©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWNW1 ;ALB/CMM NOSE, SINUS, ETC WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Location and nature of the injury or disease.
;;
;;
;; 2. Interference with breathing through nose.
;;
;;
;; 3. Purulent discharge.
;;
;;
;; 4. Dyspnea at rest or on exertion?
;;
;;
;; 5. Treatments - type,(i.e., surgery, medications, oxygen,
;; respirator, etc.), frequency, duration, response, and side effects.
;;
;;
;; 6. If speech impairment (ability to communicate by speech,
;; ability to speak above a whisper, etc.).
;;
;;
;; 7. For chronic sinusitis, indicate which sinuses are affected and
;; whether pain and headaches are present. Describe severity and
;; frequency.
;;
;;
;; 8. If allergic attacks, frequency and baseline status between attacks.
;;
;;
;; 9. Other symptoms noted.
;;
;;
;; 10. Describe frequency and duration of periods of incapacitation
;; (defined as requiring bed rest and treatment by a physician).
;;
;;TOF
;;C. Physical Examination (Objective Findings):
;;
;; Provide:
;; 1. If there is nasal obstruction, indicate percent each nostril.
;;
;;
;; 2. Sinusitis - Describe tenderness, purulent discharge, or crusting.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
;; 3. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; Comment on whether the disease primarily involves or originates
;; from the nose, sinus, larynx, or pharynx.
;;
;;
;;Signature: Date:
;;END