©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWDM1 ;ALB/CMM DIGESTIVE, MISC. DISEASES WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; 1. Describe all hernia surgery and results.
;;
;;
;; 2. For malignancy, state type of treatment, dates of treatment,
;; including last date treatment if it has ended.
;;
;;
;; 3. For peritoneal tuberculosis, state date of diagnosis, treatment,
;; and date on which inactivity was established.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. For inguinal or ventral hernia, state whether reducible, how
;; well supported by truss or belt, and whether irremediable or
;; inoperable.
;;
;;
;; 2. For ventral hernia, state size of hernia, extent of diastasis
;; of recti muscles, status of muscles and fascia of abdominal wall.
;;
;;
;; 3. All residuals of malignancy, including residuals from treatment.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;;1. Include results of all diagnostic and clinical tests conducted in
;; the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END