source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGY1.m@ 628

DVBCWGY1 ;ALB/CMM GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Provide:  
 ;;    1.  Date of onset of symptoms.
 ;;
 ;;
 ;;    2.  Describe symptoms, e.g., abnormal bleeding, vaginal discharge,
 ;;        fever, pain, bowel or bladder symptoms, etc.
 ;;
 ;;
 ;;    3.  Treatments:
 ;;        a.  Detail all breast and pelvic surgery.
 ;;
 ;;
 ;;        b.  If a malignant process has been identified, provide:  
 ;;            (1)  Date of confirmed diagnosis.
 ;;
 ;;
 ;;            (2)  Date of the last surgical, X-ray, antineoplastic
 ;;                 chemotherapy, radiation, or other therapeutic procedure.
 ;;
 ;;
 ;;            (3)  Expected date treatment regimen is to be completed.
 ;;
 ;;
 ;;            (4)  If already completed, provide date.
 ;;
 ;;
 ;;            (5)  Fully describe residuals.
 ;;
 ;;
 ;;        c.  Detail hormonal and other medications and whether continuous 
 ;;            medication is required, response, and side effects.
 ;;
 ;;
 ;;    4.  Include complete menstrual history, pregnancy history, and 
 ;;        urinary tract history.
 ;;
 ;;TOF
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Provide a full gynecological and breast examination (UNLESS ONLY A
 ;;    PARTICULAR CONDITION OR PORTION OF THE EXAMINATION IS REQUESTED).
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Uterus.
 ;;        a.  If post operative, state extent of surgery.
 ;;
 ;;
 ;;        b.  If prolapse is present, is it through the introitus?
 ;;
 ;;
 ;;        c.  If displaced, are there adhesions and/or menstrual disturbances.
 ;;
 ;;
 ;;    2.  If rectovaginal fistula is present, describe extent and 
 ;;        frequency of leakage and whether a pad is required.
 ;;
 ;;
 ;;    3.  If urethrovaginal fistula is present, describe whether absorbent 
 ;;        material is required and how often it must be changed.
 ;;
 ;;
 ;;    4.  If rectocele, cystocele, or perineal relaxation is present, is
 ;;        it due to pregnancy?
 ;;
 ;;
 ;;    5.  Breasts.
 ;;
 ;;        If post-operative, Identify the type of surgery using the 
 ;;        following definitions:
 ;;        a.  RADICAL MASTECTOMY - removal of the entire breast, 
 ;;            underlying pectoral muscles, and regional lymph nodes up 
 ;;            to the coracoclavicular ligament.
 ;;
 ;;
 ;;        b.  MODIFIED RADICAL MASTECTOMY - removal of the entire breast
 ;;            and axillary lymph nodes (in continuity with the breast). 
 ;;            Pectoral muscles are left intact.
 ;;
 ;;
 ;;        c.  SIMPLE (OR TOTAL) MASTECTOMY - removal of all the breast 
 ;;            tissue, nipple, and a small portion of the overlying skin,
 ;;            but lymph nodes and muscles are left intact.
 ;;
 ;;TOF
 ;;        d.  WIDE LOCAL INCISION - includes partial mastectomy, lumpectomy, 
 ;;            tylectomy, segmentectomy, and quadrantectomy.  This means
 ;;            removal of a portion of the breast tissue.
 ;;
 ;;
 ;;        e.  Describe any alteration of size and form.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  CBC.
 ;;    2.  Urinalysis.
 ;;    3.  Laparoscopy is required to establish diagnosis of endometriosis 
 ;;        and to confirm bowel or bladder involvement.
 ;;    4.  Ultrasound, mammography, if indicated.
 ;;    5.  Pap Smear (if none within past year).
 ;;    6.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END