©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
DVBCWRA1 ;ALB/CMM RECTUM AND ANUS 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. Degree of sphincter control.
;;
;;
;; 2. Extent and frequency of fecal leakage or involuntary bowel
;; movements- is a pad needed?
;;
;;
;; 3. Bleeding or thrombosis of hemorrhoids - frequency and extent.
;;
;;
;; 4. Current treatment.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Colostomy.
;;
;;
;; 2. Evidence of fecal leakage.
;;
;;
;; 3. Size of lumen - rectum and anus.
;;
;;
;; 4. Signs of anemia.
;;
;;
;; 5. Fissures.
;;
;;
;; 6. If hemorrhoids - location, size, and if thrombosed.
;;
;;
;; 7. Evidence of bleeding.
;;
;;TOF
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END