DVBCWRA3 ;ALB/RLC RECTUM AND ANUS WKS TEXT - 1 ; 12 FEB 2007 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9 ; ; TXT ; ;;A. Review of Medical Records: ;; ;;B. Medical History (Subjective Complaints): ;; ;; Comment on: ;; ;; 1. Current symptoms - anal itching, diarrhea, pain, tenesmus, swelling, ;; perianal discharge, etc. ;; 2. For fecal incontinence - extent and frequency of fecal leakage or ;; involuntary bowel movements- is a pad needed? ;; 3. For hemorrhoids - bleeding or thrombosis of hemorrhoids - frequency ;; and extent. ;; 4. Current treatment - type, duration, response, side effects. ;; 5. History of hospitalizations or surgery - reason or type of surgery, ;; location and dates, if known. ;; 6. History of trauma to the rectum or anus. ;; 7. History of obstetrical injury - describe. ;; 8. History of spinal cord injury affecting rectum and anus - describe. ;; 9. For rectal prolapse - frequency, extent of fecal leakage. ;; 10. History of rectal bleeding. ;; 11. History of anal infections. ;; 12. History of proctitis. ;; 13. History of fistula in ano. ;; 14. History of neoplasm. ;; ;; a. Date of diagnosis, diagnosis. ;; b. Benign or malignant. ;; c. Treatment dates and response. ;; d. Last date of treatment. ;; ;; 15. Effects of condition on occupational functioning and daily activities. ;; ;;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, reducible, presence of redundant ;; tissue and if thrombosed. ;; 7. Evidence of bleeding. ;; 8. Rectal prolapse - extent. ;; 9. Sphincter tone. ;; ;;D. Diagnostic and Clinical Tests: ;; ;; 1. Include results of all diagnostic and clinical tests conducted ;; in the examination report. ;; 2. If a history of bleeding (past 12 months), signs of anemia or chronic ;; infection, obtain CDC. ;; ;;E. Diagnosis: ;; ;; ;; ;;Signature: Date: ;;END