ASSIGNMENT 1: APPLICATION – COMPREHENSIVE WELL-WOMAN EXAM
Comprehensive Well-Woman Exam
Name
School
NURS-6551N: Primary Care of Women.
Professor
Date
,SUBJECTIVE DATA:
General patient information
This is a comprehensive assessment on a 21-year-old female, African American that has mixed
ethnicity, her mother is a white and her father is an African American. She is single and lived with her
mother, father, and her brother. G1 T0 P0 A0 L0.
Chief concern/complaint (CC) and history of present illness (HPI)
AA is a 21-year-old African American female, sexually active, G1PO visited the health care
center today with complains of vulvar itching, vaginal discharge, and pelvic pain started 7days ago. She
complains that the pelvic pain gets worst and describes pain as “come and go shooting pain”, when she
urinates or having a sexual intercourse. AA reported the pain scale as 7/8 during urination and 9/10
during intercourse. AA verbalized the aggravating factor to be a vaginal discharge that is constant,
severe and describes the color as thick, copious mucous frothy foul smelling yellow-green discharge. AA
verbalized taking OTC medications Ibuprofen 400mg every 6 hours as needed and used vaginal cream
for yeast infection to relieve the itching but the itching and the pain are not relieved. AA verbalized this
kind of health problems had happened during my first week first trimester and the doctor called it
Trichomoniasis, got treated with my partner. AA last menstrual period was July 15, 2019 and using the
Nagele´s rule, which is to add 7 days to the first day of the menstrual period, then subtract 3 months it
will calculate the estimated due date, which will be April 22, 2020 (Schuiling & Likis, 2017).
AA verbalized not exposed to Diethylstilbestrol (DES) and neither was her mother.
Diethylstilbestrol (DES) was utilized between 1940 and 1971 as an artificial formula of estrogen to
prevent miscarriages, preterm labor, and complications during pregnancy but has indicated to cause
clear cell carcinoma (Diethylstilbestrol (DES) and Cancer, 2011).
AA is currently sexually active with males, and has multiple relationship but now not in good
relationship with her baby’s father and had not seen him after being aware of her pregnancy. AA denies
using any contraception or protective barrier devices such as female condoms or male condoms to
prevent sexually transmitted diseases (STDs).
Patient Past history/PMHx: The patient has past medical history of Asthma, HTN, Obese, Pre-DM,
trichomonas’s treated in the past, and a scar on her forehead from a piece of glass through car accident
that occurs when she was four years. Psychological and mental health is imbalance due to AA father
verbally abused her and her neighbor sexually abused her but no reports filed. AA reports being bullied a
lot due to her overweight and poor dressing habit as a result of poverty. AA denies any surgeries or
hospitalizations.
Family medical history: AA mother has past medical history of hypertension and Asthma but denies any
other family history of breast cancer, colon cancer, and cervical cancer. Other family history is
unknown, verbalized that she does not known much about other family members.
, Medications: AA is taking OTC Ibuprofen 400mg 1-tab PO BID as needed for her pelvic pain and OTC
vaginal cream for itching but cannot remember the medication name. Hydrochlorothiazide 25 mg 1 tab
PO QD prescribed for her hypertension, but patient verbalized not taking the blood pressure
medication. Flagyl 500mg 1tab PO BID for 7 days – positive for trichomoniasis (completed and resolved).
Albuterol inhaler 2 puffs orally inhaled every 6 hours as need for Asthma. The patient verbalized used it
once in a while as needed. She has no known allergy to medications, foods, and environment.
AA Health maintenance/screenings such as childhood immunization are up-to-date and she did not take
the Gardasil immunizations. She had chickenpox in her 4 th grade, even though she had vaccination. She
was screen for rubella and is immune to rubella. She refuses to take to the flu vaccine and stated “it
makes me sick every year”. She had never had a pap smear done. She denies any surgeries or
hospitalizations.
