Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
This section may be blank for asymptomatic infants. Older children may express concerns about appearance or difficulty with urination.
Parents may report concerns about the location of the urethral opening, urination stream (e.g., spraying), or difficulty retracting the foreskin (if applicable).
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at diagnosis
Type of hypospadias (glandular, coronal, subcoronal, perineal)
Severity of hypospadias (based on location of urethral opening and degree of chordee – downward curvature of the penis)
Presence of chordee (severity and degree of curvature)
Presence of foreskin (redundant or adherent)
Urinary symptoms (frequency, hesitancy, spraying)
Any previous surgeries for hypospadias
既往史 (jì wàng shǐ) Past Medical History:
Prenatal history (maternal medications, exposures)
Other congenital anomalies (if present)
家族史 (jiā zú shǐ) Family History:
Family history of hypospadias (uncommon)
查体 (chá tǐ) Physical Examination:
General appearance (genital development)
Penis size and shape
Location of the urethral opening (meatus)
Presence and degree of chordee (downward penile curvature)
Foreskin examination (presence, redundancy, adhesions)
Testicular descent (palpation for undescended testes)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Urinalysis – to rule out urinary tract infection
Consideration of karyotyping (chromosome analysis) in some cases to rule out genetic syndromes
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Optional:によっては (yori itte wa) [depending on the situation] pelvic ultrasound may be used to assess for undescended testes.
诊断 (zhěn duàn) Diagnosis:
Hypospadias (type and severity)
Presence of chordee (severity)
Presence of other anomalies (e.g., undescended testes)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Non-surgical management: May be considered for mild hypospadias without chordee. Observation and reassurance for parents.
Surgical repair: Typically recommended for moderate to severe hypospadias or chordee. Timing of surgery depends on individual factors and surgeon preference (often between 6 months and 2 years old).
Pre-operative: Consider counseling for parents and child (depending on age) to address concerns and expectations.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of hypospadias and chordee.
Surgical repair can achieve a more normal appearance and improve urinary function.
Long-term follow-up is recommended to monitor for complications (e.g., urethral stricture).
健康指导 (jiàn kāng zhǐ dào) Patient Education (or Parental Education):
Importance of hygiene practices
Importance of follow-up appointments with a pediatric urologist
Potential risks and benefits of surgery (if applicable)
Support groups and resources for families with children with hypospadias
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the treatment plan and the child’s age.
Regular follow-up with a pediatric urologist is essential to monitor for complications and address any concerns.