Rectum and Anus

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Current symptoms - anal itching, diarrhea, pain, tenesmus, swelling, perianal discharge, etc.
2. For fecal incontinence - extent and frequency of fecal leakage or involuntary bowel movements- is a pad needed?
3. For hemorrhoids - bleeding or thrombosis, frequency and extent.
4. Current treatment - type, duration, response, side effects. .
5. History of hospitalizations or surgery - reason or type of surgery, location and dates, if known.
6. History of trauma to the rectum or anus.
7. History of obstetrical injury - describe.
8. History of spinal cord injury affecting rectum and anus - describe.
9. For rectal prolapse - frequency, extent of fecal leakage.
10. History of rectal bleeding.
11. History of anal infections.
12. History of proctitis.
13. History of fistula in ano.
14. History of neoplasm.

1. Date of diagnosis, diagnosis.
2. Benign or malignant.
3. Treatment, dates and response.
4. Last date of treatment.

15. Effects of condition on occupational functioning and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Colostomy.
2. Evidence of fecal leakage.
3. Size of lumen - rectum and anus.
4. Signs of anemia.
5. Fissures.
6. If hemorrhoids - location, size, reducible, presence of redundant tissue and if thrombosed.
7. Evidence of bleeding.
8. Rectal prolapse - extent.
9. Sphincter tone.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

2. If a history of bleeding (past 12 months), signs of anemia or chronic infection, obtain CBC.

E. Diagnosis: