NU576 Unit 3 Journal

NU576 Unit 3 Journal

Student Name

NU576 NP II – Primary Care of Women’s Health

Prof. Name:

Date

Unit 3 Journal: 

The patient is a healthy 24-year-old female presenting to establish primary care after not receiving routine healthcare for approximately four years. During the visit, key concerns identified include preventive health needs, management of a history of painful and prolonged menstrual periods consistent with possible endometriosis, and evaluation of low body weight with a BMI of 18.0. The patient requires ongoing primary care follow-up, nutritional counseling, gynecological evaluation, and preventive screenings such as cervical cancer screening.

Patient Information

Name: Vivian Lopez
Encounter Number: 25565216
Date of Visit: September 12, 2023
Age: 24 years
Sex: Female

Subjective Assessment

Chief Complaint

The patient states, “I am here to establish primary care.”

History of Present Illness

The patient reports that she does not currently have a primary care provider and has not been evaluated by a healthcare professional since college approximately four years ago. She has been using oral contraceptive medication prescribed through telehealth services but has not received ongoing evaluation for her reproductive health concerns.

She reports a previous history of irregular, painful menstrual periods lasting longer than two weeks before beginning birth control therapy. Her symptoms improved with hormonal contraception. She denies any current abdominal pain or gynecological complaints.

Current Medications

• Apri oral contraceptive tablet, taken once daily for birth control.

Allergies and Medication Intolerances

• No known allergies.

• No medication intolerances reported.

Past Medical History

The patient denies chronic illnesses or major medical conditions. She reports a history of a broken left arm at age 10.

• No previous hospitalizations.

• No surgical history.

Family History

Both parents are alive and healthy with no current medical concerns. The patient has one brother and one sister, both of whom are healthy.

Social History

The patient graduated from the University of San Diego and recently started working as a marketing associate. She currently lives with her girlfriend.

Social habits include:

• Former cigarette smoker; stopped smoking after college.

• Drinks alcohol socially.

• Occasionally uses marijuana.

Review of Systems

General

The patient denies weight changes, fatigue, or weakness.

Cardiovascular

The patient denies chest pain, palpitations, or swelling.

Respiratory

The patient denies cough, congestion, or shortness of breath.

Skin

The patient denies bruising, rashes, or changes in skin color.

Eyes

The patient denies blurry vision or vision changes and does not use corrective lenses.

Gastrointestinal

The patient denies abdominal pain, nausea, vomiting, diarrhea, or constipation.

Ear, Nose, and Throat

The patient denies hearing loss, ringing in the ears, sinus problems, difficulty swallowing, or throat pain.

Genitourinary and Gynecological

The patient is sexually active with a female partner. She has never had a Pap smear and denies any history of sexually transmitted infections.

Additional reproductive health information includes:

• Last menstrual period occurred two weeks prior to the visit.

• Menstrual cycles are currently regular while taking birth control.

• Previously experienced prolonged, painful, and irregular menstrual periods.

NU576 Unit 3 Journal

Breast Health

The patient denies breast changes and does not perform routine breast self-examinations.

Musculoskeletal

The patient denies back pain, muscle pain, or stiffness.

Neurological

The patient denies dizziness, weakness, or seizures.

Hematologic and Endocrine

The patient denies excessive thirst, excessive hunger, or history of blood transfusion.

Psychiatric

The patient denies a history of depression or anxiety.

Objective Assessment

Vital Signs and Measurements

• Weight: 108 pounds

• Height: 5 feet 5 inches

• BMI: 18.0

• Temperature: 98.7°F

• Blood pressure: 132/64 mmHg

• Pulse: 70 beats/minute

• Respiratory rate: 20 breaths/minute

General Appearance

The patient appears healthy and is able to communicate effectively. She appears thin and is considered underweight based on BMI evaluation.

Skin Examination

Skin is dry but intact. No bruising, lesions, or abnormalities are noted.

HEENT Examination

• Head is normocephalic and non-tender.

• Pupils are equal, round, and reactive to light and accommodation.

• Ears are symmetrical and patent bilaterally.

• Nasal passages are patent.

• Teeth are intact without dental caries.

Cardiovascular Examination

Heart sounds S1 and S2 are present with regular rate and rhythm. No murmurs, extra heart sounds, or edema are noted.

Respiratory Examination

Chest expansion is symmetrical. Lung sounds are clear bilaterally. Breathing is even and unlabored.

Gastrointestinal Examination

The abdomen is soft and non-tender. Bowel sounds are present in all four quadrants.

