Comprehensive Women’s Health History and Physical Template
Encounter date: 6/16/22
Patient Initials: E.S.
Gender: F
Age:
34yr
Race/Ethnicity: Hispanic
Reason for Seeking Health Care: Vaginal discharge, check-up
Chief complaint: “ I was having vaginal discharge and would like to be screened for STIs”
History of Present Illness (HPI): The patient is a 34-year-old female G2P1A1L1 who presents
to the clinic for a check-up. She has complaints of watery white vaginal discharge, with a foul
odor. She reports an episode earlier this week, after intercourse she had a lot of pain for four
days. When she was walking, she felt a sharp pain in the right lower pelvic region more than on
the left side, occurring after intercourse. She states relieving factors include rest and OTC
Ibuprofen. The patient denies abnormal bleeding, discharge, fever, or pain today and says her
symptoms have improved. She reports a new partner in the last three months with her LMP
being May 15, 2022. The patient states she is using the Nexplanon implant for birth control
since 2019. Her last pap smear was in April 2021 she states. She admits to a prior history of
STI in which she was treated for Chlamydia. She is requesting STI testing and a general checkup to make sure there is no presence of an infection.
Allergies (Drug/Food/Latex/Environmental/Herbal)
Drug: Penicillin- moderate hives
Food: peanuts- severe anaphylactic
Environment: dust- mild congestion, cat dander- mild hives
Herbal: no known herbal allergies
Current Perception of Health : Overall patient says she feels healthy, happy, and active.
Current Medications (including over the counter)
Omeprazole 20mg 1 capsule by mouth BID for 10 days (GERD- 2022)
Nexplanon implant for birth control (2019)
Menstrual History
Age at Menarche 12 yr old
Last menstrual period
5/15/22
Menstrual Pattern irregular
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Cycle Length
4 days
Duration of Flow 4 days
Amount of Flow: moderate
Bleeding Pattern: irregular
Break through Bleeding: none
Gynecologic History
History of breast disease, breastfeeding, use of self-breast exam, last mammogram (if
applicable) breastfeeding history: about 3 months in 2009, no recent mammogram, does selfbreast exams
Previous GYN surgery (may include that in surgical history): spontaneous abortion 2006
History of infertility: denies
History of diethylstilbestrol (DES) use by patient’s mother: denies
Last pap smear, history of abnormal pap: April 2021-LSIL
Pre-menopause/menopause: not applicable
Vasomotor symptoms: denies
Hormone Replacement Therapy: denies
Sexual and Contraceptive History
Current method of contraception: Nexplanon inserted 2/2019, expiration extended 2 more
years.
Sexually active: Yes
Number of sexual partners: 1
New partners in the 3-6 months: yes 3 months ago
Condom use: denies
History of sexual abuse: denies
History of sexually transmitted infections (STIs): Chlamydia 2006
Obstetric History (including complications): Gravida 2Para1, Term 1, Abortion 1 Living 1.
Vaginal birth- 2009
Past Medical History (PMH)
Major/Chronic Illnesses GERD 2022
Trauma/Injury: denies
Hospitalizations: 2006- abortion
Past Surgical History: Breast augmentation with implant 2019
D&C- 2006
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Family Medical History: mother(Living): HTN, father(Living): hypercholesterolemia, maternal
grandmother (deceased) DM, paternal grandfather (deceased): stroke, sister( living) none,
brother living: obesity
Social History
Living condition: lives in an apartment with partner, child
Marital status: single
Education: high school
Employment: yes, retail Victoria’s secret
Occupation: retail
Social supports: none
Habits (smoking, alcohol use, and illicit drug use): alcohol use moderate: 1-2 drinks wine a
night, Smoking: for 10 years, quit last year 2021, Illicit drug use: denies
Health Maintenance
Age-appropriate health promotion/maintenance and screening history: sunscreen uses
routinely: no, wears seatbelts: yes,
Immunization history: up to date: Covid 2021, influenza- 2021, Tdap, 2015, Diabetes screen:
2022, Lipid panel: 2022, Thyroid screen: 2022
Review of Systems (ROS):
General: Overall pt feels healthy maintains weight, is content, and denies fatigue, and fever.
HEENT: Head: denies dizziness, atraumatic, denies headaches, no lesions, no pain .Eyes:
denies visual changes, blurred vision, tearing, or redness. Ears: Denies pain in the both ears,
discharge, tinnitus, or bleeding. Nose: no nasal discharge, denies obstruction, septal deviation, or
congestion in the nasal sinuses. Mouth: no bleeding gums, no pain when chewing, denies jaw
pain, no lesions in the mouth, has cavities filled.
Neck: Denies swelling, no pain, stiffness, no limited range of motion
Breast: no breast pain, denies lumps, nipples discharge, or inverted nipples
Pulmonary: Denies shortness of breath, coughing, or wheezing
Cardiovascular: Denies palpitation, no chest pain, no skipping of heartbeat, denies irregular
rhythms
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GI: Denies pain in the abdomen, diarrhea, nausea, vomiting, or blood in the stool. admits good
appetite
GU: denies urinary pain, difficulty urinating, frequency, or urgency, blood in the urine
Female Genitalia: no vaginal ulcers, admits discharge watery discharge, admits foul odor, no
bleeding, or spotting, admits pain after sexual intercourse
Hematologic: no blood in the stool, no blood in urine, no signs of bleeding, no bruising.
