source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNW1.m@ 628

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