DVBCWGY1.m

DVBCWGY1 ;ALB/CMM GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST WKS TEXT - 1 ; 5 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Provide:  

 ;;    1.  Date of onset of symptoms.

 ;;

 ;;

 ;;    2.  Describe symptoms, e.g., abnormal bleeding, vaginal discharge,

 ;;        fever, pain, bowel or bladder symptoms, etc.

 ;;

 ;;

 ;;    3.  Treatments:

 ;;        a.  Detail all breast and pelvic surgery.

 ;;

 ;;

 ;;        b.  If a malignant process has been identified, provide:  

 ;;            (1)  Date of confirmed diagnosis.

 ;;

 ;;

 ;;            (2)  Date of the last surgical, X-ray, antineoplastic

 ;;                 chemotherapy, radiation, or other therapeutic procedure.

 ;;

 ;;

 ;;            (3)  Expected date treatment regimen is to be completed.

 ;;

 ;;

 ;;            (4)  If already completed, provide date.

 ;;

 ;;

 ;;            (5)  Fully describe residuals.

 ;;

 ;;

 ;;        c.  Detail hormonal and other medications and whether continuous 

 ;;            medication is required, response, and side effects.

 ;;

 ;;

 ;;    4.  Include complete menstrual history, pregnancy history, and 

 ;;        urinary tract history.

 ;;

 ;;TOF

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Provide a full gynecological and breast examination (UNLESS ONLY A

 ;;    PARTICULAR CONDITION OR PORTION OF THE EXAMINATION IS REQUESTED).

 ;;

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

 ;;    1.  Uterus.

 ;;        a.  If post operative, state extent of surgery.

 ;;

 ;;

 ;;        b.  If prolapse is present, is it through the introitus?

 ;;

 ;;

 ;;        c.  If displaced, are there adhesions and/or menstrual disturbances.

 ;;

 ;;

 ;;    2.  If rectovaginal fistula is present, describe extent and 

 ;;        frequency of leakage and whether a pad is required.

 ;;

 ;;

 ;;    3.  If urethrovaginal fistula is present, describe whether absorbent 

 ;;        material is required and how often it must be changed.

 ;;

 ;;

 ;;    4.  If rectocele, cystocele, or perineal relaxation is present, is

 ;;        it due to pregnancy?

 ;;

 ;;

 ;;    5.  Breasts.

 ;;

 ;;        If post-operative, Identify the type of surgery using the 

 ;;        following definitions:

 ;;        a.  RADICAL MASTECTOMY - removal of the entire breast, 

 ;;            underlying pectoral muscles, and regional lymph nodes up 

 ;;            to the coracoclavicular ligament.

 ;;

 ;;

 ;;        b.  MODIFIED RADICAL MASTECTOMY - removal of the entire breast

 ;;            and axillary lymph nodes (in continuity with the breast). 

 ;;            Pectoral muscles are left intact.

 ;;

 ;;

 ;;        c.  SIMPLE (OR TOTAL) MASTECTOMY - removal of all the breast 

 ;;            tissue, nipple, and a small portion of the overlying skin,

 ;;            but lymph nodes and muscles are left intact.

 ;;

 ;;TOF

 ;;        d.  WIDE LOCAL INCISION - includes partial mastectomy, lumpectomy, 

 ;;            tylectomy, segmentectomy, and quadrantectomy.  This means

 ;;            removal of a portion of the breast tissue.

 ;;

 ;;

 ;;        e.  Describe any alteration of size and form.

 ;;

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  CBC.

 ;;    2.  Urinalysis.

 ;;    3.  Laparoscopy is required to establish diagnosis of endometriosis 

 ;;        and to confirm bowel or bladder involvement.

 ;;    4.  Ultrasound, mammography, if indicated.

 ;;    5.  Pap Smear (if none within past year).

 ;;    6.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCWGY1   3871     printed  Apr 23, 2025@18:06:03                                                                                                                                                                                                    Page 2

DVBCWGY1  ;ALB/CMM GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST WKS TEXT - 1 ; 5 MARCH 1997

 +1       ;;2.7;AMIE;**12**;Apr 10, 1995

 +2       ;

 +3       ;

TXT       ;

 +1       ;;A.  Review of Medical Records:

 +2       ;;

 +3       ;;

 +4       ;;

 +5       ;;B.  Medical History (Subjective Complaints):

 +6       ;;

 +7       ;;    Provide:  

 +8       ;;    1.  Date of onset of symptoms.

 +9       ;;

 +10      ;;

 +11      ;;    2.  Describe symptoms, e.g., abnormal bleeding, vaginal discharge,

 +12      ;;        fever, pain, bowel or bladder symptoms, etc.

