source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWEH3.m

DVBCWEH3 ;ALB/RLC   ESOPHAGUS AND HIATAL HERNIA 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.  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.  Treatment - type, duration, response, side effects, if dilatation,
 ;;        give frequency.
 ;;    7.  History of hospitalizations and surgery - reason or type of surgery,
 ;;        location and dates, if known.
 ;;    8.  History of esophageal trauma.
 ;;    9.  Effects of condition on occupational functioning and activities of
 ;;        daily living.
 ;;    10. 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.  General state of health.
 ;;    2.  Nutrition, weight gain or loss.
 ;;    3.  Signs of anemia.
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  X-ray or endoscopic confirmation of obstruction, abnormal 
 ;;        motility, esophagitis, reflux, etc.
 ;;    2.  If there is a history of bleeding (past 12 months) or signs of
 ;;        anemia, obtain hemoglobin/hematrocrit.
 ;;    3.  Include results of all diagnostic and clinical tests conducted.
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;    1.  With obstruction or spasm, amenable to dilatation?
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END