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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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