source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWCN3.m@ 1361

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[613]1DVBCWCN3 ;ALB/RLC CRANIAL NERVES 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 (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;;
12 ;; 1. Onset, course since onset.
13 ;; 2. Symptoms.
14 ;; 3. Current treatment, response, side effects.
15 ;; 4. Effects of condition on occupational functioning and daily activities.
16 ;; 5. History of hospitalizations or surgery, location and dates, if known,
17 ;; reason or type of surgery.
18 ;; 6. History of trauma to a cranial nerve, date, type, nerve.
19 ;; 7. History of neoplasm:
20 ;;
21 ;; a. Date of diagnosis, diagnosis.
22 ;; b. Benign or malignant.
23 ;; c. Types of treatment, dates.
24 ;; d. Last date of treatment.
25 ;;
26 ;;C. Physical Examination (Objective Findings):
27 ;;
28 ;; Address each of the following and fully describe current findings:
29 ;;
30 ;; 1. Describe in detail specific motor and sensory impairment, quantifying
31 ;; as much as possible.
32 ;; 2. If smell or taste is affected, please also complete the appropriate
33 ;; worksheet.
34 ;;
35 ;;D. Diagnostic and Clinical Tests:
36 ;;
37 ;; 1. Include results of all diagnostic and clinical tests conducted
38 ;; in the examination report.
39 ;;
40 ;;E. Diagnosis:
41 ;;
42 ;; 1. Identify the nerve and the side.
43 ;; 2. Identify the disorder (i.e., paralysis, neuritis, neuralgia).
44 ;; 3. State etiology.
45 ;;
46 ;;
47 ;;Signature: Date:
48 ;;END
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