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 ---[H[J[2J[HDVBCWGY1 3871 printed Dec 13, 2024@01:51:33 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
