©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
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