Jeff quickly replied < yes, I’ll get us a table at that nice sushi place you like for 1230. You can tell me all about it then. Good luck and I love you>

Within a few minutes, she heard a knock on the door. Dr Smith and the nurse who had checked Allie in entered.

The doctor began the examination, while the nurse began to prepare things. There was a Mayo stand next to the exam bed. Allie watched as the assistant placed a sterile paper on the tray. She then placed a small jar for the pap smear, writing Allies name and DOB on the side. The assistant then placed several swabs and brushes on the stand, as well as a tube of KY surgical lubricant. The assistant then reached in a nearby drawer, finding a white and green card. Lastly, the assistant grabbed three plastic speculums, all wrapped in plastic. The speculums were all similar in nature, but had different colors on the handle. The white handle was small, green was medium, and blue was large. Allie looked, hoping the small speculum was all that was required.

Meanwhile, Dr Smith began to look at Allie. She looked into her eyes, throat, and ears. She then palpated her throat and lymph nodes. The doctor placed her stethoscope on Allies back, instructing her to take deep breaths. The doctor listened intently while Allie breathed in and out. The doctor then moved her stethoscope to the front, moving it around Allies chest and breasts to fully listen to her lungs and heart. After a few moments, the doctor announced that Allies heart and lungs sounded perfect. The doctor then asked Allie to lie back on the table. Allie did, and readjusted her gown as she lied back.

Dr smith explained she was now going to do the breast exam. The doctor opened the right side of the gown, exposing only Allies right breast. Dr Smith asked Allie if she did self breast exams. Allie replied yes, and that she has never felt anything abnormal. the Dr reminded her that the exams are best done in the week right after your period, and it is often best to do them in the shower so your hand can glide over the breast easily. Allie understood. Dr Smith then began palpating Allies breast, staring in the armpit and then working down into a circular motion all around the breast. As she approached the nipple, she told Allie that all felt well. Allie was then covered up, and the doctor went to the other side of the bed.

The doctor now exposed Allies left breast, and examined it identically to the side ahead had just examined. After feeling nothing of concern, she covered Allies chest and then moved on to the abdominal examination.

Please let me know if you feel any pain as I examine your abdomen. Dr Smith started in the right upper quadrant, feeling over the liver and gallbladder area. Next she worked across to the left side, over the pancreas and spleen. She was gentle, yet firm, in her touch, causing no discomfort to Allie. Dr Smith then worked across the lower quadrants. Allie felt no discomfort at all. Dr Smith then asked Allie if she was OK with continuing on to the pelvic exam portion. Allie stated yes.

The doctor moved towards the foot end of the table. She pulled out the two stirrups, extending them away from the table. She asked Allie to place her feet into the stirrups, and helped guide them in. The sheet was still covering Allie and giving her privacy, but Allie felt exposed as she placed her legs apart in the stirrups.

The doctor then situated herself on a small rolling stool and began to get in place. She then told Allie I’m going to examine you, is that OK? Allie replied yes. The doctor gently moved the sheet, exposing Allies pelvic area. Dr Smith asked Allie to scoot down to the end of the table, until her bottom was completely at the edge. This allows for the speculum to be maneuvered easily as well as brings the cervix lower and easier to view. Allie scooted 3 times, before Dr Smith told her that was fine.

Dr Smith applied purple nitrile gloves as she moved closer between Allies legs. She adjusted a light that was attached to the exam table. The light was bright and Allie felt fully on display. Dr Smith was now able to examine Allie fully, with the area being fully visible and lit.

Dr Smith observed Allie had a small area of pubic hair on top of her mind pubis. and the labia was completely shaved. She saw no irritation to the skin and no ingrown hairs. Dr smith started at the top and began to spread the labia with her gloved hands. Dr Smith gently retracted the clitoral hood, revealing a healthy clitoris. Then working down, Dr Smith was able to view the urethra and introitus to the vagina. Dr Smith examined the area thoroughly during her visual examination, looking for any areas of concern. Seeing none, she continued her examination. Dr Smith now examined Allies perinium, just below her vaginal opening. Next, Dr Smith slightly spread Allies buttocks to fully view her anus. She was looking for any signs of inflammation or hemorrhoids. Dr Smith saw none. Dr Smith told Allie that everything looked perfectly normal, and she would now continue with the speculum.

