History of present illness
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Comprehensive exams in women’s 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 women’s 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 menarche
Last menstrual period
Menstrual characteristics
Length
How long is flow
Amount of flow
Other symptoms? (breast tenderness, pelvic pain, etc)5
Pain?
Intermenstrual bleeding
Perimenopause/menopause
Bleeding pattern
Vasomotor 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 pap
Hx 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
Type
Concerns about libido, orgasm, dyspareunia
Any hx of abuse? Assault?
Obstetric hx
Describe each pregnancy and outcome
Any maternal, fetal or neonatal complications?
Past medical history
Current and past illnesses
Hospital admissions
Surgical hx
GYN and Non-gyn
Medications/allergies
OTC, prescribed, herbal
Allergies to meds, food, environment and reactions?
Family hx
Significant illnesses of family
Hereditary concerns
Social hx
Relationship status
Level of education
Occupation
R.O.S.
Abdomino-pelvic
GYN
GI
GU
Breast
Others
18.Health Maintenance
Smoking, alcohol use, drug use
Diet
Supplement intake
Exercise
Regular screenings (mammo, pap, colonoscopy)
Immunizations and dates
Health maintenance is very important for all ages when related to women’s 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 use
Drugs and alcohol use
Peer pressure with sexual situations
Childbearing
Annual blood work to identify challenges in anemia, TSH, Cholesterol and minerals.
Breast self-awareness
Reproductive health plan
Imitate partner violence
Peri-menopausal
Hormone therapy
Mammograms
Advance directives
Problems with sexual encounters (pain, dry, etc)
Menopausal
Sleep patterns
Changes of the body (hair growth, hormonal changes, sexual changes)
Breast self-awareness
Geriatric Women
Sexual function
Injury prevention
Neglect/abuse
Elson, N. B. (2008, July). The Gynecologic History and Examination. Retrieved from The Global Library of Womens Health: https://www.glowm.com/section_view/heading/TheGynecologicHistoryandExamination/item/3#3521
Well-Woman Recommendations. (2018, January 5). Retrieved from The American College of Obstetricians and Gynecologists: https://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations?IsMobileSet=false
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