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COMPREHENSIVE WELL-WOMAN
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.
• 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. • 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 Paper 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.
Sample Answer
I. Introduction and Patient Demographics (Page 1)
This section introduces the patient case selected from the practicum experience, focusing on demographic factors that inform the health promotion and disease prevention strategy.
Age: [Insert Patient Age]
Race and Ethnicity: [Insert Patient Race/Ethnicity]
Partner Status: [Insert Partner Status: e.g., Single, Married, Partnered, Divorced]
Current Health Status (Summary): A brief, 1–2 paragraph overview of the patient's general health, primary health maintenance needs, and any chronic conditions.
Chief Concern (CC): The patient’s main reason for the visit (e.g., "Annual well-woman exam," or a specific complaint like "Dyspareunia for 3 months").
Contraception Method (If applicable): [Insert method or "None"]
II. Subjective (S) Data: History and Review of Systems (ROS) (Pages 2–4)
This section details the patient's self-reported information, which forms the basis for the physical exam and diagnosis.
History of Present Illness (HPI)
If the CC is a complaint (e.g., pain, abnormal bleeding), describe the symptoms using OLD CARTS (Onset, Location, Duration, Character, Alleviating/Aggravating factors, Radiation, Timing, Severity).
If the CC is an annual exam, summarize the patient's health since the last visit.
First-degree relatives (parents, siblings): History of breast, ovarian, or colon cancer; diabetes; heart disease; mental health disorders.
Gynecologic History (Gyn Hx)
Age of menarche, menstrual cycle regularity (LMP), history of STIs, abnormal Pap smears, and treatments.
Obstetric History (OB Hx)
Gravida/Para (G/P): Number of pregnancies, live births, miscarriages, abortions. Describe the most recent pregnancy outcome if relevant.
Personal Social History (PSH)
Occupation, education, socioeconomic status (SES), support system, safety, alcohol/tobacco/drug use, exercise, and nutritional habits. Reflect on cultural or religious practices affecting health.
Review of Systems (ROS)
Provide a systematic head-to-toe review, noting all pertinent positives and negatives.
General: Weight change, fatigue, fever.
Skin: Rashes, lesions, changes in hair/nails.
HEENT: Headaches, vision changes, hearing loss.
Cardiovascular: Chest pain, palpations, edema.
Respiratory: Cough, shortness of breath, wheezing.