Comprehensive Well-Woman

Comprehensive Well-Woman

A comprehensive well-woman examination is an integrated part of preventive health, touching upon current issues and anticipatory guidance throughout a woman’s lifespan. The case study under consideration is of P.K., a 54-year-old white woman, who comes to her yearly well-woman test with manifestations of perimenopausal shift. She complains of experiencing hot flashes, vaginal dryness, reduced libido, and fatigue, and these are affecting her quality of life. The main aim of the visit is to determine her current symptoms, maintain routine checks, analyze her chronic immobilities, and generate an individual and evidenced-based care plan.

This paper aims to illustrate a comprehensive and integrative process of assessing the health of women by synthesizing subjective and objective data, differentials, and a management plan that is comprehensive and accommodating the special history and presentation of the patient in question. Particular focus is on her perimenopausal symptoms, sexual health, cardiovascular risk profile, and thyroid functioning. The critical importance of the nurse practitioner in the screening of intimate partner violence is also reflected in the paper. In this case, advanced practice competencies related to diagnostic reasoning, preventive care, and health promotion are used to enhance patient outcomes and inform future wellness in midlife women.

Subjective Data (S)

Patient Information

Initials: P.K. | Age: 54 | Race: White | Gender: Female | Marital Status: Married | Occupation: School Principal

Chief Complaint (CC): “The hot flashes and dryness are getting worse, and I feel more tired lately. I just want to know if this is menopause.”

History of Present Illness (HPI)

P.K. is a 54-year-old white woman who has reported to her annual well-woman exam, with complaints regarding perimenopausal symptoms. She has been having a progressive worsening of hot flashes, fatigue, vaginal dryness, pain during the last 9-12 months, and a definite decrease in libido. The hot flashes come two or more times a day and disrupt her sleep in some cases. Due to vaginal dryness, there is discomfort during sexual intercourse, resulting in low sexual activity. It is accompanied by fatigue that increases during stress associated with work. She has never received any treatment for the symptoms, and she does not experience mood swings or insomnia, urinary problems, or irregular bleeding. She had her last menstrual period on January 21, 2025. She does not take hormone therapy and wants her symptoms evaluated and advised on how to manage them at this period of life transition.

Past Medical History (PMH)

• Allergies: No known drug allergies (NKDA)
• Current Medications:
  • Levothyroxine 75 mcg PO daily
  • Lisinopril 20 mg PO daily
  • Atorvastatin 20 mg PO nightly
• Age/Health Status: 54 years old; generally healthy, including a good regulation of chronic conditions.
• Immunization Status: Has received all basic vaccines, such as COVID-19 and flu shots, on a regular basis. Tdap booster in five years ago. No pneumococcal vaccination.
• Previous Screening Test Results: The previous mammogram and Pap smear were conducted within the past 12 months, and the results were negative.
• Childhood Illnesses: No major ailments. No history of rheumatic fever or long-term childhood ailments.
• Major Adult Illnesses: At the age of 45, she was diagnosed with hypothyroidism. In her early 50s, hypertension and hyperlipidemia were diagnosed. Denies diabetes, gastrointestinal, pulmonary, cardiovascular, oncologic, or psychiatric conditions. No history of tuberculosis, STIs, HIV/AIDS, gynecologic or urologic diseases, or substance abuse.
• Injuries: No significant injuries reported.
• Hospitalizations: Hospitalized for two cesarean sections; no other admissions noted.
• Surgeries: Two cesarean deliveries were performed at City General Hospital in 1998 and 2001.

Family History (FH)

• Mother: Age 77, living. History of osteoporosis and hypertension. No history of cancer, diabetes, or mental illness.
• Father: Deceased at age 68 due to myocardial infarction. Had a history of hyperlipidemia and hypertension.
• Siblings: One brother, age 56, living with hyperlipidemia. No known cardiac, psychiatric, or endocrine disorders.
• Children: Two children. Daughter, age 25, with a history of childhood asthma; otherwise, healthy. Son, age 22, with no medical conditions.
• Extended Family History: No reported cases of breast, cervical, ovarian, or uterine cancer. No known family history of diabetes, kidney disease, tuberculosis, hemophilia, epilepsy, sickle cell disease, glaucoma, or congenital abnormalities. No family history of psychiatric illness, substance abuse, or domestic violence.
• Relevant Conditions: Family history is significant for cardiovascular disease (father) and osteoporosis (mother), both of which are relevant to the patient’s current menopausal and cardiovascular risk profile.

