DVBCWER5 ;ALB/RLC EAR DISEASE WKS TEXT - 1 ; 26 DEC 2006
;;2.7;AMIE;**170**;Apr 10, 1995;Build 1
;
;
TXT ;
;;A. Review of Medical Records: Indicate whether the C-file was reviewed.
;;
;;B. Medical History (Subjective Complaints):
;;
;; 1. Date of onset of condition and circumstances and initial manifestations
;; of the disease or injury.
;; 2. Course since onset.
;; 3. Current treatment, response to treatment, and any side effects.
;; 4. History of related hospitalizations or surgery, dates and location, if
;; known, reason or type of surgery.
;; 5. History of trauma to the ear, with date, type of injury, and cause.
;; 6. Report any of the following symptoms that are present and provide
;; additional information as requested:
;;
;; a. Tinnitus, and state whether constant or recurrent.
;; b. Hearing loss, and state whether or not it is constant. If not,
;; state frequency and duration.
;; c. Balance or gait problems, and state whether or not constant. If
;; not, state frequency and duration.
;; d. Ear pain, and state location and whether or not constant. If not,
;; state frequency and duration.
;; e. Ear discharge, and state type of discharge and whether or not
;; constant. If not, state frequency and duration.
;; f. History of ear infection, and state date of last infection and
;; frequency.
;; g. Vertigo or dizziness, and state whether or not constant. If not,
;; state frequency and duration.
;; h. Pruritus of ear, and state whether or not constant. If not, state
;; frequency and duration.
;;
;; 7. Report history of military, occupational, and recreational noise
;; exposure.
;; 8. History of neoplasm of ear:
;;
;; a. Date of diagnosis, exact diagnosis, location.
;; b. Benign or malignant.
;; c. Types of treatment and dates.
;; d. Last date of treatment.
;; e. State whether treatment has been completed.
;;
;; 9. Other significant ear history.
;;
;;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. State if there is any deformity. State if there is
;; tissue loss and extent - is it at least one-third of auricle lost,
;; is there total loss?
;; b. External canal - describe any edema, scaling, discharge.
;; c. Tympanic membrane - describe if immobile, perforated, or has other
;; abnormality.
;; d. Aural polyps - number.
;; e. Mastoids. Evidence of cholesteatoma?
;; f. Hearing loss - See audio examination protocol.
;; g. Evidence of middle ear infection (pain, edema, tenderness,
;; discharge (type), etc.).
;; h. Evidence of staggering gait or imbalance.
;; i. Complications and secondary results of ear disease, including
;; disturbance of balance, facial nerve paralysis, repeated upper
;; respiratory disease, hearing loss, tinnitus, bone loss of skull,
;; etc.
;;
;; 2. For neoplasm, describe any residuals of the neoplasm and its treatment.
;; 3. Other significant physical findings.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducted,
;; including audiologic and radiologic tests, in the examination report.
;;
;;E. Diagnosis:
;;
;; 1. If a peripheral vestibular disorder was found, what is the exact
;; diagnosis? Is the diagnosis based on tests or clinical findings? If
;; tests, please state which tests and results.
;; 2. Do any of the conditions diagnosed represent active ear disease (such
;; as current suppurative otitis media)? If so, please list which one(s).
;; 3. For each diagnosis, state effects of the condition on occupational
;; functioning and daily activities.
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWER5 4407 printed Dec 13, 2024@01:51 Page 2
DVBCWER5 ;ALB/RLC EAR DISEASE WKS TEXT - 1 ; 26 DEC 2006
+1 ;;2.7;AMIE;**170**;Apr 10, 1995;Build 1
+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. Date of onset of condition and circumstances and initial manifestations
+6 ;; of the disease or injury.
+7 ;; 2. Course since onset.
+8 ;; 3. Current treatment, response to treatment, and any side effects.
+9 ;; 4. History of related hospitalizations or surgery, dates and location, if
+10 ;; known, reason or type of surgery.
