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Routine: DVBCWGE1

DVBCWGE1.m

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  1. DVBCWGE1 ;ALB/CMM GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
  1.  ;;2.7;AMIE;**12**;Apr 10, 1995
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records: 
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  1.  ;;
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  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    Comment on:
  1.  ;;    1.  Lethargy, weakness, anorexia, weight loss or gain.
  1.  ;;
  1.  ;;
  1.  ;;    2.  Frequency (day or night, indicate voiding intervals), 
  1.  ;;        hesitancy, stream, dysuria.
  1.  ;;
  1.  ;;
  1.  ;;    3.  Incontinence - if present, describe required frequency of 
  1.  ;;        absorbent material and whether an appliance is needed.
  1.  ;;
  1.  ;;
  1.  ;;    4.  Provide details of any history of:
  1.  ;;        a.  Surgery on any part of the urinary tract.  Residuals?  
  1.  ;;            Impotence?
  1.  ;;
  1.  ;;
  1.  ;;        b.  Recurrent urinary tract infections.
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  1.  ;;
  1.  ;;
  1.  ;;        c.  Renal colic or bladder stones.
  1.  ;;
  1.  ;;
  1.  ;;        d.  Acute nephritis.
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  1.  ;;
  1.  ;;        e.  Hospitalization for urinary tract disease, if so, how many
  1.  ;;            in the past year?
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  1.  ;;
  1.  ;;        f.  Treatment for malignancy, including type and date of last
  1.  ;;            treatment.
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  1.  ;;    5.  Treatments.
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  1.  ;;        a.  Is catheterization needed?  Intermittent or continuous?
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  1.  ;;
  1.  ;;        b.  Frequency of dilations?
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  1.  ;;        c.  Drainage procedures.
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  1.  ;;        d.  Diet therapy - specify.
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  1.  ;;        e.  Medications.
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  1.  ;;        f.  Frequency per year of invasive and noninvasive procedures.
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  1.  ;;    6.  Describe the effects of the condition(s) on the veteran's 
  1.  ;;        usual occupation and daily activities.
  1.  ;;
  1.  ;;
  1.  ;;    For Male Loss of Use of a Creative Organ
  1.  ;;    Comment on:
  1.  ;;    1.  Trauma/surgery affecting penis/testicles (e.g. vasectomy?)
  1.  ;;
  1.  ;;
  1.  ;;    2.  Local and/or systemic diseases affecting sexual function.
  1.  ;;
  1.  ;;        a.  Endocrine.
  1.  ;;
  1.  ;;
  1.  ;;        b.  Neurologic.
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  1.  ;;
  1.  ;;        c.  Infections.
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  1.  ;;
  1.  ;;        d.  Vascular.
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  1.  ;;
  1.  ;;        e.  Psychological.
  1.  ;;
  1.  ;;
  1.  ;;    3.  Symptoms:  Vaginal penetration with ejaculation possible?
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  1.  ;;    4.  Past treatment:
  1.  ;;
  1.  ;;        a.  Medications, injections, implants, pump, counseling.
  1.  ;;
  1.  ;;
  1.  ;;        b.  Effectiveness in allowing intercourse.
  1.  ;;
  1.  ;;
  1.  ;;C.  Physical Examination (Objective Findings):
  1.  ;;
  1.  ;;    Address each of the following, as appropriate, to the condition 
  1.  ;;    being examined and fully describe current findings:
  1.  ;;    1.  Blood pressure, cardiovascular examination, if indicated, 
  1.  ;;        describe edema, to include persistence.
  1.  ;;
  1.  ;;
  1.  ;;    2.  If on dialysis, type, where done, and how often?
  1.  ;;
  1.  ;;
  1.  ;;    3.  Inspection and palpation of penis, testicles, epididymis, and
  1.  ;;        spermatic cord.  If there is penis deformity, state whether 
  1.  ;;        there is loss of erectile power.  Inspection of anus and 
  1.  ;;        digital exam of rectal walls, prostate, and seminal vesicles.
  1.  ;;
  1.  ;;
  1.  ;;    4.  Fistula.
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  1.  ;;
  1.  ;;    5.  Specific residuals of genitourinary disease, including post-treatment 
  1.  ;;        residuals of malignancy.
  1.  ;;
  1.  ;;
  1.  ;;    6.  Testicular atrophy - size and consistency.
  1.  ;;
  1.  ;;
  1.  ;;    7.  Sensation and reflexes.
  1.  ;;
  1.  ;;
  1.  ;;    8.  Peripheral pulses.
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  1.  ;;
  1.  ;;D.  Diagnostic and Clinical Tests:
  1.  ;;
  1.  ;;    1.  CBC.
  1.  ;;    2.  UA.
  1.  ;;    3.  Creatinine, BUN, albumin, electrolytes.
  1.  ;;    4.  Uroflowmetry, if indicated.
  1.  ;;    5.  Measurement of post-void residual, if indicated.
  1.  ;;    6.  Semen analysis, including sperm count and interpretation of 
  1.  ;;        results, if applicable.
  1.  ;;    7.  Endocrine evaluation (glucose, TSH, testosterone, LH, FSH, 
  1.  ;;        prolactin), if applicable.
  1.  ;;    8.  Psychiatric evaluation, if applicable.
  1.  ;;    9.  Include results of all diagnostic and clinical tests conducted
  1.  ;;        in the examination report.
  1.  ;;
  1.  ;;
  1.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;
  1.  ;;Signature:                             Date:
  1.  ;;END