DVBCWST3 ;ALB/RLC STOMACH, DUODENUM, AND PERITONEAL ADHESIONS WKS TEXT - 1 ; 16 JAN 2007
;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. Nausea, vomiting.
;; 2. Hematemesis or melena (describe any episodes).
;; 3. Treatment - type, duration, response, side effects.
;; 4. For postgastrectomy syndrome: Is there circulatory disturbance
;; after meals, hypoglycemic reactions, etc. (state time of onset
;; in relation to meals, frequency)?
;; 5. Diarrhea, constipation.
;; 6. For peritoneal adhesions: Are there episodes of colic, distention,
;; nausea, and/or vomiting? - frequency, duration, and severity.
;; 7. Are there periods of incapacitation due to stomach or duodenal
;; disease?
;; 8. History of hospitalizations or surgery: reason or type of surgery,
;; dates and locations, if known.
;; 9. History of trauma.
;; 10. Effects of condition on occupational functioning and activities of
;; daily living.
;; 11. Pain - location, type, precipitating, alleviating factors.
;; 12. History of neoplasm:
;;
;; a. Date of diagnosis, diagnosis.
;; b. Benign or malignant.
;; c. Treatment, dates and response.
;; d. Last date of treatment.
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;;
;; 1. Weight gain or loss.
;; 2. Signs of anemia.
;; 3. Tenderness - location.
;;
;;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. For ulcer diseases, provide specific site.
;; 4. If there is a history of hematemesis or melena (past 12 months)
;; or signs of anemia, obtain hemaglobin and hematocrit.
;; 5. Include results of all diagnostic and clinical tests conducted in
;; the examination report.
;;
;;E. Diagnosis:
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWST3 2330 printed Nov 22, 2024@17:04:19 Page 2
DVBCWST3 ;ALB/RLC STOMACH, DUODENUM, AND PERITONEAL ADHESIONS WKS TEXT - 1 ; 16 JAN 2007
+1 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
+2 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. Nausea, vomiting.
+8 ;; 2. Hematemesis or melena (describe any episodes).
+9 ;; 3. Treatment - type, duration, response, side effects.
+10 ;; 4. For postgastrectomy syndrome: Is there circulatory disturbance
+11 ;; after meals, hypoglycemic reactions, etc. (state time of onset
+12 ;; in relation to meals, frequency)?
+13 ;; 5. Diarrhea, constipation.
+14 ;; 6. For peritoneal adhesions: Are there episodes of colic, distention,
+15 ;; nausea, and/or vomiting? - frequency, duration, and severity.
+16 ;; 7. Are there periods of incapacitation due to stomach or duodenal
+17 ;; disease?
+18 ;; 8. History of hospitalizations or surgery: reason or type of surgery,
+19 ;; dates and locations, if known.
+20 ;; 9. History of trauma.
+21 ;; 10. Effects of condition on occupational functioning and activities of
+22 ;; daily living.
+23 ;; 11. Pain - location, type, precipitating, alleviating factors.
+24 ;; 12. 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 ;;C. Physical Examination (Objective Findings):
+32 ;;
+33 ;; Address each of the following and fully describe current findings:
+34 ;;
+35 ;; 1. Weight gain or loss.
+36 ;; 2. Signs of anemia.
+37 ;; 3. Tenderness - location.
+38 ;;
+39 ;;D. Diagnostic and Clinical Tests:
+40 ;;
+41 ;; 1. For gastritis, endoscopic evidence - describe hemorrhage,
+42 ;; ulcerated or eroded areas.
+43 ;; 2. For adhesions, X-ray to show partial obstruction, delayed
+44 ;; motility.
+45 ;; 3. For ulcer diseases, provide specific site.
+46 ;; 4. If there is a history of hematemesis or melena (past 12 months)
+47 ;; or signs of anemia, obtain hemaglobin and hematocrit.
+48 ;; 5. Include results of all diagnostic and clinical tests conducted in
+49 ;; the examination report.
+50 ;;
+51 ;;E. Diagnosis:
+52 ;;
+53 ;;
+54 ;;
+55 ;;Signature: Date:
+56 ;;END
