General Practitioner Template

Dysmenorrhoea/Menorrhagia

A professional General Practitioner template for healthcare professionals.

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Specialty

General Practitioner

Used

191 times

Type

Note

Last edited

7/28/2026

Created by

Hannah Allen

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About this template

This Dysmenorrhoea/Menorrhagia template is designed for General Practitioners to document patient visits related to painful menstruation. It includes sections for primary concerns, presenting issues, past medical and obstetric history, physical examination findings, assessment, investigations ordered, treatment plan, and next steps. This template ensures comprehensive documentation, aiding in accurate diagnosis and effective treatment planning. Ideal for managing cases of dysmenorrhoea, it helps clinicians provide detailed and structured notes, improving patient care and follow-up. Use this template to streamline your documentation process and enhance patient outcomes.

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Primary Concern: Dysmenorrhoea (painful menstruation) Presenting Issue: - Symptoms: Severe cramping and lower abdominal pain during menstruation, associated with nausea and fatigue - Duration: Symptoms have been present for the past 2 years, worsening over time - Menstrual History: Regular menstrual cycles, typical duration of 5 days - Impact on Daily Life: Difficulty attending work or school, need for pain medication Past Medical History: - Gynaecological History: No history of pelvic inflammatory disease, endometriosis - Chronic Conditions: No significant chronic conditions - Medications: Currently using ibuprofen for pain management Relevant Obstetric History: - Pregnancies: No previous pregnancies - Previous Gynaecological Procedures: None reported Physical Examination: - General Appearance: Appears in discomfort during examination - Abdominal Examination: Tenderness in the lower abdomen, no palpable masses - Pelvic Examination: No abnormal findings on examination, cervix and vaginal walls normal Assessment: - Working Diagnosis: Primary dysmenorrhoea - Differential Diagnosis: Secondary dysmenorrhoea due to conditions such as endometriosis or fibroids Investigations Ordered: - Pelvic Ultrasound: To rule out structural abnormalities such as fibroids or ovarian cysts - Additional Tests: Consider blood tests if secondary causes are suspected Treatment Plan: - Medications: - Pain Relief: Continue ibuprofen, consider starting hormonal contraceptives if appropriate for symptom management - Supplementation: Consider adding magnesium or vitamin B6 supplements if deficiency suspected - Lifestyle Modifications: - Exercise: Recommend regular physical activity and stretching exercises - Diet: Suggest reducing caffeine and high-sugar foods - Alternative Therapies: Acupuncture or heat application - Follow-Up: Review in 3 months or sooner if symptoms worsen Next Steps: - Follow-Up Appointment: Scheduled for [Date] to assess response to treatment and adjust management plan if needed - Referral: Referral to a gynecologist if no improvement or if secondary causes are suspected Signature: Dr. Thomas Kelly General Practitioner [Provider’s Contact Information] Date: [Date of Documentation]