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 Sep 23, 2025@19:29:02 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
