75 lines
3.2 KiB
Mathematica
75 lines
3.2 KiB
Mathematica
DVBCWNW5 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 12 FEB 2007
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;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
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TXT ;
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;;A. Review of Medical Records:
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;;
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;;B. Medical History (Including Prior Treatment and Subjective Complaints):
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;;
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;; 1. Location and nature of the injury or disease.
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;; 2. Treatment - type,(i.e., surgery, medications, oxygen, respirator, etc.),
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;; frequency, duration, response, and side effects.
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;; 3. Subjective Complaints
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;;
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;; Comment on presence or absence of each of the following:
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;;
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;; a. Interference with breathing through nose.
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;; b. Purulent discharge.
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;; c. If speech impairment (ability to communicate by speech,
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;; ability to speak above a whisper, etc.).
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;; d. For chronic sinusitis, indicate whether pain, headaches, purulent
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;; discharge or crusting are present. Describe frequency of episodes.
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;; Number of incapacitating episodes per year (defined as requiring
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;; bedrest and treatment by a physician) necessitating prolonged
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;; (lasting 4-6 weeks) antibiotic treatment. Number of non-
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;; incapacitating episodes per year.
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;; e. Other symptoms reported.
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;;
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;; 4. Effects of condition on occupational functioning and daily activities.
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;; 5. History of neoplasm.
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;;
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;; a. Date of diagnosis, diagnosis.
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;; b. Benign or malignant.
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;; c. Type and dates of treatment.
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;; d. Date of last treatment.
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;;
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;;C. Physical Examination (Objective Findings):
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;;
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;; Perform complete examination of area affected by disease and/or injury.
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;; Report all findings. Additionally, comment on presence or absence of each
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;; of the following:
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;;
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;; 1. For allergic and vasomotor rhinitis, indicate whether nasal polyps
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;; are present.
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;; 2. For bacterial rhinitis: Indicate whether there is evidence of
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;; permanent hypertrophy of turbinates, granulomatous disease including
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;; rhinoscleroma.
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;; 3. When there is obstruction (partial or complete) of one or both
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;; nostrils, indicate percent of obstruction for each.
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;; 4. Is there septal deviation?
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;; 5. Is there tissue loss, scarring or deformity of the nose?
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;; 6. Sinusitis - Describe tenderness, purulent discharge, or crusting and
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;; sinus(es) affected.
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;; 7. For disease or injury affecting the soft palate, is there nasal
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;; regurgitation or speech impairment?
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;; 8. For larynx: Describe current appearance of larynx. Indicate whether
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;; there has been a laryngectomy, partial or total.
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;; 9. For pharynx: Describe any residuals of injury or disease.
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;;
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;;D. Diagnostic and Clinical Tests:
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;;
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;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
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;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
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;; 3. Include results of all diagnostic and clinical tests conducted
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;; in the examination report.
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;;
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;;E. Diagnosis:
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;;
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;; Comment on whether the disease primarily involves or originates
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;; from the nose, sinus, larynx, or pharynx.
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;;
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;;
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;;Signature: Date:
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;;END
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