEDICAL CENTER</name>
                  </location>
                  <text>
 LOCAL TITLE: C&amp;P GENERAL MEDICAL                                
STANDARD TITLE: C &amp; P EXAMINATION NOTE                          
DATE OF NOTE: JAN 13, 2016@08:35     ENTRY DATE: JAN 13, 2016@08:35:40      
      AUTHOR: DOUGLAS,DAVID M      EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     

Ionizing Radiation 
(related issues: leukemia, lymphoma (except Hodgekin's disease), multiple
myeloma, cancers of the bile ducts, bone, brain, breast, colon, esophagus,
gall bladder, lung, pancreas, pharynx, ovary, salivary gland, small intestine,
stomach, thyroid, urinary tract).
 


-------------------------------------------------

HPI (including complaints Veteran related to the in-service exposure): 
test


Past Medical History:
test


Family History (to include any birth defects):
test


 Habits:  test

 Smoking: test
 
 Alcohol: test

 Substances: test

====================================

REVIEW OF SYSTEMS: (if yes, describe)

====================================

General (weight change, fever, fatigue, bleeding, swollen 
glands,night sweats, unexplained lumps/masses)
YES 

Endocrine (DM, thyroid disease, hot/cold intoleranc, 
polyuria/dipsia)
NO 

Eye (vision problem, pain, itching, redness of eyes)
YES 

Ear (ear pain, drainage, hearing loss, tinnitus)
NO 

Nose/sinus (nosebleeds, congestion, sinus pain, drainage)
YES 

Throat (soreness, hoarseness, problems with chewing, 
swallowing or speech)
NO 

Neck (pain, mass, swelling, goiter)
YES 

Skin (rash, sore, painful scar, itching)
NO 

Lung (cough, wheezing, SOB, hemoptysis, sleep, apnea, TB) 
YES 

GI (abd pain, heartburn, N&amp;V, bowel complaint, pancreas, 
liver, or GB disease, hemorrhoids, hernia)
NO 

GU (UTI, stones, STD, hematuria, urinary complaints, ED, 
prostate disease) 
YES 

Mental (depression, mental complaint, sleep complaint, 
substance abuse)
NO 

MS (pain, stiffness of feet, hands, joints, neck, back)
YES 

Breast (pain, lump, drainage)
NO 

====================================

PHYSICAL EXAM

====================================

VITAL SIGNS 

-----------

  PULSE:  BPM

  BP #1: /

 
  T: 

  R: 


 
GENERAL APPEARANCE: 
 test


  HEIGHT: 

  WEIGHT:  POUNDS 

  WEIGHT CHANGE: 



PHYSICAL EXAM: (If abnormal, describe)

  GENERAL (Lymph nodes, edema, bleeding or bruising)
  Normal
 

  SKIN (Skin, scalp, hair, nails) 
  Abnormal
 

  HEENT (External eye, pupils, EOMs.  External ear, canal, TM, gross hearing 
  acuity, nose, septum, sinus, tongue, palate, pharynx, teeth/gums)
  Abnormal
 

  NECK (Cervical nodes, carotid pulses/auscultation, thyroid gland)
  Normal
 

  CHEST (Chest shape/deformities, respiratory distress, auscultation and 
  percussion of lungs)
  Abnormal
 

  CARDIOVASCULAR (Rate, rhythm, heart sounds; murmurs, gallops, clicks or rubs
  jugular venous distention) 
  Normal
 

   ABDOMEN (Inspection, palpation, auscultation of abdomen, presence of 
   hepatosplenomegaly or hernias)
  Abnormal
 

   GU (Testicles, epididymis, spermatic cord, seminal vesicles, anus, rectum, 
   prostate, presence of hernias)
  Normal
 

   EXTREMITIES (Presence of cyanosis, clubbing, edema, trophic changes, 
   ulcers, varicose veins)
   Abnormal
 

   NEUROLOGIC (Mental status, speech, coordination, motor and sensory 
   testing in all four extremities, cranial nerves, deep tendon reflexes,
   babinski)
  Normal
 

   PSYCHIATRIC (Mood, behavior, and comprehension, ability to follow 
directions, 
   presence of any abnormal behavior or hallucinations)
 
 

   BREAST (Presence of masses, abnormal nodularity, nipple abnormalities, 
gynecomastia, 
   residuals of breast surgery. 
 
 

  Labs:
 
 
  Diagnosis: 
 test


 Letter sent to Veteran summarizing examination, Registry forms filled in and 
sent for inclusion in registry, Contact information given for Veteran to 
request care at VA








 
 
/es/ DAVID M. DOUGLAS MD
CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST
Signed: 01/13/2016 08:37
</text>
                  <approvedBy>
                    <id>2926</id>
                    <name>DOUGLAS,DAVID M</name>
                    <signature>DAVID M. DOUGLAS MD CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST</signature>
                  </approvedBy>
                  <status>completed</status>
                  <type>PN</type>
                  <procTimestamp>3160113.083752</procTimestamp>
                </noteTO>