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Student name: Alyssa Matulich Date: 9/30/18

Well Woman Exam

Patient’s Name: Y.M. Date of Birth: 5/7/1976 Date of Office Visit: 9/27/18

1. Age: 42 Age at first menstruation: 13 First day of last menstrual period: 9/1/18

How long does your period last? usually 7-9 days but last period/bleeding lasted 3 weeks Is your period:

Heavy? Moderate? Light?

2. Number of times pregnant (G): 3 Number of full--term live births (T): 3 Preterm births (P): 0 Spontaneous or

induced abortions (A): 0 Living children (L): 3 Date of last pregnancy: 2/17/15

Are you planning to get pregnant? YES NO

What birth control method do you use? Micronor (OCP)

3. Reason for Visit: well women and renew birth control

4. HPI: Pt here to renew presecription for birth control. Last visit was in July when she was switched to Micronor from Depo.
Last Depo shot was in April 4, 2018. Pt switched from Depo to OCP Micronor because of recommendation from provider to
not be on Depo for longer than three years. Pt had been receiving Depo since the birth of her last child 2/17/15. Pt has had
3 sexual partners in her lifetime all of which were men. Last sexual intercourse 8/28/18. Menstrual cycle occurs every 28
days with 7-9 days of bleeding with the exception of the last period on 9/1/18 which lasted 3 weeks. Uses 4-5 regular pads
per day with moderate bleeding. Denies bleeding between periods, pelvic pain, irregular or excessive bleeding. Menstrual
cycle usually associated with bloating, fatigue, and cramping that is relieved by Ibuprofen. Denies history of STIs. Pt denies
any discharge, itching, or vaginal odor. Pt expresses no interest in becoming pregnant again but states her partner wants to
have more children. Pt states she preforms self breast exams monthly and denies any changes in breast tissue, breast pain,
lumps or discharge. Last mammogram in Janruary of 2018 due to right breast pain. Results of mammorgram-no
abnormalities found. Pt no longer experiencing breast pain. Denies frequency, urgency, or pain with urination. At last visit pt
had an elevated BP and was seen at San Jose clinic on Gunbarrel 7/20/18 for blood pressure no new medications were given
and told to followup in six months.

5. Past Medical History (illnesses, surgeries, hospitalizations, etc.): No previous surgeries. Only hospitalization with child
births in 2012, 2013, and 2015. No history of blood transfusions. No history of psychiatric disorders.

6. Is health maintenance up to date? (Diagnostic tests, self-exams, vaccinations, etc.): Last Pap Jan 2017- results were
abnormal cells with negative HPV, next pap due in Jan 2020. Last STD screening in 2017 with pap. HIV screening not
performed.Last mamogram Jan 2018- WNL. Patient immunizations up to date. Last Tdap Feb 2015. Last flu vaccine October

7. Medications: Micronor OCP

Allergies & Reaction: No known allergies

8. Have you had any of the following problems? (If YES, please explain)

Abnormal pap smear       Date: Jan 2017 Treatment: repeat with
Yes No
cotesting in 3 years per ASCCP (ASC-US, negative
Yes No

Yes No
Pelvic surgery       Type:       Date:      
Yes No
Severe headaches      
Yes No
Blood clots      
Yes No
Problems with birth control      
Yes No
Bleeding between periods      
Yes No
Bleeding after periods have      
Yes No
Pain with intercourse      
Yes No
New or changing breast lump      
Yes No
Decreased interest or      
Yes No
enjoyment in sex
Change in stools, size, or texture      
Yes No
Kidney infections      
Yes No
Kidney stones      
Yes No
Anxiety or depression      
Yes No
Eating disorder      
Yes No
Yes No
Problems sleeping      
Yes No
Feeling down, depressed, or      
Yes No
hopeless in the past month
Little interest or pleasure in      
Yes No
doing things in the past month
Been a victim of domestic      
Yes No
Been a victim of sexual assault      
Yes No
Vaginal or pelvic infections      
Yes No
History of STDs      
Yes No
Anything else not mentioned      
Yes No


Do you have a parent, brother or sister with a history of breast cancer?
Yes No
Do you have a parent, brother or sister with a history of female reproductive cancer (uterine,
Yes No
ovarian, or cervical)?

Do you have a parent, brother or sister with a history of colon cancer?

Yes No
Do you have a parent, brother or sister with a history of a heart attack BEFORE the age of 55?
Yes No
Is there a history of any relatives who were stooped over, had broken bones or lost height?
Yes No

Additional family history information: Mother has diabetes, Brother has HTN


Do you have a loss of height?
Yes No
Do you have a history of a broken hip or wrist?
Yes No
Have you ever had bone density testing?
Yes No
Have you gone through menopause?
Yes No
Do you take any of these pills? Calcium Estrogen (Premarin)
Progesterone (Provera) Prednisone
Current tobacco use? Yes Never smoked
Number of packs per day:     
Quit:     (year)
Number of years smoking:     
Do you plan to quit?
Yes No When?
Current alcohol use? Yes No
How much? Less than 7 drinks per week
Do you exercise? Yes No
How often?
What do you do?
What does your diet consist of? 24 hour diet recall: breakfast: bowl of oatmeal, bannana and water.
Lunch: salad with chicken and water, dinner: baked chicken, black
beans and rice, and mixed vegetables
Do you eat vegetables? Yes, everyday
Do you eat sweets? Yes, a few times a week
Do you drink water? Yes, everyday
Do you use sunscreen?
All the time Most of the time Some Never
Do you drink caffeine?
Yes No
Have you had a tetanus shot?
Yes No
Have you had a mammogram? Yes No

