Genitourinary system

{Genitourinary system}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment
      
PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Urinary tract symptoms: 
[-] 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
[-] pruritus
[-] hiccup
[-] peripheral oedema

Gentialia:
[-] urethral discharge
[-] ulcers
[-] other lesions

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Associated symptoms:
[+] 
[-]

Treatment to date:
-

Diagnostic investigation results: 
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Female reproductive history: 
  Age of menarche: 
  Frequency/regularity: 
  Last period: 
  Reproductive history (G/P/M): 
[-] menorrhagia
[-] irregular periods
[-] intermenstrual spotting
[-] dysmenorrhoea
[-] dyspareunia
[-] post-coital bleeding
[-] vaginal discharge: 
[-] abnormal vaginal odour:

Male reproductive history: 
[-] urethral discharge
[-] change or lump in testis/es

Other history: 
[-] urinary tract infection/s: 
[-] nephrolithiasis
[-] urinary or pelvic surgery
[-] nephritis
[-] diabetes mellitus
[-] gout
[-] hypertension
[-] eclampsia
[-] analgesic use
[-] STI:

FAMILY HISTORY
Relevant family history:
[-] polycystic kidney disease
[-] renal failure
[-] nephrolithiasis
[-] gout

[Vital signs]

Skin colour: 
Temp (deg.C): 
HR (bpm): 
Heart rhythm: 
BP seated (mmHg): 
BP standing (mmHg): 
BP lying (mmHg): 
Respiratory rate (/min): 
SpO2 (%): 
Glasgow Coma Scale (/15):

PHYSICAL EXAMINATION
Abdominal examination: 
-

External genital examination: 
-

PV examination: 
-

[Urinalysis]

(-, +, ++, +++, ++++)
Protein: 
Glucose: 
Ketones: 
Bilirubin: 
WBC: 
Nitrite:

Urine pregnancy test (U-HCG):

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis:
-

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Genitourinary system

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