Client Tracker Check Boxes Indicate Selection of Multiple Answers If Appropriate
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Client Tracker Check boxes indicate selection of multiple answers if appropriate. I. Quality Assurance Required Data Circles indicate mutually exclusive answer options. Patient ID:________ Patient Initials:____ Date of Assessment (dd/mm/yyyy): ______________ Contact phone #: _____________________ Facility: ___________ Facility Record No: ______ Phone owner: Country: Patient Child Bangladesh Nigeria Spouse Other family DRC Uganda Spouse family Neighbor/friend Guinea Togo Sibling Other: ________ Niger Other: _____________ II. Obstetrics and Gynecology Profile Age on date of assessment (in years): ________ Pregnant on data of assessment: Yes Menopause status: No Pre-puberty Pregnancy: Premenopausal Total # births: _____ # live births: ___________ Menopausal Age of menopause (in years): _____________ # stillborn: ________ # children alive now: ____ Uterus status: Lactating: Yes No Intact Last menses: _____________________ Removed Congenitally absent (dd/mm/yyyy or # of weeks prior to exam) Age menarche (in years): ___________________ III. Pertinent History Prolonged/obstructed labor (P/OL) sequelae of labor reported to have lasted 2 or more days on history (check all that apply): None Other bone sequelum Fistula urinary tract Chronic pelvic or leg pain onset after P/OL Fistula colorectal tract Infertility onset after P/OL Urinary incontinence onset after P/OL Vaginal scarring Fecal/flatal incontinence onset after P/OL Depression or anxiety onset after P/OL Diastasis pubis Stillborn Footdrop Hypoxic liveborn (e.g. flaccid, cerebral palsy, Osteomyelitis developmental delays, other neuro) # prior surgeries for POP symptoms: _____ # prior surgeries for incontinence symptoms: _____ (intact anatomy and/or fistula) Fistula etiology/etiologies (check all that apply): Indeterminate Infection (schistosomiasis, amebiasis, Obstetric labor > 2 days (obstetric = due to lymphogranuloma) ischemia/necrosis from P/OL) Cancer Unclear if obstetric or iatrogenic: obstructed Trauma due to pelvic crush or impalement injury labor > 2 days with cesarean Trauma due to sexual violence Iatrogenic operative vaginal birth Trauma due to genital cutting done by traditional Iatrogenic cesarean birth cutter or vaginal packing traditional rituals Iatrogenic non-obstetric pelvic surgery Trauma due to genital cutting done by licensed Congenital defect - ectopic ureter, cloacal clinician defect, other 1 IV. Staging and Diagnoses Fistula level of complexity (surgeon assessment): Fistula staging system used: Cannot determine (check all that apply and specify staging) Simple None Moderate Goh – specify staging: _____________________ Complex, eligible for surgical repair Waaldijk – specify staging: _________________ Complex, not eligible for surgical repair Panzi – specify staging: ____________________ Tafesse – specify staging: __________________ POP staging system used: Other: _______ – specify staging: ___________ (check all that apply and specify staging) None Baden Walker – specify staging: ____________ POP Q –specify staging: ___________________ Other: _________ – specify staging: ________ Fistula diagnoses (check all that apply): No fistula Urethro-vaginal fistula – Ureteric fistula to uterus [list R L] Partial Ureteric fistula to vagina [list R L] Posterior urethra absent Vesico-uterine fistula Urethra absent Vesico-cervical fistula Urethra separated from bladder Vesico-vaginal fistula – Urethra not patent Midline, not circumferential Rectovaginal Circumferential High Lateral Mid-vagina Pericervical Low vagina 4th degree tear Pelvic organ prolapse (POP) diagnoses (check all that apply): No POP Posterior POP – enterocele Apex POP – Posterior POP – rectocele Uterus intact, cervix normal length Posterior POP – perineal damage Uterus intact, cervix hypertrophied Posterior POP – perineum completely Uterus out, cuff descending disrupted/absent Anterior POP – Levator(s) not intact (total atrophy) Central defect Levators intact – Paravaginal defect(s) 1. Diastasis: Yes No Central and paravaginal 2. Contraction Normal Absent function: Impaired Incontinence/urinary and colorectal diagnoses (intact anatomy) (check all that apply): None, normal urinary tract & colorectal tract Urinary incontinence – Ureteric stenosis [list R L] Stress (SUI) Kidneys hydronephrosis [list R L] Urge or overactive bladder (OAB) Voiding dysfunction due to bladder outlet Mixed SUI/OAB obstruction up to an including urinary retention Fecal incontinence, sphincteric – Constipation To flatus Severe hemorrhoids To flatus and soft stool Worms To flatus, soft and hard stool 2 Client