©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
DVBCWIW1 ;ALB/CMM INTESTINES (LARGE AND SMALL) WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Weight gain or loss.
;;
;;
;; 2. Nausea and/or vomiting.
;;
;;
;; 3. Constipation, diarrhea (frequency, severity, duration, and
;; episodic or not?).
;;
;;
;; 4. For fistula - frequency, duration, and amount of fecal discharge.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Malnutrition, anemia, other evidence of debility.
;;
;;
;; 2. Abdominal pain - location, type, frequency, and duration.
;;
;;
;; 3. Current treatment - type, duration, response, and side effects.
;;
;; 4. For fistula - location.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END