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 Apr 09, 2024@20:56 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
