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Routine: DVBCWNW5

DVBCWNW5.m

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  1. DVBCWNW5 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 12 FEB 2007
  1. ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;B. Medical History (Including Prior Treatment and Subjective Complaints):
  1. ;;
  1. ;; 1. Location and nature of the injury or disease.
  1. ;; 2. Treatment - type,(i.e., surgery, medications, oxygen, respirator, etc.),
  1. ;; frequency, duration, response, and side effects.
  1. ;; 3. Subjective Complaints
  1. ;;
  1. ;; Comment on presence or absence of each of the following:
  1. ;;
  1. ;; a. Interference with breathing through nose.
  1. ;; b. Purulent discharge.
  1. ;; c. If speech impairment (ability to communicate by speech,
  1. ;; ability to speak above a whisper, etc.).
  1. ;; d. For chronic sinusitis, indicate whether pain, headaches, purulent
  1. ;; discharge or crusting are present. Describe frequency of episodes.
  1. ;; Number of incapacitating episodes per year (defined as requiring
  1. ;; bedrest and treatment by a physician) necessitating prolonged
  1. ;; (lasting 4-6 weeks) antibiotic treatment. Number of non-
  1. ;; incapacitating episodes per year.
  1. ;; e. Other symptoms reported.
  1. ;;
  1. ;; 4. Effects of condition on occupational functioning and daily activities.
  1. ;; 5. History of neoplasm.
  1. ;;
  1. ;; a. Date of diagnosis, diagnosis.
  1. ;; b. Benign or malignant.
  1. ;; c. Type and dates of treatment.
  1. ;; d. Date of last treatment.
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; Perform complete examination of area affected by disease and/or injury.
  1. ;; Report all findings. Additionally, comment on presence or absence of each
  1. ;; of the following:
  1. ;;
  1. ;; 1. For allergic and vasomotor rhinitis, indicate whether nasal polyps
  1. ;; are present.
  1. ;; 2. For bacterial rhinitis: Indicate whether there is evidence of
  1. ;; permanent hypertrophy of turbinates, granulomatous disease including
  1. ;; rhinoscleroma.
  1. ;; 3. When there is obstruction (partial or complete) of one or both
  1. ;; nostrils, indicate percent of obstruction for each.
  1. ;; 4. Is there septal deviation?
  1. ;; 5. Is there tissue loss, scarring or deformity of the nose?
  1. ;; 6. Sinusitis - Describe tenderness, purulent discharge, or crusting and
  1. ;; sinus(es) affected.
  1. ;; 7. For disease or injury affecting the soft palate, is there nasal
  1. ;; regurgitation or speech impairment?
  1. ;; 8. For larynx: Describe current appearance of larynx. Indicate whether
  1. ;; there has been a laryngectomy, partial or total.
  1. ;; 9. For pharynx: Describe any residuals of injury or disease.
  1. ;;
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
  1. ;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
  1. ;; 3. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;; Comment on whether the disease primarily involves or originates
  1. ;; from the nose, sinus, larynx, or pharynx.
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END