54 lines
1.8 KiB
Mathematica
54 lines
1.8 KiB
Mathematica
DVBCWIW3 ;ALB/RLC INTESTINES (LARGE AND SMALL) WKS TEXT - 1 ; 16 JAN 2007
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;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
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;
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TXT ;
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;;A. Review of Medical Records:
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;;
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;;B. Medical History (Subjective Complaints):
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;;
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;; Comment on:
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;;
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;; 1. Weight gain or loss.
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;; 2. Nausea and/or vomiting.
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;; 3. Constipation, diarrhea (frequency, severity, duration, and
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;; episodic or not?).
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;; 4. For fistula - frequency, duration, and amount of fecal discharge.
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;; 5. Treatment-type, duration, response, side effects.
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;; 6. Abdominal pain, distress, cramps - frequency, duration, location.
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;; 7. For ulcerative colitis - number of attacks per year.
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;; 8. Effects of condition on occupations functioning and activities of
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;; daily living.
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;; 9. History of trauma.
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;; 10. History of hospitalizations or surgery - reason or type of surgery,
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;; location and dates, if known.
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;; 11. History of neoplasm:
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;;
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;; a. Date of diagnosis, diagnosis.
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;; b. Benign or malignant.
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;; c. Treatment, dates and response.
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;; d. Last date of treatment.
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;;
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;;C. Physical Examination (Objective Findings):
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;;
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;; Address each of the following and fully describe current findings:
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;; 1. Malnutrition, anemia, other evidence of debility.
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;; 2. Abdominal pain - location.
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;; 3. For fistula, location, presence of discharge.
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;; 4. Ostomy present - type.
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;; 5. Abdominal mass.
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;; 6. Signs of anemia.
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;; 7. Weight - gain or loss.
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;;
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;;D. Diagnostic and Clinical Tests:
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;;
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;; 1. If signs of anemia, obtain hemoglobin/hematocrit.
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;; 2. Include results of all diagnostic and clinical tests conducted in
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;; the examination report.
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;;
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;;E. Diagnosis:
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;;
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;;
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;;
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;;Signature: Date:
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;;END
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