Name
Purdue University Globle
NU576 NP II – Primary Care of Women’s Health
Prof. Name
Date
A comprehensive well-woman examination is an important part of preventive healthcare for young adults, particularly those who have not received routine medical care for several years. This visit provides an opportunity to establish a primary care relationship, review medical and reproductive health history, identify potential health risks, and develop an individualized plan for wellness.
In this case, Vivian Lopez is a 24-year-old woman presenting to establish primary care after approximately four years without a routine healthcare visit. Her history of painful and prolonged menstrual periods, current oral contraceptive use, low body weight, and lack of previous cervical cancer screening require careful evaluation. A patient-centered approach should address preventive screenings, menstrual health, nutrition, sexual health, and appropriate follow-up.
Vivian Lopez presented for a new-patient well-woman examination on September 12, 2023. She reported that she had not visited a healthcare provider since graduating from college approximately four years earlier. Although she did not report any significant chronic illnesses, she described a previous history of irregular menstrual cycles, severe menstrual pain, and bleeding that sometimes continued for more than two weeks.
Vivian began taking Apri, a combined oral contraceptive, through a telehealth service. Since starting the medication, her menstrual symptoms have improved significantly. She currently denies pelvic pain, abnormal bleeding, or other gynecologic concerns.
The primary purpose of this encounter is to establish ongoing primary care while addressing preventive healthcare needs, reproductive health, nutritional status, and the possibility of an underlying gynecologic condition.
Patient Name: Vivian Lopez
Encounter Number: 25565216
Date of Visit: September 12, 2023
Age: 24 years
Sex: Female
Visit Type: New-patient primary care and well-woman examination
The patient stated, “I am here to establish primary care.”
Vivian reported that she had not received routine medical care since graduating from college approximately four years ago. She currently takes Apri, a combined estrogen-progestin oral contraceptive prescribed through a telehealth platform.
Before beginning hormonal contraception, she experienced irregular menstrual cycles associated with significant pain and heavy bleeding. Her menstrual bleeding frequently lasted longer than two weeks. After initiating oral contraceptive therapy, her symptoms improved, and her menstrual cycles became regular.
At the time of the visit, Vivian denied current pelvic pain, abnormal vaginal bleeding, or additional gynecologic complaints. Her previous menstrual history remains clinically important because prolonged and painful menstruation may be associated with conditions such as endometriosis or other causes of abnormal uterine bleeding.
Apri oral contraceptive tablet, taken once daily.
Medication reconciliation should confirm the prescribed dosage, adherence, side effects, and any contraindications to continued combined hormonal contraception.
No known drug allergies.
No reported medication intolerances.
Vivian reported no chronic medical conditions. Her past medical history includes a left arm fracture at age 10. She denied previous surgeries and hospitalizations.
Both parents are living and reportedly in good health. Vivian has one brother and one sister, and no known significant health concerns were reported among her siblings.
Vivian graduated from the University of San Diego and recently began working as a marketing associate. She currently lives with her girlfriend.
Relevant social history includes:
Former cigarette smoker who quit after college.
Social alcohol consumption.
Occasional marijuana use.
A complete social history should also explore sleep, nutrition, physical activity, mental health, substance use, and personal safety. These factors help guide individualized health promotion and preventive counseling.
Vivian denied fatigue, weakness, and recent changes in weight.
She denied chest pain, palpitations, and peripheral edema.
She reported no cough, congestion, or shortness of breath.
She denied abdominal pain, nausea, vomiting, diarrhea, and constipation.
No rashes, bruising, or skin discoloration were reported.
Vivian denied vision changes and does not use corrective lenses.
She denied hearing loss, tinnitus, sinus concerns, difficulty swallowing, and throat discomfort.
Vivian is sexually active with a female partner and reported that she has never undergone cervical cancer screening. Her last menstrual period occurred approximately two weeks before the visit. Menstrual cycles are currently regular while taking oral contraceptives.
Her reproductive history is notable for:
Previous irregular menstrual cycles.
Prolonged menstrual bleeding, sometimes lasting more than two weeks.
Significant menstrual pain before starting oral contraceptive therapy.
