source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWHH1.m@ 628

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