Urologist-Vorlage
Urology CNS - OSC PSA
Eine professionelle Urologist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise way to document urology consultations? This 'Urology CNS - OSC PSA' template is designed for urologists and clinical nurse specialists. It helps streamline the documentation process, capturing essential information like presenting complaints, medical history, examination findings, and management plans. This template is perfect for recording details of PSA results, eGFR readings and other relevant clinical information. With Heidi, this template can be quickly populated from your consultation transcript, saving you time and ensuring comprehensive patient records. Simplify your urology documentation with this efficient template.
Vorlagenvorschau
Responsible Consultant: Dr. Eleanor Vance
Presenting Complaint: PSA readings 6.2 ng/mL, dated 28 October 2024. eGFR readings 65 mL/min/1.73m², dated 28 October 2024.
History of Presenting Complaint: 68-year-old male presenting with increased urinary frequency and nocturia over the past 6 months. Reports needing to urinate every 1-2 hours during the day and 2-3 times per night. No urgency, incontinence, dysuria, or haematuria. Flow is slightly reduced, no hesitancy or straining. No terminal dribbling or sensation of incomplete emptying. No PR bleeding. Appetite and weight stable. No pain.
Past Medical History: Hypertension, managed with Lisinopril 10mg daily. Previous appendectomy in 1982.
Allergies: None known.
Medications: Lisinopril 10mg daily.
Social History: Retired accountant. Lives with wife. Drinks alcohol socially, approximately 2-3 units per week. Non-smoker. Good performance status.
Family History: Father had prostate cancer diagnosed at age 75.
Examination:
- Chaperone: Nurse present.
- DRE: Prostate feels enlarged, smooth, and non-tender.
Observations:
- BP: 138/82 mmHg
- HR: 78 bpm
- SpO2: 98% on room air
Plan: Discussed the findings with the patient. Advised further investigations including repeat PSA in 3 months and consideration of further imaging if PSA continues to rise. Discussed lifestyle modifications to manage symptoms. Will review in clinic in 3 months.
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