Initial Consult OBGYN

Chief Complaint

[Reason for consult]

Template

Date: [Insert Date] Referring Physician: Dr. [Referring Physician Name] Dear Dr. [Last Name], [Patient Name] is a [age]-year-old patient presenting for [reason for consult]. [If interpreter or support person present, state here.] HISTORY OF PRESENT ILLNESS (HPI): [Chronological narrative of symptoms] - Menstrual History: [details – regularity, flow, changes, clots, pain, missing work, intermenstrual bleeding] - Menopause History: [if applicable—age of menopause, hormone therapy use] - Additional Symptoms: [if applicable - acne, facial hair, weight gain, hot flashes, night sweats, brain fog, joint pain, sleep difficulties] - Sexual History: [sexually active or not, contraception use, dyspareunia (superficial/deep), pain specifics] - Infertility Details (if applicable): [partner’s name, age, occupation, social history, coital frequency] [Only include headings which are relevant.] PELVIC FLOOR INVENTORY: [Include only if applicable, do not include if not relevant] - Prolapse Symptoms: [yes/none] - Stress Incontinence: [yes/none] - Lower Urinary Tract Symptoms: [yes/none] - Voiding Dysfunction: [yes/none] - Defecatory Dysfunction: [yes/none] - Sexual Dysfunction: [yes/none] - Daily Pad or Tampon Usage: [number and type] - Caffeinated Beverages: [daily intake] - Bathroom Trips: [frequency and nocturia details] PAST OBSTETRICAL AND GYNECOLOGICAL HISTORY: - Deliveries: [c-sections, vaginal deliveries, ectopics, miscarriages, terminations] - Gynecological Surgeries: [details, if applicable] - STI History: [if relevant] - PAP Test or HPV testing: [last completed date, due status if applicable] PAST MEDICAL HISTORY: - [List of medical conditions, separated by commas] PAST SURGICAL HISTORY: - [List of non-gynecologic surgeries, separated by commas] MEDICATIONS: - [List all medications and supplements, separated by commas] ALLERGIES: - [Bulleted list with reaction if available] - [Include any personal or family history of anaesthesia complications] SOCIAL HISTORY: - [Occupation] - [Tobacco use, alcohol use, drug use] - [History of domestic violence, sexual assault, or abuse] - [Vegetarian status if relevant] - [Drug coverage if relevant] FAMILY HISTORY: - [Breast, ovarian, uterine cancer, osteoporosis, hereditary cancers, DVT, etc.] INVESTIGATIONS: Labs: - [Include tests, results, dates] Imaging: - [Ultrasound, MRI, other imaging studies and their findings] Pathology: - [Biopsies, cytology, other results] Pending Investigations: - [Specify if any] PHYSICAL EXAMINATION: - Abdominal Exam: [Findings, if applicable] - Pelvic Examination: - External Genitalia: [Normal/abnormal findings] - Speculum Exam: [Cervical appearance, tests done (PAP, HPV, swabs), polyp removal, biopsy details, IUD insertion/removal info] - Bimanual Exam: [Uterine position, size, tenderness; adnexal masses or tenderness] - Pelvic Floor Testing (if done): [Prolapse grading, Q-tip test, cough stress test, Kegel strength] In summary, this is a [age]-year-old female with: PROBLEMS AND PLAN: 1. [Issue #1]: - [Diagnosis/impression] - [Plan for management, treatment, or follow-up] 2. [Issue #2]: - [Diagnosis/impression] - [Plan for management, treatment, or follow-up] [Continue for each relevant gynecologic issue.] Please do not hesitate to contact me if you require any further information or clarification. If discharged, the patient can contact the office about the same issue within the next two years but otherwise would require a new referral. Sincerely, [Consultant Name], [Credentials] [Contact Information]