©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
DVBCWST1 ;ALB/CMM STOMACH, DUODENUM, AND PERITONEAL ADHESIONS WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; 1. Vomiting.
;;
;;
;; 2. Hematemesis or melena (describe any episodes).
;;
;;
;; 3. Treatment - type, duration, response, side effects.
;;
;;
;; 4. Circulatory disturbance after meals, hypoglycemic reactions
;; (state time of onset in relation to meals, frequency).
;;
;;
;; 5. Diarrhea, constipation.
;;
;;
;; 6. Episodes of colic, distention, nausea, and/or vomiting -
;; frequency, duration, and severity.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Specific site of any ulcer disease.
;;
;;
;; 2. Weight gain or loss.
;;
;;
;; 3. Signs of anemia.
;;
;;
;; 4. Pain or tenderness - location, type, precipitating factors.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. For gastritis, endoscopic evidence - describe hemorrhage,
;; ulcerated or eroded areas.
;; 2. For adhesions, X-ray to show partial obstruction, delayed
;; motility.
;; 3. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END