32
G2P1
**Cervical Screening History To Date**
- 03/03/2018: HPV negative, LBC negative, endocervical component present.
- 15/06/2021: HPV positive, LBC: ASCUS, endocervical component present.
- 10/09/2024: HPV positive, LBC: HSIL, endocervical component present.
**Current Symptoms:**
The patient reports experiencing intermittent post-coital bleeding for the past three months. She denies any other current symptoms.
**Gynaecological and Obstetric History**
- Menarche at age 13.
- Regular menstrual cycles, lasting 5 days, with moderate flow.
- No history of sexually transmitted infections.
- No previous gynecological surgeries.
- One full-term vaginal delivery in 2019.
- One miscarriage in 2023.
The patient is a non-smoker.
The patient received three doses of Gardasil in 2010.
Parous, with one viable pregnancy.
The patient is not immunocompromised.
Post-coital bleeding is present.
Intermenstrual bleeding is absent.
The patient is currently using an intrauterine device (IUD) inserted in 2020.
**PMSHx**
- Asthma
- Salbutamol inhaler as needed.
- No known allergies.
- Mother: history of cervical cancer.
- Non-smoker, occasional alcohol use, works as a teacher, lives with partner, feels safe at home.
**Colposcopy Examination:**
Cervix shows AWE in the transformation zone, with a mosaic pattern.
LBC was performed, showing HSIL.
STI swabs were not taken.
Vaginal swabs were not taken.
Biopsies were taken from the 3, 6, and 9 o'clock positions.
**Impression**
HSIL.
**Plan**
The patient will be scheduled for a Loop Electrosurgical Excision Procedure (LEEP) in four weeks. The patient was counselled on the procedure and potential risks. The patient was advised to abstain from sexual intercourse for two weeks after the LEEP procedure. The patient was also advised to return for a follow-up appointment in six months for repeat cervical screening.
The patient was provided with educational materials on cervical cancer and HPV.
[patient's age] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[gravidity and parity summary] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Cervical Screening History To Date**
[chronological list of cervical screening results, including date of screening, HPV subtype, LBC findings, and presence or absence of endocervical component for each screening event] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
**Current Symptoms:**
[description of current symptoms related to the colposcopy or general gynecological health] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**Gynaecological and Obstetric History**
[details of gynecological history, including relevant past conditions, surgeries, or treatments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
[details of obstetric history, including number of pregnancies, birth outcomes, and any related complications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
[patient's current or past smoking status, including details of amount and duration if available] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[information regarding Gardasil vaccination, including dates and number of doses if available] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[indication of nulliparity or parity, and if parous, the number of pregnancies carried to viability] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[details of any immunocompromised status, including cause and management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[presence or absence and characteristics of post-coital bleeding] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[presence or absence and characteristics of intermenstrual bleeding] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[current or past contraceptive methods used by the patient, including details of type and duration of use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
**PMSHx**
[list in shortform. details of other medical and surgical history, including relevant past conditions, surgeries, or treatments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
[current medications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
[list allergies with reaction if mentioned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
[list in shortform. details of family history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
[list in shortform. Include smoking, alcohol, vaping, other substance use. Include occupation and living situation. State if feels safe at home if mentioned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".)
**Colposcopy Examination:**
[brief description of colposcopy findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use medical terminology and abbreviations. If "acetowhite" is stated, abbreviate to "AWE". Write in a brief sentence.)
[indication of whether LBC was performed, including any relevant findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[indication of whether STI swabs were taken, including any relevant findings or specific tests performed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[indication of whether vaginal swabs were taken, including any relevant findings or specific tests performed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
[indication of whether biopsies were taken, including the site and number of biopsies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.)
**Impression**
[overall colposcopic impression, categorised as Normal, LSIL, HSIL, or Cancer] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use medical terminology and abbreviations. Write in a brief sentence.)
**Plan**
[details of follow-up for any investigations performed, including expected timelines and next steps] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[other planned interventions, consultations, or patient education] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)