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1DVBCWNW5 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Including Prior Treatment and Subjective Complaints):
9 ;;
10 ;; 1. Location and nature of the injury or disease.
11 ;; 2. Treatment - type,(i.e., surgery, medications, oxygen, respirator, etc.),
12 ;; frequency, duration, response, and side effects.
13 ;; 3. Subjective Complaints
14 ;;
15 ;; Comment on presence or absence of each of the following:
16 ;;
17 ;; a. Interference with breathing through nose.
18 ;; b. Purulent discharge.
19 ;; c. If speech impairment (ability to communicate by speech,
20 ;; ability to speak above a whisper, etc.).
21 ;; d. For chronic sinusitis, indicate whether pain, headaches, purulent
22 ;; discharge or crusting are present. Describe frequency of episodes.
23 ;; Number of incapacitating episodes per year (defined as requiring
24 ;; bedrest and treatment by a physician) necessitating prolonged
25 ;; (lasting 4-6 weeks) antibiotic treatment. Number of non-
26 ;; incapacitating episodes per year.
27 ;; e. Other symptoms reported.
28 ;;
29 ;; 4. Effects of condition on occupational functioning and daily activities.
30 ;; 5. History of neoplasm.
31 ;;
32 ;; a. Date of diagnosis, diagnosis.
33 ;; b. Benign or malignant.
34 ;; c. Type and dates of treatment.
35 ;; d. Date of last treatment.
36 ;;
37 ;;C. Physical Examination (Objective Findings):
38 ;;
39 ;; Perform complete examination of area affected by disease and/or injury.
40 ;; Report all findings. Additionally, comment on presence or absence of each
41 ;; of the following:
42 ;;
43 ;; 1. For allergic and vasomotor rhinitis, indicate whether nasal polyps
44 ;; are present.
45 ;; 2. For bacterial rhinitis: Indicate whether there is evidence of
46 ;; permanent hypertrophy of turbinates, granulomatous disease including
47 ;; rhinoscleroma.
48 ;; 3. When there is obstruction (partial or complete) of one or both
49 ;; nostrils, indicate percent of obstruction for each.
50 ;; 4. Is there septal deviation?
51 ;; 5. Is there tissue loss, scarring or deformity of the nose?
52 ;; 6. Sinusitis - Describe tenderness, purulent discharge, or crusting and
53 ;; sinus(es) affected.
54 ;; 7. For disease or injury affecting the soft palate, is there nasal
55 ;; regurgitation or speech impairment?
56 ;; 8. For larynx: Describe current appearance of larynx. Indicate whether
57 ;; there has been a laryngectomy, partial or total.
58 ;; 9. For pharynx: Describe any residuals of injury or disease.
59 ;;
60 ;;D. Diagnostic and Clinical Tests:
61 ;;
62 ;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
63 ;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
64 ;; 3. Include results of all diagnostic and clinical tests conducted
65 ;; in the examination report.
66 ;;
67 ;;E. Diagnosis:
68 ;;
69 ;; Comment on whether the disease primarily involves or originates
70 ;; from the nose, sinus, larynx, or pharynx.
71 ;;
72 ;;
73 ;;Signature: Date:
74 ;;END
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