DVBCWIW3.m

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 ---DVBCWIW3   1907     printed  Apr 23, 2025@18:06:34                                                                                                                                                                                                    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