source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGY1.m@ 1046

DVBCWGY1 ;ALB/CMM GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST WKS TEXT - 1 ; 5 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Provide:  

 ;;    1.  Date of onset of symptoms.

 ;;

 ;;

 ;;    2.  Describe symptoms, e.g., abnormal bleeding, vaginal discharge,

 ;;        fever, pain, bowel or bladder symptoms, etc.

 ;;

 ;;

 ;;    3.  Treatments:

 ;;        a.  Detail all breast and pelvic surgery.

 ;;

 ;;

 ;;        b.  If a malignant process has been identified, provide:  

 ;;            (1)  Date of confirmed diagnosis.

 ;;

 ;;

 ;;            (2)  Date of the last surgical, X-ray, antineoplastic

 ;;                 chemotherapy, radiation, or other therapeutic procedure.

 ;;

 ;;

 ;;            (3)  Expected date treatment regimen is to be completed.

 ;;

 ;;

 ;;            (4)  If already completed, provide date.

 ;;

 ;;

 ;;            (5)  Fully describe residuals.

 ;;

 ;;

 ;;        c.  Detail hormonal and other medications and whether continuous 

 ;;            medication is required, response, and side effects.

 ;;

 ;;

 ;;    4.  Include complete menstrual history, pregnancy history, and 

 ;;        urinary tract history.

 ;;

 ;;TOF

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Provide a full gynecological and breast examination (UNLESS ONLY A

 ;;    PARTICULAR CONDITION OR PORTION OF THE EXAMINATION IS REQUESTED).

 ;;

 ;;    Address each of the following and fully describe current findings:

 ;;    1.  Uterus.

 ;;        a.  If post operative, state extent of surgery.

 ;;

 ;;

 ;;        b.  If prolapse is present, is it through the introitus?

 ;;

 ;;

 ;;        c.  If displaced, are there adhesions and/or menstrual disturbances.

 ;;

 ;;

 ;;    2.  If rectovaginal fistula is present, describe extent and 

 ;;        frequency of leakage and whether a pad is required.

 ;;

 ;;

 ;;    3.  If urethrovaginal fistula is present, describe whether absorbent 

 ;;        material is required and how often it must be changed.

 ;;

 ;;

 ;;    4.  If rectocele, cystocele, or perineal relaxation is present, is

 ;;        it due to pregnancy?

 ;;

 ;;

 ;;    5.  Breasts.

 ;;

 ;;        If post-operative, Identify the type of surgery using the 

 ;;        following definitions:

 ;;        a.  RADICAL MASTECTOMY - removal of the entire breast, 

 ;;            underlying pectoral muscles, and regional lymph nodes up 

 ;;            to the coracoclavicular ligament.

 ;;

 ;;

 ;;        b.  MODIFIED RADICAL MASTECTOMY - removal of the entire breast

 ;;            and axillary lymph nodes (in continuity with the breast). 

 ;;            Pectoral muscles are left intact.

 ;;

 ;;

 ;;        c.  SIMPLE (OR TOTAL) MASTECTOMY - removal of all the breast 

 ;;            tissue, nipple, and a small portion of the overlying skin,

 ;;            but lymph nodes and muscles are left intact.

 ;;

 ;;TOF

 ;;        d.  WIDE LOCAL INCISION - includes partial mastectomy, lumpectomy, 

 ;;            tylectomy, segmentectomy, and quadrantectomy.  This means

 ;;            removal of a portion of the breast tissue.

 ;;

 ;;

 ;;        e.  Describe any alteration of size and form.

 ;;

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  CBC.

 ;;    2.  Urinalysis.

 ;;    3.  Laparoscopy is required to establish diagnosis of endometriosis 

 ;;        and to confirm bowel or bladder involvement.

 ;;    4.  Ultrasound, mammography, if indicated.

 ;;    5.  Pap Smear (if none within past year).

 ;;    6.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END