source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWER1.m@ 1354

DVBCWER1 ;ALB/JAM EAR DISEASE WKS TEXT - 1 ; 6 MARCH 1997
 ;;2.7;AMIE;**26**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:  Indicate whether the C-file was reviewed.
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;    1.  Describe history of hearing loss, tinnitus, vertigo, balance or
 ;;        gait problems, discharge, pain, pruritus.  State onset and
 ;;        frequency and duration of each, if not constant.
 ;;
 ;;
 ;;    2.  Describe current or past treatment for ear conditions.
 ;;
 ;;
 ;;    3.  If a malignant neoplasm of the ear is or was present:
 ;;        a.  State date of confirmed diagnosis.
 ;;
 ;;
 ;;        b.  State date of the last surgical, X-ray, antineoplastic 
 ;;            chemotherapy, radiation, or other therapeutic procedure.
 ;;
 ;;
 ;;        c.  State expected date treatment regimen is to be completed.
 ;;
 ;;
 ;;        d.  If treatment is already completed, provide date of last 
 ;;            treatment.
 ;;
 ;;
 ;;        e.  If treatment is already completed, fully describe residuals.
 ;;
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    1.  Conduct an external and otoscopic examination.  Address each 
 ;;        of the following and describe current findings, including 
 ;;        abnormalities of size, shape, or form:
 ;;
 ;;        a.  Auricle.  Any deformity?  If there is tissue loss, state
 ;;            whether it is one-third or more of auricle.
 ;;
 ;;
 ;;        b.  External canal - describe any edema, scaling, discharge.
 ;;
 ;;
 ;;        c.  Tympanic membrane.
 ;;
 ;;
 ;;        d.  The tympanum.
 ;;
 ;;
 ;;        e.  Mastoids.  Discharge?  Evidence of cholesteatoma?
 ;;
 ;;
 ;;        f.  State all conditions secondary to ear disease, such as 
 ;;            disturbance of balance, upper respiratory disease, hearing
 ;;            loss, etc.
 ;;
 ;;
 ;;    2.  State whether an active ear disease is present.
 ;;
 ;;
 ;;    3.  Infections of the middle or inner ear.  Is there suppuration?
 ;;        Effusion?  Are aural polyps present?
 ;;
 ;;
 ;;   4.   For peripheral vestibular disorders, state the specific diagnosis
 ;;        and its basis, whether there is dizziness and how often, and 
 ;;        whether a staggering gait occurs and how often.
 ;;
 ;;
 ;;   5.   For Meniere's syndrome, state the symptoms, including the
 ;;        frequency of attacks of vertigo and cerebellar gait.  Is
 ;;        tinnitus present?  If so, how frequently and what is its
 ;;        duration?  Is there hearing loss? (See audio worksheet.)
 ;;
 ;;
 ;;  6.    Describe any complications of ear disease that are present.
 ;;
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;; 
 ;;    1.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END