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1DVBCWGY1 ;ALB/CMM GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST 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 ;; Provide:
13 ;; 1. Date of onset of symptoms.
14 ;;
15 ;;
16 ;; 2. Describe symptoms, e.g., abnormal bleeding, vaginal discharge,
17 ;; fever, pain, bowel or bladder symptoms, etc.
18 ;;
19 ;;
20 ;; 3. Treatments:
21 ;; a. Detail all breast and pelvic surgery.
22 ;;
23 ;;
24 ;; b. If a malignant process has been identified, provide:
25 ;; (1) Date of confirmed diagnosis.
26 ;;
27 ;;
28 ;; (2) Date of the last surgical, X-ray, antineoplastic
29 ;; chemotherapy, radiation, or other therapeutic procedure.
30 ;;
31 ;;
32 ;; (3) Expected date treatment regimen is to be completed.
33 ;;
34 ;;
35 ;; (4) If already completed, provide date.
36 ;;
37 ;;
38 ;; (5) Fully describe residuals.
39 ;;
40 ;;
41 ;; c. Detail hormonal and other medications and whether continuous
42 ;; medication is required, response, and side effects.
43 ;;
44 ;;
45 ;; 4. Include complete menstrual history, pregnancy history, and
46 ;; urinary tract history.
47 ;;
48 ;;TOF
49 ;;C. Physical Examination (Objective Findings):
50 ;;
51 ;; Provide a full gynecological and breast examination (UNLESS ONLY A
52 ;; PARTICULAR CONDITION OR PORTION OF THE EXAMINATION IS REQUESTED).
53 ;;
54 ;; Address each of the following and fully describe current findings:
55 ;; 1. Uterus.
56 ;; a. If post operative, state extent of surgery.
57 ;;
58 ;;
59 ;; b. If prolapse is present, is it through the introitus?
60 ;;
61 ;;
62 ;; c. If displaced, are there adhesions and/or menstrual disturbances.
63 ;;
64 ;;
65 ;; 2. If rectovaginal fistula is present, describe extent and
66 ;; frequency of leakage and whether a pad is required.
67 ;;
68 ;;
69 ;; 3. If urethrovaginal fistula is present, describe whether absorbent
70 ;; material is required and how often it must be changed.
71 ;;
72 ;;
73 ;; 4. If rectocele, cystocele, or perineal relaxation is present, is
74 ;; it due to pregnancy?
75 ;;
76 ;;
77 ;; 5. Breasts.
78 ;;
79 ;; If post-operative, Identify the type of surgery using the
80 ;; following definitions:
81 ;; a. RADICAL MASTECTOMY - removal of the entire breast,
82 ;; underlying pectoral muscles, and regional lymph nodes up
83 ;; to the coracoclavicular ligament.
84 ;;
85 ;;
86 ;; b. MODIFIED RADICAL MASTECTOMY - removal of the entire breast
87 ;; and axillary lymph nodes (in continuity with the breast).
88 ;; Pectoral muscles are left intact.
89 ;;
90 ;;
91 ;; c. SIMPLE (OR TOTAL) MASTECTOMY - removal of all the breast
92 ;; tissue, nipple, and a small portion of the overlying skin,
93 ;; but lymph nodes and muscles are left intact.
94 ;;
95 ;;TOF
96 ;; d. WIDE LOCAL INCISION - includes partial mastectomy, lumpectomy,
97 ;; tylectomy, segmentectomy, and quadrantectomy. This means
98 ;; removal of a portion of the breast tissue.
99 ;;
100 ;;
101 ;; e. Describe any alteration of size and form.
102 ;;
103 ;;
104 ;;D. Diagnostic and Clinical Tests:
105 ;;
106 ;; 1. CBC.
107 ;; 2. Urinalysis.
108 ;; 3. Laparoscopy is required to establish diagnosis of endometriosis
109 ;; and to confirm bowel or bladder involvement.
110 ;; 4. Ultrasound, mammography, if indicated.
111 ;; 5. Pap Smear (if none within past year).
112 ;; 6. Include results of all diagnostic and clinical tests conducted
113 ;; in the examination report.
114 ;;
115 ;;
116 ;;E. Diagnosis:
117 ;;
118 ;;
119 ;;Signature: Date:
120 ;;END
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