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1DVBCWEH3 ;ALB/RLC ESOPHAGUS AND HIATAL HERNIA WKS TEXT - 1 ; 16 JAN 2007
2 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;;
12 ;; 1. Dysphagia - for solids, liquids (frequency and extent).
13 ;; 2. Pyrosis, epigastric or other pain, including associated
14 ;; substernal or arm pain (frequency and severity).
15 ;; 3. Hematemesis or melena (describe any episodes).
16 ;; 4. Reflux or regurgitation (frequency); for regurgitation, contents.
17 ;; 5. Nausea, vomiting (frequency, precipitants).
18 ;; 6. Treatment - type, duration, response, side effects, if dilatation,
19 ;; give frequency.
20 ;; 7. History of hospitalizations and surgery - reason or type of surgery,
21 ;; location and dates, if known.
22 ;; 8. History of esophageal trauma.
23 ;; 9. Effects of condition on occupational functioning and activities of
24 ;; daily living.
25 ;; 10. History of neoplasm:
26 ;;
27 ;; a. Date of diagnosis, diagnosis.
28 ;; b. Benign or malignant.
29 ;; c. Treatment, dates and response.
30 ;; d. Last date of treatment.
31 ;;
32 ;;C. Physical Examination (Objective Findings):
33 ;;
34 ;; Address each of the following and fully describe current findings:
35 ;;
36 ;; 1. General state of health.
37 ;; 2. Nutrition, weight gain or loss.
38 ;; 3. Signs of anemia.
39 ;;
40 ;;D. Diagnostic and Clinical Tests:
41 ;;
42 ;; 1. X-ray or endoscopic confirmation of obstruction, abnormal
43 ;; motility, esophagitis, reflux, etc.
44 ;; 2. If there is a history of bleeding (past 12 months) or signs of
45 ;; anemia, obtain hemoglobin/hematrocrit.
46 ;; 3. Include results of all diagnostic and clinical tests conducted.
47 ;;
48 ;;E. Diagnosis:
49 ;;
50 ;; 1. With obstruction or spasm, amenable to dilatation?
51 ;;
52 ;;
53 ;;Signature: Date:
54 ;;END
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