source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNW5.m@ 628

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