Date? Jan 2018
Was it abnormal? No, it was normal
Have you had an ovarian cyst?
Yes No
Are you sexually active? Yes No In the past, but not currently
How many partners in the last 12 months? one
How many lifetime partners? 3
Have you had your cholesterol checked?
Yes No
Do you wear your seatbelt?
Yes No
Do you feel safe where you live?
Yes No

Additional personal history or social history information: Works six days a week cleaning houses. She is not married but has
been in a relationship with her partner for ten years. Lives in an apartment and has access to running water, shelter and

If positive, mark with an X and describe further. If all negative, select ‘denies all’. If not performed, leave blank.

Constitutional: Fever Chills Fatigue Weight gain Weight loss Diet changes Denies all Notes:      

Eyes: Itching Burning Vision changes Discharge Denies all Notes:      

ENT: Sore throat Hoarse Nosebleed Ear pain Drainage Congestion Dental problems Denies all
Notes: Last dental visit in March 2018

Respiratory: Shortness of breath Cough Sputum Wheezing Denies all Notes:      

Cardiovascular: Chest pain Palpitations Racing heart Edema Dyspnea on exertion Denies all Notes:      

GI: Abdominal pain Nausea Vomiting Heartburn Dysphagia Constipation Diarrhea Melena
Hematochezia Denies all Notes:      

GU: Urinary frequency Burning Itching Vaginal Discharge Pain with sex Denies all Notes:      

Female: Breast pain Breast lumps Breast discharge Heavy bleeding Painful periods Irregular periods
Denies all Notes: pt states that her periods as usually 7-9 days long but this last time her bleeding lasted three weeks. Her
bleeding was moderate and used about 4-5 regular pads per day

MS: Pain Stiffness Swelling Joint pain Denies all Notes:      

Hematology / Lymph: Bleeding Bruising Enlarged lymph nodes Tender lymph nodes Denies all Notes:      

Endo: Excessive thirst Cold intolerance Heat intolerance Night sweats Hair loss Denies all Notes:      

Skin: Rash Lesion Ulcer Pigment changes Changing moles Nail problems Denies all Notes:      

Psych: Sadness Irritability Suicidal thoughts Anxiety Insomnia Sleep problems Denies all Notes:      

Neuro: Headache Numbness Tingling Burning Pain Dizziness Vertigo Denies all Notes:      

Immune: Environmental allergies Sneezing Rhinorrhea Denies all Notes:      

Additional ROS information: OB history: 3 vaginal deliveries

Height 64" Weight 254.2 lbs BMI 43.6 BP 132/88 T 98.4 P 72 R 19 Pain 0/10 Reason for pain:n/a

General: patient appears stated age, race and gender. Sitting upright on exam table. A&O x3, speech clear and
organized. Responds to questions appropriately. Reliable historian.

Skin/Hair/Nails: Skin and clothes clean. Skin warmand dry. Skin color brown. Normal skin turgor. No edema.
Normal female hair distribution. Nail beds pink.

Eyes: PERRLA, conjuctiva pink and moist, sclera white

ENT/Mouth: ears normal placement, ear canals without cerumen or redenss. TMs intatct without redness,
fullness or fluid. Nares patenr. No maxillary or frontal tenderness. Lips and gums pink without lesions. Teeth
white. Posterior pharynx without redenss and exudate.

Neck/Thyroid: trachea midline. Full ROM of neck. No thyromegaly. No lymphadenopathy or tenderness.

Lungs: CTA, no adventisous breath sounds. Expansion equal

CV: Heart RRR, no murmurs, no rubs, no gallops. Capillary refill <3. Radial and pedal pulses 2+.

Breasts: pendulu, Symmetrical, Contour smooth without retractions. No nipple inversion. No masses palpated.
No tenderness or discharge. Axillary lympnodes without lymphadenopathy and non tender.

Abdomen: Rounded and soft. Bowel sounds active in all four quadrants. No hepatomegaly or spleenomegaly.
Non-tender. No masses. Groin lymph nodes withou lymphadenopathy and non- tender.

Female Genitalia: external: without masses, lesions, excoriation, erythema, tenderness or discharge

Vagina: walls rugated and pink, without discharge, without odor

Cervix: no motion tenderness, patent os without discharge, no lesions

Uterus: small, mobile, midline, non-tender

Adnexa: no masses or tendereness bilaterally

Rectum: patient denied rectal exam at this visit

MS: Upper and lower extremities with full ROM and strenth 5/5. No joint swelling, redness or tenderness. Gait
normal. No CVA tenderness

Neuro: A&O x3

Lymph: No pre/postauricular, ant/posterior cervical chain, occipital, submandibular, submental,


infraclavicular, axillary, inguinal node lymphadenopathy.

