Comprehensive Women’s Health History and Physical Template

Comprehensive Women’s Health History and Physical Template

Encounter date: 01/10/2023

Patient Initials: O.R. Gender: Female Age: 39 years Race/Ethnicity: Haitian American

Reason for Seeking Health Care: The patient’s primary concern is “I have noticed some discharge on my underwear.”

History of Present Illness (HPI): The patient, a 39-year-old Haitian American female, has come to the clinic with a complaint of vaginal discharge. She has experienced vaginal discharge previously on multiple occasions. The current episode of discharge began three days before her visit. The discharge is located in the genital area, specifically the vulva, which remains consistently wet and stains her underwear. The discharge is continuous, foul-smelling, and has a yellowish-brown color. It worsens with standing activity but improves when she lies supine. She experiences this discharge throughout the day and rates the severity of her symptoms at 6/10.

Allergies (Drug/Food/Latex/Environmental/Herbal): The patient has no known allergies.

Current Perception of Health: She currently perceives her health as disease-free but feels unwell.

Current Medications (including over-the-counter): She is not currently taking any medications, including over-the-counter drugs.

Menstrual History

Age at Menarche: 12 years old.

Last menstrual period: 27/10/2021

Menstrual Pattern: Regular

Cycle Length: 28 days.

Duration of Flow: Four (4) days.

Amount of Flow: Heavy.

Bleeding Pattern: Continuous.

Breakthrough Bleeding: Occasionally, but not regularly.

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable): The patient reports no history of breast disease, and she breastfed both of her children for two years, with the first six months being exclusive breastfeeding. She performs regular self-breast examinations as taught years ago. Her last mammogram was conducted five years ago in 2016, with no masses detected.

Previous GYN surgery (may include that in surgical history): She has not undergone any gynecological surgery.

History of infertility: The patient denies any history of infertility.

History of diethylstilbestrol (DES) use by patient’s mother: There is no history of DES use by the patient’s mother.

Last Pap smear, history of abnormal pap: Her last Pap smear was three years ago in 2018, and it was accompanied by a human papillomavirus (HPV) test. She has never had abnormal Pap smear results.

Pre-menopause/menopause

Vasomotor symptoms: She denies experiencing pre-menopausal vasomotor symptoms such as hot flashes.

Hormone Replacement Therapy: She has never undergone hormone replacement therapy.

Sexual and Contraceptive History

Current method of contraception: She is currently using an intrauterine contraceptive device (IUCD).

Sexually active: She is sexually active.

Number of sexual partners: Three (3).

New partners in the last 3-6 months: Yes, two.

Condom use: Sometimes, but not consistently.

History of sexual abuse: She discloses that she was sexually abused as a minor at the age of ten by someone known to her.

History of sexually transmitted infections (STIs): She has previously been treated for chlamydia and lymphogranuloma venereum.

Obstetric History (including complications)

She is a para 2 gravida 2 with two surviving children. She has never experienced a miscarriage. Both children were born at full term with good Apgar scores, and none were underweight or overweight.

Past Medical History (PMH)

The patient has a history of gestational diabetes mellitus that was treated and resolved. She currently has impaired glucose tolerance or prediabetes with a random blood sugar range of 150 mg/dL to 188 mg/dL. She does not have any other chronic conditions and has never been hospitalized.

Major/Chronic Illnesses: None.

Trauma/Injury: None.

Hospitalizations: None.

Past Surgical History: The patient has no significant surgical history.

Family Medical History: Her mother has type II diabetes, and her father has hypertension. There is also a history of overweight and obesity on her paternal side.

Social History

Living condition: She resides in a poor suburban community lacking basic commodities. She works as a housekeeper in a hotel and earns enough to support herself. Her children are grown and no longer dependent on her, but they live nearby and visit regularly.

Marital status: She has never been married but has two children from previous relationships.

Education: She dropped out of high school when she became pregnant with her first child.

