see attachment
Subjective
CC:
Follow-up for abnormal Pap smear showing HSIL and positive high-risk HPV.
HPI:
Ellen is a 35-year-old G1P0 female who presents following an abnormal Pap smear result
indicating High-Grade Squamous Intraepithelial Lesion (HSIL) with positive high-risk
HPV. She reports no symptoms and states the abnormal results were discovered about a
week ago during routine screening. She has had only two previous Pap smears,
performed 7 and 14 years ago, both of which were normal. She denies any vaginal
bleeding, discharge, pelvic pain, or discomfort. There are no aggravating or relieving
factors, as she is asymptomatic. Ellen is in a monogamous relationship with a female
partner for the past 5 years but identifies as bisexual and has had previous sexual
relationships with both males and females. She has no history of STIs or abnormal Pap
results. Her last menstrual period was 5 days ago and was normal. She is G1P0 with a
therapeutic abortion at age 25. She and her partner are currently undecided about
having children in the future. She denies any significant past medical history, surgical
history, or chronic illness. Her BMI is within normal limits, and her pregnancy test is
negative.
Medications:
None stated
Allergies:
No known drug allergies (NKDA) stated in case study
LMP:
5 days ago; regular cycles
Gyn/OB History:
• G1T0P0A1L0 (1 therapeutic abortion at age 25)
• Menarche age : ( Not stated in case study)
• Regular menstrual cycles, no menorrhagia, dysmenorrhea, or intermenstrual bleeding
• No contraception currently; sexually active with a female partner
• No history of STIs
• No prior abnormal Pap smears
• No prior cervical procedures or treatments
• HPV vaccine status unknown
PMH:
Unremarkable (none stated)
Chronic Illness / Major Trauma:
Denies any chronic conditions, surgeries, or hospitalizations
Family History:
No known history of cervical, uterine, ovarian, or breast cancer
No family history of hereditary cancer syndromes
Social History:
• Sexual orientation: Bisexual
• Relationship: Monogamous with female partner for 5 years
• Past partners: Males and females
• Tobacco: Denies use
• Alcohol: Rare social use
• Illicit drugs: Denies use
• Occupation: Not stated
• Exercise: Occasional walking ( none stated , hypothetical )
• Diet: Balanced
• HPV vaccination: None stated
Subjective Review of Systems (ROS):
General: Denies fatigue, fever, night sweats, chills, or unintended weight loss
Skin: Denies rashes, new moles, pruritus, or lesions
HEENT: Denies headaches, vision changes, sore throat, nasal congestion, or hearing loss
Neck: Denies lumps, swelling, or pain
Cardiovascular: Denies chest pain, palpitations, syncope, or edema
Respiratory: Denies cough, dyspnea, wheezing, or hemoptysis
GI: Denies nausea, vomiting, abdominal pain, constipation, diarrhea, or rectal bleeding
GU: Denies dysuria, hematuria, urgency, frequency, or incontinence
Gynecological: Per patient Menses are regular. LMP 5 days ago
• Denies abnormal uterine bleeding, intermenstrual or postcoital bleeding
• Denied vaginal discharge, odor, or pruritus
• Denies dyspareunia or pelvic pain
• No known uterine or ovarian disorders
• Denies hot flashes or signs of perimenopause
Musculoskeletal: Denies joint pain, swelling, stiffness, or muscle weakness
Neurological: Denies dizziness, syncope, numbness, or headaches
Endocrine: No heat/cold intolerance, polyuria, polydipsia, or hirsutism
Psychiatric: Denies anxiety, depression, sleep disturbance, or mood changes
Hematologic: No easy bruising or prolonged bleeding
Allergic/Immunologic: Denies seasonal allergies, food or medication reactions
1. Additional HPI Questions:
• Do you have any unusual vaginal bleeding (after intercourse or between periods)?
• Have you experienced any vaginal discharge, pelvic pain, or painful intercourse?
• Have you ever had a colposcopy or cervical procedure in the past?
