Urology — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary urologic concern]
Duration: [X] days/weeks/months/years
Current status: Improving / Stable / Worsening

History of Present Illness

For Lower Urinary Tract Symptoms (LUTS)

Storage Symptoms:

Frequency: No / Yes — [X] times/day (normal 6-8)
Nocturia: No / Yes — [X] times/night
Urgency: No / Yes — [Severity]
Urge incontinence: No / Yes — [Frequency, pads/day]
Stress incontinence: No / Yes — [Triggers]

Voiding Symptoms:

Hesitancy: No / Yes
Weak stream: No / Yes
Intermittency: No / Yes
Straining: No / Yes
Terminal dribbling: No / Yes
Incomplete emptying: No / Yes
Post-void dribbling: No / Yes

IPSS Score: [0-35]

• 0-7: Mild
• 8-19: Moderate
• 20-35: Severe

Quality of Life Score: [0-6]
Bother Score: [0-6]

Urinary Retention:

History of retention: No / Yes — [Acute/chronic, catheterization]
Current catheter: No / Yes — [Type, size, date placed]

For Hematuria

Type: Gross / Microscopic
Timing: Initial / Terminal / Throughout void
Color: Pink / Red / Brown / Clots
Associated: Pain / Dysuria / Frequency / None
Duration: [X] episodes over [X] time
Prior evaluation: None / [Prior workup, findings]
Risk factors for malignancy:

• Age >40: Yes / No
• Tobacco: [Pack-years]
• Occupational exposures: [Dyes, chemicals]
• Prior radiation: Yes / No
• Cyclophosphamide: Yes / No
• Chronic UTI/irritation: Yes / No

For Urinary Tract Infections

Frequency: Rare / Recurrent — [X] per year
Last UTI: [Date]
Culture results: [Organism, sensitivities]
Symptoms: Dysuria / Frequency / Urgency / Suprapubic pain / Hematuria / Fever
Prior workup: None / [Imaging, cystoscopy]
Prophylaxis: None / [Medication]

For Kidney Stones

Prior stones: No / Yes — [Number, dates]
Stone composition: Unknown / [Type]
Stone interventions: None / [ESWL, ureteroscopy, PCNL]
Current symptoms: None / [Flank pain, hematuria]
Imaging: [CT, US — date, findings]
Metabolic evaluation: Not done / [Results]

For Erectile Dysfunction

Duration: [X] months/years
Onset: Gradual / Sudden
Severity: Mild / Moderate / Severe
Erections: None / Partial / Full but not sustained
Morning erections: Present / Absent / Reduced
Libido: Normal / Decreased
Ejaculation: Normal / Premature / Delayed / Absent / Painful
Relationship: [Status, partner involvement]
Risk factors:

• Diabetes: No / Yes
• Cardiovascular disease: No / Yes
• Hypertension: No / Yes
• Depression: No / Yes
• Medications: [Beta-blockers, SSRIs, etc.]
• Tobacco/alcohol: [Use]
• Pelvic surgery/radiation: No / Yes

Prior treatments:

• PDE5 inhibitors: None / [Drug, dose, response]
• Injection therapy: None / [Response]
• Vacuum device: No / Yes — [Response]

SHIM/IIEF Score: [X]/25

For Prostate Cancer Concerns

PSA history:

• Current: [X] ng/mL — Date: [X]
• Trend: [Prior values, dates]
• PSA velocity: [X] ng/mL/year
• Free/total ratio: [X]% (if available)

DRE findings: [Referring provider or prior]
Family history: No / Yes — [Relationship, age at diagnosis]
Prior biopsy: None / [Date, results, Gleason]
Active surveillance: No / Yes — [Protocol]

For Scrotal/Testicular Concerns

Mass: No / Yes — [Location, duration, size]
Pain: No / Yes — [Acute/chronic, severity]
Swelling: No / Yes — [Unilateral/bilateral]
Trauma: No / Yes — [Date]
Infertility concerns: No / Yes

