Comprehensive Well Woman Physical Exam Template
A well woman exam should focus on evidence-based screening components that improve morbidity and mortality outcomes while avoiding unnecessary procedures that may cause harm. Based on current guidelines, routine pelvic examinations in asymptomatic women are not recommended 1.
Essential Components
History
Medical History
- Past medical conditions
- Current medications including over-the-counter and supplements
- Allergies
- Surgical history
- Family history of cancer, cardiovascular disease, and other hereditary conditions
- Immunization status
Reproductive and Sexual Health History
- Menstrual history (age at menarche, regularity, last menstrual period)
- Pregnancy history (gravidity, parity)
- Contraceptive use and needs
- Sexual activity and practices
- STI history and risk factors
- History of abnormal Pap tests or gynecologic problems
Social History
- Tobacco, alcohol, and substance use
- Diet and exercise habits
- Sleep patterns
- Intimate partner violence screening
- Social support systems
Review of Systems
- Focus on gynecologic symptoms (abnormal bleeding, pelvic pain, vaginal discharge)
- Constitutional symptoms (fever, weight changes)
- Breast symptoms (pain, discharge, masses)
Physical Examination
Vital Signs
- Height, weight, BMI
- Blood pressure
- Heart rate
- Temperature (if indicated)
General Examination
- Overall appearance
- Skin assessment (including acanthosis nigricans)
- Thyroid examination
- Cardiovascular and pulmonary examination
- Abdominal examination
Breast Examination
- Visual inspection with patient sitting and arms at sides, raised above head, and pressing on hips
- Palpation in systematic pattern (vertical strips) with patient supine
- Examination of axillary and supraclavicular lymph nodes 1
Pelvic Examination (selective use based on symptoms or specific indications)
- The USPSTF found insufficient evidence to recommend routine pelvic examinations in asymptomatic women 1
- Components when indicated:
- External genital inspection
- Speculum examination
- Bimanual examination
- Rectovaginal examination (rarely needed)
Preventive Screening
Cervical Cancer Screening
- Follow age-appropriate guidelines for Pap testing
- Note: Pap test can be performed without a complete pelvic examination 1
Breast Cancer Screening
- Mammography according to age-appropriate guidelines
- Discussion of breast self-awareness (not formal self-examination) 1
Other Screenings Based on Age and Risk Factors
- Colorectal cancer screening
- Osteoporosis screening
- Lipid screening
- Diabetes screening
- Depression and anxiety screening
Important Considerations
Pelvic Examination Evidence
The American College of Physicians found no data supporting routine pelvic examinations in asymptomatic women 1. Key points:
- Low positive predictive value (<4%) for detecting ovarian cancer
- No studies showing morbidity or mortality benefits
- 30-35% of women report pain, discomfort, fear, anxiety, or embarrassment 1, 2
- Routine pelvic exams may lead to unnecessary procedures and anxiety
Special Populations
- Adolescents: Focus on confidentiality, education, and preventive counseling
- Pregnant Women: Additional focus on pregnancy-related issues
- Perimenopausal/Menopausal Women: Assessment of symptoms and discussion of management options
- Women with Disabilities: Adapt examination as needed, with attention to specific needs 1
Documentation
Document all components of the history and physical examination performed, including:
- Pertinent positive and negative findings
- Screenings performed and results
- Counseling provided
- Plan for follow-up and future screenings
Common Pitfalls to Avoid
- Performing routine pelvic examinations without specific indications
- Failing to provide adequate privacy and comfort during examination
- Overlooking psychosocial aspects of care
- Missing opportunities for preventive counseling
- Neglecting to screen for intimate partner violence
By focusing on evidence-based components and avoiding unnecessary procedures like routine pelvic examinations in asymptomatic women, the well woman exam can effectively promote health while minimizing potential harms.