DVBCWGY3 ;ALB/RLC GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Provide:
;;
;; 1. Date and circumstances of onset of symptoms and initial manifestations
;; of disease or injury.
;; 2. Course since onset.
;; Treatments, (type, duration, response, side effects). Is continuous
;; medication required for control? Specify all breast and pelvic surgery.
;; 3. History of surgery or hospitalizations (location, date, reason).
;; 4. History of trauma to breast or gynecological system (type, location,
;; date).
;; 5. History of breast or gynecologic neoplasm.
;;
;; a. Date of diagnosis, exact diagnosis.
;; b. Benign or malignant.
;; c. Treatment type(s), dates.
;; d. Date of last treatment.
;; e. State if treatment has been completed, and, if not, expected date
;; of completion.
;;
;; 6. Provide complete menstrual and pregnancy history and date of last Pap
;; smear.
;; 7. Describe symptoms of abdominal or pelvic pain, breast symptoms,
;; bleeding between periods, post-coital bleeding, vaginal discharge,
;; fever, etc.
;; 8. Describe bowel symptoms, including frequency. If there is fecal
;; incontinence, state frequency and extent and whether pads are required.
;; 9. Describe urinary symptoms, including frequency (with daytime voiding
;; interval), dysuria, nocturia (with number of voidings per night),
;; urgency, hematuria, etc. If there is urinary incontinence, state type
;; of leakage and whether appliance is used (constant or intermittent),
;; and if wearing of absorbent material is required (and number of times
;; per day must be changed).
;;
;;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 and ovaries.
;;
;; a. If post operative, state extent of surgery.
;; b. If uterine prolapse is present, is it through the vagina and
;; introitus?
;; c. If uterus is displaced, state severity and whether there are
;; adhesions and/or related menstrual disturbances.
;; d. State if there is complete ovarian atrophy, the basis of that
;; conclusion, and the likely cause of the atrophy.
;;
;; 2. Describe masses, vaginal discharge, abdominal or pelvic tenderness,
;; cervical abnormality, rectovaginal or urethrovaginal fistula.
;; 3. If rectocele, cystocele, or perineal relaxation is present, is it due
;; to pregnancy?
;; 4. Describe residuals of any neoplasm and its treatment.
;; 5. Breasts.
;;
;; a. If post-operative, Identify the type of surgery using the
;; following definitions:
;;
;; RADICAL MASTECTOMY - removal of the entire breast, underlying pectoral
;; muscles, and regional lymph nodes up to the coracoclavicular ligament.
;;
;; MODIFIED RADICAL MASTECTOMY - removal of the entire breast and axillary
;; lymph nodes (in continuity with the breast). Pectoral muscles are left
;; intact.
;;
;; 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.
;;
;; WIDE LOCAL INCISION - includes partial mastectomy, lumpectomy,
;; tylectomy, segmentectomy, and quadrantectomy. This means removal of a
;; portion of the breast tissue.
;;
;; Describe any significant alteration of size and form.
;;
;; b. Describe mass, nodularity, nipple discharge, dimpling, tenderness,
;; asymmetry, lymphadenopathy, etc.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; As indicated:
;;
;; 1. CBC.
;; 2. Urinalysis.
;; 3. Laparoscopy is required to establish diagnosis of endometriosis
;; and to confirm bowel or bladder involvement.
;; 4. Ultrasound, mammography.
;; 5. Pap Smear (if none within past year).
;; 6. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; 1. Describe the effects of the condition on usual occupation and daily
;; activities.
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWGY3 4868 printed Oct 16, 2024@17:52:25 Page 2
DVBCWGY3 ;ALB/RLC GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST WKS TEXT - 1 ; 5 MARCH 1997
+1 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Provide:
+6 ;;
+7 ;; 1. Date and circumstances of onset of symptoms and initial manifestations
+8 ;; of disease or injury.
+9 ;; 2. Course since onset.
+10 ;; Treatments, (type, duration, response, side effects). Is continuous
+11 ;; medication required for control? Specify all breast and pelvic surgery.
+12 ;; 3. History of surgery or hospitalizations (location, date, reason).
+13 ;; 4. History of trauma to breast or gynecological system (type, location,
+14 ;; date).
+15 ;; 5. History of breast or gynecologic neoplasm.
+16 ;;
+17 ;; a. Date of diagnosis, exact diagnosis.
+18 ;; b. Benign or malignant.
