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1DVBCWST3 ;ALB/RLC STOMACH, DUODENUM, AND PERITONEAL ADHESIONS WKS TEXT - 1 ; 16 JAN 2007
2 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
3 ;
4TXT ;
5 ;;A. Review of Medical Records:
6 ;;
7 ;;B. Medical History (Subjective Complaints):
8 ;;
9 ;; Comment on:
10 ;;
11 ;; 1. Nausea, vomiting.
12 ;; 2. Hematemesis or melena (describe any episodes).
13 ;; 3. Treatment - type, duration, response, side effects.
14 ;; 4. For postgastrectomy syndrome: Is there circulatory disturbance
15 ;; after meals, hypoglycemic reactions, etc. (state time of onset
16 ;; in relation to meals, frequency)?
17 ;; 5. Diarrhea, constipation.
18 ;; 6. For peritoneal adhesions: Are there episodes of colic, distention,
19 ;; nausea, and/or vomiting? - frequency, duration, and severity.
20 ;; 7. Are there periods of incapacitation due to stomach or duodenal
21 ;; disease?
22 ;; 8. History of hospitalizations or surgery: reason or type of surgery,
23 ;; dates and locations, if known.
24 ;; 9. History of trauma.
25 ;; 10. Effects of condition on occupational functioning and activities of
26 ;; daily living.
27 ;; 11. Pain - location, type, precipitating, alleviating factors.
28 ;; 12. History of neoplasm:
29 ;;
30 ;; a. Date of diagnosis, diagnosis.
31 ;; b. Benign or malignant.
32 ;; c. Treatment, dates and response.
33 ;; d. Last date of treatment.
34 ;;
35 ;;C. Physical Examination (Objective Findings):
36 ;;
37 ;; Address each of the following and fully describe current findings:
38 ;;
39 ;; 1. Weight gain or loss.
40 ;; 2. Signs of anemia.
41 ;; 3. Tenderness - location.
42 ;;
43 ;;D. Diagnostic and Clinical Tests:
44 ;;
45 ;; 1. For gastritis, endoscopic evidence - describe hemorrhage,
46 ;; ulcerated or eroded areas.
47 ;; 2. For adhesions, X-ray to show partial obstruction, delayed
48 ;; motility.
49 ;; 3. For ulcer diseases, provide specific site.
50 ;; 4. If there is a history of hematemesis or melena (past 12 months)
51 ;; or signs of anemia, obtain hemaglobin and hematocrit.
52 ;; 5. Include results of all diagnostic and clinical tests conducted in
53 ;; the examination report.
54 ;;
55 ;;E. Diagnosis:
56 ;;
57 ;;
58 ;;
59 ;;Signature: Date:
60 ;;END
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