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Routine: DVBCWAUB

DVBCWAUB.m

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DVBCWAUB ;BPOIFO/RLC - AUDIO WKS TEXT - 1 ; 2/10/2010

 ;;2.7;AMIE;**150**;Apr 10, 1995;Build 13

 ;

TXT ;

 ;;   The Handbook of Standard Procedures and Best Practices for Audiology

 ;;   Compensation and Pension Exams is available online. ( This is a PDF file.

 ;;   You need Acrobat Reader to open pdf files. It is a free download. )

 ;;

 ;;Narrative:  An examination of hearing impairment must be conducted by a

 ;;state-licensed audiologist and must include a controlled speech

 ;;discrimination test (specifically, the Maryland CNC recording) and a

 ;;pure tone audiometry test in a sound isolated booth that meets American

 ;;National Standards Institute standards (ANSI S3.1.1991) for ambient noise.

 ;;Measurements will be reported at the frequencies of 500, 1000, 2000, 3000,

 ;;and 4000 Hz.  The examination will include the following tests: Pure tone

 ;;audiometry by air conduction at 250, 500, 1000, 2000, 3000, 4000, and

 ;;8000 Hz, and by bone conduction at 250, 500, 1000, 2000, 3000, and

 ;;4000 Hz, spondee thresholds, speech recognition using the recorded

 ;;Maryland CNC Test, tympanometry and acoustic reflex tests, and, when

 ;;necessary, Stenger tests.  Bone conduction thresholds are measured 

 ;;when the air conduction thresholds are poorer than 15 dB HL.  A modified

 ;;Hughson-Westlake procedure will be used with appropriate masking.  A

 ;;Stenger must be administered whenever pure tone air conduction

 ;;thresholds at 500, 1000, 2000, 3000, and 4000 Hz differ by 20 dB or more

 ;;between the two ears.  Maximum speech recognition will be reported with

 ;;the 50 word VA approved recording of the Maryland CNC test.  The starting

 ;;presentation level will be 40dB re SRT.  If necessary, the starting level

 ;;will be adjusted upward to obtain a level at least 5 dB above the threshold

 ;;at 2000 Hz, if not above the patient's tolerance level.  The examination

 ;;will be conducted without the use of hearing aids.  Both ears must be

 ;;examined for hearing impairment even if hearing loss in only one ear is

 ;;at issue.

 ;;

 ;;   When speech recognition is 92% or less, a performance intensity

 ;;   function must be obtained.

 ;;

 ;;Procedures for Obtaining a Modified Performance-Intensity Function

 ;;   1.  The starting level is 40 dB re: SRT (speech reception threshold).

 ;;   The starting level will be adjusted upward to obtain a level at least

 ;;   5 dB above the threshold at 2000 Hz, if not above the patient's

 ;;   tolerance level.

 ;;   2.  Present 25 words at 6 dB above and 6 dB below the starting level.

 ;;   3.  If recognition performance improves less than 6%, then maximum word

 ;;   recognition performance has been obtained.

 ;;       Example:  starting level=50 dB HL.  Initial performance=80%.

 ;;       Decrease level to 44 dB HL.  Performance decreases to 76%.  Increase

 ;;       level to 56 dB HL.  Performance increases to 84%.  Test level for

 ;;       full list=50 dB HL.

 ;;   4.  If performance improves by 6% or more at the first 6-dB increment,

 ;;   then word recognition is measured using another 25 words at an

 ;;   additional 6-dB increment.

 ;;       Example:  starting level=50 dB HL.  Initial performance=80%.

 ;;       Increase level to 56 dB HL.  Performance improves to 88% (+8%).

 ;;       Increase level to 62 dB HL.  Performance decreases to 84% (-4%).

 ;;       Test level for full list=56 dB HL.

 ;;   5.  A full list (50 words) is then presented at the level of maximum

 ;;   performance.  The word recognition performance at this level is reported

 ;;   as the speech recognition score.  Only the best performance for a full

 ;;   list (50 words) will be reported.

 ;;

 ;;A.  Review of Medical Records: Indicate whether the C-file was reviewed.

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;      Comment on:

 ;;

 ;;        1.  Chief complaint.

 ;;        2.  Effects of the condition on occupational functioning and daily

 ;;            activities.

 ;;        3.  Pertinent service history.

 ;;        4.  History of military, occupational, and recreational noise

 ;;            exposure.

 ;;        5.  Pertinent family and social history; history of ear disease,

 ;;            head or ear trauma, etc.

 ;;        6.  Tinnitus.

 ;;

 ;;              a.  Is there a claim for tinnitus (verify from examination

 ;;                  request, i.e., 2507)?  (yes/no)

 ;;              b.  Is there a current complaint of tinnitus? (yes/no)  If yes

 ;;                  answer the following questions whether or not the condition

 ;;                  is claimed.

 ;;              c.  Date and circumstances of onset.

 ;;              d.  Whether it is constant or recurrent (intermittent). 

 ;;                  Current complaints only.