Tracker Genital tract diagnoses (check all that apply): None [normal uterus, tubes, ovaries, vagina, Cancer of ovaries perineum, labia, clitoris] Pelvic tuberculosis Uterine fibroids Vaginal stenosis Endometritis Mild Suspected Asherman's syndrome Moderate Uterine rupture, acute or chronic Severe Cervical laceration Completely scarred shut Cervical stenosis with hematometra Prior FGC Cervix deviated into rectum or bladder No sebaceous cyst(s) Tuboovarian abscess With sebaceous cyst(s) Ovarian mass, cystic or solid Suture granuloma Cancer of cervix Gishiri cutting Cancer of uterus (sarcoma or endometrial) V. Admission Date admitted to facility Admission to facility indicated: (dd/mm/yyyy): ___________ Admit for non-surgical No admission indicated therapy – fistula, POP or Admit to hospital for stabilization incontinence before surgery Admit for surgical therapy Admit to housing facility for – fistula, POP or stabilization before surgery incontinence VI. Non-surgical Non-surgical therapy(s) for fistula, POP, incontinence, genital tract (check all that apply): Overactive bladder medications Pessary (amitryptiline, other anti-cholinergic) Catheter Pelvic floor physical therapy Debridement Dilators Other: ______________________ Timed voiding bladder drills Staged treatment indicated: Yes No Non-surgical therapy outcome(s) for fistula, POP, incontinence, genital tract (check all that apply): Fistula – POP– Incontinence– # of day(s) catheterization as therapy: _______ Worse with pessary Worse No change or worse after catheter therapy No change with No change Smaller but still patent after catheter pessary Somewhat improved, therapy Somewhat improved, persists Closed after catheter - incontinent of urine persist with pessary Significantly improved, Closed after catheter - continent of urine Cured with pessary persists Cured VII. Surgical Date of surgery (dd/mm/yyyy): ____________ Type of anesthesia (check all that apply): Route of operation (check all that apply): No anesthesia General anesthesia - endotracheal tube Vaginal Sedation only Spinal or epidural Abdominal Ketamine Local infiltration Combined vaginal/abdominal Other: ______________ 3 Client Tracker Surgical therapy(s) for fistula, POP, incontinence, genital tract (check all that apply): Fistula Procedures Vaginal – Vaginal – Vesico-vaginal Graft perineal/buttock/groin Small midline R Large circumferential L Multiple R+L "On the bone" lateral Graft peritoneal anterior compartment Peri-cervical Graft peritoneal posterior compartment Vesico-cervical fistula Vesico-uterine fistula Abdominal – Paravaginal bladder mobilization Urethral reanastomosis, circumferential Anterior bladder mobilization Vesicovaginal – Posterior vesico-uterine bladder mobilization O'Conor (bi-valve) Urethral fistula partial Cystotomy (no bi-valve) Urethral re-anastomosis, posterior Vesicouterine Urethral re-anastomosis, circumferential Vesicocervical Urethral reconstruction – anterior bladder tube Uretero-uterine Urethral reconstruction – labial/vaginal skin Recto-uterine tube Rectovaginal Urethral reconstruction – buccal mucosa graft Ureter dissection Urethral reconstruction – other Ureteric catheterization Ureteric "railroad" re-implantation [list R L] Ureteric re-implantation direct Ureteric catheterization Ureteric re-implantation non-refluxing Rectovaginal – Psoas hitch Small-medium Boari flap Circumferential mid-low vagina Graft peritoneal Circumferential high vagina/cervix Graft omental J-flap With 4th degree Vaginal cecum or sigmoid harvest for neo- Rectal advancement flap vagina Levatorplasty interposition over RVF Other concurrent surgeries: _____________ Cloacal defects - combination VVF RVF Blue test intra-op – Perineoplasty at RVF Negative Sphincteroplasty at RVF Positive Graft Martius Diversion procedures – R Urinary diversion: type: ______________ L Colostomy, type: ____________________ R+L POP Procedures Enterocele repair – Apex compartment – Sac not excised Hysteropexy (select suspension anchor below) Sac excised Trachelorrhaphy for cervix hypertrophy, cm excised: ___ Anterior compartment – Hysterectomy (select vaginal cuff suspension Anterior colporrhaphy anchor below) Paravaginal repair – Uterus absent (select vaginal cuff suspension Abdominal anchor below) Vaginal Fallopian tube(s) excised (list R L) Posterior compartment & perineum – Ovary(s) excised (list R L) Colporrhaphy Suspension to: Without levatorplasty Sacrum With levatorplasty Uterosacral ligaments abdominal approach Site-specific rectovaginal fascia repairs Uterosacral ligaments vaginal approach Perineorrhaphy Sacrospinous ligament(s) [list R L] Complete perineoplasty 4 Client Tracker Incontinence Procedures Pubovaginal sling – Other urinary