- DVBCWEH1 ;ALB/CMM ESOPHAGUS AND HIATAL HERNIA 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. Dysphagia - for solids, liquids (frequency and extent).
- ;;
- ;;
- ;; 2. Pyrosis, epigastric or other pain, including associated
- ;; substernal or arm pain (frequency and severity).
- ;;
- ;;
- ;; 3. Hematemesis or melena (describe any episodes).
- ;;
- ;;
- ;; 4. Reflux or regurgitation (frequency); for regurgitation, contents.
- ;;
- ;;
- ;; 5. Nausea, vomiting (frequency, precipitants).
- ;;
- ;;
- ;; 6. Current treatment - if dilatation, give frequency.
- ;;
- ;;
- ;;C. Physical Examination (Objective Findings):
- ;;
- ;; Address each of the following and fully describe current findings:
- ;; 1. General state of health, anemia.
- ;;
- ;;
- ;; 2. Nutrition, weight gain or loss.
- ;;
- ;;
- ;;D. Diagnostic and Clinical Tests:
- ;;
- ;; 1. X-ray or endoscopic confirmation of obstruction, abnormal
- ;; motility, esophagitis, reflux, etc.
- ;; 2. Include results of all diagnostic and clinical tests conducted
- ;; in the examination report.
- ;;
- ;;TOF
- ;;E. Diagnosis:
- ;;
- ;; 1. With obstruction or spasm, amenable to dilatation?
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWEH1 1445 printed Mar 13, 2025@20:55:30 Page 2
- DVBCWEH1 ;ALB/CMM ESOPHAGUS AND HIATAL HERNIA WKS TEXT - 1 ; 5 MARCH 1997
- +1 ;;2.7;AMIE;**12**;Apr 10, 1995
- +2 ;
- +3 ;
- TXT ;
- +1 ;;A. Review of Medical Records:
- +2 ;;
- +3 ;;
- +4 ;;
- +5 ;;B. Medical History (Subjective Complaints):
- +6 ;;
- +7 ;; Comment on:
- +8 ;; 1. Dysphagia - for solids, liquids (frequency and extent).
- +9 ;;
- +10 ;;
- +11 ;; 2. Pyrosis, epigastric or other pain, including associated
- +12 ;; substernal or arm pain (frequency and severity).
- +13 ;;
- +14 ;;
- +15 ;; 3. Hematemesis or melena (describe any episodes).
- +16 ;;
- +17 ;;
- +18 ;; 4. Reflux or regurgitation (frequency); for regurgitation, contents.
- +19 ;;
- +20 ;;
- +21 ;; 5. Nausea, vomiting (frequency, precipitants).
- +22 ;;
- +23 ;;
- +24 ;; 6. Current treatment - if dilatation, give frequency.
- +25 ;;
- +26 ;;
- +27 ;;C. Physical Examination (Objective Findings):
- +28 ;;
- +29 ;; Address each of the following and fully describe current findings:
- +30 ;; 1. General state of health, anemia.
- +31 ;;
- +32 ;;
- +33 ;; 2. Nutrition, weight gain or loss.
- +34 ;;
- +35 ;;
- +36 ;;D. Diagnostic and Clinical Tests:
- +37 ;;
- +38 ;; 1. X-ray or endoscopic confirmation of obstruction, abnormal
- +39 ;; motility, esophagitis, reflux, etc.
- +40 ;; 2. Include results of all diagnostic and clinical tests conducted
- +41 ;; in the examination report.
- +42 ;;
- +43 ;;TOF
- +44 ;;E. Diagnosis:
- +45 ;;
- +46 ;; 1. With obstruction or spasm, amenable to dilatation?
- +47 ;;
- +48 ;;
- +49 ;;Signature: Date:
- +50 ;;END