source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNW1.m@ 1800

DVBCWNW1 ;ALB/CMM NOSE, SINUS, ETC WKS TEXT - 1 ; 6 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Comment on:

 ;;    1.  Location and nature of the injury or disease.

 ;;

 ;;

 ;;    2.  Interference with breathing through nose.

 ;;

 ;;

 ;;    3.  Purulent discharge.

 ;;

 ;;

 ;;    4.  Dyspnea at rest or on exertion?

 ;;

 ;;

 ;;    5.  Treatments - type,(i.e., surgery, medications, oxygen, 

 ;;        respirator, etc.), frequency, duration, response, and side effects.

 ;;

 ;;

 ;;    6.  If speech impairment (ability to communicate by speech, 

 ;;        ability to speak above a whisper, etc.).

 ;;

 ;;

 ;;    7.  For chronic sinusitis, indicate which sinuses are affected and

 ;;        whether pain and headaches are present.  Describe severity and

 ;;        frequency.

 ;;

 ;;

 ;;    8.  If allergic attacks, frequency and baseline status between attacks.

 ;;

 ;;

 ;;    9.  Other symptoms noted.

 ;;

 ;;

 ;;   10.  Describe frequency and duration of periods of incapacitation 

 ;;        (defined as requiring bed rest and treatment by a physician).

 ;;

 ;;TOF

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Provide:

 ;;    1.  If there is nasal obstruction, indicate percent each nostril.

 ;;

 ;;

 ;;    2.  Sinusitis - Describe tenderness, purulent discharge, or crusting.

 ;;

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  If there is stenosis of larynx, order FEV-1 with flow-volume loop.

 ;;    2.  If there is facial disfigurement, order COLOR PHOTOGRAPHS.

 ;;    3.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;    Comment on whether the disease primarily involves or originates 

 ;;    from the nose, sinus, larynx, or pharynx.

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END