TN 22 (09-20)

DI 22510.109 Adult Consultative Examination (CE) Report Content Guidelines for Endocrine Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with endocrine disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report for adult endocrine disorders

The CE report guidelines for adult endocrine disorders are in addition to the general CE report content guidelines in DI 22510.100.

B. Report content specific to 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:

a. Heat or cold intolerance;

b. Sensory aberrations;

c. Any vision loss;

d. Convulsions, tetany, or episodes of alteration of consciousness;

e. Bone pain or localization of pain;

f. Abnormal bowel or urinary pattern; and

g. 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:

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

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

c. Abnormal masses of neck or abdomen;

d. Peripheral neuropathy – sensory or motor;

e. Presence of Chvostek or Trousseau signs; and

f. Mental status examination.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510109
DI 22510.109 - Adult Consultative Examination (CE) Report Content Guidelines for Endocrine Disorders - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020