Employment: She currently works as a housekeeper in a local hotel.

Occupation: Housekeeper.

Social supports: She has a strong social support system, including her children and parents, who also live in the same state.

Habits (smoking, alcohol use, and illicit drug use): She used to smoke a pack a day until two years ago when she quit on a physician’s advice. She still consumes alcohol socially on weekends when with friends.

Health Maintenance

Age-appropriate health promotion/maintenance and screening history: She has received health promotion and education during her antenatal care. She also received education on breast self-examination in the well-woman clinic. She undergoes cervical cancer screening through Pap smears and HPV tests every three years.

Immunization history: She received all childhood immunizations as a child under five years old. She also received a booster Tdp, Pneumovax, and recently had two doses of the Pfizer BioNTech Covid-19 vaccine.

Review of Systems (ROS)

General: Denies fatigue, malaise, weight loss, fever, or chills.

Dermatology: Denies rashes, eczema, or itching.

HEENT: Negative for headaches, diplopia, photophobia, otorrhea, tinnitus, sneezing, rhinorrhea, or sore throat.

Neck: Negative for cervical lymphadenopathy or jugular distension.

Pulmonary System: Denies dyspnea, coughing, or chest indrawing.

Cardiovascular System (CVS): Denies palpitations, chest tightness, or chest pain.

Breast: No lumps or masses detected on breast self-examination.

Gastrointestinal (GI) System: Negative for abnormal bowel movements, diarrhea, vomiting, or nausea.

Genitourinary (GU) System: Denies painful urination but reports vaginal discharge.

Female Genitalia: No visible lesions on the vulva, but reports a foul-smelling vaginal discharge.

Musculoskeletal System: Denies myalgia or joint pains.

Neurological System: Negative for syncope, paraesthesia, paresis, or paralysis.

Endocrine: Denies polydipsia, polyphagia, or heat/cold intolerance. Also denies hormonal therapy.

Psychologic: Negative for hallucinations, delusions, or suicidality.

Hematologic/Lymphatic: Denies lymphadenopathy or a history of splenectomy.

Physical Examination

Vital Signs

Blood Pressure (BP): 120/85 mmHg; Temperature: 98.8°F; Heart Rate (HR): 78 b/m; Respiratory Rate (RR): 17 breaths

/minute.

Height: 167.6 cm Weight: 100 kg Body Mass Index (BMI): 35.6 kg/m² Pain: 0

General Appearance: The patient is well-groomed and appropriately dressed for the time of day and weather.

Dermatology: No rashes or skin lesions suggestive of skin cancer (basal cell carcinoma) are detected.

HEENT: Normocephalic. Pupils equal, round, and reactive to light and accommodation. Throat is not erythematous.

Neck: No enlarged lymph nodes.

Pulmonary System: Scattered crackles are heard in otherwise clear lung fields. No chest indrawing.

Cardiovascular System (CVS): S1 and S2 heart sounds are audible with regular rate and rhythm.

Breast: No lumps or masses detected on breast examination.

Gastrointestinal (GI) System: Bowel sounds are present. No guarding.

Genitourinary (GU) System: No lesions found on the vulva. There is a yellowish-brown discharge present.

Female Genitalia: No external lesions. Positive for a yellowish-brown foul-smelling discharge.

Musculoskeletal System: Full range of motion with no joint stiffness. Patellar reflex is intact.

Neurological System: The patient is alert and oriented in terms of space, time, person, and event.

Endocrine: No signs of hypothyroidism are observed.

Psychologic: A normal mental status examination (MSE).

Hematologic/Lymphatic: Spleen is present and palpable.

Significant Data/Contributing Dx/Labs/Misc

– Foul-smelling discharge
– CRP 3 mg/dL
– ESR 30 mm/hr
– WBC 12.5 x 109/L

Assessment

Differential Diagnoses (3 minimum):

1. Trichomoniasis: Trichomoniasis, caused by a protozoan, can be transmitted through sexual intercourse or sharing personal items like towels or swimwear. It typically presents with foul-smelling green or yellow discharge, along with inflammation and itching in some cases.

