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Routine: DVBCWGE5

DVBCWGE5.m

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  1. DVBCWGE5 ;ALB/RLC GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
  1.  ;;2.7;AMIE;**128**;Apr 10, 1995;Build 5
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records: 
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    Comment on:
  1.  ;;
  1.  ;;    1.  For renal dysfunctions, state whether each of the following symptoms
  1.  ;;        are present or absent: lethargy, weakness, anorexia and weight loss
  1.  ;;        or gain.
  1.  ;;    2.  Urinary flow: frequency (day or night, indicate voiding intervals
  1.  ;;        during the day and number of times during the night), hesitancy,
  1.  ;;        stream, dysuria.
  1.  ;;    3.  Incontinence - if present, describe required frequency of changing
  1.  ;;        absorbent material/day and/or whether or not an appliance is needed.
  1.  ;;    4.  Provide details of any history of:
  1.  ;;
  1.  ;;        a.  Surgery on any part of the urinary tract.  Residuals?  
  1.  ;;            Impotence?
  1.  ;;        b.  Recurrent urinary tract infections.
  1.  ;;        c.  Renal colic or bladder stones.
  1.  ;;        d.  Acute nephritis.
  1.  ;;        e.  Hospitalization for urinary tract disease, if so, diagnosis,
  1.  ;;            how many in the past year?
  1.  ;;        f.  Neoplasm-diagnosis, date of diagnosis, benign or malignant,
  1.  ;;            type and date of last treatment.
  1.  ;;
  1.  ;;    5.  Treatments.
  1.  ;;
  1.  ;;        a.  Is catheterization needed?  Intermittent or continuous?
  1.  ;;        b.  Dilations - Frequency of dilations?
  1.  ;;        c.  Drainage procedures.
  1.  ;;        d.  Diet therapy - specify.
  1.  ;;        e.  Medications.
  1.  ;;        f.  Frequency per year of invasive and noninvasive procedures.
  1.  ;;            Type of procedure.
  1.  ;;
  1.  ;;    6.  Describe the effects of the condition(s) on the
  1.  ;;        veteran's usual occupation and daily activities.
  1.  ;;    7.  If on dialysis, how often?
  1.  ;;    8.  For Males-Erectile dysfunction
  1.  ;;
  1.  ;;        Comment on:
  1.  ;;
  1.  ;;        a. Presence or absence.
  1.  ;;        b. Trauma/surgery affecting penis/testicles (e.g. vasectomy?).
  1.  ;;        c. Local and/or systemic diseases affecting sexual function.
  1.  ;;             i.   Endocrine.
  1.  ;;             ii.  Neurologic.
  1.  ;;             iii. Infections.
  1.  ;;             iv.  Vascular.
  1.  ;;             v.   Psychological.
  1.  ;;
  1.  ;;        d. Symptoms: Vaginal penetration with ejaculation possible?  Is
  1.  ;;           ejaculation retrograde?
  1.  ;;        e. Past treatment:
  1.  ;;             i.   Medications, injections, implants, pump, counseling.
  1.  ;;             ii.  Effective 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.  ;;    1.  Blood pressure, describe edema, to include persistence.
  1.  ;;
  1.  ;;        a. Cardiovascular examination, if indicated.
  1.  ;;
  1.  ;;    2.  For males: inspection and palpation of penis, testicles, epididymis,
  1.  ;;        and spermatic cord.  If there is penis deformity, state whether
  1.  ;;        there is loss of erectile power.  Inspection of anus and digital
  1.  ;;        exam of rectal walls, prostate, and seminal vesicles.
  1.  ;;    3.  Sensation and reflexes.
  1.  ;;    4.  Peripheral pulses.
  1.  ;;    5.  Fistula.
  1.  ;;    6.  Testicular atrophy - size and consistency.
  1.  ;;    7.  Any other residuals of genitourinary disease, including post-
  1.  ;;        treatment residuals of malignancy.
  1.  ;;
  1.  ;;D.  Diagnostic and Clinical Tests:
  1.  ;;
  1.  ;;    1.  CBC.
  1.  ;;    2.  UA, including microscopic analysis to assess for presence or
  1.  ;;        absence of hyaline casts, granular casts, and red blood cells.
  1.  ;;    3.  Creatinine, BUN, minimum, if renal dysfunction is an issue.
  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.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;Signature:                             Date:
  1.  ;;END