Social History (SH)

• Marital Status: Married, lives with husband in a single-family home.
• Occupational History: Has worked as a full-time school principal for the last 12 years. Formerly served as a middle school educator with more than 10 years of experience.
• Military Service: No military history.
• Education Level: Acquired a Master of Educational Leadership.
• Lifestyle and Health Habits: Participates in regular moderate exercise, including walking and yoga, three times a week. Eats a relatively healthy diet, including fruits, vegetables, and lean protein. She always uses seatbelts, has working smoke detectors in her home, and refrains from exposure to firearms. Likes to read, garden, and travel a little with family.
• Living Arrangements: Lives together with her husband in a middle-class suburb. Has access to clean water, good transport, and healthy food.
• Religious Preference: Claims to be a Christian. No religious beliefs that could be in conflict with the medical treatment or decisions about health.
• Habits: Denies the use of tobacco and recreational drugs. Socially, she consumes one glass of wine per week on average.
• Resources and Access to Care: Covered with comprehensive employer-sponsored health insurance. No worries regarding the ability to afford medications and treatments. Denies postponing care due to cost. Routinely attends preventive and follow-up health appointments.
• Reproductive History: The patient’s last menstrual period was on January 21, 2025. She is G3P2, not currently pregnant or lactating. She is not using any form of contraception. She engages in vaginal intercourse exclusively with her male spouse. She reports reduced libido and vaginal dryness but denies pain, bleeding, or other sexual concerns.

Review of Systems (ROS)

Constitutional

Reports persistent fatigue, likely related to menopausal transition. Denies weight gain or loss, fever, chills, night sweats, or recurrent infections. Able to complete all activities of daily living independently.

Eyes

Denies vision changes, double vision, or eye pain. Wears reading glasses. No excessive tearing, redness, or history of trauma. The last vision screening was one year ago; results were normal.

Ears, Nose, Mouth, and Throat

Denies hearing loss, tinnitus, or ear pain. No nasal congestion, discharge, or sinus issues. Reports a normal sense of smell and taste. The last dental exam was six months ago with normal findings. No gum bleeding, mouth ulcers, or sore throat. Denies hoarseness or difficulty swallowing.

Cardiovascular

Denies chest pain, palpitations, or lower extremity edema. Exercises regularly with no activity intolerance. Known history of hypertension and hyperlipidemia. Last ECG done two years ago; results were normal. The last cholesterol test was nine months ago, with mildly elevated LDL.

Respiratory

Denies shortness of breath, cough, wheezing, or hemoptysis. No history of asthma or exposure to tuberculosis. Denies exposure to secondhand smoke. No prior chest x-rays.

Gastrointestinal

Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Reports normal bowel movements. No heartburn, melena, or jaundice. Eats a high-fiber, low-fat diet. No use of herbal or nutritional supplements.

Genitourinary

Reports vaginal dryness and reduced libido. Denies urinary frequency, urgency, dysuria, or incontinence. G3P2 via cesarean delivery. LMP 01/21/2024. No contraceptive use. Last Pap smear 11 months ago, normal. Denies history of sexually transmitted infections, kidney stones, or abnormal discharge.

Musculoskeletal

Denies joint pain, stiffness, muscle aches, or back pain. Exercises three times per week. Uses seatbelt and home safety precautions. No history of osteoporosis screening or fractures.

Integumentary (Skin and Breast)

Denies skin rashes, lesions, or hair loss. Uses sunscreen when outdoors. Performs monthly breast self-exams. Last mammogram was 11 months ago—normal. No breast lumps, discharge, or dimpling.

Neurologic

Denies dizziness, headaches, memory loss, syncope, tremors, seizures, or paresthesia. No history of stroke or neurological conditions.

Psychiatric

Denies mood swings, depression, anxiety, insomnia, or suicidal thoughts. Reports occasional work-related stress but manages it well. No psychiatric diagnoses.

Endocrine

Known history of hypothyroidism, currently treated. Denies cold or heat intolerance, polyuria, polydipsia, or weight fluctuations. No use of hormonal therapy to date.

Hematologic/Lymphatic

Denies easy bruising, bleeding, or swollen lymph nodes. No known history of anemia or blood transfusions.

Allergic/Immunologic

Denies seasonal or food allergies. No history of immunodeficiency. Immunizations, including hepatitis B, are up to date. Denies steroid use or immune suppression.

