- DVBCWRA3 ;ALB/RLC RECTUM AND ANUS WKS TEXT - 1 ; 12 FEB 2007
- ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
- ;
- ;
- TXT ;
- ;;A. Review of Medical Records:
- ;;
- ;;B. Medical History (Subjective Complaints):
- ;;
- ;; Comment on:
- ;;
- ;; 1. Current symptoms - anal itching, diarrhea, pain, tenesmus, swelling,
- ;; perianal discharge, etc.
- ;; 2. For fecal incontinence - extent and frequency of fecal leakage or
- ;; involuntary bowel movements- is a pad needed?
- ;; 3. For hemorrhoids - bleeding or thrombosis of hemorrhoids - frequency
- ;; and extent.
- ;; 4. Current treatment - type, duration, response, side effects.
- ;; 5. History of hospitalizations or surgery - reason or type of surgery,
- ;; location and dates, if known.
- ;; 6. History of trauma to the rectum or anus.
- ;; 7. History of obstetrical injury - describe.
- ;; 8. History of spinal cord injury affecting rectum and anus - describe.
- ;; 9. For rectal prolapse - frequency, extent of fecal leakage.
- ;; 10. History of rectal bleeding.
- ;; 11. History of anal infections.
- ;; 12. History of proctitis.
- ;; 13. History of fistula in ano.
- ;; 14. History of neoplasm.
- ;;
- ;; a. Date of diagnosis, diagnosis.
- ;; b. Benign or malignant.
- ;; c. Treatment dates and response.
- ;; d. Last date of treatment.
- ;;
- ;; 15. Effects of condition on occupational functioning and daily activities.
- ;;
- ;;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, reducible, presence of redundant
- ;; tissue and if thrombosed.
- ;; 7. Evidence of bleeding.
- ;; 8. Rectal prolapse - extent.
- ;; 9. Sphincter tone.
- ;;
- ;;D. Diagnostic and Clinical Tests:
- ;;
- ;; 1. Include results of all diagnostic and clinical tests conducted
- ;; in the examination report.
- ;; 2. If a history of bleeding (past 12 months), signs of anemia or chronic
- ;; infection, obtain CDC.
- ;;
- ;;E. Diagnosis:
- ;;
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWRA3 2388 printed Feb 18, 2025@23:20:10 Page 2
- DVBCWRA3 ;ALB/RLC RECTUM AND ANUS WKS TEXT - 1 ; 12 FEB 2007
- +1 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
- +2 ;
- +3 ;
- TXT ;
- +1 ;;A. Review of Medical Records:
- +2 ;;
- +3 ;;B. Medical History (Subjective Complaints):
- +4 ;;
- +5 ;; Comment on:
- +6 ;;
- +7 ;; 1. Current symptoms - anal itching, diarrhea, pain, tenesmus, swelling,
- +8 ;; perianal discharge, etc.
- +9 ;; 2. For fecal incontinence - extent and frequency of fecal leakage or
- +10 ;; involuntary bowel movements- is a pad needed?
- +11 ;; 3. For hemorrhoids - bleeding or thrombosis of hemorrhoids - frequency
- +12 ;; and extent.
- +13 ;; 4. Current treatment - type, duration, response, side effects.
- +14 ;; 5. History of hospitalizations or surgery - reason or type of surgery,
- +15 ;; location and dates, if known.
- +16 ;; 6. History of trauma to the rectum or anus.
- +17 ;; 7. History of obstetrical injury - describe.
- +18 ;; 8. History of spinal cord injury affecting rectum and anus - describe.
- +19 ;; 9. For rectal prolapse - frequency, extent of fecal leakage.
- +20 ;; 10. History of rectal bleeding.
- +21 ;; 11. History of anal infections.
- +22 ;; 12. History of proctitis.
- +23 ;; 13. History of fistula in ano.
- +24 ;; 14. History of neoplasm.
- +25 ;;
- +26 ;; a. Date of diagnosis, diagnosis.
- +27 ;; b. Benign or malignant.
- +28 ;; c. Treatment dates and response.
- +29 ;; d. Last date of treatment.
- +30 ;;
- +31 ;; 15. Effects of condition on occupational functioning and daily activities.
- +32 ;;
- +33 ;;C. Physical Examination (Objective Findings):
- +34 ;;
- +35 ;; Address each of the following and fully describe current findings:
- +36 ;;
- +37 ;; 1. Colostomy.
- +38 ;; 2. Evidence of fecal leakage.
- +39 ;; 3. Size of lumen - rectum and anus.
- +40 ;; 4. Signs of anemia.
- +41 ;; 5. Fissures.
- +42 ;; 6. If hemorrhoids - location, size, reducible, presence of redundant
- +43 ;; tissue and if thrombosed.
- +44 ;; 7. Evidence of bleeding.
- +45 ;; 8. Rectal prolapse - extent.
- +46 ;; 9. Sphincter tone.
- +47 ;;
- +48 ;;D. Diagnostic and Clinical Tests:
- +49 ;;
- +50 ;; 1. Include results of all diagnostic and clinical tests conducted
- +51 ;; in the examination report.
- +52 ;; 2. If a history of bleeding (past 12 months), signs of anemia or chronic
- +53 ;; infection, obtain CDC.
- +54 ;;
- +55 ;;E. Diagnosis:
- +56 ;;
- +57 ;;
- +58 ;;
- +59 ;;Signature: Date:
- +60 ;;END