• Are your menstrual cycles typically regular?
• Have you received the HPV vaccine?
1. Additional Medical History Questions:
• Any history of immunosuppression (HIV, long-term corticosteroids)?
• Any prior abnormal Pap smear or HPV testing?
• Any surgeries, especially gynecologic ( LEEP, D&C)?
• Any chronic conditions such as diabetes, autoimmune disorders, or thyroid disease?
• Any family history of cervical cancer?
1. Additional Social History Questions:
• Are you or your partner planning pregnancy in the near future?
• Have your previous partners (male or female) had a history of STIs or abnormal Pap
smears?
• Do you use any form of contraception or protection during sexual activity?
• What is your occupation? (May tell you about patient exposures, stress, or healthcare
access)
• Do you have access to transportation and healthcare?
(Mito & Feldman, 2025)
Objective
General:
Well-nourished, well-appearing 35-year-old female in no distress
Vital Signs: (Hypothetical VS)
• BP: 116/72 mmHg
• HR: 78 bpm
• Temp: 98.4°F
• RR: 14
• BMI: 24.7
Objective ROS:
Skin: Warm, dry, intact. No rashes, lesions, or pigmentation changes.
HEENT: Normocephalic, atraumatic. Sclerae white, conjunctivae clear. Oropharynx
moist, no lesions or erythema. No cervical lymphadenopathy.
Neck: Supple, no thyroid enlargement, no masses, no lymphadenopathy.
Cardiovascular: RRR (regular rate and rhythm), no murmurs, gallops, or rubs. No
peripheral edema.
Respiratory: Clear to auscultation bilaterally. No rales, wheezes, or rhonchi. Normal
chest expansion.
Abdomen: Soft, non-distended. No tenderness, guarding, rebound, or palpable masses.
No hepatosplenomegaly. Bowel sounds normal in all quadrants.
Genitourinary / Pelvic Exam:
• External Genitalia: No lesions, warts, discharge, or erythema.
• Speculum Exam: Cervix pink, no visible lesions, masses, or discharge. Cervical os
closed.
• Bimanual Exam: Uterus normal size, non-tender. No adnexal masses or tenderness.
No cervical motion tenderness.
Musculoskeletal: Full range of motion. No joint swelling, tenderness, or deformity.
Neurological: Alert and oriented. CN II–XII grossly intact. No motor or sensory deficits.
Psychiatric: Appropriate mood and affect. Cooperative. Good eye contact. No signs of
anxiety or depression.
Point-of-Care Testing (POCT):
Pregnancy Test: Negative
Additional POCT to Perform and Why:
1. Rapid HIV Test
a. Why: HPV-related cervical dysplasia (HSIL) is more likely in immunocompromised
individuals. HIV screening is standard in STI evaluations and recommended at least
once for all adults aged 15–65 per USPSTF and CDCguidelines.
2. Urine NAAT for Chlamydia and Gonorrhea
a. Why: Despite no history of STIs, Ellen has had past male partners, which still places
her at risk. These infections are often asymptomatic and can contribute to cervical
inflammation and complicate HSIL management. NAAT is the most sensitive method
and can be done via urine or vaginal swab..
3. HPV Genotyping (in-office or sent out)
a. Why: If not already done, genotyping for HPV 16 and 18 (highest risk types) can
guide urgency of management. This is especially relevant in women ≥30 years or with
HSIL.
4. Wet mount or vaginal pH testing: Only if patient is complaining of abnormal
discharge, odor, or itching, \ help evaluate for bacterial vaginosis, candidiasis, or
trichomoniasis, which may need to be treated before cervical procedures like
colposcopy.