Dr smith then grabbed the green, middle sized speculum. In doing thousands of these types of exams, Dr Smith was confident in her choice. She needed one large enough to reach and isolate the cervix, but not so big as to cause undue discomfort. She dabbed a very small amount of lubricant from the tray onto the tip of the speculum and prepared to insert it. Dr Smith used two fingers from her left hand to isolate the vaginal opening and pull downward pressure to ease insertion . Dr Smith then gently inserted the speculum, using downward pressure to avoid the urethral and other anterior areas. She then advanced the speculum in, rotating gently so the handle faced down. Now Dr smith began to squeeze the handle gently, to bring the cervix into view. Allie began to feel pressure as the speculum opened, but it was not painful. Dr Smith brought the cervix into complete view, and locked the speculum in place. She observed a clean vaginal vault and a round, pink cervix.

There was no blood or discharge, and the cervical opening was in the shape of a slit, indicating Allies prior vaginal birth. Dr Smith then reached towards her assistant who had the first pap brush ready. Dr Smith explained to Allie that some women describe feeling a slight scraping, and maybe even a cramp similar to a menstrual cramp while the sample is collected. Allie acknowledged this by saying OK. Dr Smith then placed the brush through the open speculum until it touched the cervix. Dr Smith placed the middle of the brush in the os of the cervix, and then rotated it in a circular motion. She did three full 360 degree rotations, as instructed for this type of pap smear. Dr Smith then handed the brush to her assistant, before grabbing a wooden spatula. The assistant placed the pap brush into the container, and sealed it for the lab. Meanwhile, Dr Smith inserted the spatula down into Allies vagina, similarly rotating it on the cervix and collecting the sample. Dr Smith handed this to her assistant, who scraped the sample onto two prepared glass slides. Dr smith told Allie, all done As she began to remove the speculum. Dr Smith released the lock, allowing the bills to close, and she applied downward pressure as she easily removed the speculum. Dr Smith told

Allie some women experience slight cramping and spotting in the day following, due to the brush on the cervix. Allie replied that she understood.

Allie told Dr Smith that she remembered her last smear as being painful, but this one was quick and easy. The doctor replied that it shouldn’t be painful, and she strives to make it as comfortable as possible. Allie instinctively let her legs come together and replaced the sheet as the exam ended. Dr Smith reached towards her assistant, who was holding a tube of KY jelly. Dr smith extended two fingers, as the nurse squeezed out some lubricant onto her waiting fingers. Next is the bimanual examination, the doctor told Allie.

Dr Smith told Allie to let her legs fall all the way to the sides. As she did this, Dr smith pushed up the sheet to fully observe the area. Dr Smith told Allie she would feel some pressure, as she began to insert her two fingers. Dr Smith pushed down on the posterior of the vaginal opening, and then began to advance her fingers while rotating her hand so that her fingers were now pointed upwards. Dr Smith advanced directly to the cervix, placing one finger on each side. Dr Smith gently moved her fingers, checking for any cervical motion tenderness. Any pain with that, Allie replied none at all. Dr smith then brought her left hand up and placed it on top of Allies lower abdomen. Dr Smith first examined the uterus, by manipulating her vaginal fingers and her abdominal hand. As she pushed up with her fingers, it brought Allies uterus up and made it both visible and easily palpable. Dr Smith then felt all around the uterus with the abdominal hand, noting the uterus was firm and about the size of a peach. These were perfectly expected, and Dr Smith told Allie that her uterus felt completely normal. Dr Smith then pushed up to the left side of the cervix, into the adnexal area, and moved her abdominal hand. She used more pressure with her fingers, and gently swept down to evaluate the right ovary. Upon passing it, she noted it was the size of an almond and did not appear to be painful upon palpation. She then felt in the area the fallopian tube would be, applying pressure with both hands. Allie winced because of the more firm pressure, but was not in any pain. Dr smith felt no abnormalities on the right side.

Dr Smith then moved her internal fingers to her right side, to evaluate Allies left side. Allie reminded her that she did not have an ovary on that side, but to her knowledge the tube was still there. Dr Smiths examination confirmed no ovary, and no pain on that side. Dr Smith stated that part of the exam was done, and there was just one more thing.

Allie watched as Dr Smith removed the glove from her right hand. The assistant handed her a new glove, which she put on her hand. Dr Smith then again outreached two fingers, to which the nurse applied a generous bit of lubricant from the tube. Dr Smith reminded Allie the last thing was the rectovaginal exam. Allie had never had this type of exam and didn’t know what to expect. Thankfully, Dr Smith was patient and sensing her nervousness explained the exam well. Dr Smith told Allie that I’m going to insert one finger in your vagina, and one in your rectum. This can cause a strange feeling, and may even feel as if you want to move your bowels. That won’t happen though, so there are no worries. After inserting my fingers, I will do an exam very similar to the last one. But with the rectal exam, I will be able to evaluate the back of your uterus and your ovary much more in depth. Allie was calmed with the explanation, and stated ahead of time was ready.