Urologic Review of Systems

[ ] Dysuria [ ] Frequency [ ] Urgency [ ] Nocturia ([X]/night)
[ ] Hesitancy [ ] Weak stream [ ] Incontinence [ ] Retention
[ ] Hematuria [ ] Flank pain [ ] Scrotal pain [ ] Penile discharge
[ ] ED [ ] Decreased libido [ ] Ejaculatory dysfunction
[ ] Fever/chills [ ] Weight loss

Past Medical History

[Relevant conditions]
Diabetes: No / Yes — [Type, duration, A1c]
Hypertension: No / Yes
Cardiovascular disease: No / Yes — [CAD, CHF, PVD]
Neurologic: No / Yes — [Stroke, Parkinson's, MS, spinal cord]
BPH: No / Yes — [Medications, prior treatment]
Prostate cancer: No / Yes — [Treatment, status]
Bladder cancer: No / Yes — [Treatment, status]
Kidney disease: No / Yes — [Stage, etiology]
Kidney stones: No / Yes — [See above]

Surgical History

[Relevant surgeries, especially:]
Prostate surgery: None / [TURP, prostatectomy, date]
Bladder surgery: None / [Procedure]
Kidney surgery: None / [Procedure]
Pelvic surgery: None / [Procedure]
Hernia repair: None / [Type, date]
Spinal surgery: None / [Procedure]

Medications

Current medications: [List]
Alpha-blockers: [Tamsulosin, etc.]
5-alpha reductase inhibitors: [Finasteride, dutasteride]
Anticholinergics: [Oxybutynin, etc.]
Beta-3 agonists: [Mirabegron]
PDE5 inhibitors: [Sildenafil, tadalafil]
Anticoagulants: [Drug, indication]
Testosterone: No / Yes — [Form, dose]

Allergies

[Drug allergies with reactions]
Contrast allergy: No / Yes — [Reaction, premedication]
Latex allergy: No / Yes

Family History

Prostate cancer: No / Yes — [Relationship, age]
Kidney cancer: No / Yes — [Relationship]
Bladder cancer: No / Yes — [Relationship]
Kidney stones: No / Yes — [Relationship]

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Quantity, frequency]
Occupation: [Exposures]
Sexual activity: Active / Inactive

• Partners: [Number, gender]
• Contraception: [If applicable]

Fluid intake: [Oz/day, caffeine, alcohol]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
Temp: [X]°F
Weight: [X] — BMI: [X]

General

Appearance: Well / [Concerns]
Distress: None / [Discomfort]

Abdominal

Soft / [Distended]
Tenderness: None / [Location]
Masses: None / [Palpable]
CVA tenderness: None / Right / Left / Bilateral
Bladder: Not palpable / Palpable / Distended
Surgical scars: None / [Location]

Genitourinary — Male

Penis:

Circumcised: Yes / No
Meatus: Normal position / [Hypospadias, epispadias]
Discharge: None / [Description]
Lesions: None / [Description]
Phimosis: No / Yes
Peyronie's plaque: No / Yes — [Location]

Scrotum:

Skin: Normal / [Lesions, edema]

Finding	Right	Left
Testis	Normal / [Atrophic, mass]	Normal / [Findings]
Epididymis	Normal / [Tender, mass]	Normal / [Findings]
Vas deferens	Palpable	Palpable
Varicocele	None / [Grade 1-3]	None / [Grade]
Hydrocele	None / [Size]	None / [Size]
Hernia	None / [Present]	None / [Present]

Digital Rectal Exam:

Sphincter tone: Normal / Decreased / Increased
Prostate:

• Size: Small / Normal / Enlarged — Estimated [X] grams
• Consistency: Soft / Firm / Hard
• Nodules: None / [Location, size]
• Tenderness: None / Present
• Median sulcus: Present / Obliterated
• Symmetry: Symmetric / Asymmetric

