source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNW1.m@ 1757

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1DVBCWNW1 ;ALB/CMM NOSE, SINUS, ETC WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Location and nature of the injury or disease.
14 ;;
15 ;;
16 ;; 2. Interference with breathing through nose.
17 ;;
18 ;;
19 ;; 3. Purulent discharge.
20 ;;
21 ;;
22 ;; 4. Dyspnea at rest or on exertion?
23 ;;
24 ;;
25 ;; 5. Treatments - type,(i.e., surgery, medications, oxygen,
26 ;; respirator, etc.), frequency, duration, response, and side effects.
27 ;;
28 ;;
29 ;; 6. If speech impairment (ability to communicate by speech,
30 ;; ability to speak above a whisper, etc.).
31 ;;
32 ;;
33 ;; 7. For chronic sinusitis, indicate which sinuses are affected and
34 ;; whether pain and headaches are present. Describe severity and
35 ;; frequency.
36 ;;
37 ;;
38 ;; 8. If allergic attacks, frequency and baseline status between attacks.
39 ;;
40 ;;
41 ;; 9. Other symptoms noted.
42 ;;
43 ;;
44 ;; 10. Describe frequency and duration of periods of incapacitation
45 ;; (defined as requiring bed rest and treatment by a physician).
46 ;;
47 ;;TOF
48 ;;C. Physical Examination (Objective Findings):
49 ;;
50 ;; Provide:
51 ;; 1. If there is nasal obstruction, indicate percent each nostril.
52 ;;
53 ;;
54 ;; 2. Sinusitis - Describe tenderness, purulent discharge, or crusting.
55 ;;
56 ;;
57 ;;D. Diagnostic and Clinical Tests:
58 ;;
59 ;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
60 ;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
61 ;; 3. Include results of all diagnostic and clinical tests conducted
62 ;; in the examination report.
63 ;;
64 ;;
65 ;;E. Diagnosis:
66 ;;
67 ;; Comment on whether the disease primarily involves or originates
68 ;; from the nose, sinus, larynx, or pharynx.
69 ;;
70 ;;
71 ;;Signature: Date:
72 ;;END
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