Gynaecology Consult

Thank you for referring Jane Doe, a 32-year-old female, whom I saw in clinic on October 15, 2023, for 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.