Improvement in menstrual symptoms with hormonal contraception.
No reported history of sexually transmitted infections.
Although Vivian reports a female sexual partner, cervical cancer screening remains important. Human papillomavirus (HPV) can be transmitted between women, and screening recommendations are based primarily on age and the presence of a cervix rather than sexual orientation alone.
The patient denied breast abnormalities and reported that she does not routinely perform breast self-examinations.
She denied back pain, muscle aches, stiffness, or limitations in movement.
Vivian denied dizziness, weakness, and seizure activity.
She denied excessive thirst and increased appetite. No history of blood transfusions was reported.
The patient denied depression, anxiety, or other mental health concerns. Routine preventive care should nevertheless include appropriate mental health screening based on current recommendations and clinical judgment.
| Measurement | Finding |
|---|---|
| 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 |
Vivian’s BMI of 18.0 is near the lower boundary of the adult healthy-weight range and is classified as underweight under standard adult BMI categories. Her weight should be interpreted alongside dietary intake, weight history, menstrual health, activity level, and other clinical findings.
Vivian appeared healthy, alert, and appropriately communicative. She was thin in appearance, consistent with her low BMI. No acute distress was described.
The skin was dry but intact, without lesions, bruising, or discoloration.
The head was normocephalic and atraumatic. Pupils were equal, round, and reactive to light and accommodation. Ear canals were patent bilaterally, nasal passages were clear, and dentition was intact without evidence of dental caries.
Cardiac examination revealed a regular rate and rhythm with normal S1 and S2 heart sounds. No murmurs, additional heart sounds, or peripheral edema were identified.
Breath sounds were clear bilaterally. Respirations were even and unlabored.
The abdomen was soft, non-tender, and non-distended. Bowel sounds were present in all four quadrants.
The breasts were non-tender, with no palpable masses, nipple discharge, or skin abnormalities identified.
Pelvic examination findings included normal external genitalia without lesions, normal vaginal mucosa, and a cervix without lesions or discharge. The uterus was anteverted and non-tender. The bladder was non-distended and non-tender.
Full range of motion was present in all extremities without pain or limitation.
Speech was clear, gait was steady, and neurological function appeared intact.
Vivian was alert and oriented to person, place, and time. Her mood, affect, and behavior were appropriate.
The purpose of diagnostic testing is to support preventive healthcare, evaluate relevant symptoms, and identify conditions that may require treatment. Laboratory testing should be individualized according to the patient’s history, physical examination, risk factors, and clinical indications.
A complete blood count (CBC) may be appropriate because of Vivian’s previous history of prolonged and heavy menstrual bleeding. The test can help assess hemoglobin, hematocrit, and other blood cell measurements for evidence of anemia or other hematologic concerns.
A basic metabolic panel (BMP) may be considered to evaluate electrolyte balance, kidney function, glucose, and other metabolic parameters when clinically indicated.
Urinalysis may be used to evaluate urinary abnormalities when symptoms, medical history, or examination findings support testing. Routine urinalysis is not required for every asymptomatic adult.
Vivian has never received cervical cancer screening. At age 24, she should be offered age-appropriate screening according to current cervical cancer screening recommendations. For average-risk individuals aged 21–29, cervical cytology (Pap testing) every three years is a commonly recommended approach in the United States.
Primary care providers should verify current guidelines and consider factors such as previous screening, immunocompromising conditions, and prior abnormal results.
HPV testing may be used in cervical cancer screening according to the patient’s age and the screening method selected. HPV vaccination status should also be reviewed. HPV infection can occur among women who have sex with women, so sexual orientation does not eliminate the need for cervical cancer prevention.
The primary assessment is a routine well-woman examination focused on establishing long-term primary care. Vivian has not received routine healthcare for approximately four years and requires preventive services, health maintenance, and individualized counseling.
Important healthcare priorities include:
Establishing regular primary care follow-up.
Completing age-appropriate cervical cancer screening.
Reviewing medication use and contraceptive safety.
Assessing menstrual and reproductive health.
Evaluating nutritional status and weight trends.
Providing lifestyle and preventive health counseling.