Objective Data

Physical Exam Findings

• Constitutional: Vital signs: Temp 98.4°F, BP 132/82 mmHg, HR 74 bpm, RR 16/min, SpO₂ 98%, Height 5’4”, Weight 172 lbs, BMI 29.6 (overweight). Patient appears well-groomed, alert, oriented ×3, and in no acute distress.
• Eyes: Pupils equal, round, and reactive to light and accommodation (PERRLA). Extraocular movements intact (EOMI). Conjunctiva clear; no discharge or scleral icterus.
• Ears, Nose, Throat (ENT): Ears: Tympanic membranes intact, no erythema or fluid. Nose: Nares patent, no discharge or lesions. Throat: Mucous membranes moist, no tonsillar enlargement or exudate. No lesions observed in the oral cavity.
• Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, gallops, or rubs. No jugular venous distension or peripheral edema. Capillary refill <2 seconds. Peripheral pulses 2+ bilaterally.
• Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi. No respiratory distress observed.
• Gastrointestinal: Abdomen soft, non-tender, non-distended. Bowel sounds active in all quadrants. No masses, hepatosplenomegaly, or rebound tenderness.
• Genitourinary: External genitalia normal. Vaginal mucosa pale and dry with decreased rugae, consistent with hypoestrogenism. No lesions or discharge noted. Cervix normal in appearance. Bimanual exam: Uterus normal size, non-tender, mobile. Adnexa non-palpable, no masses or tenderness.
• Musculoskeletal: Normal posture and gait. Full range of motion in all extremities. No joint swelling, erythema, or deformity. No spinal tenderness.
• Integumentary/Lymphatic: Skin warm, dry, intact. No rashes, lesions, or bruising. Nails without deformities. No axillary, cervical, or inguinal lymphadenopathy noted.
• Neurologic: Alert and oriented to person, place, and time. Cranial nerves II–XII grossly intact. Strength 5/5 in upper and lower extremities. Sensation intact. No tremors or focal deficits noted.
• Psychiatric: Appropriate mood and affect. Eye contact maintained. Thought process logical and goal-directed. No signs of acute anxiety, depression, or psychosis.
• Hematologic/Immunologic: No pallor, petechiae, or signs of active bleeding. No enlarged lymph nodes. No evidence of immunosuppression. No signs of anemia or infection.

Diagnostic Testing Performed During Visit

None completed at the time of visit. Orders placed for:

• Pap smear with HPV co-testing
• Mammogram (screening)
• TSH and Free T4
• Lipid panel
• Complete Metabolic Panel (CMP) and CBC
• DEXA scan (baseline)

Assessment (A)

Differential Diagnoses

Perimenopausal Symptoms – ICD-10: N95.1

P.K. presents with hallmark symptoms of perimenopause, including hot flashes, fatigue, and irregular menses, with her last period occurring over six months ago. These symptoms have gradually intensified over the past year. She denies abnormal bleeding or mood disturbances but reports significant discomfort impacting quality of life. Her age, history, and clinical presentation support a diagnosis of perimenopausal transition. No additional hormone testing is required unless symptoms are atypical. This is classified as an acute self-limited condition associated with the natural menopausal transition (Cunningham et al., 2025). Management focuses on symptom relief and anticipatory guidance.

Atrophic Vaginitis – ICD-10: N95.2

Genitourinary symptoms are prominent, particularly vaginal dryness and reduced libido. On physical exam, vaginal mucosa was pale with decreased rugae, consistent with hypoestrogenism. She reports discomfort during intercourse but denies pain or bleeding. Atrophic vaginitis is a common finding in perimenopausal and postmenopausal women due to declining estrogen (Flores & Hall, 2025). It is categorized as an acute self-limited condition that often improves with local estrogen therapy. Treatment options include vaginal estrogen cream, moisturizers, or non-hormonal alternatives if contraindicated.

Hypothyroidism – ICD-10: E03.9

This is a chronic health problem with a confirmed diagnosis. The patient has been taking levothyroxine 75 mcg daily for years. However, she continues to report persistent fatigue, which may be related to menopause, thyroid dysfunction, or both. A TSH and Free T4 have been ordered to evaluate her current thyroid status and medication effectiveness. If her levels are outside the target range, dosage adjustment may be necessary. Monitoring is essential to avoid complications such as cardiovascular strain, mood changes, or metabolic imbalance (Patil et al., 2024).

Hypertension – ICD-10: I10

P.K. has a history of hypertension managed with lisinopril 20 mg daily. Her blood pressure today was 132/82 mmHg, which is within the acceptable range for her age group and comorbidities. She reports no related symptoms such as headaches or visual changes. This chronic condition is currently well controlled, but ongoing monitoring is needed (Iqbal & Jamal, 2023). Given her menopausal status and lipid history, cardiovascular risk should continue to be assessed. Lifestyle modifications and medication adherence were reinforced during the visit.

Plan (P)

Perimenopausal Symptoms – ICD-10: N95.1

The patient and provider agreed on a conservative management approach for her perimenopausal symptoms at this time. No laboratory testing was indicated, as diagnosis is clinical. Hormone replacement therapy (HRT) was discussed but deferred until a later date due to the patient’s preference to manage symptoms non-pharmacologically. The patient was advised to adopt lifestyle modifications such as dressing in breathable layers, maintaining a cool sleep environment, engaging in regular physical activity, and practicing mindfulness or stress-reducing techniques like yoga or deep breathing exercises. Educational materials were provided, and non-hormonal pharmacologic alternatives such as low-dose SSRIs and gabapentin were discussed for future consideration if symptoms progress. The patient will observe her symptoms, as well as contact and follow up during her annual well-women check-up or anytime her symptoms get unbearable.

