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 4th 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 4th 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
