DVBCWST3.m

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 ---DVBCWST3   2330     printed  Apr 23, 2025@18:08:37                                                                                                                                                                                                    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