source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGE5.m@ 628

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