Gynecology Consultation Note (Inpatient/ED)

Date/Time of Evaluation: [Date and time of consult]

Location: [ED / inpatient unit / ICU / OR / other]

Requesting Service/Clinician: [Service and clinician name/role]

Reason for Consult: [Brief consult question]

Urgency: [STAT / urgent / routine]

Consult Summary & Recommendations

• One-line summary: [Age], [pregnancy status if known or "pregnancy status unknown"], [key presentation and acuity]
• Working diagnosis: [Primary working diagnosis] ([leading alternatives if relevant])
• Immediate actions for primary team: [Time-sensitive orders/interventions] (Include analgesia, antiemetics, NPO, IV access, labs, imaging, transfusion parameters as applicable.)
• Disposition recommendation: [OR now / admit to (service and level of care) / observe / discharge] (State rationale.)
• Contingencies and callback thresholds: [Objective triggers such as worsening vitals, peritoneal signs, declining hemoglobin, increased bleeding, fever] (Provide concrete numbers when available.)
• Follow-up plan: [Timing and venue], [who will arrange], [pending results to track]

Data Sources & Limitations

• Historians: [Patient / family / EMS / chart / interpreter with language]
• Records reviewed: [ED notes / inpatient notes / prior operative reports / prior imaging / outside records]
• Limitations: [Altered mental status / severe pain / language barrier / intoxication / unavailable records / other] (Explicitly state key missing information rather than omitting fields.)

History of Present Illness

[Consult question restated and timeline] (Begin with why Gynecology was consulted and when symptoms started.)

[Symptom characterization including onset, duration, trajectory, precipitating events, pain characteristics, bleeding if applicable with timing/volume/pad count/syncope, infection symptoms if relevant]

[Reproductive context including LMP, cycle pattern, contraception method, pregnancy possibility or known result]

[Prior episodes and treatments, pertinent negatives that reduce risk of time-critical diagnoses]

[Patient priorities or direct quotes if they clarify severity or preferences]

Gynecologic & Obstetric History

• LMP & cycles: [Date of LMP], [cycle regularity/length/flow]
• Pregnancy status: [Known positive / known negative / uncertain]; [contraception method if applicable]
• Relevant prior conditions: [Fibroids / endometriosis / PCOS / ovarian cysts / bleeding disorder / none / other]
• Prior gynecologic surgeries: [Procedures with dates, or none]
• Obstetric history: [Gravida/Para, prior ectopic, prior cesarean, gestational age if known] (Include if pregnancy possible or confirmed.)

Relevant Medical History

• Comorbidities impacting acute management: [Coagulopathy / anticoagulant or antiplatelet use / VTE history / liver disease / malignancy / immunosuppression / none / other]
• Current relevant medications: [List with doses if pertinent]
• Allergies: [Medication and reaction type]

Physical Examination

Vitals: [Temperature], [HR], [BP], [RR], [SpO2]; [hemodynamic status and trends if relevant]

General: [Appearance, distress level]

Cardiovascular: [Perfusion, pulses, tachycardia] (Include if unstable or bleeding.)

Abdomen: [Tenderness with location], [guarding/rebound], [distension], [peritoneal signs]

Pelvic Exam:

• Consent: [Obtained / emergency exception]
• Chaperone: [Present with name/role / not present with reason]
• Components performed: [External / speculum / bimanual]
• Findings: [External lesions], [blood in vault: none/scant/moderate/large], [active cervical bleeding: present/absent], [cervical lesions or friability], [discharge character], [cervical motion tenderness: present/absent], [uterine size/position/tenderness], [adnexal mass or tenderness with side/size], [cul-de-sac fullness or tenderness]
• Specimens collected: [GC/CT NAAT / wet prep / vaginal culture / none]
• If exam deferred: [Reason: patient refusal / intolerance / emergent instability / other]; [alternative data used]

Diagnostics

• Pregnancy testing: [Urine hCG / serum qualitative / quantitative hCG with value and trend if available]
• CBC: [Hgb/Hct with trend if relevant], [platelets] (Highlight critical values.)
• Type & screen/crossmatch: [Status and units available if applicable]
• Coagulation studies: [INR/PTT/fibrinogen] (If relevant.)
• UA and STI testing: [UA results], [GC/CT status], [other]
• Pelvic ultrasound: [Transabdominal/transvaginal], [IUP status], [ovary size/appearance], [Doppler flow], [free fluid], [masses/cysts with measurements], [limitations]
• CT/MRI: [Key findings if performed]
• Bedside ultrasound by consultant: [Scope and focused findings] (If performed; note limitations.)
• Interpretation: [Brief synthesis of how results support or alter the plan]

Assessment & Plan

(Problem-oriented format, numbered by acuity. For each problem: state working diagnosis with supporting evidence, differential, specific plan with responsibilities divided between Gynecology and primary team, and disposition. First problem must answer the consult question. Do not infer pregnancy status, hemodynamic stability, or absence of hemorrhage without documented objective data.)

1. [Primary problem answering consult question] – Level of concern: [high / moderate / low]

• Evidence: [Key history, exam, and diagnostic findings supporting diagnosis]
• Differential: [Brief prioritized list]
• Plan – Gynecology will: [Procedures, interventions, counseling, operative planning, follow-up]
• Plan – Primary team should: [Orders, monitoring, medications, resuscitation steps]
• Disposition: [OR now / admit to (location) / observe / discharge] (Include escalation criteria.)

2. [Additional problem] (If applicable.)

• Evidence/Differential: [Concise summary]
• Plan – Gynecology: [Actions]
• Plan – Primary team: [Actions]
• Disposition: [As above]

(If suspected ovarian torsion: Document that torsion is a clinical/surgical diagnosis and nondiagnostic imaging does not exclude it. If suspicion high, recommend NPO and expedited diagnostic laparoscopy with ovarian preservation intent; document counseling.)

(If acute abnormal uterine bleeding: Document hemodynamic status first; quantify bleeding and anemia symptoms; identify etiology; separate plan into immediate control, resuscitation/transfusion thresholds, workup, and transition plan.)

(If PID/TOA: Document exam findings supporting diagnosis; include guideline-concordant antibiotics, admission criteria, drainage consideration for TOA, partner notification counseling.)

Disposition & Follow-up

• Disposition: [Admit / discharge / observe / OR]
• If admitting: [Recommended service and level of care]
• Follow-up: [Timing], [clinic or provider], [who will arrange]
• Discharge medications: [Medications with dose/duration, or N/A]
• Return precautions: [Worsening pain, fever, heavy bleeding with quantity, syncope, vomiting, inability to tolerate PO]

Communication

[Recommendations discussed with requesting clinician (name/role) at (time if relevant). Patient counseling performed regarding (diagnosis, plan, alternatives). Patient preferences, questions, or refusals documented. Disagreements and resolution if any.]