Stomach, Duodenum, and Peritoneal Adhesions

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

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Nausea, vomiting.
2. Hematemesis or melena (describe any episodes).
3. Treatment - type, duration, response, side effects.
4. For postgastrectomy syndrome: Is there circulatory disturbance after meals, hypoglycemic reactions , etc. (state time of onset in relation to meals, frequency)?
5. Diarrhea, constipation.
6. For peritoneal adhesions: are there episodes of colic, distention, nausea, and/or vomiting? - frequency, duration, and severity.
7. Are there periods of incapacitation due to stomach or duodenal disease?
8. History of hospitalizations or surgery: reason or type of surgery, dates and locations, if known.
9. History of trauma.
10. Effects of condition on occupational functioning and activities of daily living.
11. Pain - location, type, precipitating, alleviating factors.
12. 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. Weight gain or loss.
2. Signs of anemia.
3. Tenderness - location.

D. Diagnostic and Clinical Tests:

1. For gastritis, endoscopic evidence - describe hemorrhage, ulcerated or eroded areas.
2. For adhesions, X-ray to show partial obstruction, delayed motility.
3. For ulcer disease, provide specific site.
4. If there is a history of hematemesis or melena (past 12 months) or signs of anemia, obtain hemoglobin and hematocrit.
5. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: