source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWST1.m@ 1123

DVBCWST1 ;ALB/CMM STOMACH, DUODENUM, AND PERITONEAL ADHESIONS WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
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TXT ;
 ;;A.  Review of Medical Records:
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 ;;B.  Medical History (Subjective Complaints):
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 ;;    1.  Vomiting.
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 ;;    2.  Hematemesis or melena (describe any episodes).
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 ;;    3.  Treatment - type, duration, response, side effects.
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 ;;    4.  Circulatory disturbance after meals, hypoglycemic reactions 
 ;;        (state time of onset in relation to meals, frequency).
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 ;;    5.  Diarrhea, constipation.
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 ;;    6.  Episodes of colic, distention, nausea, and/or vomiting - 
 ;;        frequency, duration, and severity.
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 ;;C.  Physical Examination (Objective Findings):
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 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Specific site of any ulcer disease.
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 ;;    2.  Weight gain or loss.
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 ;;    3.  Signs of anemia.
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 ;;    4.  Pain or tenderness - location, type, precipitating factors.
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 ;;D.  Diagnostic and Clinical Tests:
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 ;;    1.  For gastritis, endoscopic evidence - describe hemorrhage, 
 ;;        ulcerated or eroded areas.
 ;;    2.  For adhesions, X-ray to show partial obstruction, delayed 
 ;;        motility.
 ;;    3.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
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 ;;E.  Diagnosis:
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 ;;Signature:                             Date:
 ;;END