©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWED1 ;ALB/CMM EAR DISEASE WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; 1. Address each of the following and describe current findings,
;; including abnormalities of size, shape, or form:
;;
;; a. Auricle.
;;
;;
;; b. External canal.
;;
;;
;;
;; c. Tympanic membrane.
;;
;;
;; d. The tympanum.
;;
;;
;; e. The mastoid.
;;
;;
;; f. All conditions secondary to ear disease, such as disturbance
;; of balance, upper respiratory disease, hearing loss, etc.
;;
;;
;; 2. State whether an active ear disease is present.
;;
;;
;; 3. Infections of the middle or inner ear.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END