DVBCWER3 ;BPOIFO/RLC EAR DISEASE WKS TEXT - 1 ; 26 DEC 2006
;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
;
;
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, response and side effects for
;; ear conditions.
;; 3. History of hospitalization or surgery (location, date if known and
;; reason or type of surgery).
;; 4. History of military, occupational and recreational noise exposure.
;; 5. History of trauma to the ear(s).
;; 6. Describe effects on occupational functioning and activities of
;; daily living.
;; 7. If a neoplasm of the ear is or was present:
;;
;; a. State date of confirmed diagnosis, diagnosis.
;; b. Benign or malignant.
;; c. State date of the last surgical, X-ray, antineoplastic
;; chemotherapy, radiation, or other therapeutic procedure.
;; d. State expected date treatment regimen is to be completed.
;; e. If treatment is already completed, provide date of last
;; treatment.
;; f. 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[HDVBCWER3 3291 printed Nov 22, 2024@17:01:10 Page 2
DVBCWER3 ;BPOIFO/RLC EAR DISEASE WKS TEXT - 1 ; 26 DEC 2006
+1 ;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records: Indicate whether the C-file was reviewed.
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; 1. Describe history of hearing loss, tinnitus, vertigo, balance or
+6 ;; gait problems, discharge, pain, pruritus. State onset and
+7 ;; frequency and duration of each, if not constant.
+8 ;; 2. Describe current or past treatment, response and side effects for
+9 ;; ear conditions.
+10 ;; 3. History of hospitalization or surgery (location, date if known and
+11 ;; reason or type of surgery).
+12 ;; 4. History of military, occupational and recreational noise exposure.
+13 ;; 5. History of trauma to the ear(s).
+14 ;; 6. Describe effects on occupational functioning and activities of
+15 ;; daily living.
+16 ;; 7. If a neoplasm of the ear is or was present:
+17 ;;
+18 ;; a. State date of confirmed diagnosis, diagnosis.
+19 ;; b. Benign or malignant.
+20 ;; c. State date of the last surgical, X-ray, antineoplastic
+21 ;; chemotherapy, radiation, or other therapeutic procedure.
+22 ;; d. State expected date treatment regimen is to be completed.
+23 ;; e. If treatment is already completed, provide date of last
+24 ;; treatment.
+25 ;; f. If treatment is already completed, fully describe residuals.
+26 ;;
+27 ;;C. Physical Examination (Objective Findings):
+28 ;;
+29 ;; 1. Conduct an external and otoscopic examination. Address each
+30 ;; of the following and describe current findings, including
+31 ;; abnormalities of size, shape, or form:
+32 ;;
+33 ;; a. Auricle. Any deformity? If there is tissue loss, state
+34 ;; whether it is one-third or more of auricle.
+35 ;;
+36 ;; b. External canal - describe any edema, scaling, discharge.
+37 ;;
+38 ;; c. Tympanic membrane.
+39 ;;
+40 ;; d. The tympanum.
+41 ;;
+42 ;; e. Mastoids. Discharge? Evidence of cholesteatoma?
+43 ;;
+44 ;; f. State all conditions secondary to ear disease, such as
+45 ;; disturbance of balance, upper respiratory disease, hearing
+46 ;; loss, etc.
+47 ;;
+48 ;; 2. State whether an active ear disease is present.
+49 ;;
+50 ;; 3. Infections of the middle or inner ear. Is there suppuration?
+51 ;; Effusion? Are aural polyps present?
+52 ;;
+53 ;; 4. For peripheral vestibular disorders, state the specific diagnosis
+54 ;; and its basis, whether there is dizziness and how often, and
+55 ;; whether a staggering gait occurs and how often.
+56 ;;
+57 ;; 5. For Meniere's syndrome, state the symptoms, including the
+58 ;; frequency of attacks of vertigo and cerebellar gait. Is
+59 ;; tinnitus present? If so, how frequently and what is its
+60 ;; duration? Is there hearing loss? (See audio worksheet.)
+61 ;;
+62 ;; 6. Describe any complications of ear disease that are present.
+63 ;;
+64 ;;D. Diagnostic and Clinical Tests:
+65 ;;
+66 ;; 1. Include results of all diagnostic and clinical tests conducted
+67 ;; in the examination report.
+68 ;;
+69 ;;E. Diagnosis:
+70 ;;
+71 ;;
+72 ;;Signature: Date:
+73 ;;END