A well-woman visit should also address immunizations, blood pressure monitoring, mental health, sexual health, and other preventive services appropriate to the patient’s age and risk factors.
Vivian’s history of severe menstrual pain and prolonged bleeding raises concern for a possible underlying gynecologic condition, including endometriosis. Endometriosis is a chronic inflammatory condition in which tissue similar to the lining of the uterus grows outside the uterine cavity.
Common symptoms may include:
Painful menstrual periods.
Chronic pelvic pain.
Pain during sexual activity.
Pain with bowel movements or urination during menstruation.
Heavy or irregular menstrual bleeding.
Fertility-related concerns.
Vivian’s symptoms have improved with oral contraceptive therapy, but symptom improvement does not necessarily exclude an underlying condition. Further evaluation by an obstetrician-gynecologist (OB/GYN) may help determine whether additional assessment or treatment is needed.
Her history alone does not establish a diagnosis of endometriosis. Other potential causes of painful or prolonged menstruation should also be considered based on the clinical evaluation.
Vivian weighs 108 pounds at a height of 5 feet 5 inches, with a reported BMI of 18.0. This places her near the lower end of the adult healthy-weight range and near the underweight threshold.
Nutritional assessment should explore:
Daily dietary intake and meal patterns.
Adequacy of calories, protein, vitamins, and minerals.
Unintentional weight loss or difficulty maintaining weight.
Physical activity and energy expenditure.
Menstrual health and possible nutritional deficiencies.
Food insecurity or other barriers to healthy eating.
A registered dietitian may provide individualized recommendations to support adequate nutrition and healthy weight maintenance.
Vivian should continue her prescribed combined oral contraceptive as directed, provided that it remains clinically appropriate and no contraindications are identified. Combined oral contraceptives may help reduce menstrual pain and bleeding and are commonly used in the management of suspected endometriosis-related symptoms.
The primary care provider should review:
Medication adherence.
Potential adverse effects.
Smoking history and other cardiovascular risk factors.
Migraine history, particularly migraine with aura.
Blood pressure.
Contraindications to estrogen-containing contraception.
The patient’s reproductive goals and contraceptive preferences.
The decision to continue or modify therapy should be based on a complete clinical assessment.
Vivian should receive counseling focused on maintaining adequate nutrition and supporting long-term wellness. A balanced, nutrient-dense diet can help meet energy and nutritional needs.
Recommended strategies include:
Eating regular meals and nutrient-dense snacks.
Including adequate protein, healthy fats, fruits, vegetables, and whole grains.
Increasing caloric intake when clinically appropriate.
Monitoring weight trends rather than focusing only on a single BMI measurement.
Participating in regular physical activity appropriate to her health status.
Maintaining adequate hydration.
Seeking dietary counseling if weight loss or nutritional deficiencies are identified.
Preventive care should be individualized according to current clinical guidelines and the patient’s risk factors. Recommended services include:
Cervical cancer screening with Pap testing or another age-appropriate method.
Review of HPV vaccination status.
Blood pressure monitoring.
Assessment of immunization needs.
Sexual health counseling and STI screening when indicated.
Mental health screening.
Medication review and contraceptive counseling.
Ongoing nutritional assessment.
A routine breast examination was documented during this encounter. However, breast cancer screening recommendations for average-risk women should be based on age, personal history, family history, and current guidelines.
Patient education is an essential part of the well-woman visit because it encourages active participation in healthcare decisions and promotes preventive health behaviors.
Vivian should understand the benefits of regular primary care visits, even when she feels healthy. Preventive appointments help identify risk factors early, maintain immunizations, monitor vital signs, and address health concerns before they become more serious.
The patient should be educated about tracking menstrual cycles, bleeding duration, pain severity, and changes in symptoms. She should seek medical evaluation for recurrent prolonged bleeding, severe pelvic pain, dizziness, fainting, or symptoms that interfere with daily activities.
Sexual health counseling should be inclusive, respectful, and tailored to the patient’s actual sexual practices. Vivian should be informed that HPV transmission can occur between women and that cervical cancer screening remains important for individuals with a cervix.
