source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWLW1.m@ 1328

DVBCWLW1 ;ALB/CMM LIVER, GALL BLADDER AND PANCREAS 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.  Vomiting, hematemesis or melena.
 ;;
 ;;
 ;;    2.  Current treatment - type (medication, diet, enzymes, etc.), 
 ;;        duration, response, side effects.
 ;;
 ;;
 ;;    3.  Episodes of colic or other abdominal pain, distention, nausea,
 ;;        vomiting - duration, frequency, severity, treatment, and 
 ;;        response to treatment.
 ;;
 ;;
 ;;    4.  Fatigue, weakness, depression, or anxiety.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following as appropriate, and fully describe 
 ;;    current findings:
 ;;    1.  Ascites.
 ;;
 ;;
 ;;    2.  Weight gain or loss, steatorrhea, malabsorption, malnutrition.
 ;;
 ;;
 ;;    3.  Hematemesis or melena (describe any episodes).
 ;;
 ;;
 ;;    4.  Pain or tenderness - location, type, precipitating factors.
 ;;
 ;;
 ;;    5.  Liver size, superficial abdominal veins.
 ;;
 ;;
 ;;    6.  Muscle strength and wasting.
 ;;
 ;;TOF
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  For esophageal varices, X-ray, endoscopy, etc.
 ;;    2.  For adhesions, X-ray to show partial obstruction, delayed motility.
 ;;    3.  For gall bladder disease, X-ray or other objective confirmation.
 ;;    4.  Liver function tests.
 ;;    5.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END