COLPOSCOPY REPORT
COLPOSCOPY REPORT
Meharry Department of Family and Community Medicine
September 27, 1994 (5.5.03)
Date:___________________Name:______________________________Chart #:_________________
Age:_____________ Primary Physician: ____________________________Site: ________________
G_____P_____Ab_____LMP_______________Contraception_______________________________
Pregnancy test (circle one): Positive Negative Not Done
History of previous cervical treatment (describe with dates):________________________________
Indications (circle those that apply):
1. Recurrent atypia - inflammation 616.0 5. Veneral warts 078.1
2. PAP smear dysplasia 622.1 6. Koilocytosis on PAP smear
3. Visible lesion (neoplasia unspec) 236.1 7. Write-in__________________________
4. Follow-up for previous CRYO 8. Write-in__________________________
Comments:__________________________________________________________________________
____________________________________________________________________________________
Was NSAID given 30 to 60 minutes before the procedure? Yes ( ) No ( )
Appearance of Cervix
Anterior KEY
Right Left
Posterior
Note: Place a # corresponding with the biopsy site on the diagram. If 4 biopsies are taken, the #’s 1, 2, 3, and 4 should be written in appropriate places on the diagram. The ECC should be designated as #1.
FINDINGS AND MANAGEMENT PLAN
Any significant lesions on the vaginal side walls? Yes ( ) No ( )
Any significant lesions on the vulva? Yes ( ) No ( )
Was entire transition zone seen? Yes ( ) No ( )
Was an endocervical curettage performed? Yes ( ) No ( )
Additional biopsies taken? (results should be followed up later) Yes ( ) No ( )
Was cryosurgery performed? Yes ( ) No ( )
Any complications? Yes ( ) No ( )
Time required from MD entering colposcopy suite to MD leaving:_______________
Assigned follow-up. Date: ______________________by which MD___________________________
Performed as above: _____________________________________________, M.D.
FOLLOW-UP DATE:__________________
Pathologist’s Reports:
(correlate site on diagram)
Biopsy #1 Normal Other:_____________________________
(ECC, if done) _____________________________
Biopsy #2 Normal Other:_____________________________
_____________________________
Biopsy #3 Normal Other:_____________________________
_____________________________
Biopsy #4 Normal Other:_____________________________
_____________________________
Were more biopsies taken? (circle one) Yes ( ) No ( )
Please describe your management and plan for follow-up
___________________________________________________________________________________
___________________________________________________________________________________
__________________________, M.D.
colp.rpt.5.03
-----------------------
|L |Leukoplakia |
|AV |Abnormal vessels |
|WE |White epithelium |
|OS |Endocervical OS |
|M |Mosaicism |
|I |Iodine negative area |
|P |Punctation |
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