source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWIW3.m@ 628

DVBCWIW3 ;ALB/RLC  INTESTINES (LARGE AND SMALL) WKS TEXT - 1 ; 16 JAN 2007
 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
 ;
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.
 ;;    5.  Treatment-type, duration, response, side effects.
 ;;    6.  Abdominal pain, distress, cramps - frequency, duration, location.
 ;;    7.  For ulcerative colitis - number of attacks per year.
 ;;    8.  Effects of condition on occupations functioning and activities of
 ;;        daily living.
 ;;    9.  History of trauma.
 ;;    10. History of hospitalizations or surgery - reason or type of surgery,
 ;;        location and dates, if known.
 ;;    11. History of neoplasm:
 ;;
 ;;        a. Date of diagnosis, diagnosis.
 ;;        b. Benign or malignant.
 ;;        c. Treatment, dates and response.
 ;;        d. Last date of treatment.
 ;;
 ;;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.
 ;;    3.  For fistula, location, presence of discharge.
 ;;    4.  Ostomy present - type.
 ;;    5.  Abdominal mass.
 ;;    6.  Signs of anemia.
 ;;    7.  Weight - gain or loss.
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  If signs of anemia, obtain hemoglobin/hematocrit.
 ;;    2.  Include results of all diagnostic and clinical tests conducted in
 ;;        the examination report.
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END