Pap Smear

Age: ‍ years old

Gender: female



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 ‍

STI risk factors: ‍

HPV vaccination: ‍up-to-dateincompleteunvaccinated



Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Breasts: ‍normal, ‍mass, ‍axillary adenopathy

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, ‍blood, ‍mass, anus ‍

Pelvic:

- External genitalia: ‍normal, ‍rashlesions, ‍inguinal lymphadenopathy

- Vagina: ‍normal, ‍lesions, discharge ‍normal, ‍foul-smelling

- Cervix: ‍normal, ‍, ‍IUD strings visualized

- Bimanual exam: ‍normal, uterus ‍tendernessmass, adnexa ‍tendernessmass ‍on righton left, ‍cervical motion tenderness

- Tests performed: ‍Pap smearHPV test, ‍vaginal culturechlamydia/gonorrhea screeningHSV sample, pH ‍< 4.5 (normal)> 4.5, KOH sniff test ‍negative

- ‍Pelvic exam performed with chaperone 





ASSESSMENT:

‍Normal Pap smear ‍likelysuspectedpossible

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:

- ‍HPV vaccine

- Counseling on condom use

Further care:

- Referral to colposcopy clinic

- Referral to gynecologist

- Repeat Pap smear in ‍ years

- Follow-up in ‍ ‍weeksmonths