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Routine: DVBCWEH3

DVBCWEH3.m

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DVBCWEH3 ;ALB/RLC   ESOPHAGUS AND HIATAL HERNIA WKS TEXT - 1 ; 16 JAN 2007

 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4

 ;

 ;

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.  Treatment - type, duration, response, side effects, if dilatation,

 ;;        give frequency.

 ;;    7.  History of hospitalizations and surgery - reason or type of surgery,

 ;;        location and dates, if known.

 ;;    8.  History of esophageal trauma.

 ;;    9.  Effects of condition on occupational functioning and activities of

 ;;        daily living.

 ;;    10. History of neoplasm:

 ;;

 ;;        a.  Date of diagnosis, diagnosis.

 ;;        b.  Benign or malignant.

 ;;        c.  Treatment, dates and response.

 ;;        d.  Last date of treatment.

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Address each of the following and fully describe current findings:

 ;;

 ;;    1.  General state of health.

 ;;    2.  Nutrition, weight gain or loss.

 ;;    3.  Signs of anemia.

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  X-ray or endoscopic confirmation of obstruction, abnormal 

 ;;        motility, esophagitis, reflux, etc.

 ;;    2.  If there is a history of bleeding (past 12 months) or signs of

 ;;        anemia, obtain hemoglobin/hematrocrit.

 ;;    3.  Include results of all diagnostic and clinical tests conducted.

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;    1.  With obstruction or spasm, amenable to dilatation?

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END