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.
Issues:
[primary presenting issue or complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely, brief, bullet points)
[clinical findings and examination results including grades of prolapse] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely, brief, bullet points)
[Important surgical and medical histories] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely, brief, bullet points)
Plan:
[Recommended treatment plan including specific procedures, interventions, investigations, or management strategies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Age:
[Patient age in years] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, calculate age from date of birth if possible, if not available state "Unknown")
Gynaecology History:
[Previous gynaecological procedures, surgeries, and relevant historical information including timing and details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
[State Gravida and parity details] (Brief summary if mentioned in transcript, contextual notes or clinical note, if not available, state "unknown")
Gynaecology Issues:
[Current gynaecological symptoms, complaints, and problems as described by patient including specific details about urinary incontinence, prolapse, or other concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Abdo infxn/surgeries:
[Previous abdominal infections and surgical procedures with relevant details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Medications:
[Current medications including names, dosages, and formulations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Other Medical Conditions:
[Relevant past medical history and comorbidities with timing and current status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Social:
[Relevant social history including family circumstances, sexual activity status, current exercises or treatments, and caregiving responsibilities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Examination:
[Physical examination findings particularly related to gynaecological assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)