DVBCWHH1 ;ALB/CMM HEART AND HYPERTENSION 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. Dyspnea on exertion. If present, what level of activity
;; precipitates it?
;;
;;
;; 2. Angina - Extent? Frequency? Level of activity that
;; precipitates it?
;;
;;
;; 3. Other cardiac symptoms? If present, what level of activity
;; precipitates them?
;;
;;
;; 4. Describe history, including dates and severity of episodes, of
;; acute cardiac illness, including coronary occlusion or
;; thrombosis, congestive heart failure, acute rheumatic heart
;; disease, etc., and all cardiac surgery, including coronary
;; artery bypass, valvular surgery, cardiac transplant, angioplasty, etc.
;;
;;
;; 5. Current treatment, response, and side effects.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Heart size - How determined?
;;
;;
;; 2. If the diagnosis of hypertension has not been established,
;; take 2 or more blood pressure readings on at least 3 different
;; days.
;;
;;
;; 3. If hypertension has been diagnosed, take 2 or more blood
;; pressure readings.
;;
;;
;; 4. Cardiac arrhythmia - onset?
;;
;;
;; 5. Murmurs, thrills.
;;
;;
;; 6. Evidence of congestive heart failure - rales, edema, liver
;; enlargement, etc.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Chest X-ray - heart size?, pericardial adhesions?
;; 2. EKG.
;; 3. Echocardiogram, exercise stress test, thallium study, angiography,
;; etc., as appropriate, and as needed.
;; 4. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; 1. Etiology of any murmurs.
;;
;;
;; 2. If both rheumatic heart disease and arteriosclerotic heart
;; disease are present, state, if possible, which findings can be
;; attributed to each condition. If it is not possible to
;; separate the signs and symptoms of one from the other, so
;; state, and explain.
;;
;;
;; 3. Functional Assessment: - How does the heart disability or
;; hypertension affect the daily activities of the veteran? Is
;; more than sedentary employment feasible? Is more than light
;; manual labor feasible? Explain.
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWHH1 2802 printed Dec 13, 2024@01:51:41 Page 2
DVBCWHH1 ;ALB/CMM HEART AND HYPERTENSION 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. Dyspnea on exertion. If present, what level of activity
+9 ;; precipitates it?
+10 ;;
+11 ;;
+12 ;; 2. Angina - Extent? Frequency? Level of activity that
+13 ;; precipitates it?
+14 ;;
+15 ;;
+16 ;; 3. Other cardiac symptoms? If present, what level of activity
+17 ;; precipitates them?
+18 ;;
+19 ;;
+20 ;; 4. Describe history, including dates and severity of episodes, of
+21 ;; acute cardiac illness, including coronary occlusion or
+22 ;; thrombosis, congestive heart failure, acute rheumatic heart
+23 ;; disease, etc., and all cardiac surgery, including coronary
+24 ;; artery bypass, valvular surgery, cardiac transplant, angioplasty, etc.
+25 ;;
+26 ;;
+27 ;; 5. Current treatment, response, and side effects.
+28 ;;
+29 ;;
+30 ;;C. Physical Examination (Objective Findings):
+31 ;;
+32 ;; Address each of the following and fully describe current findings:
+33 ;; 1. Heart size - How determined?
+34 ;;
+35 ;;
+36 ;; 2. If the diagnosis of hypertension has not been established,
+37 ;; take 2 or more blood pressure readings on at least 3 different
+38 ;; days.
+39 ;;
+40 ;;
+41 ;; 3. If hypertension has been diagnosed, take 2 or more blood
+42 ;; pressure readings.
+43 ;;
+44 ;;
+45 ;; 4. Cardiac arrhythmia - onset?
+46 ;;
+47 ;;
+48 ;; 5. Murmurs, thrills.
+49 ;;
+50 ;;
+51 ;; 6. Evidence of congestive heart failure - rales, edema, liver
+52 ;; enlargement, etc.
+53 ;;
+54 ;;
+55 ;;D. Diagnostic and Clinical Tests:
+56 ;;
+57 ;; 1. Chest X-ray - heart size?, pericardial adhesions?
+58 ;; 2. EKG.
+59 ;; 3. Echocardiogram, exercise stress test, thallium study, angiography,
+60 ;; etc., as appropriate, and as needed.
+61 ;; 4. Include results of all diagnostic and clinical tests conducted
+62 ;; in the examination report.
+63 ;;
+64 ;;
+65 ;;E. Diagnosis:
+66 ;;
+67 ;; 1. Etiology of any murmurs.
+68 ;;
+69 ;;
+70 ;; 2. If both rheumatic heart disease and arteriosclerotic heart
+71 ;; disease are present, state, if possible, which findings can be
+72 ;; attributed to each condition. If it is not possible to
+73 ;; separate the signs and symptoms of one from the other, so
+74 ;; state, and explain.
+75 ;;
+76 ;;
+77 ;; 3. Functional Assessment: - How does the heart disability or
+78 ;; hypertension affect the daily activities of the veteran? Is
+79 ;; more than sedentary employment feasible? Is more than light
+80 ;; manual labor feasible? Explain.
+81 ;;
+82 ;;
+83 ;;Signature: Date:
+84 ;;END
