Gynecology Consultation Template

Thank you for referring Jane Doe, a 32-year-old female, whom I evaluated in clinic on October 15, 2023, for a gynecologic consultation after she was referred for irregular menstrual cycles and pelvic pain.
History of Current Concern:
Jane has been experiencing irregular menstrual cycles for the past six months, accompanied by pelvic pain and occasional spotting.
Gynecologic History:
- Menarche was at age 13.
- Her cycles are irregular, occurring every 35-45 days.
- Dysmenorrhea: significant.
- Heavy or abnormal menstrual bleeding: yes.
- Intermenstrual bleeding: yes.
- Postcoital bleeding: no.
- Vulvovaginal symptoms: yes, occasional itching.
- Vasomotor symptoms: no.
- Bladder function: normal.
- Does not deny hematuria
- Bowel function: normal.
- Does not deny rectal bleeding
Sexual History:
- Sexually active: yes, currently.
- She does not endorse safety concerns in her relationship.
- Does not report history of sexually transmitted infections.
- Does require contraception, currently using oral contraceptive pills.
Cervical Cytology:
- Has had a cervical cytology, recent findings were normal.
- Does not deny history of abnormal cervical cytology.
Obstetrical History:
- Past pregnancy? Yes, G1P1, delivered a healthy baby boy 5 years ago.
- Previously tried to conceive? No.
Medical History:
- Hypothyroidism
Surgical History:
- Appendectomy in 2015
Medications:
1. Levothyroxine 50 mcg daily
2. Oral contraceptive pills
External Medications:
- None
Allergies:
- Penicillin
Family History:
- She does not have a family history of breast and ovarian malignancy.
- She does not have a family history of uterine cancer.
- She does not have a family history of gastrointestinal malignancy.
- She does not have a family history of bleeding or clotting disorders.
- She does not have a family history of recurrent miscarriage, pregnancy loss, or congenital anomalies.
Social/Lifestyle History:
- Cigarettes: No
- Marijuana/THC: No
- Alcohol: Yes, socially
- Other recreational substances: No
- She currently supports herself by: working as a software engineer.
- Coverage for prescription medications: through employer-provided insurance.
- She lives: with her husband and son in a two-story house.
- Her current relationship status is: married.
Imaging:
- Recent pelvic ultrasound showed a small ovarian cyst on the right ovary.
Labwork/Investigations:
- Recent labs showed normal thyroid function tests.
Physical Exam:
- Abdomen was soft and nontender.
- There was no superficial lymphadenopathy in the inguinal area.
- The external genitalia were normal.
- A medium speculum was inserted, revealing a healthy cervix with no lesions.
- The cervix was completely visualized and was normal in appearance.
- A pap smear was taken today.
- On bimanual examination, her uterus was anteverted and of normal size.
- The uterus was not difficult to palpate.
- The adnexa were normal with no tenderness.
- Pelvirectal exam was normal.
- Digital rectal exam findings were unremarkable.
Impression and Plan:
- Jane Doe is a 32-year-old female with:
  1. Irregular menstrual cycles
  2. Pelvic pain
  3. Small ovarian cyst
Thank you for involving me in her care.