©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
DVBCWLW1 ;ALB/CMM LIVER, GALL BLADDER AND PANCREAS 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. Vomiting, hematemesis or melena.
;;
;;
;; 2. Current treatment - type (medication, diet, enzymes, etc.),
;; duration, response, side effects.
;;
;;
;; 3. Episodes of colic or other abdominal pain, distention, nausea,
;; vomiting - duration, frequency, severity, treatment, and
;; response to treatment.
;;
;;
;; 4. Fatigue, weakness, depression, or anxiety.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following as appropriate, and fully describe
;; current findings:
;; 1. Ascites.
;;
;;
;; 2. Weight gain or loss, steatorrhea, malabsorption, malnutrition.
;;
;;
;; 3. Hematemesis or melena (describe any episodes).
;;
;;
;; 4. Pain or tenderness - location, type, precipitating factors.
;;
;;
;; 5. Liver size, superficial abdominal veins.
;;
;;
;; 6. Muscle strength and wasting.
;;
;;TOF
;;D. Diagnostic and Clinical Tests:
;;
;; 1. For esophageal varices, X-ray, endoscopy, etc.
;; 2. For adhesions, X-ray to show partial obstruction, delayed motility.
;; 3. For gall bladder disease, X-ray or other objective confirmation.
;; 4. Liver function tests.
;; 5. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END