Urology Template Pack

Context: Egyptian urology clinic. Patient presenting with renal colic.

Structure the note with:
- Chief complaint (with laterality, duration, character)
- Pain history: onset, radiation pattern (loin → groin / testis / labia), severity (NRS), associated nausea/vomiting/hematuria
- Previous stone history, family stone history
- Past medical, surgical, drug history
- Examination: vitals, abdomen, costovertebral angle tenderness
- Investigations ordered: urinalysis, serum creatinine, NCCT KUB
- Working diagnosis with ICD-10 (N20.0 / N20.1 / N20.2)
- Plan: analgesia, MET if appropriate, follow-up timing, red-flag advice (fever, anuria, intractable pain)

Write in formal medical English. Use international generic drug names; I will substitute local brands.

Context: Patient presenting with hematuria. Determine gross vs microscopic. Patient age and smoking status are critical for risk stratification.

Structure:
- Type (gross/microscopic), timing (initial/terminal/total), clots, duration
- Associated symptoms: pain, dysuria, frequency, weight loss, constitutional
- Risk factors: age, smoking pack-years, occupational exposure (dye/rubber/leather), schistosomiasis exposure, analgesic use, family history
- Examination: abdomen, external genitalia, DRE if indicated
- Investigations: urinalysis with cytology x3, ultrasound KUB, CT urogram if >40y or smoker, cystoscopy
- Differential: benign vs malignant causes prioritized by risk
- ICD-10: R31.0 / R31.1 / R31.2 + suspected etiology
- Plan: specific workup pathway based on risk stratification
- Document the cancer-risk discussion explicitly

Context: Male patient with lower urinary tract symptoms suspicious for BPH.

Structure:
- Voiding symptoms (hesitancy, weak stream, intermittency, straining, incomplete emptying)
- Storage symptoms (frequency, urgency, nocturia, urge incontinence)
- IPSS score and quality-of-life score
- Sexual function (erectile, ejaculatory)
- Past medical history (diabetes, neurological, prior urological surgery)
- Medications affecting voiding (anticholinergics, alpha agonists)
- Examination: abdomen, genitalia, DRE (size, consistency, nodules, tenderness)
- Investigations: urinalysis, PSA (counsel before testing), serum creatinine, ultrasound KUB with post-void residual, uroflowmetry
- Differential: BPH vs prostate cancer vs urethral stricture vs neurogenic bladder vs UTI
- ICD-10: N40.0 / N40.1
- Plan: lifestyle, alpha-blocker / 5-ARI / combination, follow-up at 4-6 weeks, surgical thresholds discussed

Context: Asymptomatic male presenting for PSA discussion or with elevated PSA on screening.

Structure:
- Indication for PSA: screening (age, family history, ethnicity) vs symptomatic
- Current PSA value and trajectory if available, free PSA ratio
- Risk factors: age, family history (1st/2nd degree), African ancestry, BRCA family history
- LUTS evaluation (concurrent BPH)
- Examination: DRE (size, nodules, asymmetry)
- Document the shared decision-making conversation about screening / further workup
- Investigations to consider: PSA repeat in 4-8 weeks, MRI prostate (PI-RADS), prostate biopsy decision
- Differential: BPH, prostatitis, instrumentation effect, prostate cancer
- ICD-10: R97.20 (elevated PSA), Z12.5 (screening), or specific malignancy code
- Plan with explicit risk discussion and follow-up timing

Context: Post-TURP follow-up visit. Procedure date and operative findings should be referenced.

Structure:
- Days/weeks since TURP, operative findings (resected weight, intra-op events)
- Current symptoms: voiding (improvement vs persistent), continence status, hematuria episodes, dysuria, ejaculatory function
- Compliance with post-op instructions
- Examination: abdomen, perineum, DRE if indicated
- Investigations: urinalysis, post-void residual, IPSS if appropriate
- Histology review if not yet discussed (benign vs incidental cancer findings)
- Complications surveillance: stricture (uroflow), incontinence, retrograde ejaculation counselling
- ICD-10: Z48.815 (post-procedure visit), N32.81 (post-procedure stricture if present)
- Plan: continuation/cessation of post-op medications, next follow-up timing

Context: Male patient presenting with erectile dysfunction. Sensitive consultation — note the patient's framing of the problem.

Structure:
- Duration of symptoms, sudden vs gradual onset, situational vs constant
- Erectile function: rigidity for penetration, maintenance, morning erections (preserved suggests psychogenic)
- Libido, ejaculation, orgasm separately documented
- Relationship context (briefly, as patient discloses)
- Cardiovascular risk factors (HTN, DM, dyslipidemia, smoking, family CAD) — ED is a CV warning sign
- Medications (antihypertensives, antidepressants, finasteride, recreational)
- Surgical/trauma history (pelvic surgery, radiation, spinal injury)
- Examination: cardiovascular, peripheral pulses, external genitalia, secondary sex characteristics
- Investigations: morning testosterone, fasting glucose, HbA1c, lipid panel, TSH if indicated
- ICD-10: N52.9 + underlying etiology codes
- Plan: lifestyle, PDE5 inhibitor trial (counselling on use), CV risk referral if needed, partner involvement discussed

Context: Bladder cancer surveillance cystoscopy follow-up. Initial pathology stage/grade should be referenced.

Structure:
- Original tumor: stage (Ta / T1 / CIS / T2+), grade (low/high), date of TURBT, intravesical therapy received (BCG / MMC) and number of doses
- Time since last cystoscopy, any interim symptoms (gross hematuria, irritative symptoms, suprapubic pain)
- Today's cystoscopy findings: number, size, location of any new lesions; mucosal changes
- Cytology result if performed
- Imaging surveillance (CT urogram timing for high-risk disease)
- Risk-stratified management:
  - Low risk: continue surveillance per EAU schedule
  - Intermediate risk: consider re-induction BCG / MMC
  - High risk: discuss radical cystectomy if BCG-unresponsive
- ICD-10: Z85.51 (history of bladder cancer), C67.x (current malignancy code)
- Plan with explicit surveillance interval and trigger thresholds for escalation