Pap Smear

HISTORY:

Presents for a cervical cancer screening

Last Pap smear was ‍ ‍years ago

Current symptoms: ‍ ‍noneno changes in health



Past medical history: ‍ ‍unremarkable



Gynecological history:

Last menstrual period: ‍ ‍daysweeksmonths ago

Menstrual cycles: ‍ days, ‍regularirregular

Menarche: ‍ years old

G‍01234 P‍01234 A‍01234

Coitarche: ‍ years old ‍never

Menopause: ‍ years old ‍no

Sexual activity: ‍activeinactive

Contraception: ‍yesno ‍oral contraceptives

Condom use: ‍alwayssometimesnever

History of STIs: ‍none ‍

HPV vaccination: ‍up-to-dateincompleteunvaccinated



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Breasts: -R: ‍normal, -L: ‍normal

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, anus ‍normal

Pelvic:

- External genitalia: ‍normal, ‍inguinal lymphadenopathy

- Vagina: ‍normal, discharge ‍normal, ‍malodorous

- Cervix: ‍normal

- Uterus: ‍normal, ‍no cervical motion tenderness

- Adnexa: -R ‍normal, -L ‍normal

- Tests performed: ‍Pap test, ‍HPV DNA, ‍vaginal culture, ‍chlamydia/gonorrhea, vaginal pH ‍< 4.5> 4.5, whiff test with KOH ‍negative

- Performed with chaperone



ASSESSMENT:

‍Normal Pap smear ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Pap smear

- HPV testing

- Colposcopy

- ‍HPV vaccine

- Counseling on condom use

- Referral to colposcopy clinic

- Referral to gynecologist

- Repeat Pap smear in ‍ years

- Follow-up in ‍ ‍weeksmonths