source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRA1.m@ 628

DVBCWRA1 ;ALB/CMM RECTUM AND ANUS 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.  Degree of sphincter control.
 ;;
 ;;
 ;;    2.  Extent and frequency of fecal leakage or involuntary bowel
 ;;        movements- is a pad needed?
 ;;
 ;;
 ;;    3.  Bleeding or thrombosis of hemorrhoids - frequency and extent.
 ;;
 ;;
 ;;    4.  Current treatment.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Colostomy.
 ;;
 ;;
 ;;    2.  Evidence of fecal leakage.
 ;;
 ;;
 ;;    3.  Size of lumen - rectum and anus.
 ;;
 ;;
 ;;    4.  Signs of anemia.
 ;;
 ;;
 ;;    5.  Fissures.
 ;;
 ;;
 ;;    6.  If hemorrhoids - location, size, and if thrombosed.
 ;;
 ;;
 ;;    7.  Evidence of bleeding.
 ;;
 ;;TOF
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END