DVBCWGE7 ;ALB/RLC GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. Date and circumstances of onset, course since onset.
;; 2. History of hospitalizations or surgery (dates, location, if known, and
;; reason).
;; 3. History of genitourinary system trauma (type, location, dates).
;; 4. History of genitourinary neoplasm:
;;
;; a. Date of diagnosis, exact diagnosis.
;; b. Benign or malignant.
;; c. Treatment, dates, and response.
;; d. Date of last treatment.
;; e. State if treatment has been completed, and, if not, expected date
;; of completion.
;;
;; 5. Systemic symptoms, such as fever, chills, anorexia, nausea, vomiting,
;; lethargy, fatigue, weakness, flank or back pain, lower abdominal or
;; pelvic pain, etc. Report cardiovascular symptoms, such as dyspnea,
;; angina, fatigue, syncope, edema.
;; 6. Urinary symptoms: frequency (with daytime voiding interval), nocturia
;; (with number of voidings per night), dysuria, hesitancy/difficulty
;; starting stream, weak or intermittent stream, dysuria, straining,
;; hematuria, urethral discharge, dribbling, etc.
;; 7. Urinary leakage/incontinence: Describe type, number of times per day
;; absorbent material, if needed, must be changed, and/or whether or not
;; an appliance is needed (and if constantly or intermittently needed).
;; 8. History of recurrent urinary tract infections (UTIs): Number of
;; hospitalizations for infection during past 12 months, number of times
;; drainage was required during past 12 months, total duration of treat-
;; ment for UTI by medication during past 12 months, whether or not
;; intensive management is required (continuous, intermittent?). State
;; whether long-term drug therapy is required.
;; 9. History of obstructed voiding: Has obstruction caused recurrent UTIs
;; (number of infections in past 12 months)? Is catheterization required
;; (intermittent? constant?)? Are dilations required (number per year)?
;; Are dilations needed for stricture?
;; 10. History of urinary tract stones: Special diet prescribed? Number of
;; invasive procedures during past 12 months? Number of noninvasive
;; procedures during past 12 months?
;; 11. History of renal dysfunction or renal failure: Is dialysis required?
;; (if yes, state number of times per week.) Is more than sedentary
;; activity precluded?
;; 12. History of acute nephritis: Describe residual symptoms and ongoing
;; treatment, if any.
;; 13. History of hydronephrosis: Number of attacks of colic with infection
;; in past 12 months? Has ureteral or kidney drainage been required?
;; (if yes, number of times in past 12 months.)
;; 14. For males: Erectile dysfunction? If yes, state most likely cause,
;; whether vaginal penetration is possible, current treatment, and its
;; effectiveness in allowing intercourse. State whether ejaculation is
;; normal, absent, or retrograde, and if abnormal, most likely cause.
;; 15. Treatment: medical and surgical, response, side effects.
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following, as appropriate, to the condition
;; being examined and fully describe current findings. Note: if there is
;; hypertension or other cardiovascular disease that may be related to renal
;; disease, follow appropriate cardiovascular examination protocols.
;;
;; 1. Vital signs.
;; 2. Describe abdominal or flank tenderness, abnormal bladder or urethra
;; (including fistulas), peripheral edema (extent and severity),
;; abnormalities of anus or rectal walls, perineal sensation, bulbo-
;; cavernosus reflex, peripheral pulses.
;; 3. For males: Describe abnormality of penis, testicles, epididymis,
;; spermatic cord, scrotum, prostate, seminal vesicles, cremasteric
;; reflex.
;;
;; a. If either testicle is abnormal, state size in relationship to
;; normal size or whether completely atrophic, report consistency,
;; tenderness, mass, etc.
;;
;; b. If there is loss of part of penis, state whether there has been
;; loss or removal of glans, and overall extent of loss or removal of
;; penis. If there is penis deformity, state whether there is loss of
;; erectile power.
;;
;; 4. Report other significant findings of genitourinary disease, including
;; residuals of malignancy and its treatment.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; Request the following tests, as applicable. When renal dysfunction is
;; possible, BUN and creatinine are minimum tests required.
;;
;; 1. CBC.
;; 2. UA - including microscopic analysis to assess for presence or
;; absence of hyaline casts, granular casts, and red blood cells,
;; creatinine, BUN, albumin, sodium, potassium, chloride, glucose, CO2,
;; PSA.
;; 3. Uroflowmetry.
;; 4. Post-void residual.
;; 5. Semen analysis.
;; 6. Endocrine evaluation.
;; 7. Psychiatric evaluation.
;; 8. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;E. Diagnosis:
;;
;; 1. Describe the effects of the condition(s) on the veteran's usual
;; occupation and daily activities.
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWGE7 5950 printed Oct 16, 2024@17:52:12 Page 2
DVBCWGE7 ;ALB/RLC GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
+1 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. Date and circumstances of onset, course since onset.
+8 ;; 2. History of hospitalizations or surgery (dates, location, if known, and
+9 ;; reason).
+10 ;; 3. History of genitourinary system trauma (type, location, dates).
+11 ;; 4. History of genitourinary neoplasm:
+12 ;;
+13 ;; a. Date of diagnosis, exact diagnosis.
+14 ;; b. Benign or malignant.
+15 ;; c. Treatment, dates, and response.
+16 ;; d. Date of last treatment.
+17 ;; e. State if treatment has been completed, and, if not, expected date
+18 ;; of completion.
