Follow Up Urology Note

CHIEF COMPLAINT: [urological symptoms or reason for consultation — e.g. lower urinary tract symptoms, recurrent UTIs, haematuria, flank pain, erectile dysfunction] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) PAST UROLOGICAL HISTORY: [summary of prior urology consultations, public or private sector labs/imaging, state hospital procedures, known conditions such as history of catheterisation, prostate issues, kidney stones, or previous urological surgeries. Include prior clinician or hospital name and patient’s occupation if mentioned] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) HPI TODAY [DD/MM/YYYY]: [description of any recent changes in urological condition, symptom flare-up, or new concerns since last consultation — e.g. increased frequency, urgency, nocturia, or pain] [current symptoms or patient confirmation that there are no current symptoms] [summary of relevant scan or ultrasound (e.g. from district or tertiary hospital) with findings. Include: “I personally reviewed and independently interpreted the scan and concur with findings.”] [lab results relevant to today’s consultation — e.g. urine dipstick, U&E, PSA, or FBC] [AUA symptom score, if documented] [PVR volume post-void residual if done at clinic/hospital] [PSA density, if available] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) PMH, PSH, MEDS, ALLERGIES, SH, and FH: - [Past medical history: e.g. HIV, hypertension, diabetes, TB, stroke] - [Past surgical history: e.g. hernia repair, circumcision, prostate biopsy] - [Medications: ART, chronic medications, over-the-counter or herbal remedies] - [Allergies: medications, contrast agents, latex] - [Social history: smoking, alcohol, occupation, housing situation] - [Family history: urological cancers or renal disease] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) PHYSICAL EXAMINATION: [General appearance and level of consciousness if patient was visibly unwell or in distress] [Psychiatric findings if applicable — e.g. mood, insight, cooperation] [Urological exam findings — e.g. DRE findings (size, nodularity, tenderness), palpable bladder, scrotal findings, catheter in situ] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) ASSESSMENT AND PLAN: [Patient’s age and clinical summary — e.g. “68-year-old male presenting with LUTS, stable on treatment”] (Only include if explicitly mentioned.) [urological condition name — e.g. BPH, UTI, renal calculi] - [Assessment of current status — e.g. stable, improving, worsening] - [Plan — e.g. continue medication, refer for TRUS biopsy, trial of alpha-blocker, surgical listing] - [Counselling — e.g. medication adherence, lifestyle modifications, risks and benefits of surgery] (Only include each line if explicitly mentioned.) [additional urological condition name] - [Assessment] - [Plan] - [Counselling] (Only include if explicitly mentioned.) ORDERS: [laboratory tests (e.g. PSA, U&E, urine MC&S), medications (e.g. Tamsulosin, antibiotics), imaging (e.g. renal ultrasound, KUB X-ray)] (Only include if explicitly mentioned. If nothing was ordered, write: “No orders.”) FOLLOW UP: [follow-up plan, e.g. “Review in urology OPD in 6 weeks,” “Return with PSA results,” “Follow up after imaging”] (Only include if explicitly mentioned.) SHORT SUMMARY: [1–2 sentence summary — e.g. “Patient reviewed for follow-up of LUTS. Remains stable on Tamsulosin; will continue same treatment and return for PSA result.”] (Only include if explicitly mentioned.) (Never come up with your own assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the section entirely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)