source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRA3.m@ 1384

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[613]1DVBCWRA3 ;ALB/RLC RECTUM AND ANUS WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
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
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