Comprehensive Well-Woman Paper
Patient Overview
Age, Race and Ethnicity, and Partner Status
The patient is a 28-year-old Hispanic female, currently in a monogamous relationship. She has been with her partner for approximately three years.
Current Health Status
The chief complaint of the patient is irregular menstrual cycles, characterized by periods occurring every 2–3 months. The patient reports accompanying symptoms of mild dysmenorrhea and occasional mood swings. She expresses concern about the implications of these irregularities on her reproductive health and fertility.
Contraception Method
The patient is currently using a combination oral contraceptive pill (OCP) for pregnancy prevention, which she has been taking consistently for the past year.
Patient History
Medical History
The patient has a history of asthma, controlled with an albuterol inhaler as needed. She has no known allergies and is not currently on any other medication.
Family Medical History
The patient’s mother has a history of hypertension and diabetes mellitus type 2, while her father has a history of hyperlipidemia. There is no documented family history of gynecological disorders.
Gynecologic History
Menarche occurred at age 13, with regular cycles until approximately six months ago. She has had one Pap smear in the past year, which was normal. The patient denies experiencing heavy bleeding or intermenstrual spotting.
Obstetric History
The patient has never been pregnant and has never undergone any surgical procedures.
Personal Social History
The patient works as a school teacher and lives with her partner. She reports a supportive social circle and engages in moderate exercise several times a week. The patient denies any substance abuse and reports minimal alcohol consumption.
Review of Systems
– General: No significant weight changes; energy levels are normal.
– Constitutional: Denies fever, chills, or night sweats.
– Cardiovascular: Denies palpitations or chest pain.
– Respiratory: Controlled asthma without recent exacerbations.
– Gastrointestinal: Regular bowel movements; no nausea or diarrhea.
– Genitourinary: Reports irregular menstrual cycles; denies dysuria or hematuria.
– Neurological: Denies headaches, dizziness, or visual changes.
– Psychiatric: Occasional mood swings; denies anxiety or depression.
Physical Exam
– Vital Signs: BP 118/75 mmHg, HR 72 bpm, Temp 98.6°F.
– General Appearance: Alert and oriented; appears well-nourished.
– Abdomen: Soft, non-tender; no masses palpated.
– Pelvic Exam: External genitalia normal; cervix visualized and appears healthy. Bimanual exam reveals a normal-sized uterus without adnexal tenderness.
Labs, Tests, and Other Diagnostics
– Pregnancy Test: Negative.
– Complete Blood Count (CBC): Normal.
– Thyroid Function Tests: Within normal limits.
– Hormonal Panel (FSH, LH, Estradiol, Progesterone): To be ordered based on findings.
Differential Diagnoses
1. Polycystic Ovary Syndrome (PCOS)
2. Hypothyroidism
3. Hyperprolactinemia
4. Uterine Fibroids
Management Plan
Diagnosis
The most likely diagnosis is Polycystic Ovary Syndrome (PCOS), given the patient’s age, irregular menstrual cycles, and symptoms.
Treatment
1. Continue oral contraceptive pills to regulate menstrual cycles.
2. Educate the patient about lifestyle modifications, including a balanced diet and regular exercise to manage weight and improve insulin sensitivity.
3. Consider referral to an endocrinologist if hormonal abnormalities are confirmed.
Patient Education
– Discuss the importance of regular follow-ups to monitor menstrual cycles and any potential complications associated with PCOS, such as infertility or metabolic syndrome.
– Provide information about the condition, including possible long-term effects on reproductive health.
Follow-Up Care
Schedule follow-up appointment in three months to reassess menstrual cycle regulation and discuss lab results.
Evidence-Based Guidelines
According to the American College of Obstetricians and Gynecologists (ACOG) guidelines, OCPs are recommended for women with PCOS to regulate menstrual cycles and reduce androgen levels (ACOG, 2020).
Reflection
Domestic Violence Considerations
If there were indications or concerns regarding domestic violence, this would significantly alter the management plan. Recognizing signs of domestic violence is crucial; it would require immediate attention to ensure the patient’s safety and wellbeing.
In such a scenario, I would prioritize establishing a safe environment for the patient during visits, provide resources for shelters or counseling services, and ensure that the patient understands her options without pressure to disclose more than she feels comfortable sharing. Furthermore, it would be essential to engage social services to provide comprehensive support.
Impact on Care Plan
This heightened awareness would necessitate a more sensitive approach to history-taking and physical examinations while ensuring confidentiality. The management plan would focus not only on her reproductive health needs but also on her safety and emotional support.
References
American College of Obstetricians and Gynecologists (ACOG). (2020). Polycystic Ovary Syndrome. ACOG Practice Bulletin No. 194.
This comprehensive well-woman paper provides an overview of a fictional patient’s health status and management plan while reflecting on critical issues such as domestic violence that may impact care. Each section is designed to align with standard clinical practices while incorporating evidence-based guidelines for treatment.
