source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWIW1.m@ 628

DVBCWIW1 ;ALB/CMM INTESTINES (LARGE AND SMALL) WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Weight gain or loss.
 ;;
 ;;
 ;;    2.  Nausea and/or vomiting.
 ;;
 ;;
 ;;    3.  Constipation, diarrhea (frequency, severity, duration, and 
 ;;        episodic or not?).
 ;;
 ;;
 ;;    4.  For fistula - frequency, duration, and amount of fecal discharge.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Malnutrition, anemia, other evidence of debility.
 ;;
 ;;
 ;;    2.  Abdominal pain - location, type, frequency, and duration.
 ;;
 ;;
 ;;    3.  Current treatment - type, duration, response, and side effects.
 ;;
 ;;    4.  For fistula - location.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END