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.
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.
Past Medical History (PMH):
Ob/Gyn: G2P2 (two full-term deliveries). OCPs for contraception. Denies history of STIs, abnormal Pap results, or chronic pelvic pain.
Medical: Denies HTN, Diabetes, high cholesterol. History of seasonal allergies only.
Surgical: Two uncomplicated C-sections (2018, 2020).
Family History (FHx): Mother diagnosed with Type 2 Diabetes at age 50 and Hypertension at age 55. Father has high cholesterol. Maternal aunt has breast cancer (post-menopausal).
Social History:
Occupation: Full-time Marketing Manager. Describes job as high-stress with long hours (50–60 hours/week).
Exercise: Sporadic. Averages 30 minutes of walking/week. Reports desire to increase activity.
Nutrition: Tends to eat out or order delivery (convenience). Admits to high intake of processed foods and often skips breakfast.
Substance Use: Occasional glass of wine (2-3 per week). Denies tobacco or illicit drug use.
Intimate Partner Violence (IPV) Screening: Negative. Reports safe, supportive relationship.
O: Objective
Vitals:
BP: 135/85 mmHg (Sitting, Right Arm) - Elevated, Stage 1 Hypertension classification (requires recheck)
HR: 78 bpm (Regular)
RR: 16
Temp: 98.6°F (Oral)
Height: 5' 5" (165 cm)
Weight: 170 lbs (77.1 kg)
BMI: 28.3 kg/m$^2$ (Overweight)
Physical Exam (Focused):
General: Alert, oriented, cooperative. Appears well-groomed but slightly tense.
Cardiovascular: Regular rate and rhythm, S1/S2 audible, no murmurs, rubs, or gallops.
Breast: No masses, dimpling, or nipple discharge. Axillary lymph nodes non-tender, non-palpable.
Abdomen: Soft, non-tender. Well-healed horizontal C-section scar.
Pelvic/External Genitalia: Normal female external genitalia.
Vaginal/Cervical: Vagina pink, rugated. Cervix nulliparous appearance, without lesions, discharge, or inflammation. Speculum inserted for collection.
Uterus/Adnexa: Uterus small, mobile, non-tender. Adnexa non-tender, no masses appreciated.
Diagnostic Testing (Ordered Today):
Cervical Cancer Screening: Co-testing (Cytology + HPV) as she is 35 years old. (USPSTF recommends cotesting every 5 years for ages 30-65).
Metabolic/Cardiovascular: Complete Metabolic Panel (CMP), Fasting Lipid Panel (FLP), and Hemoglobin A1c (HbA1c). (Screening for Diabetes begins at age 35, earlier with risk factors like high BMI and FHx).