[613] | 1 | DVBCWRA3 ;ALB/RLC RECTUM AND ANUS WKS TEXT - 1 ; 12 FEB 2007
|
---|
| 2 | ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
|
---|
| 3 | ;
|
---|
| 4 | ;
|
---|
| 5 | TXT ;
|
---|
| 6 | ;;A. Review of Medical Records:
|
---|
| 7 | ;;
|
---|
| 8 | ;;B. Medical History (Subjective Complaints):
|
---|
| 9 | ;;
|
---|
| 10 | ;; Comment on:
|
---|
| 11 | ;;
|
---|
| 12 | ;; 1. Current symptoms - anal itching, diarrhea, pain, tenesmus, swelling,
|
---|
| 13 | ;; perianal discharge, etc.
|
---|
| 14 | ;; 2. For fecal incontinence - extent and frequency of fecal leakage or
|
---|
| 15 | ;; involuntary bowel movements- is a pad needed?
|
---|
| 16 | ;; 3. For hemorrhoids - bleeding or thrombosis of hemorrhoids - frequency
|
---|
| 17 | ;; and extent.
|
---|
| 18 | ;; 4. Current treatment - type, duration, response, side effects.
|
---|
| 19 | ;; 5. History of hospitalizations or surgery - reason or type of surgery,
|
---|
| 20 | ;; location and dates, if known.
|
---|
| 21 | ;; 6. History of trauma to the rectum or anus.
|
---|
| 22 | ;; 7. History of obstetrical injury - describe.
|
---|
| 23 | ;; 8. History of spinal cord injury affecting rectum and anus - describe.
|
---|
| 24 | ;; 9. For rectal prolapse - frequency, extent of fecal leakage.
|
---|
| 25 | ;; 10. History of rectal bleeding.
|
---|
| 26 | ;; 11. History of anal infections.
|
---|
| 27 | ;; 12. History of proctitis.
|
---|
| 28 | ;; 13. History of fistula in ano.
|
---|
| 29 | ;; 14. History of neoplasm.
|
---|
| 30 | ;;
|
---|
| 31 | ;; a. Date of diagnosis, diagnosis.
|
---|
| 32 | ;; b. Benign or malignant.
|
---|
| 33 | ;; c. Treatment dates and response.
|
---|
| 34 | ;; d. Last date of treatment.
|
---|
| 35 | ;;
|
---|
| 36 | ;; 15. Effects of condition on occupational functioning and daily activities.
|
---|
| 37 | ;;
|
---|
| 38 | ;;C. Physical Examination (Objective Findings):
|
---|
| 39 | ;;
|
---|
| 40 | ;; Address each of the following and fully describe current findings:
|
---|
| 41 | ;;
|
---|
| 42 | ;; 1. Colostomy.
|
---|
| 43 | ;; 2. Evidence of fecal leakage.
|
---|
| 44 | ;; 3. Size of lumen - rectum and anus.
|
---|
| 45 | ;; 4. Signs of anemia.
|
---|
| 46 | ;; 5. Fissures.
|
---|
| 47 | ;; 6. If hemorrhoids - location, size, reducible, presence of redundant
|
---|
| 48 | ;; tissue and if thrombosed.
|
---|
| 49 | ;; 7. Evidence of bleeding.
|
---|
| 50 | ;; 8. Rectal prolapse - extent.
|
---|
| 51 | ;; 9. Sphincter tone.
|
---|
| 52 | ;;
|
---|
| 53 | ;;D. Diagnostic and Clinical Tests:
|
---|
| 54 | ;;
|
---|
| 55 | ;; 1. Include results of all diagnostic and clinical tests conducted
|
---|
| 56 | ;; in the examination report.
|
---|
| 57 | ;; 2. If a history of bleeding (past 12 months), signs of anemia or chronic
|
---|
| 58 | ;; infection, obtain CDC.
|
---|
| 59 | ;;
|
---|
| 60 | ;;E. Diagnosis:
|
---|
| 61 | ;;
|
---|
| 62 | ;;
|
---|
| 63 | ;;
|
---|
| 64 | ;;Signature: Date:
|
---|
| 65 | ;;END
|
---|