- DVBCWNW5 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 12 FEB 2007
- ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
- ;
- ;
- TXT ;
- ;;A. Review of Medical Records:
- ;;
- ;;B. Medical History (Including Prior Treatment and Subjective Complaints):
- ;;
- ;; 1. Location and nature of the injury or disease.
- ;; 2. Treatment - type,(i.e., surgery, medications, oxygen, respirator, etc.),
- ;; frequency, duration, response, and side effects.
- ;; 3. Subjective Complaints
- ;;
- ;; Comment on presence or absence of each of the following:
- ;;
- ;; a. Interference with breathing through nose.
- ;; b. Purulent discharge.
- ;; c. If speech impairment (ability to communicate by speech,
- ;; ability to speak above a whisper, etc.).
- ;; d. For chronic sinusitis, indicate whether pain, headaches, purulent
- ;; discharge or crusting are present. Describe frequency of episodes.
- ;; Number of incapacitating episodes per year (defined as requiring
- ;; bedrest and treatment by a physician) necessitating prolonged
- ;; (lasting 4-6 weeks) antibiotic treatment. Number of non-
- ;; incapacitating episodes per year.
- ;; e. Other symptoms reported.
- ;;
- ;; 4. Effects of condition on occupational functioning and daily activities.
- ;; 5. History of neoplasm.
- ;;
- ;; a. Date of diagnosis, diagnosis.
- ;; b. Benign or malignant.
- ;; c. Type and dates of treatment.
- ;; d. Date of last treatment.
- ;;
- ;;C. Physical Examination (Objective Findings):
- ;;
- ;; Perform complete examination of area affected by disease and/or injury.
- ;; Report all findings. Additionally, comment on presence or absence of each
- ;; of the following:
- ;;
- ;; 1. For allergic and vasomotor rhinitis, indicate whether nasal polyps
- ;; are present.
- ;; 2. For bacterial rhinitis: Indicate whether there is evidence of
- ;; permanent hypertrophy of turbinates, granulomatous disease including
- ;; rhinoscleroma.
- ;; 3. When there is obstruction (partial or complete) of one or both
- ;; nostrils, indicate percent of obstruction for each.
- ;; 4. Is there septal deviation?
- ;; 5. Is there tissue loss, scarring or deformity of the nose?
- ;; 6. Sinusitis - Describe tenderness, purulent discharge, or crusting and
- ;; sinus(es) affected.
- ;; 7. For disease or injury affecting the soft palate, is there nasal
- ;; regurgitation or speech impairment?
- ;; 8. For larynx: Describe current appearance of larynx. Indicate whether
- ;; there has been a laryngectomy, partial or total.
- ;; 9. For pharynx: Describe any residuals of injury or disease.
- ;;
- ;;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
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWNW5 3360 printed Jan 18, 2025@02:54:11 Page 2
- DVBCWNW5 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 12 FEB 2007
- +1 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
- +2 ;
- +3 ;
- TXT ;
- +1 ;;A. Review of Medical Records:
- +2 ;;
- +3 ;;B. Medical History (Including Prior Treatment and Subjective Complaints):
- +4 ;;
- +5 ;; 1. Location and nature of the injury or disease.
- +6 ;; 2. Treatment - type,(i.e., surgery, medications, oxygen, respirator, etc.),
- +7 ;; frequency, duration, response, and side effects.
- +8 ;; 3. Subjective Complaints
- +9 ;;
- +10 ;; Comment on presence or absence of each of the following:
- +11 ;;
- +12 ;; a. Interference with breathing through nose.
- +13 ;; b. Purulent discharge.
- +14 ;; c. If speech impairment (ability to communicate by speech,
- +15 ;; ability to speak above a whisper, etc.).
- +16 ;; d. For chronic sinusitis, indicate whether pain, headaches, purulent
- +17 ;; discharge or crusting are present. Describe frequency of episodes.
- +18 ;; Number of incapacitating episodes per year (defined as requiring
- +19 ;; bedrest and treatment by a physician) necessitating prolonged
- +20 ;; (lasting 4-6 weeks) antibiotic treatment. Number of non-
- +21 ;; incapacitating episodes per year.
- +22 ;; e. Other symptoms reported.
- +23 ;;
- +24 ;; 4. Effects of condition on occupational functioning and daily activities.
- +25 ;; 5. History of neoplasm.
- +26 ;;
- +27 ;; a. Date of diagnosis, diagnosis.
- +28 ;; b. Benign or malignant.
- +29 ;; c. Type and dates of treatment.
- +30 ;; d. Date of last treatment.
- +31 ;;
- +32 ;;C. Physical Examination (Objective Findings):
- +33 ;;
- +34 ;; Perform complete examination of area affected by disease and/or injury.
- +35 ;; Report all findings. Additionally, comment on presence or absence of each
- +36 ;; of the following:
- +37 ;;
- +38 ;; 1. For allergic and vasomotor rhinitis, indicate whether nasal polyps
- +39 ;; are present.
- +40 ;; 2. For bacterial rhinitis: Indicate whether there is evidence of
- +41 ;; permanent hypertrophy of turbinates, granulomatous disease including
- +42 ;; rhinoscleroma.
- +43 ;; 3. When there is obstruction (partial or complete) of one or both
- +44 ;; nostrils, indicate percent of obstruction for each.
- +45 ;; 4. Is there septal deviation?
- +46 ;; 5. Is there tissue loss, scarring or deformity of the nose?
- +47 ;; 6. Sinusitis - Describe tenderness, purulent discharge, or crusting and
- +48 ;; sinus(es) affected.
- +49 ;; 7. For disease or injury affecting the soft palate, is there nasal
- +50 ;; regurgitation or speech impairment?
- +51 ;; 8. For larynx: Describe current appearance of larynx. Indicate whether
- +52 ;; there has been a laryngectomy, partial or total.
- +53 ;; 9. For pharynx: Describe any residuals of injury or disease.
- +54 ;;
- +55 ;;D. Diagnostic and Clinical Tests:
- +56 ;;
- +57 ;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
- +58 ;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
- +59 ;; 3. Include results of all diagnostic and clinical tests conducted
- +60 ;; in the examination report.
- +61 ;;
- +62 ;;E. Diagnosis:
- +63 ;;
- +64 ;; Comment on whether the disease primarily involves or originates
- +65 ;; from the nose, sinus, larynx, or pharynx.
- +66 ;;
- +67 ;;
- +68 ;;Signature: Date:
- +69 ;;END