61 lines
2.2 KiB
Mathematica
61 lines
2.2 KiB
Mathematica
DVBCWST3 ;ALB/RLC STOMACH, DUODENUM, AND PERITONEAL ADHESIONS 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. Nausea, vomiting.
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;; 2. Hematemesis or melena (describe any episodes).
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;; 3. Treatment - type, duration, response, side effects.
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;; 4. For postgastrectomy syndrome: Is there circulatory disturbance
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;; after meals, hypoglycemic reactions, etc. (state time of onset
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;; in relation to meals, frequency)?
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;; 5. Diarrhea, constipation.
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;; 6. For peritoneal adhesions: Are there episodes of colic, distention,
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;; nausea, and/or vomiting? - frequency, duration, and severity.
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;; 7. Are there periods of incapacitation due to stomach or duodenal
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;; disease?
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;; 8. History of hospitalizations or surgery: reason or type of surgery,
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;; dates and locations, if known.
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;; 9. History of trauma.
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;; 10. Effects of condition on occupational functioning and activities of
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;; daily living.
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;; 11. Pain - location, type, precipitating, alleviating factors.
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;; 12. 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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;;
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;; 1. Weight gain or loss.
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;; 2. Signs of anemia.
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;; 3. Tenderness - location.
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;;
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;;D. Diagnostic and Clinical Tests:
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;;
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;; 1. For gastritis, endoscopic evidence - describe hemorrhage,
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;; ulcerated or eroded areas.
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;; 2. For adhesions, X-ray to show partial obstruction, delayed
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;; motility.
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;; 3. For ulcer diseases, provide specific site.
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;; 4. If there is a history of hematemesis or melena (past 12 months)
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;; or signs of anemia, obtain hemaglobin and hematocrit.
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;; 5. 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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