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Routine: DVBCWST3

DVBCWST3.m

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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