source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRA1.m@ 1800

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[613]1DVBCWRA1 ;ALB/CMM RECTUM AND ANUS 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. Degree of sphincter control.
14 ;;
15 ;;
16 ;; 2. Extent and frequency of fecal leakage or involuntary bowel
17 ;; movements- is a pad needed?
18 ;;
19 ;;
20 ;; 3. Bleeding or thrombosis of hemorrhoids - frequency and extent.
21 ;;
22 ;;
23 ;; 4. Current treatment.
24 ;;
25 ;;
26 ;;C. Physical Examination (Objective Findings):
27 ;;
28 ;; Address each of the following and fully describe current findings:
29 ;; 1. Colostomy.
30 ;;
31 ;;
32 ;; 2. Evidence of fecal leakage.
33 ;;
34 ;;
35 ;; 3. Size of lumen - rectum and anus.
36 ;;
37 ;;
38 ;; 4. Signs of anemia.
39 ;;
40 ;;
41 ;; 5. Fissures.
42 ;;
43 ;;
44 ;; 6. If hemorrhoids - location, size, and if thrombosed.
45 ;;
46 ;;
47 ;; 7. Evidence of bleeding.
48 ;;
49 ;;TOF
50 ;;D. Diagnostic and Clinical Tests:
51 ;;
52 ;; 1. Include results of all diagnostic and clinical tests conducted
53 ;; in the examination report.
54 ;;
55 ;;
56 ;;E. Diagnosis:
57 ;;
58 ;;
59 ;;Signature: Date:
60 ;;END
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