Gyne/PAP Visit

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Menstrual and Gynaecological History

Sarah is premenopausal with LMP on 2026-03-10.

Menstrual cycles are regular.

Cycle length is 28 days with 4 days of moderate flow.

Uses a levonorgestrel-releasing intrauterine system (Mirena®) inserted in 2023.

Reports a new male partner in the past 3 months and requests routine STI screening; inconsistent barrier protection.

Cervical Screening History

Last Pap smear was on 2023-03-15.

History of ASCUS in 2020, which resolved on subsequent routine screening.

No previous colposcopy or excisional cervical procedures.

No history of hysterectomy.

Consent and Chaperone

[x] Informed consent obtained

[x] Chaperone present

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Sarah appears well, comfortable, and in NAD.

Medium Pederson speculum used to visualise the cervix.

External genitalia and vulva are normal with no lesions, erythema, or masses.

Vaginal mucosa is pink, moist, and well-rugated.

Cervix is pink, smooth, with no friability, lesions, or CMT; IUD strings visible at the external os.

Small amount of clear, physiological mucoid discharge present.

Liquid-based cervical cytology obtained using a cytobrush and plastic spatula.

STI and Infection Screening Swabs

[x] Gonorrhoea/GC swab

[x] Chlamydia swab

[ ] Bacterial vaginosis/BV swab

[ ] Yeast swab

[ ] Trichomonas swab

Bimanual Examination Findings

Uterus is anteverted, normal size, mobile, and non-tender. Adnexa and ovaries are non-palpable with no masses or tenderness bilaterally.

A/P

Routine cervical cancer and STI screening in an asymptomatic 31-year-old female; normal pelvic examination.

Pap smear and endocervical GC/CT NAAT results pending.

1. Repeat routine cervical screening in 3 years if cytology is normal.
2. Counselled on consistent condom use for STI prevention.
3. Return to clinic PRN for abnormal bleeding, pelvic pain, or purulent discharge.

Clinic will contact Sarah only if Pap or STI results are abnormal; results will also be accessible via the patient portal.