2. Bacterial vaginosis: Bacterial vaginosis is a common cause of abnormal vaginal discharge in reproductive-age females. It can result in a “fishy” odor and vaginal discomfort, but some individuals may be asymptomatic.

3. Chlamydia/Gonorrhea: Sexually transmitted diseases like chlamydia and gonorrhea can lead to abnormal vaginal discharge, often with a yellowish or greenish appearance.

Primary Diagnoses: Trichomoniasi

References

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6^th ed. Elsevier, Inc.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2018). Harrison’s principles of internal medicine, 20^th ed. McGraw-Hill Education. NUR 514 Comprehensive Womens Health history Soap note

Nall, R. (June 24, 2019). Is it possible to treat trichomoniasis at home? https://www.healthline.com/health/home-treatments-for-trichomoniasis#popular-treatments

Comprehensive Women’s Health History and Physical Template

  

Encounter date:

 

Patient Initials:                     Gender:                      Age:                Race/Ethnicity:

 

Reason for Seeking Health Care

 

History of Present Illness (HPI)

 

Allergies (Drug/Food/Latex/Environmental/Herbal)

 

Current Perception of Health

 

Current Medications (including over the counter)

 

Menstrual History

Age at Menarche

Last menstrual period

Menstrual Pattern

Cycle Length

Duration of Flow

Amount of Flow

Bleeding Pattern

Break through Bleeding

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)

Previous GYN surgery (may include that in surgical history)

History of infertility NUR 514 Comprehensive Women’s Health History Soap Note

History of diethylstilbestrol (DES) use by patient’s mother

Last pap smear, history of abnormal pap

Pre-menopause/menopause

Vasomotor symptoms

Hormone Replacement Therapy

Sexual and Contraceptive History

Current method of contraception

Sexually active

Number of sexual partners

New partners in the 3-6 months

Condom use

History of sexual abuse

History of sexually transmitted infections (STIs)

Obstetric History (including complications)

Past Medical History (PMH)

Major/Chronic Illnesses

Trauma/Injury

Hospitalizations

Past Surgical History

Family Medical History

Social History

Living condition

Marital status

Education

Employment

Occupation

Social supports

Habits (smoking, alcohol use, and illicit drugs use)

Health Maintenance

Reliability Coefficient

Age-appropriate health promotion/maintenance and screening history

Immunization history

Review of Systems (ROS)

General

Dermatology

HEENT

Neck

Pulmonary System

Cardiovascular System (CVS)

Breast

Gastrointestinal (GI) System

Genitourinary (GU) System

Female Genitalia

Musculoskeletal System

Neurological System.

Endocrine

Psychologic

Hematologic/Lymphatic

Physical Examination

Vital Signs

Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)

Height Weight Body Mass Index (BMI) Pain

General Appearance

Dermatology

HEENT

Neck

Pulmonary System

Cardiovascular System (CVS)

Breast

Gastrointestinal (GI) System

Genitourinary (GU) System

Female Genitalia

Musculoskeletal System

Neurological System.

Endocrine

Psychologic

Hematologic/Lymphatic

Significant Data/Contributing Dx/Labs/Misc

Assessment

Differential Diagnoses (3 minimum)

Primary Diagnoses

Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)

Diagnoses

Laboratory/Diagnostic Studies

Therapeutic (Non-pharmacological interventions)

Pharmacological Therapy

Patient Education/Anticipatory Guidance

Referrals

Follow up

DEA#: 101xxx STU Clinic LIC# 100xx

Tel: (000) 5xx-123xx FAX: (000) x5-12xx

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature: ____________________________________________________________

Signature (with appropriate credentials): __________________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory]) NUR 514 Comprehensive Women’s Health History Soap Note