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1DVBCWGE5 ;ALB/RLC GENITOURINARY EXAMINATION WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**128**;Apr 10, 1995;Build 5
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;;
12 ;; 1. For renal dysfunctions, state whether each of the following symptoms
13 ;; are present or absent: lethargy, weakness, anorexia and weight loss
14 ;; or gain.
15 ;; 2. Urinary flow: frequency (day or night, indicate voiding intervals
16 ;; during the day and number of times during the night), hesitancy,
17 ;; stream, dysuria.
18 ;; 3. Incontinence - if present, describe required frequency of changing
19 ;; absorbent material/day and/or whether or not an appliance is needed.
20 ;; 4. Provide details of any history of:
21 ;;
22 ;; a. Surgery on any part of the urinary tract. Residuals?
23 ;; Impotence?
24 ;; b. Recurrent urinary tract infections.
25 ;; c. Renal colic or bladder stones.
26 ;; d. Acute nephritis.
27 ;; e. Hospitalization for urinary tract disease, if so, diagnosis,
28 ;; how many in the past year?
29 ;; f. Neoplasm-diagnosis, date of diagnosis, benign or malignant,
30 ;; type and date of last treatment.
31 ;;
32 ;; 5. Treatments.
33 ;;
34 ;; a. Is catheterization needed? Intermittent or continuous?
35 ;; b. Dilations - Frequency of dilations?
36 ;; c. Drainage procedures.
37 ;; d. Diet therapy - specify.
38 ;; e. Medications.
39 ;; f. Frequency per year of invasive and noninvasive procedures.
40 ;; Type of procedure.
41 ;;
42 ;; 6. Describe the effects of the condition(s) on the
43 ;; veteran's usual occupation and daily activities.
44 ;; 7. If on dialysis, how often?
45 ;; 8. For Males-Erectile dysfunction
46 ;;
47 ;; Comment on:
48 ;;
49 ;; a. Presence or absence.
50 ;; b. Trauma/surgery affecting penis/testicles (e.g. vasectomy?).
51 ;; c. Local and/or systemic diseases affecting sexual function.
52 ;; i. Endocrine.
53 ;; ii. Neurologic.
54 ;; iii. Infections.
55 ;; iv. Vascular.
56 ;; v. Psychological.
57 ;;
58 ;; d. Symptoms: Vaginal penetration with ejaculation possible? Is
59 ;; ejaculation retrograde?
60 ;; e. Past treatment:
61 ;; i. Medications, injections, implants, pump, counseling.
62 ;; ii. Effective in allowing intercourse.
63 ;;
64 ;;
65 ;;C. Physical Examination (Objective Findings):
66 ;;
67 ;; Address each of the following, as appropriate, to the condition
68 ;; being examined and fully describe current findings:
69 ;;
70 ;; 1. Blood pressure, describe edema, to include persistence.
71 ;;
72 ;; a. Cardiovascular examination, if indicated.
73 ;;
74 ;; 2. For males: inspection and palpation of penis, testicles, epididymis,
75 ;; and spermatic cord. If there is penis deformity, state whether
76 ;; there is loss of erectile power. Inspection of anus and digital
77 ;; exam of rectal walls, prostate, and seminal vesicles.
78 ;; 3. Sensation and reflexes.
79 ;; 4. Peripheral pulses.
80 ;; 5. Fistula.
81 ;; 6. Testicular atrophy - size and consistency.
82 ;; 7. Any other residuals of genitourinary disease, including post-
83 ;; treatment residuals of malignancy.
84 ;;
85 ;;D. Diagnostic and Clinical Tests:
86 ;;
87 ;; 1. CBC.
88 ;; 2. UA, including microscopic analysis to assess for presence or
89 ;; absence of hyaline casts, granular casts, and red blood cells.
90 ;; 3. Creatinine, BUN, minimum, if renal dysfunction is an issue.
91 ;; 4. Uroflowmetry, if indicated.
92 ;; 5. Measurement of post-void residual, if indicated.
93 ;; 6. Semen analysis, including sperm count and interpretation of
94 ;; results, if applicable.
95 ;; 7. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH,
96 ;; prolactin), if applicable.
97 ;; 8. Psychiatric evaluation, if applicable.
98 ;; 9. Include results of all diagnostic and clinical tests conducted
99 ;; in the examination report.
100 ;;
101 ;;E. Diagnosis:
102 ;;
103 ;;
104 ;;
105 ;;Signature: Date:
106 ;;END
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