- 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 Jan 18, 2025@02:52:54 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