Chamberlain College of Nursing
Well-Woman Exam for Kayla
Patient Information:
KF, 37, F, Latin American
S.
CC (chief complaint): “I am here for a physical exam.” Reports fatigue and trouble falling and
staying asleep at night.
HPI:
Onset: About 8 weeks ago
Location: n/a
Duration: daily at night for sleep problems, constant for fatigue
Characteristics: Hard time falling asleep and staying asleep. Feeling tired all the time.
Aggravating Factors: Stress, financial worries, and sleeping in the same room as
children.
Relieving Factors: No information given.
Treatment: Taking Advil PM and drinking a glass of wine every night to help with sleep.
Current Meds: No current medications. Takes Advil PM at night or sleep prn.
Allergies: NKDA.
PMHx: In general good health. No surgeries or hospitalizations other than childbirths. Four
Pregnancies: 3 births (1 pre-term, 2 C-sections). One miscarriage at 10 wks at the age of 16.
PCOS diagnosed as teenager with irregular menses. Gestational diabetes with last pregnancy. No
information given for immunization status. Doesn’t know date of last tetanus.
Social History: Recently separated from husband. Moved to the area with her children to live
with parents. Three children, ages 13 months, 5 yrs, and 15 yrs. Trying to resolve marital issues,
in marital counseling. Reports financial worries, stress and ongoing fatigue. Former smoker,
smoked 1 PPD x 15 yrs, quit smoking 18 months ago when pregnant. Drinks a glass of wine
every night to sleep. Does not exercise routinely. Often skips breakfast and lunch. Family diet
consists largely of processed, quick food.
Revised 4/16
, Chamberlain College of Nursing
Family History: Mother with hyperlipidemia, Type 2 DM, and HTN. Father with HTN,
hyperlipidemia, and an MI with stenting 2 yrs ago. Children all healthy.
ROS:
CONSTITUTIONAL: (+) fatigue, (+) stress, (+) unable to fall asleep and stay asleep
CARDIOVASCULAR: no information given
RESPIRATORY: no information given
GASTROINTESTINAL: (+) skips breakfast and lunch, (+) consume quick, processed food
daily.
REPRODUCTIVE: (+) No menses since birth of last child
NEUROLOGICAL: no information given
MUSCULOSKELETAL: no information given
HEMATOLOGIC: no information given
PSYCHIATRIC: (+) stress
ENDOCRINOLOGIC: no information given
O.
Vital signs: height: 155 centimeters, weight: 65.5 kilograms. B/P: 130/76, HR: 82, T: 98.7, Resp:
16, SpO2: 97%. BMI 27.3 (Overweight)
General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam;
HEENT: head normocephalic; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic
membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils
1/4 bil; neck supple w/o lymphadenopathy.
Skin: warm, dry, intact;
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored. Peripheral pulses reg., equal
Breast Exam: Breasts of normal development bil. Areola unremarkable. Nipples without
discharge or tenderness. No masses or tenderness upon palpation
Abdomen: abdomen, soft, with normoactive bowel sounds throughout; tenderness to palpation in
the super-pubic area, no masses or organomegally. External Genitalia: Mons intact with normal
Revised 4/16
Well-Woman Exam for Kayla
Patient Information:
KF, 37, F, Latin American
S.
CC (chief complaint): “I am here for a physical exam.” Reports fatigue and trouble falling and
staying asleep at night.
HPI:
Onset: About 8 weeks ago
Location: n/a
Duration: daily at night for sleep problems, constant for fatigue
Characteristics: Hard time falling asleep and staying asleep. Feeling tired all the time.
Aggravating Factors: Stress, financial worries, and sleeping in the same room as
children.
Relieving Factors: No information given.
Treatment: Taking Advil PM and drinking a glass of wine every night to help with sleep.
Current Meds: No current medications. Takes Advil PM at night or sleep prn.
Allergies: NKDA.
PMHx: In general good health. No surgeries or hospitalizations other than childbirths. Four
Pregnancies: 3 births (1 pre-term, 2 C-sections). One miscarriage at 10 wks at the age of 16.
PCOS diagnosed as teenager with irregular menses. Gestational diabetes with last pregnancy. No
information given for immunization status. Doesn’t know date of last tetanus.
Social History: Recently separated from husband. Moved to the area with her children to live
with parents. Three children, ages 13 months, 5 yrs, and 15 yrs. Trying to resolve marital issues,
in marital counseling. Reports financial worries, stress and ongoing fatigue. Former smoker,
smoked 1 PPD x 15 yrs, quit smoking 18 months ago when pregnant. Drinks a glass of wine
every night to sleep. Does not exercise routinely. Often skips breakfast and lunch. Family diet
consists largely of processed, quick food.
Revised 4/16
, Chamberlain College of Nursing
Family History: Mother with hyperlipidemia, Type 2 DM, and HTN. Father with HTN,
hyperlipidemia, and an MI with stenting 2 yrs ago. Children all healthy.
ROS:
CONSTITUTIONAL: (+) fatigue, (+) stress, (+) unable to fall asleep and stay asleep
CARDIOVASCULAR: no information given
RESPIRATORY: no information given
GASTROINTESTINAL: (+) skips breakfast and lunch, (+) consume quick, processed food
daily.
REPRODUCTIVE: (+) No menses since birth of last child
NEUROLOGICAL: no information given
MUSCULOSKELETAL: no information given
HEMATOLOGIC: no information given
PSYCHIATRIC: (+) stress
ENDOCRINOLOGIC: no information given
O.
Vital signs: height: 155 centimeters, weight: 65.5 kilograms. B/P: 130/76, HR: 82, T: 98.7, Resp:
16, SpO2: 97%. BMI 27.3 (Overweight)
General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam;
HEENT: head normocephalic; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic
membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils
1/4 bil; neck supple w/o lymphadenopathy.
Skin: warm, dry, intact;
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored. Peripheral pulses reg., equal
Breast Exam: Breasts of normal development bil. Areola unremarkable. Nipples without
discharge or tenderness. No masses or tenderness upon palpation
Abdomen: abdomen, soft, with normoactive bowel sounds throughout; tenderness to palpation in
the super-pubic area, no masses or organomegally. External Genitalia: Mons intact with normal
Revised 4/16
