Genitourinary System

#Genitourinary System

S: Subjective

History: 
Urinary tract: 
(-) fever
(-) dysuria
(-) urinary frequency/urgency
(-) loin pain -> (-) right, (-) left

Urine: 
(-) haematuria
(-) cloudiness
(-) malodorous

Urinary obstruction: 
(-) hesitancy
(-) poor stream
(-) post micturition dribbling

Renal failure: 
(-) decreased urine output
(-) anuria
(-) polyuria
(-) nocturia
(-) nausea
(-) fatigue
(-) pruritis
(-) hiccup
(-) peripheral oedema

Gentialia:
(-) urethral discharge
(-) ulcers
(-) other lesions

Other Symptoms ->

Symptom Development: 
- Onset: 
- Variation: 
- Aggravating factors: 
- Relieving factors:

Female Reproductive History: 
(-) menorrhagia
(-) irregular periods
(-) intermenstrual spotting
(-) dysmenorrhoea
(-) dyspareunia
(-) post-coital bleeding
(-) vaginal discharge, description -> 
(-) abnormal vaginal odour ->

Age of menarche: 
Frequency/regularity: 
Last period: 
Reproductive history: G/P/M

Male Reproductive History: 
(-) urethral discharge
(-) change or lump in testis/es

Past History: 
(-) urinary tract infection/s -> 
(-) nephrolithiasis
(-) urinary or pelvic surgery
(-) nephritis
(-) diabetes mellitus
(-) gout
(-) hypertension
(-) eclampsia
(-) analgesic use
(-) STI ->

Family History: 
(-) polycystic renal disease
(-) renal failure
(-) nephrolithiasis
(-) gout

O: Objective

Examination: 
- Skin colour: 
- Heart rate (bpm): 
- Blood pressure (mmHg): 
- Temperature (deg. C):

- Height (m): 
- Weight (kg): 
- BMI (weight/height^2):

Abdominal Examination:

External Genital Examination:

PV Examination:

Urinalysis: 
(-) Protein
(-) Glucose
(-) Ketones
(-) Bilirubin
(-) WBC
(-) Nitrite

Investigation Findings:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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