+19 ;;
+20 ;; 5. Systemic symptoms, such as fever, chills, anorexia, nausea, vomiting,
+21 ;; lethargy, fatigue, weakness, flank or back pain, lower abdominal or
+22 ;; pelvic pain, etc. Report cardiovascular symptoms, such as dyspnea,
+23 ;; angina, fatigue, syncope, edema.
+24 ;; 6. Urinary symptoms: frequency (with daytime voiding interval), nocturia
+25 ;; (with number of voidings per night), dysuria, hesitancy/difficulty
+26 ;; starting stream, weak or intermittent stream, dysuria, straining,
+27 ;; hematuria, urethral discharge, dribbling, etc.
+28 ;; 7. Urinary leakage/incontinence: Describe type, number of times per day
+29 ;; absorbent material, if needed, must be changed, and/or whether or not
+30 ;; an appliance is needed (and if constantly or intermittently needed).
+31 ;; 8. History of recurrent urinary tract infections (UTIs): Number of
+32 ;; hospitalizations for infection during past 12 months, number of times
+33 ;; drainage was required during past 12 months, total duration of treat-
+34 ;; ment for UTI by medication during past 12 months, whether or not
+35 ;; intensive management is required (continuous, intermittent?). State
+36 ;; whether long-term drug therapy is required.
+37 ;; 9. History of obstructed voiding: Has obstruction caused recurrent UTIs
+38 ;; (number of infections in past 12 months)? Is catheterization required
+39 ;; (intermittent? constant?)? Are dilations required (number per year)?
+40 ;; Are dilations needed for stricture?
+41 ;; 10. History of urinary tract stones: Special diet prescribed? Number of
+42 ;; invasive procedures during past 12 months? Number of noninvasive
+43 ;; procedures during past 12 months?
+44 ;; 11. History of renal dysfunction or renal failure: Is dialysis required?
+45 ;; (if yes, state number of times per week.) Is more than sedentary
+46 ;; activity precluded?
+47 ;; 12. History of acute nephritis: Describe residual symptoms and ongoing
+48 ;; treatment, if any.
+49 ;; 13. History of hydronephrosis: Number of attacks of colic with infection
+50 ;; in past 12 months? Has ureteral or kidney drainage been required?
+51 ;; (if yes, number of times in past 12 months.)
+52 ;; 14. For males: Erectile dysfunction? If yes, state most likely cause,
+53 ;; whether vaginal penetration is possible, current treatment, and its
+54 ;; effectiveness in allowing intercourse. State whether ejaculation is
+55 ;; normal, absent, or retrograde, and if abnormal, most likely cause.
+56 ;; 15. Treatment: medical and surgical, response, side effects.
+57 ;;
+58 ;;C. Physical Examination (Objective Findings):
+59 ;;
+60 ;; Address each of the following, as appropriate, to the condition
+61 ;; being examined and fully describe current findings. Note: if there is
+62 ;; hypertension or other cardiovascular disease that may be related to renal
+63 ;; disease, follow appropriate cardiovascular examination protocols.
+64 ;;
+65 ;; 1. Vital signs.
+66 ;; 2. Describe abdominal or flank tenderness, abnormal bladder or urethra
+67 ;; (including fistulas), peripheral edema (extent and severity),
+68 ;; abnormalities of anus or rectal walls, perineal sensation, bulbo-
+69 ;; cavernosus reflex, peripheral pulses.
+70 ;; 3. For males: Describe abnormality of penis, testicles, epididymis,
+71 ;; spermatic cord, scrotum, prostate, seminal vesicles, cremasteric
+72 ;; reflex.
+73 ;;
+74 ;; a. If either testicle is abnormal, state size in relationship to
+75 ;; normal size or whether completely atrophic, report consistency,
+76 ;; tenderness, mass, etc.
+77 ;;
+78 ;; b. If there is loss of part of penis, state whether there has been
+79 ;; loss or removal of glans, and overall extent of loss or removal of
+80 ;; penis. If there is penis deformity, state whether there is loss of
+81 ;; erectile power.
+82 ;;
+83 ;; 4. Report other significant findings of genitourinary disease, including
+84 ;; residuals of malignancy and its treatment.
+85 ;;
+86 ;;D. Diagnostic and Clinical Tests:
+87 ;;
+88 ;; Request the following tests, as applicable. When renal dysfunction is
+89 ;; possible, BUN and creatinine are minimum tests required.
+90 ;;
+91 ;; 1. CBC.
+92 ;; 2. UA - including microscopic analysis to assess for presence or
+93 ;; absence of hyaline casts, granular casts, and red blood cells,
+94 ;; creatinine, BUN, albumin, sodium, potassium, chloride, glucose, CO2,
+95 ;; PSA.
+96 ;; 3. Uroflowmetry.
+97 ;; 4. Post-void residual.
+98 ;; 5. Semen analysis.
+99 ;; 6. Endocrine evaluation.
+100 ;; 7. Psychiatric evaluation.
+101 ;; 8. Include results of all diagnostic and clinical tests conducted
+102 ;; in the examination report.
+103 ;;
+104 ;;E. Diagnosis:
+105 ;;
+106 ;; 1. Describe the effects of the condition(s) on the veteran's usual
+107 ;; occupation and daily activities.
+108 ;;
+109 ;;
+110 ;;Signature: Date:
+111 ;;END
