source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWEH1.m@ 794

DVBCWEH1 ;ALB/CMM ESOPHAGUS AND HIATAL HERNIA WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
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 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Dysphagia - for solids, liquids (frequency and extent).
 ;;
 ;;
 ;;    2.  Pyrosis, epigastric or other pain, including associated 
 ;;        substernal or arm pain (frequency and severity).
 ;;
 ;;
 ;;    3.  Hematemesis or melena (describe any episodes).
 ;;
 ;;
 ;;    4.  Reflux or regurgitation (frequency); for regurgitation, contents.
 ;;
 ;;
 ;;    5.  Nausea, vomiting (frequency, precipitants).
 ;;
 ;;
 ;;    6.  Current treatment - if dilatation, give frequency.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  General state of health, anemia.
 ;;
 ;;
 ;;    2.  Nutrition, weight gain or loss.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  X-ray or endoscopic confirmation of obstruction, abnormal 
 ;;        motility, esophagitis, reflux, etc.
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;TOF
 ;;E.  Diagnosis:
 ;;
 ;;    1.  With obstruction or spasm, amenable to dilatation?
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END