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Comprehensive Patient Assessment



Write an 8- to 10-page comprehensive paper that addresses the following:
1. General patient information
a. Age
b. Race/ethnicity
c. Partner status
2. Current health status
a. Chief concern/complaint and history of present illness (include a complete
symptom analysis of chief complaint(s) utilizing OLDCART for a sick/problem
focused visit)
b. Last menstrual period or year of menopause
c. DES exposure (if born between 1948 and 1971)
d. Sexual activity status
e. Barrier prevention
f. Sexual preference
g. Satisfaction with sexual relations
3. Contraception method (if any)
4. Patient history
a. Past medical history
Major medical events (including pediatric events)
Psychological and mental health
Surgeries and/or hospitalizations if pertinent
Medications, including prescriptions, over-the-counter medications, home
and herbal remedies, calcium, and vitamin supplements
Allergies, including drug, food, and environment
© 2013 Laureate Education, Inc. 2
Health maintenance/screenings, including results of patient’s last Pap and
mammogram as appropriate, as well as previous vaccinations (HPV,
MMR, hepatitis B, last DT, and Pneumovax/influenza as appropriate)
b. Family medical history
c. Gynecologic history
Nullipara vs. multipara
History of sexually transmitted infections and sexually transmitted
Menarche and menstrual patterns
Menopause or peri-menopausal symptoms (if applicable)
d. Obstetric history
Gravida and parity status (TPAL)
Pregnancy history, including history of preterm or low birth weight, other
pregnancy complications, history of sexually transmitted diseases, and
any pertinent negatives
e. Personal social history (as appropriate to the current problem)
Cultural background
Education and economic condition
Abuse history including assault and forced sex (past and current)
Occupational health patterns
Current health habits and/or risk factors
Substance use (must include for every patient)
Tobacco including frequency and longevity
Alcohol including results of CAGE unless patient has never used
Recreational drug use (past and current)
Exercise and physical activity
Diet and nutrition
5. Review of systems (ROS)
a. Must include reproductive system as well as other pertinent systems (systems
relevant to HPI should be included under HPI)
6. Physical exam
a. General exam, including vital signs, height, weight, and BMI on every patient
b. Physical exam focused on episodic complaint (include numbers of weeks
gestation, fundal height, and fetal heart tones for OB patients)
7. Labs, tests, and other diagnostics

a. Pertinent labs, test, and other diagnostics (include routine tests such as triple
screen and urine dip for OB patients)
8. Differential diagnoses
a. Explain why this set of differential diagnoses should be considered and why
each diagnosis should be ruled in or ruled out.
9. Management plan
a. Diagnosis
b. Treatment
c. Patient education
d. Follow-up care

Required Readings: Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers ( Course Textbook . Must be used as a reference)




Subject Nursing Pages 12 Style APA


Comprehensive Patient Assessment
The primary goal of every healthcare provider is ensuring quality patient outcome. Achieving this takes an assortment of factors with the most important being effective evaluation of a patient’s presented condition and developing an efficient management plan. Considering the later, it is approached holistically with regards to using both pharmaceutical and non-pharmacological interventions. Essentially, the medicinal approach is considered the most effective, although the therapeutic framework that entails altering the patient’s lifestyle aids in achieving better results (Tharpe, Frley & Jordan, 2013). Women’s reproductive system anatomy is considered delicate and complex. As a result, it is recommended that routine checkups are taken. To the physicians, an imperative aspect regarding promoting a woman’s reproductive health is offering advice on regular tests, their intervals and ways to ensure wellness (Schuiling & Likis, 2013). Examples of these tests include Pap smear, whose interval varies based on the age of the woman. Those below 30 years are recommended to take the check up at an interval of two years, while those above this age have it after three years. Pelvic exams are also critical as well as breasts screenings. To the physicians, these checkups enable them detect any possible issues in the patient’s condition and offer early medical interventions. This paper is a comprehensive patient assessment on a client who presents to the clinic with complaints regarding their reproductive health. In addition, this paper details the patient’s condition and develops an effective management plan while considering differential diagnosis.
Chief Complaint (CC): “Good morning, I have been having yellowish fluid from my vagina which is also smelly for the last two days. Today morning, I began feeling some itchiness around my genital and I feel uncomfortable. Also, there is redness and am in pain. I have tried taking a bath every three hours and keeping the area dry but there is no improvement.”
History of Present Illness (HPI): Paula A. a twenty-four year old African American woman presents to the clinic with several complaints. First, she mentions of an increased discharge from her vagina forcing her to wear a sanitary pad yet she is not in her menstrual periods. She notes the color of the fluid as yellowish. She also states having pain which she rates as five on a scale of one to ten. This pain has been increasing for the last two days. Another complaint is redness on her vaginal mucosa as well as itchiness. She is also concerned with the smell of her genital. As a result, she has resolved to douche every hour yet there is no improvement. She does this and uses cologne, but still, the odor is detectable. PA admits being sexually active. Having two partners for more than three months and having met another three days ago, she has sex at least three times a week and is inconsistent with using protection. She is indeed stressed regarding her condition and is anxious about the results.
Current Medication: Tylenol (2 caplets per six hours) for pain relieve.
Allergies: Patient denies any allergies.
Past Medical History: Besides the common cold and monthly menstrual periods, patient notes that she had Pelvic Inflammatory Disease (PID) which she treated with antibiotics two years ago. No other serious conditions noted.
Past Surgical History: Patient denies any surgery in the past
Social History: PA is both a student and an employee. She works in a restaurant for half a day and later takes her business management classes in a nearby institution. She resides near the restaurant. Her income cannot suffice her school fees and daily expenditure. As a result, she is supported by one of her partners who is 26 years old and who also anticipates settling down with her. Her second partner is a schoolmate with whom she has been having an affair for two months. She met her new partner three days ago and has already slept with him. Paula notes that she has had sex with the trio and has not been constituent with using protection as her partners dislike it. She affirms being aware of the risks of not using contraceptives but expresses her weakness in controlling her boyfriends. She, however, states that she has not been abused nor forced for sex. She likes to party with her friends including her boyfriends every weekend unless she is working. She smokes tobacco but no illegal drugs. She is a Roman Catholic, although she rarely attends church as a result of work and partying. She is not socially involved in activities such as community development.
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Brocklehurst, P., Gordon, A., Heatley, E., & Milan, S. J. (2013).Antibiotics for treating BacterialVaginosis in pregnancy. The Cochrane Library.
Centers for Disease Control and Prevention. (2010). Sexually transmitted diseases treatment guidelines, 2010.Morbidity and Mortality Weekly Report, 59(RR-12). Retrieved from http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
Chauhan, V., Shah, M., Thakkar, S., Patel, S. V., &Marfatia, Y. (2014).Sexually transmitted infections in women: A correlation of clinical and laboratory diagnosis in cases of vaginal discharge syndrome. Indian Dermatology online journal, 5(5), 1.
Jahic, M., Mulavdic, M., Nurkic, J., Jahic, E., &Nurkic, M. (2013).Clinical characteristics of aerobic vaginitis and its association to vaginal Candidiasis, trichomonas vaginitis, and BacterialVaginosis. MedicalArchives, 67(6), 428.


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