(Mito & Feldman , 2025)
Assessment / Diagnosis
Final Diagnosis: High-Grade Squamous Intraepithelial Lesion (HSIL) of cervix with
positive high-risk HPV-ICD-10 Code: R87.619 –
Rationale / Pertinent Positives:
• HSIL on Pap indicates moderate to severe cervical dysplasia (CIN 2/3)
• Positive high-risk HPV, which increases the risk of progression to cervical cancer
• Limited history of prior Pap tests (only 2 in the past 14 years)
• No prior abnormal results or STI diagnoses
• Denies immunocompromising conditions
(Wright, 2025)
Pertinent Negatives:
• No abnormal vaginal bleeding, pain, or discharge reported
• No visible cervical lesions on pelvic exam
• Negative pregnancy test
• No history of smoking, which is a cofactor for cervical dysplasia progression
(Wright, 2025)
Differential Diagnoses:
1. Cervical Intraepithelial Neoplasia (CIN 2/3) ICD- N87.1
• Rationale: CIN 2/3 often underlies HSIL cytology; caused by persistent high-risk HPV
infection.
(Schmeler, 2025)
2. Cervical Cancer – ICD-10 Code: C53.0
• Rationale: While less likely without symptoms, HSIL may indicate or mask early
cervical cancer, especially in women with poor screening history.
(Schmeler, 2025) (Wright,
2025)
Explain Ellen’s Pap smear results (pathophysiology) and the action(s) that will be taken
next to follow up this abnormality, including patient education (explain the procedure
to the patient).
Ellen’s Pap test shows significant changes in the cells on her cervix. These changes are
called HSIL, which means that some cells look very abnormal. This doesn’t mean she has
cancer, but it does mean there is a higher risk that these abnormal cells could become
cancer in the future if not treated.The test also shows that she has a high-risk type of
HPV (human papillomavirus). HPV is a common virus that spreads through sexual
contact. Some types of HPV can cause cervical cancer over time, especially if the
infection lasts for many years.
(Palefsky, 2025)
Next Steps:
The best way to find out how serious these changes are is to do a procedure called a
colposcopy.
• Colposcopy is done in the clinic and is similar to a Pap smear, but the provider uses a
special microscope to look more closely at the cervix.
• If any areas look suspicious, small samples (biopsies) will be taken and sent to the lab.
• This helps confirm whether the abnormal cells are moderate or severe, and what
treatment is needed.
(Palefsky, 2025) ( Schmeler, 2025)
What to Tell the Patient (Patient Education):
I would explain to the patient in these words “ Ellen you pap test shows some abnormal
cells on your cervix that we want to look at more closely. It’s not cancer, but we want to
make sure it doesn’t turn into cancer in the future. We’ll do a simple in-office procedure
called a colposcopy. It’s like a longer Pap test and may involve taking a small sample of
tissue. It’s important we check this now so we can treat it early if needed. Most women
do very well after early treatment, and this can help protect your future health.”
Plan: Colposcopy with biopsy is the recommended next step to confirm how abnormal
the cells are and decide if treatment like LEEP (loop electrosurgical excision procedure)
or cryotherapy is needed.
Diagnostic Tests:
• Colposcopy with directed cervical biopsies (This test allows for visualization of the
cervix and biopsy is taken to determine the exact grade of CIN ( CIN 2 or 3) or
presence of invasive cancer.)
Lab Tests:
1. HPV Genotyping ( Should be done if cytology was only taken during pap smear. This
test looks for high risk HPV (especially types 16 or 18).
1. STI Testing (chlamydia, gonorrhea, syphilis, HIV) (important to check because some
infections can weaken the immune system and make HPV worse or harder to clear.)
1. Pregnancy Test (Already done and negative) (Important to check because some
treatments like LEEP or biopsies can affect a pregnancy.
1. Blood Tests (CBC) (It checks for anemia or infection if Ellen needs treatment like
LEEP)
(Schmeler, 2025) (Wright, 2025)
Treatment (Pending Colposcopy Results):
If results are CIN 1 (Mild Dyplasia)
Treatment:
• Observation is preferred, especially in young or reproductive-age women.
• Repeat Pap + HPV co-testing at 12 months or colposcopy at 12 months.
• If abnormalities persist for >2 years, consider excisional treatment ( LEEP).