Atrophic Vaginitis – ICD-10: N95.2

To relieve her vaginal dryness and related pain, the patient was prescribed Estradiol vaginal cream 0.01%. The instructions included applying 2-4 grams intravaginally daily in the first 2 weeks, and 1 gram twice a week as maintenance. The dispensing was done in three refills on a 30-gram tube. The patient was educated on the correct usage of the applicator and medication and told about the possible side effects, like local irritation or spotting. She was also advised to apply water-based lubricants during intercourse and vaginal moisturizers frequently to aid in keeping the tissues hydrated. The symptoms are expected to improve in 1-2 weeks. A follow-up appointment will be made in eight weeks to assess the treatment response, or sooner should adverse symptoms arise.

Hypothyroidism – ICD-10: E03.9

In order to evaluate the status of her hypothyroidism, thyroid functions such as TSH and Free T4 were requested. The patient will remain on levothyroxine 75 mcg orally once a day on an empty stomach. She was advised not to take calcium or iron supplements four hours before taking her thyroid medication to avoid interference with absorption. Signs of under- and over-treatment, including changes in weight, palpitations, or excessive tiredness, were also discussed. The provider will check the lab result and make contact with the patient in case changes to the medication are necessitated. In case labs stabilize, the next regular thyroid assessment will be after a period of six months.

Hypertension – ICD-10: I10

The patient is now in good control of blood pressure with lisinopril 20 mg daily, which she will continue taking. To assess renal function and rule out possible electrolyte imbalance induced by medications, a comprehensive metabolic panel (CMP) was requested. There was increased emphasis on lifestyle change that followed a low-sodium DASH diet, daily exercise, and weight loss to a BMI less than 25. The patient was advised to use a home blood pressure monitoring device and record the pressure every two to three days to conduct follow-ups. She was taught about the warning signs of uncontrolled hypertension, including daily headaches or seeing lights, and told to notify her doctor about them immediately. Her husband was involved in a short conversation about healthy cooking, communication, and support. Since her blood pressure is well controlled, follow-up will be scheduled on a yearly basis, with PRN visits as the interim appointment in case of a worsening of symptoms or medication concerns.

Reflection

In the event that domestic violence was observed or suspected in this patient, it would change the plan of care considerably. Intimate partner violence (IPV) may be concealed by such non-specific manifestations as fatigue or sexual dysfunction that are common in women (Centers for Disease Control and Prevention, 2022). Regarding this situation, I would put a high preference on patient safety, initiating a confidential discussion, and applying a validated instrument of IPV screening, like HITS or WAST. A positive screen would prompt immediate referral to social services, domestic violence advocacy programs, and possibly law enforcement, depending on patient consent and severity (Kyle, 2022). The management plan would shift focus from solely managing perimenopausal symptoms to crisis intervention and trauma-informed care.

Perimenopausal women are particularly vulnerable to IPV, as hormonal changes and life transitions may increase psychological stress and dependency. Understanding these dynamics reinforces the need for routine IPV screening during gynecologic visits. It also underscores how a safe environment and a trusting environment can be built by an advanced practice nurse to facilitate disclosure (Blackson et al., 2024). Ultimately, recognizing and addressing domestic violence not only affects the care plan but can also save lives. Notably, clinicians must integrate vigilance and compassion into every encounter, especially when subtle cues may indicate deeper suffering.

References

Blackson, E. A., McCarthy, C., Bell, C., Ramirez, S., & Bazzano, A. N. (2024). Experiences of menopausal transition among populations exposed to chronic psychosocial stress in the United States: A scoping review. BMC Women S Health, 24(1). https://doi.org/10.1186/s12905-024-03329-z

Centers for Disease Control and Prevention. (2022, October 11). Fast facts: Preventing intimate partner violence. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html

Cunningham, A. C., Hewings-Martin, Y., Wickham, A. P., Prentice, C., Payne, J. L., & Zhaunova, L. (2025). Perimenopause symptoms, severity, and healthcare seeking in women in the US. Npj Women’s Health, 3(1), 1–8. https://doi.org/10.1038/s44294-025-00061-3

Flores, S. A., & Hall, C. A. (2025, June 19). Atrophic vaginitis (Archived). PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/33232011/

Iqbal, A., & Jamal, S. (2023, July 20). Essential hypertension. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539859/

Kyle, J. (2022). Intimate partner violence. Medical Clinics of North America, 107(2). https://doi.org/10.1016/j.mcna.2022.10.012

Patil, N., Rehman, A., Anastasopoulou, C., & Jialal, I. (2024, February 18). Hypothyroidism. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK519536/

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For a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.
Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.
For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.
Note: All Focused Notes must be signed, and each page must be initialed by your