Urogynaecologist Template
Gynaecology Consultation Note
A professional Urogynaecologist template for healthcare professionals.
About this template
Streamline your gynaecology consultations with our dedicated Gynaecology Consultation Note template. Perfect for Urogynaecologists and general gynaecologists, this comprehensive template helps you capture essential patient information efficiently. Document presenting issues, clinical findings, treatment plans, and detailed gynaecological history, including gravida and parity. Easily record medication lists, social history, and examination findings to ensure a thorough and accurate patient record. Heidi, our AI medical scribe, intelligently populates relevant sections from your consultation, making documentation quicker and more precise. Enhance your clinical workflow and maintain high-quality patient notes with this indispensable tool for managing gynaecological health.
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Gynaecology Consultation Note
Issues:
* Pelvic organ prolapse (POP) with reported sensation of a bulge.
* Stress urinary incontinence (SUI).
* Anterior vaginal wall prolapse – Grade 2; Uterine prolapse – Grade 1.
* Previous laparoscopic appendectomy (2010).
Plan:
* Proceed with pelvic floor physiotherapy (PFP) for 12 weeks.
* Prescribe Ovestin cream 0.5mg/g, apply twice weekly.
* Discuss surgical options for prolapse and SUI if PFP is unsuccessful, including sacrohysteropexy and tension-free vaginal tape (TVT) procedure.
* Refer for urodynamic studies.
Age:
58 years
Gynaecology History:
* Hysterectomy for fibroids in 2005.
* Gravida 2, Parity 2 (two successful full-term vaginal deliveries in 1990 and 1993).
Gynaecology Issues:
* "Something coming down" sensation in the vagina for the past 6 months, worse with standing and coughing.
* Leaking urine with coughs, sneezes, and exercise (SUI).
* No dyspareunia or abnormal bleeding.
Abdo infxn/surgeries:
* Laparoscopic appendectomy (2010) – uneventful recovery.
* No history of abdominal infections.
Medications:
* Lisinopril 10mg daily for hypertension.
* Atorvastatin 20mg daily for hyperlipidaemia.
Other Medical Conditions:
* Hypertension (diagnosed 2015) – well-controlled.
* Hyperlipidaemia (diagnosed 2018) – stable.
Social:
* Lives with husband.
* Sexually active.
* Attends Pilates classes twice a week.
* No caregiving responsibilities.
Examination:
* Pelvic examination: Anterior vaginal wall prolapse Grade 2, Uterine prolapse Grade 1. Perineal body intact. Good anal tone. Vaginal mucosa healthy.
* Stress test positive for urine leakage with cough.
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