NU576 Unit 3 Journal

Student Name

Purdue University Globle 

NU576 NP II – Primary Care of Women’s Health

Prof. Name

Date

NU576 Unit 3 Journal

A comprehensive well-woman examination is essential for young adults who have not received routine healthcare for several years. In this case, a 24-year-old female presenting to establish primary care requires preventive screenings, evaluation for possible endometriosis, nutritional assessment due to a low BMI, and ongoing reproductive healthcare. Early intervention and regular follow-up can improve long-term health outcomes and ensure appropriate preventive care.

Overview of the Patient Encounter

Vivian Lopez, a 24-year-old female, presented on September 12, 2023, to establish primary care after approximately four years without routine medical evaluation. She reports no significant chronic medical conditions but has a history of prolonged and painful menstrual periods that improved after initiating oral contraceptive therapy through telehealth services.

The patient’s primary healthcare needs include preventive screening, reproductive health monitoring, assessment of low body weight, and establishing an ongoing relationship with a primary care provider.

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 stated, “I am here to establish primary care.”

History of Present Illness

Vivian reported that she has not seen a healthcare provider since graduating from college approximately four years ago. She currently takes Apri, a combined oral contraceptive, prescribed through a telehealth platform. Before beginning hormonal contraception, she experienced irregular menstrual cycles accompanied by severe pain and bleeding that often lasted longer than two weeks.

Since starting birth control, her symptoms have significantly improved. She denies current pelvic pain, abnormal bleeding, or additional gynecologic concerns.

Current Medications

• Apri oral contraceptive tablet once daily.

Allergies

• No known drug allergies.

• No reported medication intolerances.

Past Medical History

The patient reports:

• No chronic illnesses.

• Left arm fracture at age 10.

• No prior surgeries.

• No previous hospitalizations.

Family History

Both parents are living and report good health. She has one brother and one sister, both without known medical concerns.

Social History

Vivian graduated from the University of San Diego and recently began employment as a marketing associate. She currently resides with her girlfriend.

Additional social history includes:

• Former cigarette smoker who quit after college.

• Social alcohol consumption.

• Occasional marijuana use.

Review of Systems

General

The patient denies fatigue, weakness, and recent weight changes.

Cardiovascular

No chest pain, palpitations, or peripheral edema were reported.

Respiratory

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

Gastrointestinal

No abdominal pain, nausea, vomiting, diarrhea, or constipation.

Skin

The patient denies rashes, bruising, or skin discoloration.

Eyes

No vision changes or use of corrective lenses.

Ear, Nose, and Throat

The patient denies hearing loss, tinnitus, sinus issues, dysphagia, or throat discomfort.

Genitourinary and Gynecological

Vivian is sexually active with a female partner and reports never having undergone cervical cancer screening.

Additional reproductive history includes:

• Last menstrual period occurred two weeks before the visit.

• Menstrual cycles are currently regular while taking oral contraceptives.

• Previous history of prolonged, painful, and irregular menstruation.

• No history of sexually transmitted infections.

Breast Health

The patient denies breast abnormalities and does not routinely perform self-breast examinations.

Musculoskeletal

No back pain, muscle aches, or stiffness.

Neurological

The patient denies dizziness, weakness, or seizure activity.

Hematologic and Endocrine

No excessive thirst, increased appetite, or history of blood transfusions.

Psychiatric

The patient denies depression, anxiety, or other mental health concerns.

Objective Assessment

Vital Signs

• Weight: 108 pounds

• Height: 5 feet 5 inches

• BMI: 18.0

• Temperature: 98.7°F

• Blood Pressure: 132/64 mmHg

• Pulse: 70 beats per minute

• Respiratory Rate: 20 breaths per minute

Physical Examination Findings

General Appearance

The patient appears healthy, alert, and communicates appropriately. She is thin in appearance and classified as underweight based on BMI.

Skin

Skin is dry but intact without lesions, bruising, or discoloration.

HEENT

• Head is normocephalic and atraumatic.

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

• Ear canals are patent bilaterally.

• Nasal passages are clear.

• Dentition is intact without evidence of caries.

Cardiovascular

Regular rate and rhythm noted with normal S1 and S2 heart sounds. No murmurs, edema, or extra heart sounds were identified.

Respiratory

Breath sounds are clear bilaterally, and respirations are even and unlabored.

