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1DVBCWGE1 ;ALB/CMM GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Lethargy, weakness, anorexia, weight loss or gain.
14 ;;
15 ;;
16 ;; 2. Frequency (day or night, indicate voiding intervals),
17 ;; hesitancy, stream, dysuria.
18 ;;
19 ;;
20 ;; 3. Incontinence - if present, describe required frequency of
21 ;; absorbent material and whether an appliance is needed.
22 ;;
23 ;;
24 ;; 4. Provide details of any history of:
25 ;; a. Surgery on any part of the urinary tract. Residuals?
26 ;; Impotence?
27 ;;
28 ;;
29 ;; b. Recurrent urinary tract infections.
30 ;;
31 ;;
32 ;;
33 ;; c. Renal colic or bladder stones.
34 ;;
35 ;;
36 ;; d. Acute nephritis.
37 ;;
38 ;;
39 ;; e. Hospitalization for urinary tract disease, if so, how many
40 ;; in the past year?
41 ;;
42 ;;
43 ;; f. Treatment for malignancy, including type and date of last
44 ;; treatment.
45 ;;
46 ;;
47 ;; 5. Treatments.
48 ;;
49 ;; a. Is catheterization needed? Intermittent or continuous?
50 ;;
51 ;;
52 ;; b. Frequency of dilations?
53 ;;
54 ;;
55 ;; c. Drainage procedures.
56 ;;
57 ;;
58 ;; d. Diet therapy - specify.
59 ;;
60 ;;
61 ;; e. Medications.
62 ;;
63 ;;
64 ;; f. Frequency per year of invasive and noninvasive procedures.
65 ;;
66 ;;
67 ;; 6. Describe the effects of the condition(s) on the veteran's
68 ;; usual occupation and daily activities.
69 ;;
70 ;;
71 ;; For Male Loss of Use of a Creative Organ
72 ;; Comment on:
73 ;; 1. Trauma/surgery affecting penis/testicles (e.g. vasectomy?)
74 ;;
75 ;;
76 ;; 2. Local and/or systemic diseases affecting sexual function.
77 ;;
78 ;; a. Endocrine.
79 ;;
80 ;;
81 ;; b. Neurologic.
82 ;;
83 ;;
84 ;; c. Infections.
85 ;;
86 ;;
87 ;; d. Vascular.
88 ;;
89 ;;
90 ;; e. Psychological.
91 ;;
92 ;;
93 ;; 3. Symptoms: Vaginal penetration with ejaculation possible?
94 ;;
95 ;;
96 ;; 4. Past treatment:
97 ;;
98 ;; a. Medications, injections, implants, pump, counseling.
99 ;;
100 ;;
101 ;; b. Effectiveness in allowing intercourse.
102 ;;
103 ;;
104 ;;C. Physical Examination (Objective Findings):
105 ;;
106 ;; Address each of the following, as appropriate, to the condition
107 ;; being examined and fully describe current findings:
108 ;; 1. Blood pressure, cardiovascular examination, if indicated,
109 ;; describe edema, to include persistence.
110 ;;
111 ;;
112 ;; 2. If on dialysis, type, where done, and how often?
113 ;;
114 ;;
115 ;; 3. Inspection and palpation of penis, testicles, epididymis, and
116 ;; spermatic cord. If there is penis deformity, state whether
117 ;; there is loss of erectile power. Inspection of anus and
118 ;; digital exam of rectal walls, prostate, and seminal vesicles.
119 ;;
120 ;;
121 ;; 4. Fistula.
122 ;;
123 ;;
124 ;; 5. Specific residuals of genitourinary disease, including post-treatment
125 ;; residuals of malignancy.
126 ;;
127 ;;
128 ;; 6. Testicular atrophy - size and consistency.
129 ;;
130 ;;
131 ;; 7. Sensation and reflexes.
132 ;;
133 ;;
134 ;; 8. Peripheral pulses.
135 ;;
136 ;;
137 ;;D. Diagnostic and Clinical Tests:
138 ;;
139 ;; 1. CBC.
140 ;; 2. UA.
141 ;; 3. Creatinine, BUN, albumin, electrolytes.
142 ;; 4. Uroflowmetry, if indicated.
143 ;; 5. Measurement of post-void residual, if indicated.
144 ;; 6. Semen analysis, including sperm count and interpretation of
145 ;; results, if applicable.
146 ;; 7. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH,
147 ;; prolactin), if applicable.
148 ;; 8. Psychiatric evaluation, if applicable.
149 ;; 9. Include results of all diagnostic and clinical tests conducted
150 ;; in the examination report.
151 ;;
152 ;;
153 ;;E. Diagnosis:
154 ;;
155 ;;
156 ;;Signature: Date:
157 ;;END
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