Infectious, Immune, and Nutritional Disorders

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Narrative: Many infectious diseases, immune disorders, and nutritional deficiencies have acute phases at onset and accompanying recurrences but leave little or no residual disability beyond the acute phase. Other such conditions may have slow progression and show significant residual disability. The examiner must diligently search for residual disabilities upon which adjudication of the case may be made.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date of symptom onset.
2. Date of diagnosis.
3. Clinical manifestations.
4. Treatment (type, frequency, duration, response, side effects).
5. Disease activity (exacerbations and/or remissions)? If there were exacerbations, what was the state of the veteran's health between exacerbations? Frequency and duration of exacerbations.
6. Current symptoms

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Is the condition still present?
2. Current weight, nutrition. Any residuals of malnutrition, vitamin deficiency?
3. General appearance.
4. Describe findings of all organ systems involved. See appropriate examination worksheets - respiratory, joints, cardiovascular, etc.

D. Diagnostic and Clinical Tests:

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

Note: If an infectious etiology is documented, specify the organism.

E. Diagnosis:

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