I HUMAN CASE STUDY FOR LAURA WOOD A 41 YEARS OLD FEMALE CC; REASON FOR ENCOUNTER-WELL WOMAN EVALUATION (WEEK 9); INCLUDES HPI, PE, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT PLAN | EXPERT FEEDBACK LATEST AND COMPLETE UPDATE GRADED A+

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I HUMAN CASE STUDY FOR LAURA WOOD A 41
YEARS OLD FEMALE CC; REASON FOR
ENCOUNTER-WELL WOMAN EVALUATION (WEEK
9); INCLUDES HPI, PE, DIFFERENTIAL DIAGNOSIS,
AND MANAGEMENT PLAN | EXPERT FEEDBACK
LATEST AND COMPLETE UPDATE GRADED A+

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VERSION A g;




❢ Patient Demographics
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• Name: Laura Wood g; g;


• Age/Sex: 41-year-old female g; g;


• Reason for Encounter: Annual well-woman examination
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• Class: 6512 – Week 9 g; g; g; g;




1️⃣ History of Present Illness (HPI):
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Laura Wood presents for a routine annual well-woman visit. She has no acute
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complaints and considers herself generally healthy. She requests an assessment
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of overall health, updating of vaccinations, and screening recommendations
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appropriate for her age.
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Additional Context: g;




• Gynecologic History: g;


o LMP: 14 days ago. g; g; g;


o Regular menstrual cycles every 28–30 days. g; g; g; g; g;


o No abnormal bleeding, dysmenorrhea, or vaginal discharge.
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o No new sexual partners, long-term monogamous relationship for
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15 years. g; g;


o Gravida 2, Para 2 (last delivery 9 years ago). g; g; g; g; g; g; g; g;


• Family History: g;


o Mother: Hypertension, breast cancer (diagnosed at 55)
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o Father: Type 2 diabetes, hyperlipidemia g; g; g; g;


o No other significant family medical history.
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• Social History: g;


o Occupation: Accountant. g;


o Lifestyle: Exercises 2–3 times/week. g; g; g;


o Diet: Balanced. g;


o Alcohol: Social, ~1–2 drinks/week. g; g; g;


o Smoking: Never. g;


o Sexual activity: Monogamous, long-term partner.
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• Review of Systems: g; g;


o No weight changes, fatigue, or night sweats. g; g; g; g; g; g;


o No vaginal bleeding or discharge. g; g; g; g;


o No urinary symptoms. g; g;


o No breast lumps or nipple discharge. g; g; g; g; g;




Summary of HPI: g; g;


A 41-year-old woman presenting for annual examination, denies any new or active
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complaints. Seeks screening and prevention recommendations as per guidelines.
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2️⃣ Physical Examination (PE):
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Vital Signs: BP 118/72, HR 72 bpm, RR 14, Temp 98.5 °F, SpO₂ 99%
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RA. General: Alert, well-appearing, appropriately groomed, and in no
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apparent distress.
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HEENT: Normocephalic, no lymphadenopathy, no oral lesions.
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Breasts: Symmetric, no palpable masses or lymphadenopathy, no
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nipple discharge.
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Cardiovascular: Regular rate and rhythm, no murmurs. g; g; g; g; g; g;


Respiratory: Clear breath sounds bilaterally. g; g; g; g;


Abdomen: Non-tender, no masses or hepatosplenomegaly.
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Pelvic Exam: Normal external genitalia, vaginal walls and cervix healthy, no
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cervical motion tenderness, uterus and adnexa unremarkable.
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Extremities: No edema or joint abnormalities. g; g; g; g; g;


Skin: No suspicious lesions.
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Summary of PE: g; g;


Normal examination, consistent with a well-woman visit.
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3️⃣ Differential Diagnosis:
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Although this is a routine screening visit, certain considerations must be kept
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in mind when assessing women in this age bracket:
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