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Routine: DVBCWRA3

DVBCWRA3.m

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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