Disability Examination Worksheets
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:
- Nausea, vomiting.
- Hematemesis or melena (describe any episodes).
- Treatment - type, duration, response, side effects.
- For postgastrectomy syndrome: Is there circulatory disturbance after meals, hypoglycemic reactions , etc.
(state time of onset in relation to meals, frequency)?
- Diarrhea, constipation.
- For peritoneal adhesions: are there episodes of colic, distention, nausea, and/or vomiting? -
frequency, duration, and severity.
- Are there periods of incapacitation due to stomach or duodenal disease?
- History of hospitalizations or surgery: reason or type of surgery, dates and locations, if known.
- History of trauma.
- Effects of condition on occupational functioning and activities of daily living.
- Pain - location, type, precipitating, alleviating factors.
- History of neoplasm:
- Date of diagnosis, diagnosis.
- Benign or malignant.
- Treatment, dates and response.
- Last date of treatment.
C. Physical Examination (Objective Findings):
Address each of the following and fully describe current
findings:
- Weight gain or loss.
- Signs of anemia.
- Tenderness - location.
D. Diagnostic and Clinical Tests:
- For gastritis, endoscopic evidence - describe hemorrhage,
ulcerated or eroded areas.
- For adhesions, X-ray to show partial obstruction, delayed
motility.
- For ulcer disease, provide specific site.
- If there is a history of hematemesis or melena (past 12 months) or signs of anemia, obtain hemoglobin and hematocrit.
- Include results of all diagnostic and clinical tests conducted in the examination report.
E. Diagnosis:
Signature: |
|
Date: |
|
|
|
Reviewed/Updated Date:
May 1, 2007
|
|