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Routine: DVBCWHH1

DVBCWHH1.m

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  1. DVBCWHH1 ;ALB/CMM HEART AND HYPERTENSION WKS TEXT - 1 ; 5 MARCH 1997
  1. ;;2.7;AMIE;**12**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;;
  1. ;; Comment on:
  1. ;; 1. Dyspnea on exertion. If present, what level of activity
  1. ;; precipitates it?
  1. ;;
  1. ;;
  1. ;; 2. Angina - Extent? Frequency? Level of activity that
  1. ;; precipitates it?
  1. ;;
  1. ;;
  1. ;; 3. Other cardiac symptoms? If present, what level of activity
  1. ;; precipitates them?
  1. ;;
  1. ;;
  1. ;; 4. Describe history, including dates and severity of episodes, of
  1. ;; acute cardiac illness, including coronary occlusion or
  1. ;; thrombosis, congestive heart failure, acute rheumatic heart
  1. ;; disease, etc., and all cardiac surgery, including coronary
  1. ;; artery bypass, valvular surgery, cardiac transplant, angioplasty, etc.
  1. ;;
  1. ;;
  1. ;; 5. Current treatment, response, and side effects.
  1. ;;
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; Address each of the following and fully describe current findings:
  1. ;; 1. Heart size - How determined?
  1. ;;
  1. ;;
  1. ;; 2. If the diagnosis of hypertension has not been established,
  1. ;; take 2 or more blood pressure readings on at least 3 different
  1. ;; days.
  1. ;;
  1. ;;
  1. ;; 3. If hypertension has been diagnosed, take 2 or more blood
  1. ;; pressure readings.
  1. ;;
  1. ;;
  1. ;; 4. Cardiac arrhythmia - onset?
  1. ;;
  1. ;;
  1. ;; 5. Murmurs, thrills.
  1. ;;
  1. ;;
  1. ;; 6. Evidence of congestive heart failure - rales, edema, liver
  1. ;; enlargement, etc.
  1. ;;
  1. ;;
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. Chest X-ray - heart size?, pericardial adhesions?
  1. ;; 2. EKG.
  1. ;; 3. Echocardiogram, exercise stress test, thallium study, angiography,
  1. ;; etc., as appropriate, and as needed.
  1. ;; 4. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;;
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;; 1. Etiology of any murmurs.
  1. ;;
  1. ;;
  1. ;; 2. If both rheumatic heart disease and arteriosclerotic heart
  1. ;; disease are present, state, if possible, which findings can be
  1. ;; attributed to each condition. If it is not possible to
  1. ;; separate the signs and symptoms of one from the other, so
  1. ;; state, and explain.
  1. ;;
  1. ;;
  1. ;; 3. Functional Assessment: - How does the heart disability or
  1. ;; hypertension affect the daily activities of the veteran? Is
  1. ;; more than sedentary employment feasible? Is more than light
  1. ;; manual labor feasible? Explain.
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END