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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Gynaecology

Document Title

: Gynaecology Urogynae Clerking Note

PATIENT DATA

Occupation

Marital Status

Sexual Activity

ActiveNon active

Dyspareunia

YesNo

Past Obstetric History

Please Update Method

LMP

Pap Smear

YesNo

Year

Completed Family

YesNo

Menopause

YesNo

Year

Hormone Replacement Therapy

YesNo

Specify

HISTORY

Frequency

Nocturia

Urgency

YesNo

Duration

Urge Incontinence

YesNo

Year

Stress Urinary Incontinence

YesNo

Year

Frequency Of Incontinence

Pads

YesNo

Restriction Of Social / Physical Activity

YesNo

Specify

Continuous Incontinence

YesNo

Incontinence During Sexual Intercourse

YesNo

Enuresis

YesNo

Dysuria

YesNo

Hematuria

YesNo

Uti In The Past

YesNo

Times

Flatus / Faecal Incontinence

YesNo

Constipation

YesNo

Prolapse + Voiding Difficulty Symptoms

Hesitancy

Year

Summary Of Main Complaints And Duration

Please Update Method

Past Medical History

Past Surgical History

General abdominal

Gynae abdominal

Uro / Urogynae surgery

Others, specify

Current Medication

Allergies And Alert

EXAMINATION

Breast

Not DoneNormalAbnormal

Specify

Abdomen

Not DoneNormalAbnormal

Specify

Erect Stress (10 Cough) / Pad Test

SPECULUM EXAMINATION / EXAMINATION IN STANDING POSITION

Stress Incontinence

DemonstrableNot Demonstrable

Cystocele / Cystourethrocele

Rectocele

Enterocele

YesNo

Cervical / Uterine Descent

Vault Descent

Atrophic Changes

YesNo

Pop q

Please Update Method

Pop Q 2

Please Update Method

Pop Q 3

Please Update Method

Uterus Size (mm)

No Abnormalities Detected (NAD)

Size In Weeks

Adnexa

Vaginal Capacity

Vaginal Mobility

YesNo

Levator Ani Tone

01234

Anal Tone

01234

Orders

CLINICAL DIAGNOSIS

Diagnosis

Urodynamics Diagnosis

TREATMENT

Physiotherapy

PFR

Electrical stimulation

Bladder Training

Oestrogen

Vagifem

Premarin cream

Medical

Oxybutinin

Imipramine

Detrusitol

Urispas

Desmopressin

Surgical

Others, Specify

Discussed Diagnosis / Treatment Options / Complications / Cure Rates With:

Patient

Husband

Family members

Relatives

Tcu

SIGNATURES

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