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
Age at menarche
Last menstrual period
How long is flow
Amount of flow
Other symptoms? (breast tenderness, pelvic pain, etc)5
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?
Hx of STD?
Hx of vaginitis (types, frequency and treatment)
Hx of PID
Any desire for future?
Difficulty conceiving? Treatments in past?
Concerns about libido, orgasm, dyspareunia
Any hx of abuse? Assault?
Describe each pregnancy and outcome
Any maternal, fetal or neonatal complications?
Past medical history
Current and past illnesses
GYN and Non-gyn
OTC, prescribed, herbal
Allergies to meds, food, environment and reactions?
Significant illnesses of family
Level of education
Smoking, alcohol use, drug use
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);
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
Annual blood work to identify challenges in anemia, TSH, Cholesterol and minerals.
Reproductive health plan
Imitate partner violence
Problems with sexual encounters (pain, dry, etc)
Changes of the body (hair growth, hormonal changes, sexual changes)
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