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Routine: DVBCWER1

DVBCWER1.m

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  1. DVBCWER1 ;ALB/JAM EAR DISEASE WKS TEXT - 1 ; 6 MARCH 1997
  1. ;;2.7;AMIE;**26**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records: Indicate whether the C-file was reviewed.
  1. ;;
  1. ;;
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;; 1. Describe history of hearing loss, tinnitus, vertigo, balance or
  1. ;; gait problems, discharge, pain, pruritus. State onset and
  1. ;; frequency and duration of each, if not constant.
  1. ;;
  1. ;;
  1. ;; 2. Describe current or past treatment for ear conditions.
  1. ;;
  1. ;;
  1. ;; 3. If a malignant neoplasm of the ear is or was present:
  1. ;; a. State date of confirmed diagnosis.
  1. ;;
  1. ;;
  1. ;; b. State date of the last surgical, X-ray, antineoplastic
  1. ;; chemotherapy, radiation, or other therapeutic procedure.
  1. ;;
  1. ;;
  1. ;; c. State expected date treatment regimen is to be completed.
  1. ;;
  1. ;;
  1. ;; d. If treatment is already completed, provide date of last
  1. ;; treatment.
  1. ;;
  1. ;;
  1. ;; e. If treatment is already completed, fully describe residuals.
  1. ;;
  1. ;;
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; 1. Conduct an external and otoscopic examination. Address each
  1. ;; of the following and describe current findings, including
  1. ;; abnormalities of size, shape, or form:
  1. ;;
  1. ;; a. Auricle. Any deformity? If there is tissue loss, state
  1. ;; whether it is one-third or more of auricle.
  1. ;;
  1. ;;
  1. ;; b. External canal - describe any edema, scaling, discharge.
  1. ;;
  1. ;;
  1. ;; c. Tympanic membrane.
  1. ;;
  1. ;;
  1. ;; d. The tympanum.
  1. ;;
  1. ;;
  1. ;; e. Mastoids. Discharge? Evidence of cholesteatoma?
  1. ;;
  1. ;;
  1. ;; f. State all conditions secondary to ear disease, such as
  1. ;; disturbance of balance, upper respiratory disease, hearing
  1. ;; loss, etc.
  1. ;;
  1. ;;
  1. ;; 2. State whether an active ear disease is present.
  1. ;;
  1. ;;
  1. ;; 3. Infections of the middle or inner ear. Is there suppuration?
  1. ;; Effusion? Are aural polyps present?
  1. ;;
  1. ;;
  1. ;; 4. For peripheral vestibular disorders, state the specific diagnosis
  1. ;; and its basis, whether there is dizziness and how often, and
  1. ;; whether a staggering gait occurs and how often.
  1. ;;
  1. ;;
  1. ;; 5. For Meniere's syndrome, state the symptoms, including the
  1. ;; frequency of attacks of vertigo and cerebellar gait. Is
  1. ;; tinnitus present? If so, how frequently and what is its
  1. ;; duration? Is there hearing loss? (See audio worksheet.)
  1. ;;
  1. ;;
  1. ;; 6. Describe any complications of ear disease that are present.
  1. ;;
  1. ;;
  1. ;;
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;;
  1. ;;
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END