Mary Lewis is a 36 year old African American female in the clinic with complaints of frequent urination, itching vaginal discharges foul odor and abdominal pain for 3 days. Pt reports a positive pregnancy test. Pt has a history anxiety, DM and smoker.
COMPREHENSIVE WELL-WOMAN EXAM
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.
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.
To PREPARE
- Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
- Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.
- What additional considerations might you think about if your patient was pregnant or just delivered?
- Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Assignment:
Write an 8- to 10-page 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:
- 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.
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