+19 ;; c. Treatment type(s), dates.
+20 ;; d. Date of last treatment.
+21 ;; e. State if treatment has been completed, and, if not, expected date
+22 ;; of completion.
+23 ;;
+24 ;; 6. Provide complete menstrual and pregnancy history and date of last Pap
+25 ;; smear.
+26 ;; 7. Describe symptoms of abdominal or pelvic pain, breast symptoms,
+27 ;; bleeding between periods, post-coital bleeding, vaginal discharge,
+28 ;; fever, etc.
+29 ;; 8. Describe bowel symptoms, including frequency. If there is fecal
+30 ;; incontinence, state frequency and extent and whether pads are required.
+31 ;; 9. Describe urinary symptoms, including frequency (with daytime voiding
+32 ;; interval), dysuria, nocturia (with number of voidings per night),
+33 ;; urgency, hematuria, etc. If there is urinary incontinence, state type
+34 ;; of leakage and whether appliance is used (constant or intermittent),
+35 ;; and if wearing of absorbent material is required (and number of times
+36 ;; per day must be changed).
+37 ;;
+38 ;;C. Physical Examination (Objective Findings): Provide a full gynecological
+39 ;; and breast examination (unless only a particular condition or portion of
+40 ;; the examination is requested).
+41 ;;
+42 ;; Address each of the following and fully describe current findings:
+43 ;;
+44 ;; 1. Uterus and ovaries.
+45 ;;
+46 ;; a. If post operative, state extent of surgery.
+47 ;; b. If uterine prolapse is present, is it through the vagina and
+48 ;; introitus?
+49 ;; c. If uterus is displaced, state severity and whether there are
+50 ;; adhesions and/or related menstrual disturbances.
+51 ;; d. State if there is complete ovarian atrophy, the basis of that
+52 ;; conclusion, and the likely cause of the atrophy.
+53 ;;
+54 ;; 2. Describe masses, vaginal discharge, abdominal or pelvic tenderness,
+55 ;; cervical abnormality, rectovaginal or urethrovaginal fistula.
+56 ;; 3. If rectocele, cystocele, or perineal relaxation is present, is it due
+57 ;; to pregnancy?
+58 ;; 4. Describe residuals of any neoplasm and its treatment.
+59 ;; 5. Breasts.
+60 ;;
+61 ;; a. If post-operative, Identify the type of surgery using the
+62 ;; following definitions:
+63 ;;
+64 ;; RADICAL MASTECTOMY - removal of the entire breast, underlying pectoral
+65 ;; muscles, and regional lymph nodes up to the coracoclavicular ligament.
+66 ;;
+67 ;; MODIFIED RADICAL MASTECTOMY - removal of the entire breast and axillary
+68 ;; lymph nodes (in continuity with the breast). Pectoral muscles are left
+69 ;; intact.
+70 ;;
+71 ;; SIMPLE (OR TOTAL) MASTECTOMY - removal of all the breast tissue, nipple,
+72 ;; and a small portion of the overlying skin, but lymph nodes and muscles
+73 ;; are left intact.
+74 ;;
+75 ;; WIDE LOCAL INCISION - includes partial mastectomy, lumpectomy,
+76 ;; tylectomy, segmentectomy, and quadrantectomy. This means removal of a
+77 ;; portion of the breast tissue.
+78 ;;
+79 ;; Describe any significant alteration of size and form.
+80 ;;
+81 ;; b. Describe mass, nodularity, nipple discharge, dimpling, tenderness,
+82 ;; asymmetry, lymphadenopathy, etc.
+83 ;;
+84 ;;D. Diagnostic and Clinical Tests:
+85 ;;
+86 ;; As indicated:
+87 ;;
+88 ;; 1. CBC.
+89 ;; 2. Urinalysis.
+90 ;; 3. Laparoscopy is required to establish diagnosis of endometriosis
+91 ;; and to confirm bowel or bladder involvement.
+92 ;; 4. Ultrasound, mammography.
+93 ;; 5. Pap Smear (if none within past year).
+94 ;; 6. Include results of all diagnostic and clinical tests conducted
+95 ;; in the examination report.
+96 ;;
+97 ;;
+98 ;;E. Diagnosis:
+99 ;;
+100 ;; 1. Describe the effects of the condition on usual occupation and daily
+101 ;; activities.
+102 ;;
+103 ;;
+104 ;;Signature: Date:
+105 ;;END