Gynecologic history: The patient verbalized that her periods started at the age of 11, was always
regular occurs every 28 days but runs 5 days long, but very heavy used 5 pads a day throughout the
whole cycle. She has a positive history of trichomoniasis, which she verbalized that she took all
prescribed medications earlier in the pregnancy but since she is sexually active 4 to 5 times a week and
has multiple partners for intercourse without protection it is possible that she may have been exposed
to the STD again. She is nulligravida one para 0, term 0, Labor 0, Spontaneous abortion-0 (G-1, T-0, P-0,
A-0, L-0).
The patient never given birth to any child before, no term delivery, no pre-term deliveries, no
spontaneous abortion or miscarriage or induced abortions and no living children.
Personal social history: AA is an African American single female that lived with the parent and brother
in a one-story town house with smoke alarm already paid in full by the grandma. She is from poor family
background. Patient denies living near any factory plants that may produce harmful smoke to her or to
the fetus (Schuiling & Likis, 2017). She dropped out of school after high school due to inadequate funds,
unemployed and family incomes are in poor economic condition. She does wears seatbelt in the car
when receiving a ride from a friend. She has Medicaid insurance and a link card for foods. She is
currently unhappy and has unplanned pregnancy stated that her boyfriend left after finding out she was
pregnant. She denies being current physically or verbally abused or forced sex by her boyfriend. She
verbalized only being sexually abused once by her neighbor which she never made a report long time
ago. She is obese at 285 lbs. and breathes heavily during communication. My preceptor mentioned that
the patient was instructed and encouraged to lose weight several times to control her diet and exercise
due to her BMI is 44. The patient verbalized that she hates doing any physical activity and exercise
because it caused her body pain. Also, she complains that when she is stressed out she hates to cook
and eats a lot of fast food to control her stress. She verbalized sleeping only five hours in the night and
complains of insomnia sometimes. The patient appears poor grooming and hair unkempt. She was
unable to remember the last dental visit or last checkup for her health routine. She smokes two sticks of
cigarettes a day for three years plus and stop after she found out she was pregnant. She denies drinking
alcohol while pregnant but used to drink 3 bottles of beer and a glass of vodka twice a week. Also, the
patient denies using illicit drugs but her Urine drug screen indicates positive for THC. She denies taking
any caffeine but like drinking coke and Pepsi a lot which contains caffeine. According to one prospective
Comprehensive Well-Woman Exam
Name
School
NURS-6551N: Primary Care of Women.
Professor
Date
,SUBJECTIVE DATA:
General patient information
This is a comprehensive assessment on a 21-year-old female, African American that has mixed
ethnicity, her mother is a white and her father is an African American. She is single and lived with her
mother, father, and her brother. G1 T0 P0 A0 L0.
Chief concern/complaint (CC) and history of present illness (HPI)
AA is a 21-year-old African American female, sexually active, G1PO visited the health care
center today with complains of vulvar itching, vaginal discharge, and pelvic pain started 7days ago. She
complains that the pelvic pain gets worst and describes pain as “come and go shooting pain”, when she
urinates or having a sexual intercourse. AA reported the pain scale as 7/8 during urination and 9/10
during intercourse. AA verbalized the aggravating factor to be a vaginal discharge that is constant,
severe and describes the color as thick, copious mucous frothy foul smelling yellow-green discharge. AA
verbalized taking OTC medications Ibuprofen 400mg every 6 hours as needed and used vaginal cream
for yeast infection to relieve the itching but the itching and the pain are not relieved. AA verbalized this
kind of health problems had happened during my first week first trimester and the doctor called it
Trichomoniasis, got treated with my partner. AA last menstrual period was July 15, 2019 and using the
Nagele´s rule, which is to add 7 days to the first day of the menstrual period, then subtract 3 months it
will calculate the estimated due date, which will be April 22, 2020 (Schuiling & Likis, 2017).
AA verbalized not exposed to Diethylstilbestrol (DES) and neither was her mother.
Diethylstilbestrol (DES) was utilized between 1940 and 1971 as an artificial formula of estrogen to
prevent miscarriages, preterm labor, and complications during pregnancy but has indicated to cause
clear cell carcinoma (Diethylstilbestrol (DES) and Cancer, 2011).
AA is currently sexually active with males, and has multiple relationship but now not in good
relationship with her baby’s father and had not seen him after being aware of her pregnancy. AA denies
using any contraception or protective barrier devices such as female condoms or male condoms to
prevent sexually transmitted diseases (STDs).
