Chief complaint (is this a focused complaint or a first meeting or annual meeting)

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);

1. Chief complaint (is this a focused complaint or a first meeting or annual meeting)
2. History of present illness
3.  Menstrual History
   1.  Age at menarche
   2. Last menstrual period
   3. Menstrual characteristics
      1. Length
      2. How long is flow
      3. Amount of flow
4. Other symptoms? (breast tenderness, pelvic pain, etc)5
5. Pain?
6. Intermenstrual bleeding
7. Perimenopause/menopause
   1. Bleeding pattern
   2. Vasomotor symptoms
8.  Contraception
   1. Current method; is it working?
   2. Previous method; any complications and reason for change
9. Cervical and vaginal cytology
   1. Results and date of most recent pap
   2. Hx of abnormal paps? Why? Treatment?
10.  Infections
    1. Hx of STD?
    2. Hx of vaginitis (types, frequency and treatment)
    3. Hx of PID
11.  Fertility/infertility
    1. Any desire for future?
    2. Difficulty conceiving? Treatments in past?
12. Sexual hx
    1. Type
    2. Concerns about libido, orgasm, dyspareunia
    3. Any hx of abuse? Assault?
13. Obstetric hx
    1. Describe each pregnancy and outcome
    2. Any maternal, fetal or neonatal complications?
14. Past medical history
    1. Current and past illnesses
    2. Hospital admissions
    3. Surgical hx
       1. GYN and Non-gyn
    4.  Medications/allergies
       1. OTC, prescribed, herbal
       2. Allergies to meds, food, environment and reactions?
15. Family hx
    1. Significant illnesses of family
    2. Hereditary concerns
16. Social hx
    1. Relationship status
    2. Level of education
    3. Occupation
17. R.O.S.
18. Abdomino-pelvic
    1. GYN
    2. GI
    3. GU
19. Breast
20. Others

18.Health Maintenance

1. Smoking, alcohol use, drug use
2. Diet
3. Supplement intake
4. Exercise
5. Regular screenings (mammo, pap, colonoscopy)
6. 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);

1. Adolescents
   1. If sexually active the patient should have discussion with provider on sexually transmitted diseases and contraceptive use
   2. Drugs and alcohol use
   3. Peer pressure with sexual situations
2. Childbearing
   1. Annual blood work to identify challenges in anemia, TSH, Cholesterol and minerals.
   2. Breast self-awareness
   3. Reproductive health plan
   4. Imitate partner violence

• Peri-menopausal
  1. Hormone therapy
  2. Mammograms
  3. Advance directives