 +13      ;;

 +14      ;;

 +15      ;;    3.  Treatments:

 +16      ;;        a.  Detail all breast and pelvic surgery.

 +17      ;;

 +18      ;;

 +19      ;;        b.  If a malignant process has been identified, provide:  

 +20      ;;            (1)  Date of confirmed diagnosis.

 +21      ;;

 +22      ;;

 +23      ;;            (2)  Date of the last surgical, X-ray, antineoplastic

 +24      ;;                 chemotherapy, radiation, or other therapeutic procedure.

 +25      ;;

 +26      ;;

 +27      ;;            (3)  Expected date treatment regimen is to be completed.

 +28      ;;

 +29      ;;

 +30      ;;            (4)  If already completed, provide date.

 +31      ;;

 +32      ;;

 +33      ;;            (5)  Fully describe residuals.

 +34      ;;

 +35      ;;

 +36      ;;        c.  Detail hormonal and other medications and whether continuous 

 +37      ;;            medication is required, response, and side effects.

 +38      ;;

 +39      ;;

 +40      ;;    4.  Include complete menstrual history, pregnancy history, and 

 +41      ;;        urinary tract history.

 +42      ;;

 +43      ;;TOF

 +44      ;;C.  Physical Examination (Objective Findings):

 +45      ;;

 +46      ;;    Provide a full gynecological and breast examination (UNLESS ONLY A

 +47      ;;    PARTICULAR CONDITION OR PORTION OF THE EXAMINATION IS REQUESTED).

 +48      ;;

 +49      ;;    Address each of the following and fully describe current findings:

 +50      ;;    1.  Uterus.

 +51      ;;        a.  If post operative, state extent of surgery.

 +52      ;;

 +53      ;;

 +54      ;;        b.  If prolapse is present, is it through the introitus?

 +55      ;;

 +56      ;;

 +57      ;;        c.  If displaced, are there adhesions and/or menstrual disturbances.

 +58      ;;

 +59      ;;

 +60      ;;    2.  If rectovaginal fistula is present, describe extent and 

 +61      ;;        frequency of leakage and whether a pad is required.

 +62      ;;

 +63      ;;

 +64      ;;    3.  If urethrovaginal fistula is present, describe whether absorbent 

 +65      ;;        material is required and how often it must be changed.

 +66      ;;

 +67      ;;

 +68      ;;    4.  If rectocele, cystocele, or perineal relaxation is present, is

 +69      ;;        it due to pregnancy?

 +70      ;;

 +71      ;;

 +72      ;;    5.  Breasts.

 +73      ;;

 +74      ;;        If post-operative, Identify the type of surgery using the 

 +75      ;;        following definitions:

 +76      ;;        a.  RADICAL MASTECTOMY - removal of the entire breast, 

 +77      ;;            underlying pectoral muscles, and regional lymph nodes up 

 +78      ;;            to the coracoclavicular ligament.

 +79      ;;

 +80      ;;

 +81      ;;        b.  MODIFIED RADICAL MASTECTOMY - removal of the entire breast

 +82      ;;            and axillary lymph nodes (in continuity with the breast). 

 +83      ;;            Pectoral muscles are left intact.

 +84      ;;

 +85      ;;

 +86      ;;        c.  SIMPLE (OR TOTAL) MASTECTOMY - removal of all the breast 

 +87      ;;            tissue, nipple, and a small portion of the overlying skin,

 +88      ;;            but lymph nodes and muscles are left intact.

 +89      ;;

 +90      ;;TOF

 +91      ;;        d.  WIDE LOCAL INCISION - includes partial mastectomy, lumpectomy, 

 +92      ;;            tylectomy, segmentectomy, and quadrantectomy.  This means

 +93      ;;            removal of a portion of the breast tissue.

 +94      ;;

 +95      ;;

 +96      ;;        e.  Describe any alteration of size and form.

 +97      ;;

 +98      ;;

 +99      ;;D.  Diagnostic and Clinical Tests:

 +100     ;;

 +101     ;;    1.  CBC.

 +102     ;;    2.  Urinalysis.

 +103     ;;    3.  Laparoscopy is required to establish diagnosis of endometriosis 

 +104     ;;        and to confirm bowel or bladder involvement.

 +105     ;;    4.  Ultrasound, mammography, if indicated.

 +106     ;;    5.  Pap Smear (if none within past year).

 +107     ;;    6.  Include results of all diagnostic and clinical tests conducted

 +108     ;;        in the examination report.

 +109     ;;

 +110     ;;

 +111     ;;E.  Diagnosis:

 +112     ;;

 +113     ;;

 +114     ;;Signature:                             Date:

 +115     ;;END