Disability Examination Worksheets
Ear Disease
Name: |
SSN: |
Date of Exam: |
C-number: |
Place of Exam: |
A. Review of Medical Records: Indicate whether
the C-file was reviewed. B. Medical History (Subjective
Complaints):
- Describe history of hearing loss, tinnitus, vertigo, balance or
gait problems, discharge, pain, pruritus. State onset and frequency and
duration of each, if not constant.
- Describe current or past treatment, response and side effects for ear conditions.
- History of hospitalization or surgery (location, date if known and reason or type of surgery).
- History of military, occupational and recreational noise exposure.
- History of trauma to the ear(s).
- Describe effects on occupational functioning and activities of daily living.
- If a neoplasm of the ear is or was present:
- State date of confirmed diagnosis, diagnosis.
- Benign or malignant.
- State date of the last surgical, X-ray, antineoplastic
chemotherapy, radiation, or other therapeutic procedure.
- State expected date treatment regimen is to be
completed.
- If treatment is already completed, provide date of last
treatment.
- If treatment is already completed, fully describe
residuals.
C. Physical Examination (Objective
Findings):
- Conduct an external and otoscopic examination. Address each of
the following and describe current findings, including abnormalities of size,
shape, or form:
- Auricle. Any deformity? If there is tissue loss, state whether
it is one-third or more of auricle.
- External canal - describe any edema, scaling,
discharge.
- Tympanic membrane.
- The tympanum.
- Mastoids. Discharge? Evidence of cholesteatoma?
- State all conditions secondary to ear disease, such
as disturbance of balance, upper respiratory disease, hearing loss, etc.
- State whether an active ear disease is present.
- Infections of the middle or inner ear. Is there
suppuration? Effusion? Are aural polyps present?
- For peripheral vestibular disorders, state the specific
diagnosis and its basis, whether there is dizziness and how often, and whether
a staggering gait occurs and how often.
- For Menieres syndrome, state the symptoms,
including the frequency of attacks of vertigo and cerebellar gait. Is tinnitus
present? If so, how frequently and what is its duration? Is there hearing loss?
(See audio worksheet.)
- Describe any complications of ear disease that are
present.
D. Diagnostic and Clinical Tests:
1. Include results of all diagnostic and clinical tests
conducted in the examination report. E. Diagnosis:
Signature: |
![it says not signed](../../Images/compnsig.gif) |
Date: |
![it says not dated](../../Images/compndat.gif) |
|
|
|
Reviewed/Updated Date: December 15, 2008 |
|