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Routine: DVBCWER5

DVBCWER5.m

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  1. DVBCWER5 ;ALB/RLC EAR DISEASE WKS TEXT - 1 ; 26 DEC 2006
  1.  ;;2.7;AMIE;**170**;Apr 10, 1995;Build 1
  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.  Date of onset of condition and circumstances and initial manifestations
  1.  ;;        of the disease or injury.
  1.  ;;    2.  Course since onset.
  1.  ;;    3.  Current treatment, response to treatment, and any side effects.
  1.  ;;    4.  History of related hospitalizations or surgery, dates and location, if
  1.  ;;        known, reason or type of surgery.
  1.  ;;    5.  History of trauma to the ear, with date, type of injury, and cause.
  1.  ;;    6.  Report any of the following symptoms that are present and provide
  1.  ;;        additional information as requested:
  1.  ;;
  1.  ;;        a.  Tinnitus, and state whether constant or recurrent.
  1.  ;;        b.  Hearing loss, and state whether or not it is constant.  If not,
  1.  ;;            state frequency and duration.
  1.  ;;        c.  Balance or gait problems, and state whether or not constant.  If
  1.  ;;            not, state frequency and duration.
  1.  ;;        d.  Ear pain, and state location and whether or not constant.  If not,
  1.  ;;            state frequency and duration.
  1.  ;;        e.  Ear discharge, and state type of discharge and whether or not
  1.  ;;            constant.  If not, state frequency and duration.
  1.  ;;        f.  History of ear infection, and state date of last infection and
  1.  ;;            frequency.
  1.  ;;        g.  Vertigo or dizziness, and state whether or not constant.  If not,
  1.  ;;            state frequency and duration.
  1.  ;;        h.  Pruritus of ear, and state whether or not constant.  If not, state
  1.  ;;            frequency and duration.
  1.  ;;
  1.  ;;    7.  Report history of military, occupational, and recreational noise
  1.  ;;        exposure.
  1.  ;;    8.  History of neoplasm of ear:
  1.  ;;
  1.  ;;        a.  Date of diagnosis, exact diagnosis, location.
  1.  ;;        b.  Benign or malignant.
  1.  ;;        c.  Types of treatment and dates.
  1.  ;;        d.  Last date of treatment.
  1.  ;;        e.  State whether treatment has been completed.
  1.  ;;
  1.  ;;    9.  Other significant ear history.
  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.  State if there is any deformity.  State if there is
  1.  ;;            tissue loss and extent - is it at least one-third of auricle lost,
  1.  ;;            is there total loss?
  1.  ;;        b.  External canal - describe any edema, scaling, discharge.
  1.  ;;        c.  Tympanic membrane - describe if immobile, perforated, or has other
  1.  ;;            abnormality.
  1.  ;;        d.  Aural polyps - number.
  1.  ;;        e.  Mastoids.  Evidence of cholesteatoma?
  1.  ;;        f.  Hearing loss - See audio examination protocol.
  1.  ;;        g.  Evidence of middle ear infection (pain, edema, tenderness,
  1.  ;;            discharge (type), etc.).
  1.  ;;        h.  Evidence of staggering gait or imbalance.
  1.  ;;        i.  Complications and secondary results of ear disease, including
  1.  ;;            disturbance of balance, facial nerve paralysis, repeated upper
  1.  ;;            respiratory disease, hearing loss, tinnitus, bone loss of skull,
  1.  ;;            etc.
  1.  ;;
  1.  ;;    2.  For neoplasm, describe any residuals of the neoplasm and its treatment.
  1.  ;;    3.  Other significant physical findings.
  1.  ;;
  1.  ;;D.  Diagnostic and Clinical Tests:
  1.  ;; 
  1.  ;;    1.  Include results of all diagnostic and clinical tests conducted,
  1.  ;;        including audiologic and radiologic tests, in the examination report.
  1.  ;;
  1.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;    1.  If a peripheral vestibular disorder was found, what is the exact
  1.  ;;        diagnosis?  Is the diagnosis based on tests or clinical findings?  If
  1.  ;;        tests, please state which tests and results.
  1.  ;;    2.  Do any of the conditions diagnosed represent active ear disease (such
  1.  ;;        as current suppurative otitis media)?  If so, please list which one(s).
  1.  ;;    3.  For each diagnosis, state effects of the condition on occupational
  1.  ;;        functioning and daily activities.
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;Signature:                             Date:
  1.  ;;END