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Routine: DVBCWDM3

DVBCWDM3.m

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DVBCWDM3 ;ALB/CMM DIGESTIVE, MISC. DISEASES WKS TEXT - 1 ; 5 MARCH 1997

 ;;2.7;AMIE;**164**;Apr 10, 1995;Build 2

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    1.  State date of onset, and describe circumstances and initial

 ;;        manifestations.

 ;;    2.  Course of condition since onset.

 ;;    3.  Current treatment, response to treatment, and side effects of

 ;;        treatment.

 ;;    4.  History of related hospitalizations or surgery, dates and location, if

 ;;        known, reason or type of surgery.

 ;;    5.  If there was hernia surgery, report side, type of hernia, type of

 ;;        repair, and results, including current symptoms.

 ;;    6.  If there was injury or wound related to hernia, state date and type of

 ;;        injury or wound and relationship to hernia.

 ;;    7.  History of neoplasm:

 ;;

 ;;        a.  Date of diagnosis, exact diagnosis, location.

 ;;        b.  Benign or malignant.

 ;;        c.  Types of treatment and dates.

 ;;        d.  Last date of treatment.

 ;;        e.  State whether treatment has been completed.

 ;;

 ;;    8.  For tuberculosis of the peritoneum, state date of diagnosis, type(s)

 ;;        and dates of treatment, date on which inactivity was established, and

 ;;        current symptoms. 

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Address each of the following and fully describe current findings:

 ;;

 ;;    1.  For hernia, state:

 ;;

 ;;        a.  Type and location (including side).

 ;;        b.  Diameter in cm.

 ;;        c.  Whether remediable or operable.

 ;;        d.  Whether a truss or belt is indicated, and whether it is well-

 ;;            supported by truss or belt.

 ;;        e.  Whether it is readily reducible.

 ;;        f.  Whether it has been previously repaired, and if so, whether it is

 ;;            healed and whether it is recurrent.

 ;;        g.  For inguinal and femoral hernias, also state (1) whether there is

 ;;            a true hernial protrusion and (2) whether the hernia is readily

 ;;            reducible.

 ;;        h.  For ventral hernia, also state (1) severity and extent of weakening

 ;;            of muscular and fascial support of abdominal wall, (2) extent of

 ;;            diastasis of recti muscles, and (3) whether diastasis is persistent.

 ;;

 ;;    2.  For neoplasm, describe residuals of neoplasm and its treatment.

 ;;    3.  For tuberculous peritonitis, describe any abnormal physical findings.

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;1.  Include results of all diagnostic and clinical tests conducted in

 ;;    the examination report.

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;    1.  For each diagnosis, state effects of the condition on occupational

 ;;        functioning and daily activities.

 ;;

 ;;Signature:                             Date:

 ;;END