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