Esophagus and Hiatal Hernia

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

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:

1. Date of diagnosis, diagnosis.
2. Benign or malignant.
3. Treatment, dates and response.
4. 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/hematocrit
3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. With obstruction or spasm, amenable to dilatation?

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