TN 23 (09-20)

DI 22510.045 Pediatric Consultative Examination (CE) Report Content Guidelines for Endocrine Disorders

Use the following guidelines to provide the minimum content in a CE report for a child disability case. Each Disability Determination Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for pediatric endocrine disorders

The CE report content guidelines in this section are in addition to the general pediatric CE report content guidelines in DI 22510.035. For additional CE policy in a child’s case, also see DI 25205.015.

B. Report content specific to pediatric endocrine disorders

The CE provider will use the specific requirements below to complete the CE report for an endocrine disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Fatigue;

  2. b. 

    Drowsiness;

  3. c. 

    Gastroparesis;

  4. d. 

    Any vision loss or other visual changes;

  5. e. 

    Heat or cold intolerance;

  6. f. 

    Sensory aberrations;

  7. g. 

    Hypoglycemia unawareness;

  8. h. 

    Convulsions, tetany, or episodes of alteration of consciousness;

  9. i. 

    Bone pain or localization of pain;

  10. j. 

    Increased thirst;

  11. k. 

    Abdominal pain;

  12. l. 

    Abnormal bowel or urinary tract changes, including change in frequency;

  13. m. 

    Growth failure or weight loss;

  14. n. 

    Hospitalizations due to diabetic ketoacidosis; and

  15. o. 

    Dates and results of relevant diagnostic procedures, such as CBC, liver enzymes, adrenal function, serum electrolytes, calcium and phosphorus, fasting blood glucose, glucose tolerance testing, Hb1AC, blood chemistries, T3, TSH, urinalysis, and relevant imaging studies.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

  1. a. 

    Abnormal sweating, dry skin, or changes in color or texture of skin;

  2. b. 

    Abnormal eye changes, such as exophthalmia, visual field loss, extra ocular muscle movement, and fundus changes (retinitis proliferens);

  3. c. 

    Abnormal masses of neck or abdomen;

  4. d. 

    Assessment of reflex activity and muscle strength;

  5. e. 

    Presence of tremulousness, Chvostek, or Trousseau signs; and

  6. f. 

    Mental status.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510045
DI 22510.045 - Pediatric Consultative Examination (CE) Report Content Guidelines for Endocrine Disorders - 01/14/2015
Batch run: 09/25/2020
Rev:01/14/2015