STI screening should be based on exposure history, sexual practices, and risk factors rather than assumptions about sexual orientation.
The patient should receive education about adequate caloric intake, balanced nutrition, hydration, and monitoring weight changes. A dietitian referral may be appropriate if she has difficulty maintaining weight or meeting nutritional requirements.
Vivian identifies as a member of the LGBTQ+ community. Culturally responsive healthcare should promote dignity, respect, privacy, and patient autonomy.
Healthcare professionals should use inclusive communication and avoid assumptions about sexual orientation, gender identity, sexual practices, or reproductive goals. Asking open-ended questions and using the patient’s preferred name and pronouns can help build trust.
An inclusive approach includes:
Providing respectful and nonjudgmental communication.
Asking about sexual health without making assumptions.
Tailoring screening recommendations to anatomy and risk factors.
Protecting confidentiality.
Encouraging shared decision-making.
Addressing barriers to accessing healthcare.
Building a trusting relationship may improve patient engagement and support continuity of care.
Health promotion should focus on preventing illness, improving quality of life, and supporting Vivian’s long-term physical and emotional well-being.
Vivian should establish a routine primary care schedule and complete age-appropriate preventive services. Because she has not received routine medical care for several years, the initial visit provides an opportunity to review health history, immunizations, screening needs, and lifestyle habits.
Reproductive health counseling should include menstrual symptom monitoring, contraceptive management, cervical cancer screening, and evaluation of symptoms that may suggest endometriosis.
Maintaining adequate nutrition and engaging in regular physical activity can support overall health. Recommendations should be realistic, individualized, and appropriate for the patient’s nutritional needs and health status.
Although Vivian denied current depression and anxiety, routine assessment of mental health, social support, sleep, stress, and personal safety can contribute to comprehensive preventive care.
Referral to a registered dietitian is recommended for individualized nutritional assessment and counseling. The dietitian can evaluate dietary intake, calorie adequacy, weight trends, and strategies for maintaining a healthy nutritional status.
An OB/GYN referral is appropriate for further evaluation of Vivian’s history of painful and prolonged menstrual periods and possible endometriosis. The specialist can assess whether additional diagnostic evaluation or treatment is needed.
Vivian should return to primary care within approximately three months, or sooner if symptoms develop or laboratory results require earlier review. Follow-up should include evaluation of preventive screening completion, laboratory findings when ordered, nutritional status, medication tolerance, and menstrual symptoms.
The follow-up plan should also address:
Completion or scheduling of cervical cancer screening.
Review of immunization needs.
Assessment of weight trends and dietary intake.
Review of CBC or other clinically indicated laboratory results.
Evaluation of oral contraceptive effectiveness and safety.
Progress on OB/GYN and dietitian referrals.
Any new pelvic pain, abnormal bleeding, or other health concerns.
Regular follow-up supports continuity of care and allows the healthcare provider to adjust the plan based on Vivian’s changing needs.
Vivian Lopez’s well-woman examination demonstrates the importance of preventive healthcare for young adults who have been away from routine medical care. Although she appears generally healthy and reports improvement in menstrual symptoms with oral contraceptive therapy, her history of prolonged and painful menstruation warrants continued attention.
The primary care plan should prioritize cervical cancer screening, medication safety, nutritional assessment, health promotion, and appropriate referrals. An inclusive, patient-centered approach can strengthen trust, support informed healthcare decisions, and promote long-term wellness. Ongoing follow-up will help ensure that preventive needs are addressed and that potential reproductive or nutritional concerns are identified early.
American College of Obstetricians and Gynecologists. (n.d.). Well-woman visit. https://www.acog.org/womens-health/faqs/well-woman-visit
American College of Obstetricians and Gynecologists. (n.d.). Endometriosis. https://www.acog.org/womens-health/diseases/endometriosis
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
Centers for Disease Control and Prevention. (n.d.). Screening for cervical cancer. https://www.cdc.gov/cervical-cancer/screening/index.html
Centers for Disease Control and Prevention. (n.d.). HPV vaccination recommendations. https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html
World Health Organization. (2023). Endometriosis. https://www.who.int/news-room/fact-sheets/detail/endometriosis