Breast Examination

Breasts are non-tender with no masses, skin changes, or abnormal discharge noted.

Genitourinary and Pelvic Examination

The bladder is non-distended and non-tender. A pelvic examination was completed using a speculum.

Findings include:

• Normal vulva without lesions or masses.

• Normal vaginal appearance without abnormalities.

• Cervix appears normal without discharge or lesions.

• Uterus is anteverted and non-tender.

Musculoskeletal Examination

The patient demonstrates full range of motion in all extremities without pain or stiffness.

Neurological Examination

Speech is clear. Posture is straight, gait is steady, and neurological function appears intact.

Psychiatric Examination

The patient is alert and oriented to person, place, and time. Appearance and behavior are appropriate, with normal speech and tone.

Diagnostic Testing

Recommended laboratory and screening evaluations include:

• Complete blood count (CBC) to evaluate for infection and anemia.

• Basic metabolic panel (BMP) to assess electrolyte balance and metabolic function.

• Urinalysis to evaluate for urinary tract infection or other abnormalities.

• Human papillomavirus (HPV) testing because sexually active women who have sex with women may still be at risk for HPV infection and require appropriate cervical cancer screening.

Assessment

1. Well-Woman Examination (Primary Diagnosis)

The patient presents to establish primary care after several years without routine healthcare visits. She requires preventive health services, reproductive health monitoring, and continued management of medications previously obtained through telehealth.

Preventive care priorities include:

• Cervical cancer screening.

• Breast health evaluation.

• Routine laboratory testing.

• Health maintenance counseling.

2. Possible Endometriosis

The patient’s history of prolonged, painful, and irregular menstrual periods raises concern for possible endometriosis. Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus, potentially causing pelvic pain, heavy menstrual bleeding, infertility concerns, and other complications.

Further gynecological evaluation is recommended.

3. Low Body Weight and Nutritional Risk

The patient has a BMI of 18.0, which falls near the underweight range. Nutritional assessment is recommended to evaluate dietary intake, weight goals, and overall health.

Plan of Care

Medication Management

Continue combined estrogen-progestin oral contraceptive therapy as appropriate. Combined hormonal contraceptives can help regulate menstrual cycles, reduce heavy bleeding, and decrease menstrual cramping associated with conditions such as endometriosis.

Non-Pharmacological Recommendations

The patient should focus on:

• Maintaining a balanced diet with adequate calories and nutrients.

• Engaging in regular physical activity.

• Monitoring weight changes and nutritional status.

Preventive Screening Recommendations

During a well-woman visit, recommended preventive services include:

• Pap smear for cervical cancer screening.

• Breast examination.

• HPV screening when indicated.

• Routine health maintenance evaluation.

Patient Education

The patient should receive education regarding:

• Healthy weight management.

• Importance of regular primary care visits.

• Menstrual symptom monitoring.

• Benefits of preventive screenings.

• Safe sexual health practices.

Cultural Considerations

The patient identifies as part of the LGBTQ+ community. Healthcare providers should provide inclusive, respectful care by using appropriate language, respecting patient preferences, and understanding health concerns that may affect LGBTQ+ individuals.

Health Promotion

Health promotion strategies include:

• Establishing consistent primary care follow-up.

• Completing recommended cancer screenings.

• Maintaining reproductive health care.

• Addressing nutritional needs.

Referrals

Recommended referrals include:

• Registered dietitian or nutritionist for weight and dietary counseling.

• Obstetrician-gynecologist (OB/GYN) for evaluation of possible endometriosis and ongoing reproductive healthcare.

Follow-Up

The patient should follow up with primary care in approximately three months for reassessment, review of laboratory results, and evaluation of progress with nutritional and preventive health goals.

References

Allen, R. (2023). Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use. UpToDate. https://www.uptodate.com/contents/combined-estrogen-progestin-oral-contraceptives-patient-selection-counseling-and-use

Baylor College of Medicine. (2020). Well woman exam. Center for Research on Women with Disabilities. https://www.bcm.edu/research/research-centers/center-for-research-on-women-with-disabilities/a-to-z-directory/reproductive-health/well-woman-exam

NU576 Unit 3 Journal

Nolan-Pleckham, M. (2022). The facts about HPV risk in lesbians. Verywell Health. https://www.verywellhealth.com/lesbians-and-hpv-514139

World Health Organization. (2023). Endometriosis. https://www.who.int/news-room/fact-sheets/detail/endometriosis