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1DVBCWER3 ;BPOIFO/RLC EAR DISEASE WKS TEXT - 1 ; 26 DEC 2006
2 ;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records: Indicate whether the C-file was reviewed.
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; 1. Describe history of hearing loss, tinnitus, vertigo, balance or
11 ;; gait problems, discharge, pain, pruritus. State onset and
12 ;; frequency and duration of each, if not constant.
13 ;; 2. Describe current or past treatment, response and side effects for
14 ;; ear conditions.
15 ;; 3. History of hospitalization or surgery (location, date if known and
16 ;; reason or type of surgery).
17 ;; 4. History of military, occupational and recreational noise exposure.
18 ;; 5. History of trauma to the ear(s).
19 ;; 6. Describe effects on occupational functioning and activities of
20 ;; daily living.
21 ;; 7. If a neoplasm of the ear is or was present:
22 ;;
23 ;; a. State date of confirmed diagnosis, diagnosis.
24 ;; b. Benign or malignant.
25 ;; c. State date of the last surgical, X-ray, antineoplastic
26 ;; chemotherapy, radiation, or other therapeutic procedure.
27 ;; d. State expected date treatment regimen is to be completed.
28 ;; e. If treatment is already completed, provide date of last
29 ;; treatment.
30 ;; f. If treatment is already completed, fully describe residuals.
31 ;;
32 ;;C. Physical Examination (Objective Findings):
33 ;;
34 ;; 1. Conduct an external and otoscopic examination. Address each
35 ;; of the following and describe current findings, including
36 ;; abnormalities of size, shape, or form:
37 ;;
38 ;; a. Auricle. Any deformity? If there is tissue loss, state
39 ;; whether it is one-third or more of auricle.
40 ;;
41 ;; b. External canal - describe any edema, scaling, discharge.
42 ;;
43 ;; c. Tympanic membrane.
44 ;;
45 ;; d. The tympanum.
46 ;;
47 ;; e. Mastoids. Discharge? Evidence of cholesteatoma?
48 ;;
49 ;; f. State all conditions secondary to ear disease, such as
50 ;; disturbance of balance, upper respiratory disease, hearing
51 ;; loss, etc.
52 ;;
53 ;; 2. State whether an active ear disease is present.
54 ;;
55 ;; 3. Infections of the middle or inner ear. Is there suppuration?
56 ;; Effusion? Are aural polyps present?
57 ;;
58 ;; 4. For peripheral vestibular disorders, state the specific diagnosis
59 ;; and its basis, whether there is dizziness and how often, and
60 ;; whether a staggering gait occurs and how often.
61 ;;
62 ;; 5. For Meniere's syndrome, state the symptoms, including the
63 ;; frequency of attacks of vertigo and cerebellar gait. Is
64 ;; tinnitus present? If so, how frequently and what is its
65 ;; duration? Is there hearing loss? (See audio worksheet.)
66 ;;
67 ;; 6. Describe any complications of ear disease that are present.
68 ;;
69 ;;D. Diagnostic and Clinical Tests:
70 ;;
71 ;; 1. Include results of all diagnostic and clinical tests conducted
72 ;; in the examination report.
73 ;;
74 ;;E. Diagnosis:
75 ;;
76 ;;
77 ;;Signature: Date:
78 ;;END
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