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1DVBCWHH1 ;ALB/CMM HEART AND HYPERTENSION WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Dyspnea on exertion. If present, what level of activity
14 ;; precipitates it?
15 ;;
16 ;;
17 ;; 2. Angina - Extent? Frequency? Level of activity that
18 ;; precipitates it?
19 ;;
20 ;;
21 ;; 3. Other cardiac symptoms? If present, what level of activity
22 ;; precipitates them?
23 ;;
24 ;;
25 ;; 4. Describe history, including dates and severity of episodes, of
26 ;; acute cardiac illness, including coronary occlusion or
27 ;; thrombosis, congestive heart failure, acute rheumatic heart
28 ;; disease, etc., and all cardiac surgery, including coronary
29 ;; artery bypass, valvular surgery, cardiac transplant, angioplasty, etc.
30 ;;
31 ;;
32 ;; 5. Current treatment, response, and side effects.
33 ;;
34 ;;
35 ;;C. Physical Examination (Objective Findings):
36 ;;
37 ;; Address each of the following and fully describe current findings:
38 ;; 1. Heart size - How determined?
39 ;;
40 ;;
41 ;; 2. If the diagnosis of hypertension has not been established,
42 ;; take 2 or more blood pressure readings on at least 3 different
43 ;; days.
44 ;;
45 ;;
46 ;; 3. If hypertension has been diagnosed, take 2 or more blood
47 ;; pressure readings.
48 ;;
49 ;;
50 ;; 4. Cardiac arrhythmia - onset?
51 ;;
52 ;;
53 ;; 5. Murmurs, thrills.
54 ;;
55 ;;
56 ;; 6. Evidence of congestive heart failure - rales, edema, liver
57 ;; enlargement, etc.
58 ;;
59 ;;
60 ;;D. Diagnostic and Clinical Tests:
61 ;;
62 ;; 1. Chest X-ray - heart size?, pericardial adhesions?
63 ;; 2. EKG.
64 ;; 3. Echocardiogram, exercise stress test, thallium study, angiography,
65 ;; etc., as appropriate, and as needed.
66 ;; 4. Include results of all diagnostic and clinical tests conducted
67 ;; in the examination report.
68 ;;
69 ;;
70 ;;E. Diagnosis:
71 ;;
72 ;; 1. Etiology of any murmurs.
73 ;;
74 ;;
75 ;; 2. If both rheumatic heart disease and arteriosclerotic heart
76 ;; disease are present, state, if possible, which findings can be
77 ;; attributed to each condition. If it is not possible to
78 ;; separate the signs and symptoms of one from the other, so
79 ;; state, and explain.
80 ;;
81 ;;
82 ;; 3. Functional Assessment: - How does the heart disability or
83 ;; hypertension affect the daily activities of the veteran? Is
84 ;; more than sedentary employment feasible? Is more than light
85 ;; manual labor feasible? Explain.
86 ;;
87 ;;
88 ;;Signature: Date:
89 ;;END
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