+11 ;; 5. History of trauma to the ear, with date, type of injury, and cause.
+12 ;; 6. Report any of the following symptoms that are present and provide
+13 ;; additional information as requested:
+14 ;;
+15 ;; a. Tinnitus, and state whether constant or recurrent.
+16 ;; b. Hearing loss, and state whether or not it is constant. If not,
+17 ;; state frequency and duration.
+18 ;; c. Balance or gait problems, and state whether or not constant. If
+19 ;; not, state frequency and duration.
+20 ;; d. Ear pain, and state location and whether or not constant. If not,
+21 ;; state frequency and duration.
+22 ;; e. Ear discharge, and state type of discharge and whether or not
+23 ;; constant. If not, state frequency and duration.
+24 ;; f. History of ear infection, and state date of last infection and
+25 ;; frequency.
+26 ;; g. Vertigo or dizziness, and state whether or not constant. If not,
+27 ;; state frequency and duration.
+28 ;; h. Pruritus of ear, and state whether or not constant. If not, state
+29 ;; frequency and duration.
+30 ;;
+31 ;; 7. Report history of military, occupational, and recreational noise
+32 ;; exposure.
+33 ;; 8. History of neoplasm of ear:
+34 ;;
+35 ;; a. Date of diagnosis, exact diagnosis, location.
+36 ;; b. Benign or malignant.
+37 ;; c. Types of treatment and dates.
+38 ;; d. Last date of treatment.
+39 ;; e. State whether treatment has been completed.
+40 ;;
+41 ;; 9. Other significant ear history.
+42 ;;
+43 ;;C. Physical Examination (Objective Findings):
+44 ;;
+45 ;; 1. Conduct an external and otoscopic examination. Address each
+46 ;; of the following and describe current findings, including
+47 ;; abnormalities of size, shape, or form:
+48 ;;
+49 ;; a. Auricle. State if there is any deformity. State if there is
+50 ;; tissue loss and extent - is it at least one-third of auricle lost,
+51 ;; is there total loss?
+52 ;; b. External canal - describe any edema, scaling, discharge.
+53 ;; c. Tympanic membrane - describe if immobile, perforated, or has other
+54 ;; abnormality.
+55 ;; d. Aural polyps - number.
+56 ;; e. Mastoids. Evidence of cholesteatoma?
+57 ;; f. Hearing loss - See audio examination protocol.
+58 ;; g. Evidence of middle ear infection (pain, edema, tenderness,
+59 ;; discharge (type), etc.).
+60 ;; h. Evidence of staggering gait or imbalance.
+61 ;; i. Complications and secondary results of ear disease, including
+62 ;; disturbance of balance, facial nerve paralysis, repeated upper
+63 ;; respiratory disease, hearing loss, tinnitus, bone loss of skull,
+64 ;; etc.
+65 ;;
+66 ;; 2. For neoplasm, describe any residuals of the neoplasm and its treatment.
+67 ;; 3. Other significant physical findings.
+68 ;;
+69 ;;D. Diagnostic and Clinical Tests:
+70 ;;
+71 ;; 1. Include results of all diagnostic and clinical tests conducted,
+72 ;; including audiologic and radiologic tests, in the examination report.
+73 ;;
+74 ;;E. Diagnosis:
+75 ;;
+76 ;; 1. If a peripheral vestibular disorder was found, what is the exact
+77 ;; diagnosis? Is the diagnosis based on tests or clinical findings? If
+78 ;; tests, please state which tests and results.
+79 ;; 2. Do any of the conditions diagnosed represent active ear disease (such
+80 ;; as current suppurative otitis media)? If so, please list which one(s).
+81 ;; 3. For each diagnosis, state effects of the condition on occupational
+82 ;; functioning and daily activities.
+83 ;;
+84 ;;
+85 ;;
+86 ;;Signature: Date:
+87 ;;END
