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[613] | 1 | DVBCWRA1 ;ALB/CMM RECTUM AND ANUS WKS TEXT - 1 ; 5 MARCH 1997
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| 2 | ;;2.7;AMIE;**12**;Apr 10, 1995
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| 3 | ;
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| 4 | ;
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| 5 | TXT ;
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| 6 | ;;A. Review of Medical Records:
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| 7 | ;;
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| 8 | ;;
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| 9 | ;;
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| 10 | ;;B. Medical History (Subjective Complaints):
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| 11 | ;;
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| 12 | ;; Comment on:
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| 13 | ;; 1. Degree of sphincter control.
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| 14 | ;;
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| 15 | ;;
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| 16 | ;; 2. Extent and frequency of fecal leakage or involuntary bowel
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| 17 | ;; movements- is a pad needed?
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| 18 | ;;
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| 19 | ;;
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| 20 | ;; 3. Bleeding or thrombosis of hemorrhoids - frequency and extent.
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| 21 | ;;
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| 22 | ;;
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| 23 | ;; 4. Current treatment.
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| 24 | ;;
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| 25 | ;;
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| 26 | ;;C. Physical Examination (Objective Findings):
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| 27 | ;;
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| 28 | ;; Address each of the following and fully describe current findings:
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| 29 | ;; 1. Colostomy.
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| 30 | ;;
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| 31 | ;;
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| 32 | ;; 2. Evidence of fecal leakage.
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| 33 | ;;
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| 34 | ;;
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| 35 | ;; 3. Size of lumen - rectum and anus.
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| 36 | ;;
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| 37 | ;;
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| 38 | ;; 4. Signs of anemia.
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| 39 | ;;
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| 40 | ;;
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| 41 | ;; 5. Fissures.
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| 42 | ;;
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| 43 | ;;
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| 44 | ;; 6. If hemorrhoids - location, size, and if thrombosed.
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| 45 | ;;
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| 46 | ;;
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| 47 | ;; 7. Evidence of bleeding.
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| 48 | ;;
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| 49 | ;;TOF
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| 50 | ;;D. Diagnostic and Clinical Tests:
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| 51 | ;;
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| 52 | ;; 1. Include results of all diagnostic and clinical tests conducted
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| 53 | ;; in the examination report.
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| 54 | ;;
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| 55 | ;;
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| 56 | ;;E. Diagnosis:
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| 57 | ;;
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| 58 | ;;
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| 59 | ;;Signature: Date:
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| 60 | ;;END
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