DVBCWGE5 ;ALB/RLC GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**128**;Apr 10, 1995;Build 5
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. For renal dysfunctions, state whether each of the following symptoms
;; are present or absent: lethargy, weakness, anorexia and weight loss
;; or gain.
;; 2. Urinary flow: frequency (day or night, indicate voiding intervals
;; during the day and number of times during the night), hesitancy,
;; stream, dysuria.
;; 3. Incontinence - if present, describe required frequency of changing
;; absorbent material/day and/or whether or not an appliance is needed.
;; 4. Provide details of any history of:
;;
;; a. Surgery on any part of the urinary tract. Residuals?
;; Impotence?
;; b. Recurrent urinary tract infections.
;; c. Renal colic or bladder stones.
;; d. Acute nephritis.
;; e. Hospitalization for urinary tract disease, if so, diagnosis,
;; how many in the past year?
;; f. Neoplasm-diagnosis, date of diagnosis, benign or malignant,
;; type and date of last treatment.
;;
;; 5. Treatments.
;;
;; a. Is catheterization needed? Intermittent or continuous?
;; b. Dilations - Frequency of dilations?
;; c. Drainage procedures.
;; d. Diet therapy - specify.
;; e. Medications.
;; f. Frequency per year of invasive and noninvasive procedures.
;; Type of procedure.
;;
;; 6. Describe the effects of the condition(s) on the
;; veteran's usual occupation and daily activities.
;; 7. If on dialysis, how often?
;; 8. For Males-Erectile dysfunction
;;
;; Comment on:
;;
;; a. Presence or absence.
;; b. Trauma/surgery affecting penis/testicles (e.g. vasectomy?).
;; c. Local and/or systemic diseases affecting sexual function.
;; i. Endocrine.
;; ii. Neurologic.
;; iii. Infections.
;; iv. Vascular.
;; v. Psychological.
;;
;; d. Symptoms: Vaginal penetration with ejaculation possible? Is
;; ejaculation retrograde?
;; e. Past treatment:
;; i. Medications, injections, implants, pump, counseling.
;; ii. Effective in allowing intercourse.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following, as appropriate, to the condition
;; being examined and fully describe current findings:
;;
;; 1. Blood pressure, describe edema, to include persistence.
;;
;; a. Cardiovascular examination, if indicated.
;;
;; 2. For males: inspection and palpation of penis, testicles, epididymis,
;; and spermatic cord. If there is penis deformity, state whether
;; there is loss of erectile power. Inspection of anus and digital
;; exam of rectal walls, prostate, and seminal vesicles.
;; 3. Sensation and reflexes.
;; 4. Peripheral pulses.
;; 5. Fistula.
;; 6. Testicular atrophy - size and consistency.
;; 7. Any other residuals of genitourinary disease, including post-
;; treatment residuals of malignancy.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. CBC.
;; 2. UA, including microscopic analysis to assess for presence or
;; absence of hyaline casts, granular casts, and red blood cells.
;; 3. Creatinine, BUN, minimum, if renal dysfunction is an issue.
;; 4. Uroflowmetry, if indicated.
;; 5. Measurement of post-void residual, if indicated.
;; 6. Semen analysis, including sperm count and interpretation of
;; results, if applicable.
;; 7. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH,
;; prolactin), if applicable.
;; 8. Psychiatric evaluation, if applicable.
;; 9. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;E. Diagnosis:
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWGE5 4329 printed Dec 13, 2024@01:51:20 Page 2
DVBCWGE5 ;ALB/RLC GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
+1 ;;2.7;AMIE;**128**;Apr 10, 1995;Build 5
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. For renal dysfunctions, state whether each of the following symptoms
+8 ;; are present or absent: lethargy, weakness, anorexia and weight loss
+9 ;; or gain.
+10 ;; 2. Urinary flow: frequency (day or night, indicate voiding intervals
+11 ;; during the day and number of times during the night), hesitancy,
+12 ;; stream, dysuria.
+13 ;; 3. Incontinence - if present, describe required frequency of changing
+14 ;; absorbent material/day and/or whether or not an appliance is needed.
