DVBCWLL2 ;ALB/JEH LIVER, GALL BLADDER AND PANCREAS WKS TEXT - 1 ; 19 FEBRUARY 1999
 ;;2.7;AMIE;**74**;July 22, 2004
 ;
 ;
TXT ;
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 ;;C. Physical Examination (Objective Findings): 
 ;;
 ;;Address each of the following as appropriate, and fully describe current
 ;;findings: 
 ;;
 ;;   1. Abdominal Exam
 ;;
 ;;      a. Describe any areas of tenderness and/or organomegaly, including liver
 ;;         size and whether it is tender to palpation. 
 ;;      b. Presence or absence of ascites 
 ;;      c. Evidence of Portal Hypertension (e.g. superficial abdominal veins,
 ;;         splenomegaly, abdominal pain) 
 ;;
 ;;   2. General exam
 ;;
 ;;      a. Describe all other signs of liver disease (e.g. jaundice, palmar
 ;;         erythema, spider angiomata). 
 ;;      b. Evidence of Malnutrition (e.g. muscle wasting)
 ;; 
 ;;D. Diagnostic and Clinical Tests: 
 ;;
 ;;        1. For esophageal varices, X-ray, endoscopy, etc.
 ;;
 ;;        2. For gall bladder disease, X-ray or other objective confirmation.
 ;;
 ;;        3. For liver disease: 
 ;;
 ;;             a. serologic tests for hepatitis as appropriate (e.g. HbsAg,
 ;;                anti-HCV, anti-HBc, ferritin, alpha-fetoprotein); liver imaging
 ;;                as appropriate, (e.g. ultrasound or abdominal CT scan), biopsy
 ;;                report (when available). 
 ;;
 ;;             b. Viral hepatitis (including Hepatitis C): Name the specific type
 ;;                (A, B, C, or other). For hepatitis B and / or hepatitis C,
 ;;                provide an opinion as to which risk factor is the most likely
 ;;                cause, and whether these risk factors were present during the
 ;;                veteran's time in the military. Please support your opinion by
 ;;                discussing all risk factors in the individual and your rationale
 ;;                for your opinion. If you cannot determine which risk factor is
 ;;                the likely cause, state that there is no risk factor that is
 ;;                more likely than another to be the cause, and explain.
 ;;
 ;;             c. Hepatitis C: Please note that Hepatitis C generally does not
 ;;                produce clinically evident hepatitis at the time of infection.
 ;;                Please provide results of serologic (anti-HCV antibody) and
 ;;                viral (HCV RNA) testing for hepatitis C. The anti-HCV assay
 ;;                confirms exposure to hepatitis C but does not differentiate
 ;;                between chronic, acute, or resolved infection. False positive
 ;;                and false negative results occur, but rarely. A positive
 ;;                qualitative or quantitative HCV RNA assay indicates current
 ;;                hepatitis C infection. A negative qualitative HCV RNA assay
 ;;                indicates that the individual does not have active, chronic
 ;;                hepatitis C. The recombinant immunoblot assay (RIBA) is a
 ;;                confirmatory serologic test that establishes the diagnosis of
 ;;                past (resolved) infection if the anti-HCV is positive but the
 ;;                HCV RNA assay is negative. (Reference: Under Secretary for
 ;;                Health's Information Letter 10-2002-019 "Diagnostic Testing
 ;;                for Hepatitis C"
 ;;                http://vaww.va.gov/publ/direc/health/infolet/10200219.pdf
 ;; 
 ;;The following are established risk factors for acquisition of hepatitis C
 ;;infection:
 ;;
 ;;  -Blood transfusion before 1992 
 ;;  -Past or present intravenous drug use 
 ;;  -Blood exposure of skin or mucous membranes including accidental needle
 ;;   punctures 
 ;;  -Sexual transmission (though most studies have failed to identify sexual
 ;;   transmission of this agent). Sexual transmission appears to be confined
 ;;   to such subgroups as persons with multiple sexual partners and sexually
 ;;   transmitted diseases. 
 ;;  -History of hemodialysis 
 ;;  -Tattoo or repeated body piercing 
 ;;  -History of intranasal cocaine use
 ;; 
 ;;See Harrison's Principles of Internal Medicine, 15th edition, The McGraw Hill
 ;;Companies, Inc., page 1709, 1729-1730.
 ;;
 ;;Please consider the veteran's potential for skin and mucous membrane exposure
 ;;to blood, especially where the veteran was a military corpsman, a medical
 ;;worker, or a combat veteran.
 ;;
 ;;     (d) Cirrhosis, chronic hepatitis, liver malignancy, or other chronic liver
 ;;         disease: State the most likely etiology. Address the relationship of
 ;;         the disease to active service, including any hepatitis that occurred
 ;;         in service.
 ;; 
 ;;  5.Include results of all diagnostic and clinical tests conducted in the
 ;;    examination report.
 ;; 
 ;;E. Diagnosis: 
 ;;
 ;;
 ;;Signature:                                                    Date:
 ;;END