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:
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Breasts: -R: , -L:
Abdomen: , , ,
Anorectal: DRE , anus
Pelvic:
- External genitalia: ,
- Vagina: , discharge ,
- Cervix:
- Uterus: ,
- Adnexa: -R , -L
- Tests performed: , , , , vaginal pH , whiff test with KOH
- Performed with chaperone
ASSESSMENT:
DDx:
PLAN:
- Pap smear
- HPV testing
- Colposcopy
-
- Counseling on condom use
- Referral to colposcopy clinic
- Referral to gynecologist
- Repeat Pap smear in years
- Follow-up in