Microscopic Hematuria Consult Note

OVERALL_INSTRUCTIONS

Chief Complaint

[Consult Purpose]

Template

Date: [Insert Date] Referring Physician: Dr. [Referring Physician Name] Dear Dr. [Last Name], HISTORY OF PRESENTING ILLNESS: Thank you for asking me to see [Patient Name] today regarding [Consult Purpose]. Briefly, [Patient Name] was noted to have [Relevant Details] in [Date]. [He/She/They] denies any gross hematuria or symptoms of infection around the time of [Relevant Details]. [He/She/They] denies any baseline LUTS or history of recurrent UTIs. [He/She/They] has had a previous work up for [Relevant Details] with cystoscopy in [Date] which was negative. [He/She/They] has also had an [Imaging Type] that showed normal kidneys. PAST MEDICAL HISTORY: 1. [Condition 1] 2. [Condition 2] 3. [Condition 3] PAST SURGICAL HISTORY: 1. [Surgery 1] 2. [Surgery 2] 3. [Surgery 3] MEDICATIONS: [List Medications] ALLERGIES: [List any drug allergies] SOCIAL HISTORY: [Living Situation] [Employment Situation] [Smoking History] [Alcohol Use] FAMILY HISTORY: [Relevant Family History, e.g., Negative for genitourinary malignancies] EXAMINATION: [General Examination Findings, e.g., Alert and oriented, Not in any acute distress] INVESTIGATIONS: [Investigation Type and Date]: [Results] [Investigation Type and Date]: [Results] [Investigation Type and Date]: [Results] ASSESSMENT AND PLAN: This patient has a history of [Relevant Details]. Regarding [his/her/their] microscopic hematuria, we discussed various etiology including stones, inflammation, and malignancy. However, in about 50% of cases, we are not able to find a cause. Ultimately, given the history of microscopic hematuria, we discussed the need to proceed forward with a complete work-up to rule out malignancy. We will arrange for a [Procedure] to assess the [Relevant Anatomy]. [He/She/They] has already had [Relevant Investigations] which were [Results]. Going forward, if [His/Her/Their] work up for microscopic hematuria is negative, we counselled the patient to follow up with their GP annually with urine microscopy, urine cytology and blood pressure check on yearly basis. If the patient develops worsening hematuria, positive or suspicious cytology, or irritative voiding symptoms without infection, they should be referred back for repeat work up. If they are negative for 3 years, they can discontinue this work up. [If multiple issues are discussed please include them. Regarding issue 2, please list management including conservative measures or pharmacotherapy or surgery. Include relevant risks and complications associated with pharmacotherapy and surgery.] [Insert a time period for a follow appointment Details] Sincerely, [Consultant Name], [Credentials] [Contact Information]