Clinical Oral Presentation
Jessica Ward
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“I committed myself to the proactive stance of health promotion and disease
prevention with the conviction that it is much better to experience exuberant wellbeing and prevent disease than let disease happen when it is avoidable and then try
and cope with it.”
Nola J. Pender, PhD, RN, FAAN
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Name: JA
Age: 38
Ethnicity: Caucasian
Chief complaint: follow-up of abnormal pap
smear
HPI: Patient presented to office for f/u for
abnormal pap smear results on 05/22/12.
LNMP: 06/13/12
Gravida: 0
Last pap smear 05/22/12 showed ASCUS high
risk HPV
History: negative for STDs
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Neuro: alert/oriented x3, negative for mood disorder.
Answers questions appropriately.
Endocrine: negative for thyromegaly, negative for lymph
node enlargement
Respiratory: clear bilateral, equal lung expansion,RR= 16
Cardiovascular: negative for murmurs or gallops, no
edema noted in lower extremity, denies palpations.
b/p=114/86 HR=74
GI: no abdominal masses, bowel sounds present in all
four quadrants, patient states she has regular bowel
movements daily.
GU: unremarkable, negative for flank pain upon percussion
of kidneys
Skin: non-raised moles on lower and upper back, negative
for rashes, or lesions
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Inflammation of cervix
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Dysplasia
795.04 (Pap Smear with ASCUS)
616 (Cervicitis)
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Pap Smear with HPV- helps to screen for
abnormal precancerous cells
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Colposcopy biopsy taken from 2, 3, and 9
o'clock of external os
Specimens sent to pathology
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Abstain from sex for two weeks
Rest and exercise to help strengthening
immunity
Do not use tampons, or douche for two
weeks
Report any heavy bleeding, or foul smelling
discharge
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Continue current birth control method
Orthro Tri- Cyclen for pregnancy prevention
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Indications of HPV Screening and results
Colposcopy indication, side effects, and care
after colposcopy
Risk for cervical cancer
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Continue to do monthly Self-Breast exams
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STD Screening
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Continue Pap Smear series as recommended
for abnormal pap smear results
Abstain from unprotected sex
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Patient with abnormal cervical cytology
require further evaluation, which include HPV
testing, colposcopy, cervical biopsy,
endometrial sampling, or a diagnostic
excisional procedure, depending upon the
severity of cytology results.
Cervical cancer screening can detect
precancerous lesions and prevent cancer, as
well as detect early stage disease and
decrease cancer mortality
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Alligood, M. R., & Tomey, M. A. (2010). Nursing
Theories and Their Work. In M. R. Alligood, & M.
A. Tomey. Mosby Elsevier.
Arasi, T.-V. (2012). Cervicitis. Retrieved from
emedicinehealth: www.emedicinehealth.com
Feldman, S., Sirovich, B. E., & Goodman, A. (2012).
Screening for Cervical Cancer. Retrieved from
Up-to-date: www.uptodate.com
Fred, F. F. (2013). Ferri's Clinical Advisor. In F. F.
Fred, Ferri's Clinical Advisor (pp. 225-226).
Rhode Island: Elsevier Mosby.
WebMD. (2010). Colposcopy and Cervical Biopsy.
Retrieved from WebMD: www.webmd.com