source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGE5.m@ 1211

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