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 Sep 23, 2025@19:29:48 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
