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1DVBCWLW1 ;ALB/CMM LIVER, GALL BLADDER AND PANCREAS WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Vomiting, hematemesis or melena.
14 ;;
15 ;;
16 ;; 2. Current treatment - type (medication, diet, enzymes, etc.),
17 ;; duration, response, side effects.
18 ;;
19 ;;
20 ;; 3. Episodes of colic or other abdominal pain, distention, nausea,
21 ;; vomiting - duration, frequency, severity, treatment, and
22 ;; response to treatment.
23 ;;
24 ;;
25 ;; 4. Fatigue, weakness, depression, or anxiety.
26 ;;
27 ;;
28 ;;C. Physical Examination (Objective Findings):
29 ;;
30 ;; Address each of the following as appropriate, and fully describe
31 ;; current findings:
32 ;; 1. Ascites.
33 ;;
34 ;;
35 ;; 2. Weight gain or loss, steatorrhea, malabsorption, malnutrition.
36 ;;
37 ;;
38 ;; 3. Hematemesis or melena (describe any episodes).
39 ;;
40 ;;
41 ;; 4. Pain or tenderness - location, type, precipitating factors.
42 ;;
43 ;;
44 ;; 5. Liver size, superficial abdominal veins.
45 ;;
46 ;;
47 ;; 6. Muscle strength and wasting.
48 ;;
49 ;;TOF
50 ;;D. Diagnostic and Clinical Tests:
51 ;;
52 ;; 1. For esophageal varices, X-ray, endoscopy, etc.
53 ;; 2. For adhesions, X-ray to show partial obstruction, delayed motility.
54 ;; 3. For gall bladder disease, X-ray or other objective confirmation.
55 ;; 4. Liver function tests.
56 ;; 5. Include results of all diagnostic and clinical tests conducted
57 ;; in the examination report.
58 ;;
59 ;;
60 ;;E. Diagnosis:
61 ;;
62 ;;
63 ;;Signature: Date:
64 ;;END
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