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Posted: June 14th, 2023
Comprehensive Well-Woman Exam
Number of sources: 4
Paper instructions:
For a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.
Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.
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For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.
Comprehensive Well-Woman Exam that addresses the following:
Age, race and ethnicity, and partner status of the patient
Current health status, including chief concern or complaint of the patient
Contraception method (if any)
Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
Review of systems
Physical exam
Labs, tests, and other diagnostics
Differential diagnoses
Management plan, including diagnosis, treatment, patient education, and follow-up care
Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflection
Reflect on some additional factors for your patient:
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What are the implications if your patient was pregnant or just delivered?
What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.
May use another problem if better for paper.
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Comprehensive Well-Woman Exam
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Patient Information
Age: 25
Race and ethnicity: White
Partner status: Single
Current Health Status
Chief concern: None
Current medications: None
Allergies: None
Medical history: None
Family medical history: Mother with breast cancer
Gynecologic history: Regular menstrual cycles, no history of sexually transmitted infections
Obstetric history: None
Personal social history: Smokes 1 pack of cigarettes per day, drinks alcohol socially
Review of Systems
General: Well-developed, well-nourished female in no acute distress
Skin: No rashes, lesions, or bruising
Head, eyes, ears, nose, and throat: Pupils equal, round, and reactive to light; no nystagmus; oropharynx clear; tympanic membranes intact
Neck: No masses, tenderness, or lymphadenopathy
Chest: Clear to auscultation bilaterally
Heart: Regular rate and rhythm, no murmurs, rubs, or gallops
Abdomen: Soft, non-tender, non-distended, no hepatosplenomegaly
Musculoskeletal: No pain, swelling, or limitation of range of motion
Neurological: Alert and oriented x 3, no focal deficits
Physical Exam
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Breasts: Symmetric, no masses, tenderness, or nipple discharge
Pelvic exam: External genitalia without lesions or discharge; vagina pink and moist; cervix smooth, non-erythematous, and without lesions; uterus anteverted, non-tender, and mobile; ovaries not palpable
Labs, Tests, and Other Diagnostics
Pap smear: Negative for abnormal cells
Mammogram: Negative for breast cancer
Differential Diagnoses
None at this time
Management Plan
Continue current medications
No further testing or treatment indicated at this time
Discuss smoking cessation and alcohol use with patient
Provide patient with information about breast cancer screening and prevention
Schedule follow-up visit in 1 year
Evidence-Based Guidelines
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American College of Obstetricians and Gynecologists (ACOG). Committee Opinion No. 755: Well-Woman Visit. Obstet Gynecol. 2018;132(3):e157-e164.
U.S. Preventive Services Task Force (USPSTF). Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2018;168(1):31-40.
USPSTF. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2022;176(1):18-34.
Reflection
If the patient was pregnant or had just delivered, I would need to adjust my management plan accordingly. For example, I would need to discuss the risks and benefits of breastfeeding with the patient, and I would also need to provide her with information about postpartum depression.
If I observed or knew of some domestic violence, I would need to take steps to ensure the safety of the patient. I would also need to provide the patient with information about domestic violence resources and support services.
It is important to remember that every patient is an individual, and each well-woman exam should be tailored to the specific needs of the patient. By taking a comprehensive approach to well-woman care, we can help women maintain their overall health and well-being.
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