NURS 6551, WEEK 9 COMPREHENSIVE WELL
WOMEN EXAM ASSIGNMENT 1
,ASSIGNMENT 1: APPLICATION – COMPREHENSIVE WELL-WOMAN EXAM
Comprehensive Well-Woman Exam
Name
Walden University
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.
WOMEN EXAM ASSIGNMENT 1
,ASSIGNMENT 1: APPLICATION – COMPREHENSIVE WELL-WOMAN EXAM
Comprehensive Well-Woman Exam
Name
Walden University
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.
