Comprehensive exams in womens health need to
As with any assessment, the chief complain is often what drives what our questions are and what clinical pathways we explore. With womens health that approach is not any different, as we need to explore the what was, what is and what will be for the patient. The comprehensive assessment is one that is longer in nature and normally saved for the first visit, as if this patient will be a returning patient a more focused examine comes during their following appointments. The follow is a blanket comprehensive assessment that can be tweaked for any patient (Elson, 2008);
Chief complaint (is this a focused complaint or a first meeting or annual meeting)History of present illness Menstrual History
Age at menarcheLast menstrual periodMenstrual characteristics
LengthHow long is flowAmount of flow
Other symptoms? (breast tenderness, pelvic pain, etc)5Pain?Intermenstrual bleedingPerimenopause/menopause
Bleeding patternVasomotor symptoms
Contraception
Current method; is it working?Previous method; any complications and reason for change
Cervical and vaginal cytology
Results and date of most recent papHx of abnormal paps? Why? Treatment?
Infections
Hx of STD?Hx of vaginitis (types, frequency and treatment)Hx of PID
Fertility/infertility
Any desire for future?Difficulty conceiving? Treatments in past?
Sexual hx
TypeConcerns about libido, orgasm, dyspareuniaAny hx of abuse? Assault?
Obstetric hx
Describe each pregnancy and outcomeAny maternal, fetal or neonatal complications?
Past medical history
Current and past illnessesHospital admissionsSurgical hx
GYN and Non-gyn
Medications/allergies
OTC, prescribed, herbalAllergies to meds, food, environment and reactions?
Family hx
Significant illnesses of familyHereditary concerns
Social hx
Relationship statusLevel of educationOccupation
R.O.S.Abdomino-pelvic
GYNGIGU
BreastOthers
18.Health Maintenance
Smoking, alcohol use, drug useDietSupplement intakeExerciseRegular screenings (mammo, pap, colonoscopy)Immunizations and dates
Health maintenance is very important for all ages when related to womens health. The following are some ideas of health maintenance for each age group (Well-Woman Recommendations, 2018);
Adolescents
If sexually active the patient should have discussion with provider on sexually transmitted diseases and contraceptive useDrugs and alcohol usePeer pressure with sexual situations
Childbearing
Annual blood work to identify challenges in anemia, TSH, Cholesterol and minerals.Breast self-awarenessReproductive health planImitate partner violence
Peri-menopausal
Hormone therapyMammogramsAdvance directives