Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Reason for Visit:
Document the reason for this visit. Is this a new patient with suspected endometriosis, a follow-up visit after diagnosis or treatment, or a visit to address specific symptoms?
History of Present Illness:
Pelvic pain:
Characterize the pain (location, severity, duration, cyclical pattern related to menstrual periods).
Inquire about pain during intercourse (dyspareunia).
Menstrual irregularities:
Heavy menstrual bleeding (menorrhagia)
Painful periods (dysmenorrhea)
Infertility:
Inquire about attempts to conceive and any history of infertility evaluation.
Other symptoms:
Fatigue
Gastrointestinal symptoms (bloating, diarrhea, constipation)
Urinary urgency or frequency
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially prior pelvic surgeries or hormonal therapies.
Social History:
Tobacco use (may worsen endometriosis symptoms)
Family history (mother, sister, or daughter with endometriosis)
Medications:
List all current medications, including any hormonal therapies (birth control pills, pain medications).
Allergies:
Document any known allergies, especially allergies to medications used in treatment.
Physical Exam:
Vital Signs: Include blood pressure.
Pelvic Exam:
May reveal pelvic tenderness or nodularity.
Consider bimanual exam to assess for uterosacral tenderness.
Laboratory:
Laboratory testing is not diagnostic for endometriosis, but may be performed to rule out other conditions:
Complete blood count (CBC): May show anemia if there is heavy menstrual bleeding.
CA-125: This tumor marker can be elevated in some cases of endometriosis, but it is not specific for this diagnosis.
Imaging:
Imaging studies are not routinely used for diagnosis but may be helpful in some cases:
Pelvic ultrasound: May reveal ovarian endometriomas (chocolate cysts).
MRI: More detailed imaging to visualize endometriosis implants, especially if surgery is planned.
Assessment:
Suspected endometriosis: Based on clinical presentation and ongoing evaluation.
Endometriosis diagnosed: If laparoscopy with biopsy confirms endometriosis implants.
Consider staging system used (e.g., American Society for Reproductive Medicine [ASRM] classification) to categorize the extent of disease.
Consider differential diagnoses based on symptoms (e pelvic inflammatory disease (PID), ovarian cysts, uterine fibroids).
Plan:
The treatment plan will depend on the severity of symptoms, desire for future fertility, and patient preferences.
Discuss treatment options with the patient, which may include:
Pain management:
Over-the-counter pain relievers (e.g., ibuprofen)
Hormonal therapy (birth control pills, continuous oral contraceptives, progestin-only therapy)
Non-steroidal anti-inflammatory drugs (NSAIDs)
Surgery:
Laparoscopy is the preferred surgical approach to diagnose and treat endometriosis by removing implants and scar tissue.
Other therapies:
Gonadotropin-releasing hormone (GnRH) agonists or antagonists (may have side effects like bone loss)
Follow-up:
The follow-up schedule will depend on the treatment chosen and the severity of symptoms.
Monitor for symptom control and recurrence.
Consider referral to a pain specialist if chronic pain persists.
Discuss fertility options if desired, as endometriosis can affect fertility.
Provide resources for support groups and educational materials on endometriosis.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding symptoms, duration, risk factors, physical exam findings, laboratory and imaging results (if performed), and individualized treatment plan.