+15 ;; 4. Provide details of any history of:
+16 ;;
+17 ;; a. Surgery on any part of the urinary tract. Residuals?
+18 ;; Impotence?
+19 ;; b. Recurrent urinary tract infections.
+20 ;; c. Renal colic or bladder stones.
+21 ;; d. Acute nephritis.
+22 ;; e. Hospitalization for urinary tract disease, if so, diagnosis,
+23 ;; how many in the past year?
+24 ;; f. Neoplasm-diagnosis, date of diagnosis, benign or malignant,
+25 ;; type and date of last treatment.
+26 ;;
+27 ;; 5. Treatments.
+28 ;;
+29 ;; a. Is catheterization needed? Intermittent or continuous?
+30 ;; b. Dilations - Frequency of dilations?
+31 ;; c. Drainage procedures.
+32 ;; d. Diet therapy - specify.
+33 ;; e. Medications.
+34 ;; f. Frequency per year of invasive and noninvasive procedures.
+35 ;; Type of procedure.
+36 ;;
+37 ;; 6. Describe the effects of the condition(s) on the
+38 ;; veteran's usual occupation and daily activities.
+39 ;; 7. If on dialysis, how often?
+40 ;; 8. For Males-Erectile dysfunction
+41 ;;
+42 ;; Comment on:
+43 ;;
+44 ;; a. Presence or absence.
+45 ;; b. Trauma/surgery affecting penis/testicles (e.g. vasectomy?).
+46 ;; c. Local and/or systemic diseases affecting sexual function.
+47 ;; i. Endocrine.
+48 ;; ii. Neurologic.
+49 ;; iii. Infections.
+50 ;; iv. Vascular.
+51 ;; v. Psychological.
+52 ;;
+53 ;; d. Symptoms: Vaginal penetration with ejaculation possible? Is
+54 ;; ejaculation retrograde?
+55 ;; e. Past treatment:
+56 ;; i. Medications, injections, implants, pump, counseling.
+57 ;; ii. Effective in allowing intercourse.
+58 ;;
+59 ;;
+60 ;;C. Physical Examination (Objective Findings):
+61 ;;
+62 ;; Address each of the following, as appropriate, to the condition
+63 ;; being examined and fully describe current findings:
+64 ;;
+65 ;; 1. Blood pressure, describe edema, to include persistence.
+66 ;;
+67 ;; a. Cardiovascular examination, if indicated.
+68 ;;
+69 ;; 2. For males: inspection and palpation of penis, testicles, epididymis,
+70 ;; and spermatic cord. If there is penis deformity, state whether
+71 ;; there is loss of erectile power. Inspection of anus and digital
+72 ;; exam of rectal walls, prostate, and seminal vesicles.
+73 ;; 3. Sensation and reflexes.
+74 ;; 4. Peripheral pulses.
+75 ;; 5. Fistula.
+76 ;; 6. Testicular atrophy - size and consistency.
+77 ;; 7. Any other residuals of genitourinary disease, including post-
+78 ;; treatment residuals of malignancy.
+79 ;;
+80 ;;D. Diagnostic and Clinical Tests:
+81 ;;
+82 ;; 1. CBC.
+83 ;; 2. UA, including microscopic analysis to assess for presence or
+84 ;; absence of hyaline casts, granular casts, and red blood cells.
+85 ;; 3. Creatinine, BUN, minimum, if renal dysfunction is an issue.
+86 ;; 4. Uroflowmetry, if indicated.
+87 ;; 5. Measurement of post-void residual, if indicated.
+88 ;; 6. Semen analysis, including sperm count and interpretation of
+89 ;; results, if applicable.
+90 ;; 7. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH,
+91 ;; prolactin), if applicable.
+92 ;; 8. Psychiatric evaluation, if applicable.
+93 ;; 9. Include results of all diagnostic and clinical tests conducted
+94 ;; in the examination report.
+95 ;;
+96 ;;E. Diagnosis:
+97 ;;
+98 ;;
+99 ;;
+100 ;;Signature: Date:
+101 ;;END
