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Routine: DVBCWGE7

DVBCWGE7.m

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  1. DVBCWGE7 ;ALB/RLC GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
  1.  ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records: 
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    Comment on:
  1.  ;;
  1.  ;;    1.  Date and circumstances of onset, course since onset.
  1.  ;;    2.  History of hospitalizations or surgery (dates, location, if known, and
  1.  ;;        reason).
  1.  ;;    3.  History of genitourinary system trauma (type, location, dates).
  1.  ;;    4.  History of genitourinary neoplasm:
  1.  ;;
  1.  ;;        a. Date of diagnosis, exact diagnosis.
  1.  ;;        b. Benign or malignant.
  1.  ;;        c. Treatment, dates, and response.
  1.  ;;        d. Date of last treatment.
  1.  ;;        e. State if treatment has been completed, and, if not, expected date
  1.  ;;            of completion.
  1.  ;;
  1.  ;;    5.  Systemic symptoms, such as fever, chills, anorexia, nausea, vomiting,
  1.  ;;        lethargy, fatigue, weakness, flank or back pain, lower abdominal or
  1.  ;;        pelvic pain, etc.  Report cardiovascular symptoms, such as dyspnea,
  1.  ;;        angina, fatigue, syncope, edema.
  1.  ;;    6.  Urinary symptoms:  frequency (with daytime voiding interval), nocturia
  1.  ;;        (with number of voidings per night), dysuria, hesitancy/difficulty
  1.  ;;        starting stream, weak or intermittent stream, dysuria, straining,
  1.  ;;        hematuria, urethral discharge, dribbling, etc.
  1.  ;;    7.  Urinary leakage/incontinence:  Describe type, number of times per day
  1.  ;;        absorbent material, if needed, must be changed, and/or whether or not
  1.  ;;        an appliance is needed (and if constantly or intermittently needed).
  1.  ;;    8.  History of recurrent urinary tract infections (UTIs):  Number of
  1.  ;;        hospitalizations for infection during past 12 months, number of times
  1.  ;;        drainage was required during past 12 months, total duration of treat-
  1.  ;;        ment for UTI by medication during past 12 months, whether or not
  1.  ;;        intensive management is required (continuous, intermittent?).  State
  1.  ;;        whether long-term drug therapy is required.
  1.  ;;    9.  History of obstructed voiding:  Has obstruction caused recurrent UTIs
  1.  ;;        (number of infections in past 12 months)?  Is catheterization required
  1.  ;;        (intermittent?  constant?)?  Are dilations required (number per year)?
  1.  ;;        Are dilations needed for stricture?
  1.  ;;   10.  History of urinary tract stones:  Special diet prescribed?  Number of
  1.  ;;        invasive procedures during past 12 months?  Number of noninvasive
  1.  ;;        procedures during past 12 months?
  1.  ;;   11.  History of renal dysfunction or renal failure:  Is dialysis required?
  1.  ;;        (if yes, state number of times per week.)  Is more than sedentary
  1.  ;;        activity precluded?
  1.  ;;   12.  History of acute nephritis:  Describe residual symptoms and ongoing
  1.  ;;        treatment, if any.
  1.  ;;   13.  History of hydronephrosis:  Number of attacks of colic with infection
  1.  ;;        in past 12 months?  Has ureteral or kidney drainage been required?
  1.  ;;        (if yes, number of times in past 12 months.)
  1.  ;;   14.  For males:  Erectile dysfunction?  If yes, state most likely cause,
  1.  ;;        whether vaginal penetration is possible, current treatment, and its
  1.  ;;        effectiveness in allowing intercourse.  State whether ejaculation is
  1.  ;;        normal, absent, or retrograde, and if abnormal, most likely cause.
  1.  ;;   15.  Treatment:  medical and surgical, response, side effects.
  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.  Note:  if there is
  1.  ;;    hypertension or other cardiovascular disease that may be related to renal
  1.  ;;    disease, follow appropriate cardiovascular examination protocols.
  1.  ;;
  1.  ;;    1.  Vital signs.
  1.  ;;    2.  Describe abdominal or flank tenderness, abnormal bladder or urethra
  1.  ;;        (including fistulas), peripheral edema (extent and severity),
  1.  ;;        abnormalities of anus or rectal walls, perineal sensation, bulbo-
  1.  ;;        cavernosus reflex, peripheral pulses.
  1.  ;;    3.  For males:  Describe abnormality of penis, testicles, epididymis,
  1.  ;;        spermatic cord, scrotum, prostate, seminal vesicles, cremasteric
  1.  ;;        reflex.
  1.  ;;
  1.  ;;        a. If either testicle is abnormal, state size in relationship to
  1.  ;;        normal size or whether completely atrophic, report consistency,
  1.  ;;        tenderness, mass, etc.
  1.  ;;
  1.  ;;        b. If there is loss of part of penis, state whether there has been
  1.  ;;        loss or removal of glans, and overall extent of loss or removal of
  1.  ;;        penis.  If there is penis deformity, state whether there is loss of
  1.  ;;        erectile power.
  1.  ;;
  1.  ;;    4.  Report other significant findings of genitourinary disease, including
  1.  ;;        residuals of malignancy and its treatment.
  1.  ;;
  1.  ;;D.  Diagnostic and Clinical Tests:
  1.  ;;
  1.  ;;    Request the following tests, as applicable.  When renal dysfunction is
  1.  ;;    possible, BUN and creatinine are minimum tests required.
  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.  ;;        creatinine, BUN, albumin, sodium, potassium, chloride, glucose, CO2,
  1.  ;;        PSA.
  1.  ;;    3.  Uroflowmetry.
  1.  ;;    4.  Post-void residual.
  1.  ;;    5.  Semen analysis.
  1.  ;;    6.  Endocrine evaluation.
  1.  ;;    7.  Psychiatric evaluation.
  1.  ;;    8.  Include results of all diagnostic and clinical tests conducted
  1.  ;;        in the examination report.
  1.  ;;
  1.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;    1.  Describe the effects of the condition(s) on the veteran's usual
  1.  ;;        occupation and daily activities.
  1.  ;;
  1.  ;;
  1.  ;;Signature:                             Date:
  1.  ;;END