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1DVBCWIW3 ;ALB/RLC INTESTINES (LARGE AND SMALL) WKS TEXT - 1 ; 16 JAN 2007
2 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
3 ;
4TXT ;
5 ;;A. Review of Medical Records:
6 ;;
7 ;;B. Medical History (Subjective Complaints):
8 ;;
9 ;; Comment on:
10 ;;
11 ;; 1. Weight gain or loss.
12 ;; 2. Nausea and/or vomiting.
13 ;; 3. Constipation, diarrhea (frequency, severity, duration, and
14 ;; episodic or not?).
15 ;; 4. For fistula - frequency, duration, and amount of fecal discharge.
16 ;; 5. Treatment-type, duration, response, side effects.
17 ;; 6. Abdominal pain, distress, cramps - frequency, duration, location.
18 ;; 7. For ulcerative colitis - number of attacks per year.
19 ;; 8. Effects of condition on occupations functioning and activities of
20 ;; daily living.
21 ;; 9. History of trauma.
22 ;; 10. History of hospitalizations or surgery - reason or type of surgery,
23 ;; location and dates, if known.
24 ;; 11. History of neoplasm:
25 ;;
26 ;; a. Date of diagnosis, diagnosis.
27 ;; b. Benign or malignant.
28 ;; c. Treatment, dates and response.
29 ;; d. Last date of treatment.
30 ;;
31 ;;C. Physical Examination (Objective Findings):
32 ;;
33 ;; Address each of the following and fully describe current findings:
34 ;; 1. Malnutrition, anemia, other evidence of debility.
35 ;; 2. Abdominal pain - location.
36 ;; 3. For fistula, location, presence of discharge.
37 ;; 4. Ostomy present - type.
38 ;; 5. Abdominal mass.
39 ;; 6. Signs of anemia.
40 ;; 7. Weight - gain or loss.
41 ;;
42 ;;D. Diagnostic and Clinical Tests:
43 ;;
44 ;; 1. If signs of anemia, obtain hemoglobin/hematocrit.
45 ;; 2. Include results of all diagnostic and clinical tests conducted in
46 ;; the examination report.
47 ;;
48 ;;E. Diagnosis:
49 ;;
50 ;;
51 ;;
52 ;;Signature: Date:
53 ;;END
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