source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNW3.m@ 636

DVBCWNW3 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 30 MARCH 2005
 ;;2.7;AMIE;**93**;Aug 7, 2003
 ;
 ;
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.  Dyspnea at rest or on exertion?
 ;;
 ;;
 ;;        d.  If speech impairment (ability to communicate by speech, 
 ;;            ability to speak above a whisper, etc.).
 ;;
 ;;
 ;;        e.  For disease or injury affecting soft palate, is there nasal
 ;;            regurgitation or speech impairment?
 ;;
 ;;
 ;;        f.  For chronic sinusitis, indicate which sinuses are affected and
 ;;            whether pain and headaches are present.  Describe severity and
 ;;            frequency.
 ;;
 ;;
 ;;        g.  If allergic attacks, frequency and baseline status between attacks.
 ;;
 ;;
 ;;        h.  Other symptoms noted.
 ;;
 ;;
 ;;        i.  Describe frequency and duration of periods of incapacitation 
 ;;            (defined as requiring bed rest and treatment by a physician).
 ;;
 ;;
 ;;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
 ;;        granulomatous disease including rhinoscleroma.
 ;;
 ;;
 ;;    3.  When there is obstruction (partial or complete) of one or both
 ;;        nostrils, indicate percent of obstruction for each.
 ;;
 ;;
 ;;    4.  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