 ;;              e.  If there is a claim and no current complaint, the

 ;;                  audiologist must:

 ;;

 ;;                  State when veteran last experienced tinnitus.

 ;;

 ;;                  Describe the tinnitus experienced at that time.

 ;;

 ;;                  Describe intervening course between onset and last episode,

 ;;                  e.g., how frequently in a year does a veteran experience

 ;;                  tinnitus.

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    1.  Measure and record puretone thresholds in decibels at the indicated

 ;;        frequencies (air conduction):

 ;;

 ;;    = = = = =RIGHT EAR= = = = = = = = = = = = = LEFT EAR = = = = = = 

 ;;    A*    B    C    D    E    **       A*   B    C   D    E     **

 ;;    500|1000|2000|3000|4000|average   500|1000|2000|3000|4000|average

 ;;       |    |    |    |    |             |    |    |    |    |

 ;;  

 ;;    *  The puretone threshold at 500 Hz is not used in calculating the

 ;;       puretone threshold average for evaluation purposes but is used in

 ;;       determining whether or not, for VA purposes, a hearing impairment

 ;;       reaches the level of a disability.  Puretone thresholds should not

 ;;       exceed 105 decibels or the tolerance level.

 ;;    ** The average of B, C, D, and E.

 ;;

 ;;    2.  Speech Recognition Score: Maryland CNC word list

 ;;

 ;;                         _____% right ear _____% left ear.

 ;;

 ;;    When only puretone results should be used to evaluate hearing loss, 

 ;;    the examiner, who must be a state-licensed audiologist, should certify

 ;;    that language difficulties or other problems (specify what the problems

 ;;    are) make the combined use of puretone average and speech

 ;;    discrimination inappropriate.

 ;;

 ;;    Thresholds should not exceed 100 decibels or the tolerance level.

 ;;

 ;;    Pausing:  Examiners should pause when necessary during speech

 ;;    recognition tests, in order to give the veteran sufficient time to

 ;;    respond.  This will ensure that the test results are based on actual

 ;;    hearing loss rather than on the effects of other problems that might

 ;;    slow a veteran's response.  There are a variety of problems that might

 ;;    require pausing, for example, the presence of cognitive impairment.  It

 ;;    is up to the examiner to determine when to use pausing and the length

 ;;    of the pauses.

 ;;

 ;;    Need for a modified performance-intensity function:  The normal speech

 ;;    recognition performance is 94% or better for a full (50 word) list.  If

 ;;    speech recognition is worse than 94% after presentation of a full list,

 ;;    then a modified performance-intensity function must be obtained to

 ;;    determine best performance (see Narrative for description of procedures).

 ;;

 ;;When describing speech recognition performance, use these terms:

 ;;

 ;;     Percent        Correct Description

 ;;     100-94%        Excellent (Normal)

 ;;     92-80%         Good

 ;;     78-70%         Fair

 ;;     Less than 70%  Poor

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  Report middle ear status, confirm type of loss and indicate need

 ;;        for medical follow-up.  In cases where there is poor inter-test

 ;;        reliability and/or positive Stenger test results, obtain and report

 ;;        estimates of hearing thresholds using a combination of behavioral

 ;;        testing, Stenger interference levels, and electrophysiological

 ;;        tests.

 ;;    2.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;    1.  Summary of audiologic test results.  Indicate type and degree 

 ;;        of hearing loss for the frequency range from 500 to 4000 Hz.

 ;;        For type of loss, indicate whether it is normal, conductive,

 ;;        sensorineural, central, or mixed.  For degree, indicate whether

 ;;        it is mild (26-40 HL), moderate (41-54 HL), moderately severe 

 ;;        (55-69 HL), severe (70-89 HL), or profound (90+ HL).

 ;;

 ;;    [For VA purposes, impaired hearing is considered to be a disability

 ;;    when the auditory threshold in any of the frequencies 500, 1000, 2000,

 ;;    3000, and 4000 Hz is 40 dB HL or greater; or when the auditory thresholds

 ;;    for at least three of these frequencies are 26 dB HL or greater; or when

 ;;    speech recognition scores are less than 94%]

 ;;

 ;;    2.  Note whether, based on audiologic results, medical follow-up

 ;;        is needed for an ear or hearing problem, and whether there is

 ;;        a problem that, if treated, might cause a change in hearing 

 ;;        threshold levels.

 ;;

 ;;    3.  If there is a current complaint of tinnitus, indicate whether or not

 ;;        tinnitus is as likely as not a symptom associated with hearing loss,

 ;;        if hearing loss is present.  If there is no hearing loss present;

 ;;        or the audiologist determines that it is as likely as not that

 ;;        tinnitus is associated with another medical condition; or the

 ;;        etiology of tinnitus cannot be determined on the basis of available

 ;;        information without resorting to speculation, so state.  The VBA

 ;;        regional office will then determine whether further non-audiological

 ;;        examination is needed, based on their review of all evidence of

 ;;        record.

 ;;

 ;;

 ;;

 ;;Signature:                                        Date:

 ;;END