DVBCWIW3 ;ALB/RLC INTESTINES (LARGE AND SMALL) WKS TEXT - 1 ; 16 JAN 2007
;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
;
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.
;; 5. Treatment-type, duration, response, side effects.
;; 6. Abdominal pain, distress, cramps - frequency, duration, location.
;; 7. For ulcerative colitis - number of attacks per year.
;; 8. Effects of condition on occupations functioning and activities of
;; daily living.
;; 9. History of trauma.
;; 10. History of hospitalizations or surgery - reason or type of surgery,
;; location and dates, if known.
;; 11. History of neoplasm:
;;
;; a. Date of diagnosis, diagnosis.
;; b. Benign or malignant.
;; c. Treatment, dates and response.
;; d. Last date of treatment.
;;
;;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.
;; 3. For fistula, location, presence of discharge.
;; 4. Ostomy present - type.
;; 5. Abdominal mass.
;; 6. Signs of anemia.
;; 7. Weight - gain or loss.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. If signs of anemia, obtain hemoglobin/hematocrit.
;; 2. 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[HDVBCWIW3 1907 printed Nov 22, 2024@17:02:15 Page 2
DVBCWIW3 ;ALB/RLC INTESTINES (LARGE AND SMALL) WKS TEXT - 1 ; 16 JAN 2007
+1 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
+2 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. Weight gain or loss.
+8 ;; 2. Nausea and/or vomiting.
+9 ;; 3. Constipation, diarrhea (frequency, severity, duration, and
+10 ;; episodic or not?).
+11 ;; 4. For fistula - frequency, duration, and amount of fecal discharge.
+12 ;; 5. Treatment-type, duration, response, side effects.
+13 ;; 6. Abdominal pain, distress, cramps - frequency, duration, location.
+14 ;; 7. For ulcerative colitis - number of attacks per year.
+15 ;; 8. Effects of condition on occupations functioning and activities of
+16 ;; daily living.
+17 ;; 9. History of trauma.
+18 ;; 10. History of hospitalizations or surgery - reason or type of surgery,
+19 ;; location and dates, if known.
+20 ;; 11. History of neoplasm:
+21 ;;
+22 ;; a. Date of diagnosis, diagnosis.
+23 ;; b. Benign or malignant.
+24 ;; c. Treatment, dates and response.
+25 ;; d. Last date of treatment.
+26 ;;
+27 ;;C. Physical Examination (Objective Findings):
+28 ;;
+29 ;; Address each of the following and fully describe current findings:
+30 ;; 1. Malnutrition, anemia, other evidence of debility.
+31 ;; 2. Abdominal pain - location.
+32 ;; 3. For fistula, location, presence of discharge.
+33 ;; 4. Ostomy present - type.
+34 ;; 5. Abdominal mass.
+35 ;; 6. Signs of anemia.
+36 ;; 7. Weight - gain or loss.
+37 ;;
+38 ;;D. Diagnostic and Clinical Tests:
+39 ;;
+40 ;; 1. If signs of anemia, obtain hemoglobin/hematocrit.
+41 ;; 2. Include results of all diagnostic and clinical tests conducted in
+42 ;; the examination report.
+43 ;;
+44 ;;E. Diagnosis:
+45 ;;
+46 ;;
+47 ;;
+48 ;;Signature: Date:
+49 ;;END