Psych: affect pleasant

Additional PE information:      

In-Office Diagnostics and Results:      

UA: WNL except proteinuria 2+

Pregnancy test- negative
Hgb- 13.7

Differential Diagnoses (provide rationales and references):

1. Elevated BP-In patients who have an elevated office blood pressure, the diagnosis of hypertension
should be confirmed using out-of-office blood pressure measurement whenever possible. Ambulatory
blood pressure monitoring (ABPM) is considered the “gold standard” in determining out-of-office blood
pressure. However, many payers require evidence of normal out-of-office readings (suspected white
coat hypertension) for reimbursement of ABPM. As such, we suggest home blood pressure
measurement as the initial strategy to confirm the diagnosis of hypertension in most patients:
Hypertension is diagnosed if the mean home blood pressure, when measured with appropriate
technique and with a device that has been validated in the office, is ≥130/≥80 mmHg. ***This patients
bp was 132/88 today so her pressures are elevated but for a diagnosis of hypertensionfurther
evaulation by her primary care provider is necessary. (up to date)
2. Proteinuria- Dipstick analysis is used in most outpatient settings to semiquantitatively measure the urine
protein concentration. The results are graded as negative (less than 10 mg per dL), trace (10 to 20 mg per
dL), 1+ (30 mg per dL), 2+ (100 mg per dL), 3+ (300 mg per dL) or 4+ (1,000 mg per dL). ***This patient had
2+ protein on Urine dipstick.
3. Elevated BMI- According to CDC a BMI greater than 30 is considered obese. ***This patient has a BMI of
43.6 so she would be considered obese. (CDC)
4. Chlamydia A56.02: A female patient may present with dysuria and pelvic pain as well as vaginal discharge,
intermenstrual spotting, postcoital bleeding, mucopurulent discharge. This patient is not complaining of
any discharge. No cervical friability or tenderness. Vaginal discharge is thin and white. ***Diagnosis not
likely . Pt denied testing at this visit. (Hawkins, 2016)
5. Gonorrhea A54.02: A pt may present with dysuria and lower abdominal discomfort but may also have
purulent and irritating vaginal discharge, fever, abnormal menstrual bleeding, labial pain and swelling, and
dyspareunia. ***Diagnosis not likely, patient denied testing at this visit (Hawkins, 2016)

Additional information:      

Assessment (ICD 10 codes, visit level codes, CPT codes):      

Pregnancy test, negative- Z32.02

Contraceptive Pill encounter- Z30.41
Encounter or gynocological exam- Z01.419
BMI 40.0-44.90- Z68.41
Proteinuria- R80.9
UA- 5463
Urine pregnancy test 81205
visit code- 99396
HGB- 88738

Plan (diagnostics, treatments, patient education, health promotion, health maintenance, referrals, and

- ordered Pregnancy test and hgb for prolonged bleeding
- renewed prescription for Micronor
- educated pt on taking Micronor everyday within a two hour time frame, what to do if the patient misses a pill,
using condoms to protect against STDs, side effects like breast tenderness or nausea. Schedule follow up when
pt has two packs/ refills remaining on presecription to prevent running out. Bleeding should regulated within
another 3-6months with OCP if patient has any concerns or changes follow-up sooner.

- diagnositics: ordered UA showing 2+ in urine
- educated patient to Increase fluid intake to at least 2 liters of water per day, increase physical activity to 3
days a week for 30-45 minutes, eat a diet low in fats and carbs
- follow up with primary care provider for retest of urine in one month

Elevated BP:
- follow up with primary care provider in Novemeber as scheduled for six month follow up from June visit
- Educated patient to increase physcial activity to 3 days a week for 30-45 minutes, eat a diet low in fats, carbs
and sugar. Instructed pt to monitor blood pressure at home once per day using home blood pressure monitor
and bring readings to next visit with primary care provider.

Health Maintainence:
- Mammogram: pt has requested to repeart mamogram in Janruary 2019
- Next Pap in Jan 2020 with co testing per ASCCP guidelines
- Preform monthly breast exams preferrably after menstural cycle when breast tissue least effected by

- HIV and STD screening- pt declined today but recommened to do at next visit with STD testing at least yearly.
- Return for annual well women exam yearly.
- Pt has elevated BMI and should increase physical activity and eat a healthy diet to encourage weight loss
- Will discuss advanced directive at next visit.

Additional Information:      

Provider signature: alyssa matulich Date:  9/30/18    


Basile, J., & Bloch, M. (2018, January). Retrieved from


Carroll, M. F., & Temte, J. L. (2000, September 15). Proteinuria in Adults: A Diagnostic Approach. Retrieved from

Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2016). Guidelines for nurse practitioners in gynecologic
settings (11th ed.). New York, NY: Springer Publishing Company, LLC.

Healthy Weight. (2017, August 29). Retrieved from

Schuiling, K., & Likis, F. E. (2011). Womens gynecological health (3rd ed.). Sudbury: Jones & Bartlett Learning.