Chapter 8: The Male and Female Reproductive Systems | Tyra McNamara's Chart Note

CHART NOTE

Patient Name: McNamara, Tyra
ID Number: MT 33412
Examination Date: July 28, 20xx

SUBJECTIVE
This newly married patient complains of painful intercourse, which is often associated with her menstrual period. She has random episodes of pain with urination and bowel movements.

OBJECTIVE
Patient had one child delivered vaginally. No history of STDs or cancer. Dysmenorrhea and menorrhagia.

ASSESSMENT
Probable endometriosis.

PLAN
Patient prescribed hormonal contraceptives and ibuprofen to help reduce pelvic pain. Patient to return for follow-up.