Cervical Cancer Screening
Age: years old
Gender: female
HISTORY:
Presents for a cervical cancer screening
Last Pap smear was ago
Current symptoms:
Past medical history:
Gynecological history:
Last menstrual period: ago
Menstrual cycles: days,
Menarche: years old
G P A
Coitarche: years old
Menopause: years old
Sexual activity:
Contraception:
Condom use:
History of STIs:
STI risk factors:
HPV vaccination:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Breasts: , ,
Abdomen: , , ,
Anorectal: DRE , , , anus
Pelvic:
- External genitalia: , ,
- Vagina: , , discharge ,
- Cervix: , ,
- Bimanual exam: , uterus , adnexa ,
- Tests performed: , , pH , KOH sniff test
-
ASSESSMENT:
DDx: ASC-US (Atypical Squamous Cells of Undetermined Significance), LSIL (Low-Grade Squamous Intraepithelial Lesion), HSIL (High-Grade Squamous Intraepithelial Lesion), ASC-H (Atypical Squamous Cells, cannot exclude HSIL), AGC (Atypical Glandular Cells), AIS (Adenocarcinoma In Situ), cervical cancer, HPV infection, cervical polyp, cervical ectropion, cervical inflammation, cervical intraepithelial neoplasia (CIN), endometrial hyperplasia, endometrial cancer, vaginal intraepithelial neoplasia (VAIN), vaginal cancer
PLAN:
Investigations:
- Pap smear
- HPV testing
- Colposcopy
Treatments:
-
- Counseling on condom use
Further care:
- Referral to colposcopy clinic
- Referral to gynecologist
- Repeat Pap smear in years
- Follow-up in
HISTORY: EXAM: Pelvic: ASSESSMENT: PLAN: