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Routine: DVBCWER3

DVBCWER3.m

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  1. DVBCWER3 ;BPOIFO/RLC EAR DISEASE WKS TEXT - 1 ; 26 DEC 2006
  1.  ;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records:  Indicate whether the C-file was reviewed.
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  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.  ;;    2.  Describe current or past treatment, response and side effects for
  1.  ;;        ear conditions.
  1.  ;;    3.  History of hospitalization or surgery (location, date if known and
  1.  ;;        reason or type of surgery).
  1.  ;;    4.  History of military, occupational and recreational noise exposure.
  1.  ;;    5.  History of trauma to the ear(s).
  1.  ;;    6.  Describe effects on occupational functioning and activities of
  1.  ;;        daily living.
  1.  ;;    7.  If a neoplasm of the ear is or was present:
  1.  ;;
  1.  ;;        a.  State date of confirmed diagnosis, diagnosis.
  1.  ;;        b.  Benign or malignant.
  1.  ;;        c.  State date of the last surgical, X-ray, antineoplastic 
  1.  ;;            chemotherapy, radiation, or other therapeutic procedure.
  1.  ;;        d.  State expected date treatment regimen is to be completed.
  1.  ;;        e.  If treatment is already completed, provide date of last 
  1.  ;;            treatment.
  1.  ;;        f.  If treatment is already completed, fully describe residuals.
  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.  ;;        b.  External canal - describe any edema, scaling, discharge.
  1.  ;;
  1.  ;;        c.  Tympanic membrane.
  1.  ;;
  1.  ;;        d.  The tympanum.
  1.  ;;
  1.  ;;        e.  Mastoids.  Discharge?  Evidence of cholesteatoma?
  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.  ;;    2.  State whether an active ear disease is present.
  1.  ;;
  1.  ;;    3.  Infections of the middle or inner ear.  Is there suppuration?
  1.  ;;        Effusion?  Are aural polyps present?
  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.  ;;    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.  ;;    6.  Describe any complications of ear disease that are present.
  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.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;
  1.  ;;Signature:                             Date:
  1.  ;;END