source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWDM1.m@ 628

DVBCWDM1 ;ALB/CMM DIGESTIVE, MISC. DISEASES WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    1.  Describe all hernia surgery and results.
 ;;
 ;;
 ;;    2.  For malignancy, state type of treatment, dates of treatment, 
 ;;        including last date treatment if it has ended.
 ;;
 ;;
 ;;    3.  For peritoneal tuberculosis, state date of diagnosis, treatment, 
 ;;        and date on which inactivity was established.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  For inguinal or ventral hernia, state whether reducible, how 
 ;;        well supported by truss or belt, and whether irremediable or 
 ;;        inoperable.
 ;;
 ;;
 ;;    2.  For ventral hernia, state size of hernia, extent of diastasis
 ;;        of recti muscles, status of muscles and fascia of abdominal wall.
 ;;
 ;;
 ;;    3.  All residuals of malignancy, including residuals from treatment.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;1.  Include results of all diagnostic and clinical tests conducted in
 ;;    the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END