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
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWEH3 2008 printed Dec 13, 2024@01:50:49 Page 2
DVBCWEH3 ;ALB/RLC ESOPHAGUS AND HIATAL HERNIA WKS TEXT - 1 ; 16 JAN 2007
+1 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. Dysphagia - for solids, liquids (frequency and extent).
+8 ;; 2. Pyrosis, epigastric or other pain, including associated
+9 ;; substernal or arm pain (frequency and severity).
+10 ;; 3. Hematemesis or melena (describe any episodes).
+11 ;; 4. Reflux or regurgitation (frequency); for regurgitation, contents.
+12 ;; 5. Nausea, vomiting (frequency, precipitants).
+13 ;; 6. Treatment - type, duration, response, side effects, if dilatation,
+14 ;; give frequency.
+15 ;; 7. History of hospitalizations and surgery - reason or type of surgery,
+16 ;; location and dates, if known.
+17 ;; 8. History of esophageal trauma.
+18 ;; 9. Effects of condition on occupational functioning and activities of
+19 ;; daily living.
+20 ;; 10. History of neoplasm:
+21 ;;
+22 ;; a. Date of diagnosis, diagnosis.
+23 ;; b. Benign or malignant.
+24 ;; c. Treatment, dates and response.
+25 ;; d. Last date of treatment.
+26 ;;
+27 ;;C. Physical Examination (Objective Findings):
+28 ;;
+29 ;; Address each of the following and fully describe current findings:
+30 ;;
+31 ;; 1. General state of health.
+32 ;; 2. Nutrition, weight gain or loss.
+33 ;; 3. Signs of anemia.
+34 ;;
+35 ;;D. Diagnostic and Clinical Tests:
+36 ;;
+37 ;; 1. X-ray or endoscopic confirmation of obstruction, abnormal
+38 ;; motility, esophagitis, reflux, etc.
+39 ;; 2. If there is a history of bleeding (past 12 months) or signs of
+40 ;; anemia, obtain hemoglobin/hematrocrit.
+41 ;; 3. Include results of all diagnostic and clinical tests conducted.
+42 ;;
+43 ;;E. Diagnosis:
+44 ;;
+45 ;; 1. With obstruction or spasm, amenable to dilatation?
+46 ;;
+47 ;;
+48 ;;Signature: Date:
+49 ;;END