Lymphatic no swollen lymph nodes, non-tender lymph nodes
Musculoskeletal: no weakness, full range of motion in all extremities, ambulatory, no joints
pain
Neuro: no ambulation issues, denies numbness, tingling, no paresthesia, gait is steady
Activity and exercise: no activity intolerance, no SOB with activity, do light walking
Psychologic: sometimes has anxiety, stressed out, denies depression
Sleep: denies insomnia, sleeps well at night, sometimes can’t sleep if she is stressed out.
Nutrition: intentional dieting to lose weight
STI hx: Admits safe sexual practices, has hx of STI chlamydia
Physical Examination
Vital Signs
Blood Pressure (BP: 101/65
Temperature 98.7 temporal route Heart Rate (HR) 80
Respiratory 16 Rate (RR)
Height
5’8 feet Weight: 145 lbs Body Mass Index (BMI) 22 Pain 0
Chaperone: Chaperone: present.
Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed.
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Psychologic: pt. is alert, and oriented. Normal mood and affect and active and alert.
Skin: Appearance: no rashes or lesions
HEENT: Eyes: no presence of periorbital swelling, no redness, no drainage, sclera is white,
Pupils equal reactive to light accommodating. Ears: symmetrical bilaterally, no lesions, no
redness visualized. Face is symmetrical, no nasal drainage, no polyps, no bleeding from the nose.
Mouth mucosa is pink, no erythema, no exudate, and no teeth missing.
Neck: Neck: no lymphadenopathy, no thyromegaly, no pain, full range of motion
Lungs: normal respirations, equal lung rise, and fall, lung sounds clear to auscultation, no
adventitious sounds heard
Cardiovascular: normal rate and rhythm S1, S2 noted, no edema in extremities, no cyanosis
noted.
Breast: inspection color, shape, symmetry, no discharge, no redness, swelling, nontender
axillary lymph nodes bilaterally,
Abdomen: nontenderness, no masses, or CVA tenderness and soft, non-distended, and normal
bowel sounds. Hernia: none palpated.
GU: costovertebral angle nontender,
Female Genitalia: Vulva: no masses or atrophy. Bladder/Urethra: no urethral discharge or mass
and normal meatus and bladder nondistended. Vagina no tenderness, erythema, cystocele,
rectocele, or vesicle(s) or ulcers and abnormal vaginal discharge (copious white discharge,
sample obtained). Cervix: grossly normal and no cervical motion tenderness; white discharge.
Uterus: normal size and shape and midline, mobile, non-tender, and no uterine prolapse.
Adnexa/Parametria: no parametrial tenderness or mass and no adnexal tenderness or ovarian
mass.
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Significant Data/Contributing Dx/Labs/Misc
STI screening is done reviewed results shows
STI is negative for chlamydia, gonorrhea,
trichomonas, candidiasis
Positive for Bacterial vaginosis
Assessment
Differential Diagnoses (3 minimum)
1. Candidiasis vaginitis
2. STI: Gonorrhea/ Chlamydia
3. Trichomoniasis
Primary Diagnoses:
1. Acute Vaginitis N76.0 (BV)
2. Encounter for screening for infections with a predominantly sexual mode of transmission
SURESWAB(R), BACTERIAL VAGINOSIS/VAGINITIS
3. Z72.51 High risk heterosexual behavior
Laboratory STI screening culture results were used to confirm the diagnosis.
Therapeutic (Non-pharmacological interventions) – Use proper hygiene, if sexually active
void after intercourse, wipe from front to back. Avoid douching, soaps or soaps with perfume.
Use safe sexual practices, and limit sexual partners. Wear cotton, lose clothes. Take the
medication as prescribed and avoid alcohol while on the medication. Eat a healthy diet and
avoid refined sugars.
Pharmacologic Therapy: Metronidazole 500 mg orally 2 times/day for 7 days
Patient Education- same as therapeutic education. Metronidazole antibiotic cost is around $815$. Take the full course of the medication and avoid alcohol with the medication.
Anticipatory Guidance- Annual pap smear, regular STI check-up especially if with a new
partner to check for chlamydia, gonorrhea, BV, gonorrhea, candidiasis yeast infections, etc.
Maintain a healthy weight, proper diet, and exercise counseling provided. Annual
preventative care screening with PCP for diabetes, hypertension, lipid panel, CBC, CMP, and
TSH. Vitamin D levels were checked. Avoid excess alcohol drinking and reduce intake if
possible, to avoid liver damage.
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Follow up in 1 week or PRN if symptoms persist. Follow up for WWE visit this year and pap
smear test after the infection clears up.
Plan: BACTERIAL VAGINOSIS/VAGINITIS
DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)____________E.J.__________________
Age ___34________
Date: ______6/16/22_________
RX _________ Metronidazole ____________________________
SIG: 500 mg orally 2 times per day for 7 days
Dispense: ___14 tabs________
Refill: _____0____________
No Substitution
Signature: ___________________Rohina_________________________________
Signature (with appropriate credentials): __________________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
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