Gastrointestinal

Abdomen is soft, non-tender, and non-distended with bowel sounds present in all quadrants.

Breast Examination

Breasts are non-tender with no palpable masses, discharge, or skin abnormalities.

Genitourinary and Pelvic Examination

Pelvic examination findings include:

• Normal vulva without lesions.

• Normal vaginal mucosa.

• Cervix without lesions or discharge.

• Anteverted, non-tender uterus.

• Non-distended and non-tender bladder.

Musculoskeletal

Full range of motion is present in all extremities without pain or limitation.

Neurological

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

Psychiatric

The patient is alert and oriented to person, place, and time with appropriate mood, affect, and behavior.

Recommended Diagnostic Testing

To support preventive care and identify potential health concerns, the following tests are recommended:

• Complete Blood Count (CBC) to assess for anemia and infection.

• Basic Metabolic Panel (BMP) to evaluate metabolic and electrolyte status.

• Urinalysis to identify urinary abnormalities.

• Human Papillomavirus (HPV) testing.

• Pap smear for cervical cancer screening.

It is important to note that women who have sex with women remain at risk for HPV transmission and should follow established cervical cancer screening guidelines.

Assessment

Well-Woman Examination

The primary diagnosis is a routine well-woman examination with a focus on establishing long-term primary care. The patient requires preventive services and health maintenance interventions after several years without medical follow-up.

Healthcare priorities include:

• Cervical cancer screening.

• Preventive laboratory testing.

• Breast health assessment.

• Medication management.

• Lifestyle counseling.

Possible Endometriosis

The patient’s history of prolonged, painful, and irregular menstrual periods is concerning for possible endometriosis. This chronic condition occurs when tissue similar to the uterine lining grows outside the uterus and may contribute to:

• Pelvic pain.

• Dysmenorrhea.

• Heavy menstrual bleeding.

• Fertility complications.

• Reduced quality of life.

Although her symptoms have improved with oral contraceptives, further evaluation by an OB/GYN is recommended.

Low Body Weight and Nutritional Risk

Vivian’s BMI of 18.0 places her at the lower end of the normal range and near the underweight category. Nutritional assessment should focus on dietary intake, caloric adequacy, and maintaining a healthy body weight to support overall wellness.

Plan of Care

Medication Management

The patient should continue her prescribed combined estrogen-progestin oral contraceptive therapy, which has effectively controlled menstrual symptoms and may provide continued benefits if endometriosis is present.

Non-Pharmacologic Recommendations

Lifestyle recommendations include:

• Consuming a nutrient-dense, balanced diet.

• Increasing caloric intake if appropriate.

• Participating in regular physical activity.

• Monitoring weight trends over time.

• Maintaining adequate hydration.

Preventive Screening Recommendations

Routine preventive services should include:

• Pap smear.

• HPV screening as indicated.

• Breast examination.

• Annual wellness visits.

• Routine laboratory assessments.

Patient Education

Patient education topics discussed include:

• Healthy weight management strategies.

• Importance of regular primary care appointments.

• Monitoring menstrual symptoms.

• Benefits of preventive healthcare screenings.

• Safe sexual health practices.

• Understanding HPV risk regardless of sexual orientation.

Cultural Considerations

Vivian identifies as a member of the LGBTQ+ community. Providing culturally competent and inclusive healthcare is critical to building trust and improving outcomes. Healthcare professionals should ensure respectful communication, avoid assumptions regarding sexual practices, and provide evidence-based preventive recommendations tailored to the patient’s needs.

Health Promotion Strategies

Health promotion efforts should focus on maintaining long-term wellness through preventive care and lifestyle modifications.

Recommended strategies include:

• Establishing routine primary care follow-up.

• Completing age-appropriate cancer screenings.

• Maintaining reproductive health evaluations.

• Addressing nutritional concerns.

• Encouraging healthy lifestyle habits.

Referrals

The following referrals are recommended:

• Registered Dietitian for nutritional counseling.

• Obstetrician-Gynecologist (OB/GYN) for evaluation of possible endometriosis and continued reproductive healthcare management.

Follow-Up Recommendations

The patient should return to primary care within three months to review laboratory findings, reassess nutritional status, and evaluate progress toward preventive healthcare goals. Continued monitoring will help ensure early identification of health concerns and support comprehensive, patient-centered care.

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