(Einstein et al., 2025) (Wright, 2025)
CIN 2 -3
Treatment: Excisional treatment (LEEP or cold knife conization).
Screening guidelines post-treatment
Negative Margins: HPV- testing 6 months later
• If HPV is positive, then colposcopy and biopsies should be performed and managed
based on these results.
• If HPV is negative, then HPV testing should occur annually for three years.
• If HPV remains negative, then HPV testing can occur every three years for at least 25
years.
Positive Margins: HPV testing in six months or colposcopy
• If HPV is negative, then HPV testing should occur annually for three years. If testing
remains negative, then HPV every three years for at least 25 years.
• If positive, then colposcopy with biopsy. If it continues to be positive, excision must
be done again.
(Einstein et al., 2025) (Wright, 2025)
Medication:
None at this time unless STI identified
Referrals:
• Refer to GYN for colposcopy within 4 weeks
• Referral to GYN oncology only if invasive cancer is identified on biopsy
Education:
• HSIL is not cancer but is considered pre-cancer, meaning that abnormal cells may
become cancer if not treated.
• A colposcopy is needed to get a closer look at the cervix.
• If abnormal cells are found on biopsy, a procedure like LEEP or cryotherapy may be
recommended to remove them.
• HPV is very common, and most people get it at some point, this is not a sign of
infidelity or risky behavior.
• Continue regular follow-ups, early detection and treatment prevent cervical cancer.
What to expect from the colposcopy:
• Done in the office, takes 10–20 minutes.
• May feel pressure or mild cramping.
• Spotting is normal afterward.
• Avoid sex, douching, or tampons for 48 hours after.
Education regarding her current female partner:
• HPV can be transmitted between female partners through skin-to-skin contact,
shared sex toys, or genital contact.
• Encourage her partner to:
o Get regular Pap smears if she has a cervix.
o Receive the HPV vaccine (if age 9–45), especially if not already vaccinated.
• Emphasize that HPV is common and can be dormant for years, so this does not mean
recent transmission.
• Discuss safe sex practices, including cleaning shared items and using barrier
protection if appropriate.
(Wright, 2025)
Health Maintenance:
• Review/update immunizations including HPV
• Lifestyle: stress reduction, healthy diet, smoking cessation if applicable
• Encourage regular Pap screening per follow-up recommendations
Follow-up:
• Colposcopy results in 1–2 weeks post-procedure
• Return to clinic to review pathology and determine next steps
• Emphasize importance of follow-up due to cancer risk
If biopsy confirms CIN 2 or 3, treatment options will be considered. à(LEEP procedure)
1. What patient education is important to include for this patient?
Key points to educate Ellen:
• HSIL is not cancer but is considered pre-cancer, meaning that abnormal cells may
become cancer if not treated.
• A colposcopy is needed to get a closer look at the cervix.
• If abnormal cells are found on biopsy, a procedure like LEEP or cryotherapy may be
recommended to remove them.
• HPV is very common, and most people get it at some point—this is not a sign of
infidelity or risky behavior.
• Continue regular follow-ups early detection and treatment prevent cervical cancer.
(Wright, 2025)
Explain what to expect from the colposcopy:
• Done in the office, takes 10–20 minutes.
• May feel pressure or mild cramping.
• Spotting is normal afterward.
• Avoid sex, douching, or tampons for 48 hours after.
(American Cancer Society, 2024)
1. Is there any education or advice you would give to Ellen regarding her current
female partner?
Yes. Although Ellen is in a monogamous relationship with a female partner, it’s important
to know that:
• HPV can be transmitted between female partners through skin-to-skin contact,
shared sex toys, or genital contact.
• Encourage her partner to:
o Get regular Pap smears if she has a cervix.
o Receive the HPV vaccine (if age 9–45), especially if not already vaccinated.
• Emphasize that HPV is common and can be dormant for years, so this does not mean
recent transmission.
• Discuss safe sex practices, including cleaning shared items and using barrier
protection if appropriate.