Patient Past history/PMHx: The patient has past medical history of Asthma, HTN, Obese, Pre-DM,
trichomonas’s treated in the past, and a scar on her forehead from a piece of glass through car accident
that occurs when she was four years. Psychological and mental health is imbalance due to AA father
verbally abused her and her neighbor sexually abused her but no reports filed. AA reports being bullied a
lot due to her overweight and poor dressing habit as a result of poverty. AA denies any surgeries or
hospitalizations.
Family medical history: AA mother has past medical history of hypertension and Asthma but denies any
other family history of breast cancer, colon cancer, and cervical cancer. Other family history is
unknown, verbalized that she does not known much about other family members.
, Medications: AA is taking OTC Ibuprofen 400mg 1-tab PO BID as needed for her pelvic pain and OTC
vaginal cream for itching but cannot remember the medication name. Hydrochlorothiazide 25 mg 1 tab
PO QD prescribed for her hypertension, but patient verbalized not taking the blood pressure
medication. Flagyl 500mg 1tab PO BID for 7 days – positive for trichomoniasis (completed and resolved).
Albuterol inhaler 2 puffs orally inhaled every 6 hours as need for Asthma. The patient verbalized used it
once in a while as needed. She has no known allergy to medications, foods, and environment.
AA Health maintenance/screenings such as childhood immunization are up-to-date and she did not take
the Gardasil immunizations. She had chickenpox in her 4 th grade, even though she had vaccination. She
was screen for rubella and is immune to rubella. She refuses to take to the flu vaccine and stated “it
makes me sick every year”. She had never had a pap smear done. She denies any surgeries or
hospitalizations.
Gynecologic history: The patient verbalized that her periods started at the age of 11, was always
regular occurs every 28 days but runs 5 days long, but very heavy used 5 pads a day throughout the
whole cycle. She has a positive history of trichomoniasis, which she verbalized that she took all
prescribed medications earlier in the pregnancy but since she is sexually active 4 to 5 times a week and
has multiple partners for intercourse without protection it is possible that she may have been exposed
to the STD again. She is nulligravida one para 0, term 0, Labor 0, Spontaneous abortion-0 (G-1, T-0, P-0,
A-0, L-0).
The patient never given birth to any child before, no term delivery, no pre-term deliveries, no
spontaneous abortion or miscarriage or induced abortions and no living children.
Personal social history: AA is an African American single female that lived with the parent and brother
in a one-story town house with smoke alarm already paid in full by the grandma. She is from poor family
background. Patient denies living near any factory plants that may produce harmful smoke to her or to
the fetus (Schuiling & Likis, 2017). She dropped out of school after high school due to inadequate funds,
unemployed and family incomes are in poor economic condition. She does wears seatbelt in the car
when receiving a ride from a friend. She has Medicaid insurance and a link card for foods. She is
currently unhappy and has unplanned pregnancy stated that her boyfriend left after finding out she was
pregnant. She denies being current physically or verbally abused or forced sex by her boyfriend. She
verbalized only being sexually abused once by her neighbor which she never made a report long time
ago. She is obese at 285 lbs. and breathes heavily during communication. My preceptor mentioned that
the patient was instructed and encouraged to lose weight several times to control her diet and exercise
due to her BMI is 44. The patient verbalized that she hates doing any physical activity and exercise
because it caused her body pain. Also, she complains that when she is stressed out she hates to cook
and eats a lot of fast food to control her stress. She verbalized sleeping only five hours in the night and
complains of insomnia sometimes. The patient appears poor grooming and hair unkempt. She was
unable to remember the last dental visit or last checkup for her health routine. She smokes two sticks of
cigarettes a day for three years plus and stop after she found out she was pregnant. She denies drinking
alcohol while pregnant but used to drink 3 bottles of beer and a glass of vodka twice a week. Also, the
patient denies using illicit drugs but her Urine drug screen indicates positive for THC. She denies taking
any caffeine but like drinking coke and Pepsi a lot which contains caffeine. According to one prospective
