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Routine: DVBCWRA3

DVBCWRA3.m

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  1. DVBCWRA3 ;ALB/RLC RECTUM AND ANUS WKS TEXT - 1 ; 12 FEB 2007
  1. ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;;
  1. ;; Comment on:
  1. ;;
  1. ;; 1. Current symptoms - anal itching, diarrhea, pain, tenesmus, swelling,
  1. ;; perianal discharge, etc.
  1. ;; 2. For fecal incontinence - extent and frequency of fecal leakage or
  1. ;; involuntary bowel movements- is a pad needed?
  1. ;; 3. For hemorrhoids - bleeding or thrombosis of hemorrhoids - frequency
  1. ;; and extent.
  1. ;; 4. Current treatment - type, duration, response, side effects.
  1. ;; 5. History of hospitalizations or surgery - reason or type of surgery,
  1. ;; location and dates, if known.
  1. ;; 6. History of trauma to the rectum or anus.
  1. ;; 7. History of obstetrical injury - describe.
  1. ;; 8. History of spinal cord injury affecting rectum and anus - describe.
  1. ;; 9. For rectal prolapse - frequency, extent of fecal leakage.
  1. ;; 10. History of rectal bleeding.
  1. ;; 11. History of anal infections.
  1. ;; 12. History of proctitis.
  1. ;; 13. History of fistula in ano.
  1. ;; 14. History of neoplasm.
  1. ;;
  1. ;; a. Date of diagnosis, diagnosis.
  1. ;; b. Benign or malignant.
  1. ;; c. Treatment dates and response.
  1. ;; d. Last date of treatment.
  1. ;;
  1. ;; 15. Effects of condition on occupational functioning and daily activities.
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; Address each of the following and fully describe current findings:
  1. ;;
  1. ;; 1. Colostomy.
  1. ;; 2. Evidence of fecal leakage.
  1. ;; 3. Size of lumen - rectum and anus.
  1. ;; 4. Signs of anemia.
  1. ;; 5. Fissures.
  1. ;; 6. If hemorrhoids - location, size, reducible, presence of redundant
  1. ;; tissue and if thrombosed.
  1. ;; 7. Evidence of bleeding.
  1. ;; 8. Rectal prolapse - extent.
  1. ;; 9. Sphincter tone.
  1. ;;
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;; 2. If a history of bleeding (past 12 months), signs of anemia or chronic
  1. ;; infection, obtain CDC.
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END