Scribe BC - Urology Consult - Female

(Write from the perspective of an expert urologist providing a consultation report to another physician. Be succinct and precise and use professional, technical medical language.Avoid direct patient quotations. ) "Thank you for the referral of your [patient's age, patient's gender] patient [Patient's first name]. We met today regarding [patient's chief complaint]." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) History of Present Illness: (Describe current issues, symptoms, duration, and any relevant details as they relate to the reason for referral. Include details from the contextual notes associated with the abbreviation HPI. Write the section in full sentences. Do not use point form.) [Discuss urinary symptoms including frequency of voids, presence/absence of urgency, number of voids per night, presence/absence of dysuria, strength of urinary stream, presence/absence of complete bladder emptying, presence/absence of straining to void, presence/absence of intermittent urinary stream] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Mention pain complaints including location, character, severity, radiation, aggravating and alleviating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Mention gross hematuria including timing, frequency, associated symptoms, and relationship to voiding] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Mention recurrent UTIs including frequency, severity, associated symptoms, and previous treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Past Medical History: [describe past medical history and previous surgeries including dates and relevant surgical details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Include details from the contextual notes associated with the abbreviation PMH. List diagnoses and procedures in a list without line breaks, separated by commas.) Medications: [mention current medications, dosages, and herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Include details from the contextual notes associated with the abbreviation Meds.) Allergies: [mention known allergies to medications, foods, or environmental factors and type of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If no allergies to medications, state NKDA.) Social History: [describe social history including smoking status, alcohol use, occupation, and relevant lifestyle factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Family History: [mention family medical history relevant to genitourinary malignancy, particularly prostate cancer in first or second-degree relatives; cancer of the breast, pancreas or ovary in first or second-degree relatives; cancer of the colon, stomach and endometrium in first- or second-degree relatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Physical Examination: [General appearance and vital signs including weight, BMI, blood pressure if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Abdominal examination findings including tenderness, masses, distension, organomegaly, and suprapubic tenderness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [External genitalia examination findings including inspection of external structures, inguinal lymph node assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Pelvic examination findings including vaginal mucosa condition (estrogenized/hypoestrogenized), urethral mobility assessment, stress incontinence testing results, pelvic organ prolapse staging] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [POPQ examination measurements: Aa, Ba, C, GH, Pb, TVL, Ap, Bp, D values if performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Urethral palpation findings including tenderness, masses, and bladder neck assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Cystoscopy [Cystoscopy findings including urethral appearance, bladder urothelium condition, presence/absence of tumors, stones, diverticula, inflammatory changes, ureteric orifice position and appearance, sphincter function assessment, and post-void residual volume measurement] (Only include if cystoscopy was performed and explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Document all findings as observed during the procedure.) [Procedural details including patient positioning, anesthetic used, cystoscope type, and any complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Post-procedure antibiotic prophylaxis if administered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Investigations: [mention any investigations ordered or reviewed including lab tests, imaging studies, urodynamics, and their results with dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Assessment: [provide clinical assessment including diagnosis, differential diagnoses, and discussion of treatment options with risks and benefits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Include description of discussion with patient regarding diagnosis and treatment options. Briefly discuss risks and benefits of different treatment options if mentioned. Include rationale for treatment recommendations if discussed explicitly. Write in full sentences.) Plan: [outline the management plan including medications, procedures, follow-up appointments, referrals, and patient education] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Format as a numbered list of specific actions. Use brief, succinct language.) "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian." (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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 placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) Urology