source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRA3.m@ 628

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