source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWST3.m@ 628

DVBCWST3 ;ALB/RLC  STOMACH, DUODENUM, AND PERITONEAL ADHESIONS WKS TEXT - 1 ; 16 JAN 2007
 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;
 ;;    1.  Nausea, vomiting.
 ;;    2.  Hematemesis or melena (describe any episodes).
 ;;    3.  Treatment - type, duration, response, side effects.
 ;;    4.  For postgastrectomy syndrome:  Is there circulatory disturbance
 ;;        after meals, hypoglycemic reactions, etc. (state time of onset
 ;;        in relation to meals, frequency)?
 ;;    5.  Diarrhea, constipation.
 ;;    6.  For peritoneal adhesions:  Are there episodes of colic, distention,
 ;;        nausea, and/or vomiting? - frequency, duration, and severity.
 ;;    7.  Are there periods of incapacitation due to stomach or duodenal
 ;;        disease?
 ;;    8.  History of hospitalizations or surgery:  reason or type of surgery,
 ;;        dates and locations, if known.
 ;;    9.  History of trauma.
 ;;    10. Effects of condition on occupational functioning and activities of
 ;;        daily living.
 ;;    11. Pain - location, type, precipitating, alleviating factors.
 ;;    12. History of neoplasm:
 ;;
 ;;        a. Date of diagnosis, diagnosis.
 ;;        b. Benign or malignant.
 ;;        c. Treatment, dates and response.
 ;;        d. Last date of treatment.
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;
 ;;    1.  Weight gain or loss.
 ;;    2.  Signs of anemia.
 ;;    3.  Tenderness - location.
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  For gastritis, endoscopic evidence - describe hemorrhage, 
 ;;        ulcerated or eroded areas.
 ;;    2.  For adhesions, X-ray to show partial obstruction, delayed 
 ;;        motility.
 ;;    3.  For ulcer diseases, provide specific site.
 ;;    4.  If there is a history of hematemesis or melena (past 12 months)
 ;;        or signs of anemia, obtain hemaglobin and hematocrit.
 ;;    5.  Include results of all diagnostic and clinical tests conducted in
 ;;        the examination report.
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END