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Routine: DVBCWNW5

DVBCWNW5.m

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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