Rectal mass: None / [Description]
Stool guaiac: Not performed / Negative / Positive

Genitourinary — Female (if applicable)

External genitalia: Normal / [Findings]
Prolapse: None / [Cystocele, rectocele, uterine — grade]
Urethral meatus: Normal / [Caruncle, prolapse]
Pelvic exam: [Deferred / Performed — findings]

Neurologic (if indicated)

Perineal sensation: Intact / Decreased
Bulbocavernosus reflex: Present / Absent
Lower extremity: [Motor, sensory, reflexes]

Diagnostic Studies Review

Laboratory

Urinalysis: [Findings]
Urine culture: [Results]
PSA: [X] ng/mL — Date: [X]

• Free PSA: [X]%
• PSA density: [X]

Creatinine: [X] — GFR: [X]
Testosterone: [X] ng/dL (if checked)
Other: [Relevant labs]

Imaging

Renal ultrasound: [Date, findings]
CT urogram: [Date, findings]
MRI prostate: [Date, PI-RADS score, findings]
Bladder ultrasound / PVR: [X] mL
KUB: [Findings]

Urodynamics (if performed)

Uroflow: Qmax [X] mL/s, voided volume [X] mL
PVR: [X] mL
CMG: [Findings — capacity, compliance, DO]
Pressure-flow: [BOO vs impaired contractility]

Cystoscopy (if performed)

Urethra: Normal / [Stricture, lesion]
Prostate: [Lobes, obstruction]
Bladder: [Mucosa, trabeculation, diverticula, tumors]
Ureteral orifices: Normal / [Findings]

Assessment

1) [Primary urologic diagnosis]
Severity: [Mild/moderate/severe]
2) [Secondary diagnoses]
Differential diagnosis (if applicable):

• [Most likely]
• [Alternative 1]
• [Alternative 2]

Plan

Diagnostic Workup

• [ ] Urinalysis with culture
• [ ] PSA (if not recent)
• [ ] Basic metabolic panel
• [ ] Testosterone level
• [ ] 24-hour urine (stone metabolic evaluation)
• [ ] Renal ultrasound
• [ ] CT urogram
• [ ] MRI prostate
• [ ] Bladder scan / PVR
• [ ] Uroflow
• [ ] Urodynamics
• [ ] Cystoscopy
• [ ] Prostate biopsy
• [ ] Other: [Specify]

Medical Treatment

• [ ] Alpha-blocker: [Drug, dose]
• [ ] 5-alpha reductase inhibitor: [Drug, dose]
• [ ] Combination therapy
• [ ] Anticholinergic: [Drug, dose]
• [ ] Beta-3 agonist: [Drug, dose]
• [ ] PDE5 inhibitor: [Drug, dose]
• [ ] Testosterone: [Form, dose]
• [ ] Antibiotics: [Drug, dose, duration]
• [ ] Analgesic/alpha-blocker for stones
• [ ] Stone prevention: [Thiazide, citrate, allopurinol]
• [ ] Behavioral therapy: [Fluid management, timed voiding]
• [ ] Other: [Specify]

Surgical Options Discussed

• [ ] Not indicated at this time
• [ ] [Procedure] — Risks/benefits discussed
• [ ] Scheduled: [Date]
• [ ] Patient to consider and return

Referrals

• [ ] Radiation oncology
• [ ] Medical oncology
• [ ] Nephrology
• [ ] Neurology
• [ ] Physical therapy (pelvic floor)
• [ ] Sexual health specialist
• [ ] Other: [Specify]

Patient Education

• Diagnosis explanation
• Treatment options reviewed
• Medication instructions
• Dietary recommendations (if applicable)
• Warning signs requiring urgent evaluation

Follow-up

Return: [X] weeks for [Lab results, treatment response, procedure]
Sooner if: [Retention, gross hematuria, fever, severe pain]

Communication

Discussed with patient: [Topics covered]
Report sent to: [Referring physician, PCP]