- DVBCWER1 ;ALB/JAM EAR DISEASE WKS TEXT - 1 ; 6 MARCH 1997
- ;;2.7;AMIE;**26**;Apr 10, 1995
- ;
- ;
- TXT ;
- ;;A. Review of Medical Records: Indicate whether the C-file was reviewed.
- ;;
- ;;
- ;;
- ;;B. Medical History (Subjective Complaints):
- ;; 1. Describe history of hearing loss, tinnitus, vertigo, balance or
- ;; gait problems, discharge, pain, pruritus. State onset and
- ;; frequency and duration of each, if not constant.
- ;;
- ;;
- ;; 2. Describe current or past treatment for ear conditions.
- ;;
- ;;
- ;; 3. If a malignant neoplasm of the ear is or was present:
- ;; a. State date of confirmed diagnosis.
- ;;
- ;;
- ;; b. State date of the last surgical, X-ray, antineoplastic
- ;; chemotherapy, radiation, or other therapeutic procedure.
- ;;
- ;;
- ;; c. State expected date treatment regimen is to be completed.
- ;;
- ;;
- ;; d. If treatment is already completed, provide date of last
- ;; treatment.
- ;;
- ;;
- ;; e. If treatment is already completed, fully describe residuals.
- ;;
- ;;
- ;;
- ;;C. Physical Examination (Objective Findings):
- ;;
- ;; 1. Conduct an external and otoscopic examination. Address each
- ;; of the following and describe current findings, including
- ;; abnormalities of size, shape, or form:
- ;;
- ;; a. Auricle. Any deformity? If there is tissue loss, state
- ;; whether it is one-third or more of auricle.
- ;;
- ;;
- ;; b. External canal - describe any edema, scaling, discharge.
- ;;
- ;;
- ;; c. Tympanic membrane.
- ;;
- ;;
- ;; d. The tympanum.
- ;;
- ;;
- ;; e. Mastoids. Discharge? Evidence of cholesteatoma?
- ;;
- ;;
- ;; f. State 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. Is there suppuration?
- ;; Effusion? Are aural polyps present?
- ;;
- ;;
- ;; 4. For peripheral vestibular disorders, state the specific diagnosis
- ;; and its basis, whether there is dizziness and how often, and
- ;; whether a staggering gait occurs and how often.
- ;;
- ;;
- ;; 5. For Meniere's syndrome, state the symptoms, including the
- ;; frequency of attacks of vertigo and cerebellar gait. Is
- ;; tinnitus present? If so, how frequently and what is its
- ;; duration? Is there hearing loss? (See audio worksheet.)
- ;;
- ;;
- ;; 6. Describe any complications of ear disease that are present.
- ;;
- ;;
- ;;
- ;;D. Diagnostic and Clinical Tests:
- ;;
- ;; 1. Include results of all diagnostic and clinical tests conducted
- ;; in the examination report.
- ;;
- ;;
- ;;
- ;;E. Diagnosis:
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWER1 2999 printed Feb 18, 2025@23:17:22 Page 2
- DVBCWER1 ;ALB/JAM EAR DISEASE WKS TEXT - 1 ; 6 MARCH 1997
- +1 ;;2.7;AMIE;**26**;Apr 10, 1995
- +2 ;
- +3 ;
- TXT ;
- +1 ;;A. Review of Medical Records: Indicate whether the C-file was reviewed.
- +2 ;;
- +3 ;;
- +4 ;;
- +5 ;;B. Medical History (Subjective Complaints):
- +6 ;; 1. Describe history of hearing loss, tinnitus, vertigo, balance or
- +7 ;; gait problems, discharge, pain, pruritus. State onset and
- +8 ;; frequency and duration of each, if not constant.
- +9 ;;
- +10 ;;
- +11 ;; 2. Describe current or past treatment for ear conditions.
- +12 ;;
- +13 ;;
- +14 ;; 3. If a malignant neoplasm of the ear is or was present:
- +15 ;; a. State date of confirmed diagnosis.
- +16 ;;
- +17 ;;
- +18 ;; b. State date of the last surgical, X-ray, antineoplastic
- +19 ;; chemotherapy, radiation, or other therapeutic procedure.
- +20 ;;
- +21 ;;
- +22 ;; c. State expected date treatment regimen is to be completed.
- +23 ;;
- +24 ;;
- +25 ;; d. If treatment is already completed, provide date of last
- +26 ;; treatment.
- +27 ;;
- +28 ;;
- +29 ;; e. If treatment is already completed, fully describe residuals.
- +30 ;;
- +31 ;;
- +32 ;;
- +33 ;;C. Physical Examination (Objective Findings):
- +34 ;;
- +35 ;; 1. Conduct an external and otoscopic examination. Address each
- +36 ;; of the following and describe current findings, including
- +37 ;; abnormalities of size, shape, or form:
- +38 ;;
- +39 ;; a. Auricle. Any deformity? If there is tissue loss, state
- +40 ;; whether it is one-third or more of auricle.
- +41 ;;
- +42 ;;
- +43 ;; b. External canal - describe any edema, scaling, discharge.
- +44 ;;
- +45 ;;
- +46 ;; c. Tympanic membrane.
- +47 ;;
- +48 ;;
- +49 ;; d. The tympanum.
- +50 ;;
- +51 ;;
- +52 ;; e. Mastoids. Discharge? Evidence of cholesteatoma?
- +53 ;;
- +54 ;;
- +55 ;; f. State all conditions secondary to ear disease, such as
- +56 ;; disturbance of balance, upper respiratory disease, hearing
- +57 ;; loss, etc.
- +58 ;;
- +59 ;;
- +60 ;; 2. State whether an active ear disease is present.
- +61 ;;
- +62 ;;
- +63 ;; 3. Infections of the middle or inner ear. Is there suppuration?
- +64 ;; Effusion? Are aural polyps present?
- +65 ;;
- +66 ;;
- +67 ;; 4. For peripheral vestibular disorders, state the specific diagnosis
- +68 ;; and its basis, whether there is dizziness and how often, and
- +69 ;; whether a staggering gait occurs and how often.
- +70 ;;
- +71 ;;
- +72 ;; 5. For Meniere's syndrome, state the symptoms, including the
- +73 ;; frequency of attacks of vertigo and cerebellar gait. Is
- +74 ;; tinnitus present? If so, how frequently and what is its
- +75 ;; duration? Is there hearing loss? (See audio worksheet.)
- +76 ;;
- +77 ;;
- +78 ;; 6. Describe any complications of ear disease that are present.
- +79 ;;
- +80 ;;
- +81 ;;
- +82 ;;D. Diagnostic and Clinical Tests:
- +83 ;;
- +84 ;; 1. Include results of all diagnostic and clinical tests conducted
- +85 ;; in the examination report.
- +86 ;;
- +87 ;;
- +88 ;;
- +89 ;;E. Diagnosis:
- +90 ;;
- +91 ;;
- +92 ;;Signature: Date:
- +93 ;;END