Lalani Gynecological Consult Letter

OVERALL_INSTRUCTIONS

Chief Complaint

Gynecological Assessment Report

Template

Thank you for referring [name] for a gynecological assessment. [name] is a pleasant [age]-year-old G[gravida]P[para]A[abortions]L[living children] patient. [If interpreter or support person present, state here.] Reason for Consult [reason for referral clearly stated] 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: [acne, facial hair, weight gain, hot flashes, night sweats, brain fog, joint pain, sleep difficulties] 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] Past Medical History: [paragraph form list of medical conditions] Past Surgical History: [list of all surgeries, details if applicable] Pelvic Floor Inventory (if applicable): 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 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], STI History: [if relevant], PAP Test: [last completed date, due status], 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] Medications: [list all medications and supplements, separated by commas] Allergies: [list with reaction if available, Separated by commas] Social History: [occupation], [tobacco use, alcohol use, drug use] Family History: [breast, ovarian, uterine cancer, osteoporosis, hereditary cancers, DVT, etc. separated by commas] Physical Examination: Vitals: Height [height], Weight [weight], BMI [calculated], BP [blood pressure], HCG: [result, if done], Abdominal Exam: [findings] 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] Impression and Recommendations In summary, this is a [age]-year-old [postmenopausal/nulliparous if applicable] female with: Problems and Plan [as verbatim}: 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.] Follow-Up Plan: [booked follow-up appointment or patient advised to return PRN], [if shared care or return to referring doctor] Thank you again for referring [name]. Please do not hesitate to contact me if you require any further information or clarification.