Telehealth Gynecological Follow up Consultation

Date of Consultation: 2025-07-13  
Time: Not specified  
Mode: Not specified  

TELEHEALTH CONSENT  
☐ Patient verbally consented to telehealth consultation  
☐ Patient identity verified via Not specified  

Thank you for referring Sarah for ongoing gynecologic care.  

Reason for Follow-Up  
Pelvic pain management and evaluation.  

Interval History  
Progress since last visit: Pelvic pain has been ongoing for almost 3 months. No associated bleeding or abnormal vaginal discharge reported.  
Medications: Patient was administered a regular dose on December 28, 2024, and was compliant with the last dose on July 6.  
Relevant symptoms:  
Menstrual changes: No  
Pain: Yes, pelvic pain ongoing for 3 months  
Vaginal symptoms: No abnormal vaginal discharge reported  
Other: None reported  
Sexual Activity Update: Sexually active, uses combined birth control for contraception  
Fertility Update: Not applicable  
New relevant medical history since last visit: None  

Investigations Reviewed  
No investigations were reviewed during this consultation.  

Assessment  
- Pelvic pain ongoing for 3 months with no associated bleeding or abnormal vaginal discharge.  
- History of depression.  
- Uses combined birth control for contraception.  

Plan  
- Continue monitoring pelvic pain and assess for any changes or worsening symptoms.  
- Consider further evaluation if symptoms persist or worsen, including imaging or referral to a specialist if necessary.  
- Encourage patient to report any new symptoms or concerns promptly.  

Follow-Up Plan  
- Schedule follow-up in-person or telehealth consultation as needed based on symptom progression.  
- Patient instructed to contact the clinic if symptoms worsen or new symptoms arise.  

Thank you for your ongoing collaboration in the care of Sarah.  
Please feel free to reach out if further information is required.  

Yours sincerely,  
David Carter, MD  
Obstetrician-Gynecologist  
Regional Womens Health Clinic