Dr smith then inserted her index finger into the vagina, which was already well lubricated. The doctor then put the pad of her finger on Allies anus. Allie felt the coolness of the gel, and instinctively tensed up. Dr Smith felt Allie tighten her sphincter, knowing it would go away in just a second. Within about 2 seconds, Allie relaxed and Dr Smith felt the anal sphincter relax. Dr Smith explained to Allie that she was going to feel a lot of pressure, and if possible to bear down as if having a bowel movement. Allie hadn’t felt this before, and it felt counter intuitive to push down. However she did as the doctor instructed and tried to push out. Dr Smith felt this and was able to start inserting her finger. She made it in the outer sphincter, and then through the internal one. Allie could only describe the feeling as weird, but not painful. Dr Smith fully advanced her fingers, and now Allie felt the pressure that had been described. She felt very full in her vagina and rectum, as the doctor settled her fingers inside. Dr Smith moved her fingers first from side to side, evaluating the rectovaginal septum. Dr Smith explained this, and told Allie that was the thin membrane between the vagina and rectum. Dr Smith then moved her vaginal finger so that it was just under the cervix. Her other finger pushed up inside the rectum, again making Allies uterus visible on top of her abdomen. Dr Smith then placed her left hand on the abdomen, and repeated the examination of the uterus, ovaries, and tubes. Allie felt this exam much more the the previous one, and felt much more pressure. Dr Smith evaluated the posterior fornix and announced almost done. Dr Smith withdrew her vaginal finger, leaving her middle finger in the rectum. Dr Smith advanced the finger fully, and began to rotate it in a full 360 degree motion. The walls were smooth without irregularities, and the exam was perfectly normal. Dr Smith told Allie it was going to feel weird, before withdrawing her finger. Dr Smith looked at her glove, noting no blood or discharge. She kept her middle finger separated, as her assistant handed her the guiac card. Dr Smith rubbed her middle finger onto the two places in the card, and removed her gloves. The assistant added the solution to the card, and there was no blood present.

Dr Smith told Allie that they were done, and handed her a box of wipes. She told Allie they would step out while she got dressed, and she would be back in a few minutes. Allie used the wipe to remove the excess lubricant from her vulva and rectum, and quickly got dressed. She looked at the tray with the speculums, used gloves, and lubricant, and was relieved to have finished the appointment. A few moments later, Dr Smith knocked and came back in.

Dr Smith had several forms in her hand. The first was the prescription for the topical cream. Dr Smith told Allie to use it twice daily, and the problem should go away. The second for was a radiology consult form for a mammogram screening.

Dr Smith then told Allie that throughout the exam, everything appeared healthy and normal. She told Allie she does not need another Pap smear for 3 years, but a yearly visit is always encouraged for a general physical exam. Allie was thankful of the doctors time and did not have any further questions when asked. Allie then checked out, and returned to work. In hindsight, she was glad to have made the appointment and regretted putting it off for so many years. Thankfully she now knew that she was perfectly healthy.

Dr Smith then wrote up her notes for the file

.

Allie Johnson, age 40 female, presented for annual physical exam. She complains only of scalp itching x 2-3 months and bilateral wrist pain x 1 year, exacerbated by job related typing.

Pt has no significant medical history other than status post left oopherectomy at age 15, and bilateral tubal ligation at age 30. No daily medications, no known allergies.

Vitals were well within normal limits. LMP was two weeks prior and reported to be normal.

Exam:

HEENT normal, other than several small spots of contact dermatitis.

Neck normal.

Chest: equal clear bilateral lung sounds, heart sounds were normal.

Abdomen: No tenderness or pain in all quadrants. No reports of nausea, vomiting, diarrhea.

Extremities: unremarkable and appearingly atraumatic. Pt reports on/off pain in both wrists. No deformity noted, has full range of motion but is tender when fully ante or dorsiflexed. Pt given support brace, and instruction sheet for carpal tunnel stretches. Will reevaluate in 1 year.

Breast exam unremarkable bilaterally. No lumps felt, pt instructed on proper self exams. Pt referred for mammogram due to age.

Pap/Pelvic:

External exam appeared normal, no redness or irritation observed. Pubic hair is absent, allowing clear visualization. Clitoris, urethral meatus, and introitus all appear normal. Anus has no visible irritation or hemorrhoid.

Pap smear taken using medium plastic Graves speculum and Thinprep testing solution. Cervical os easily observed. No redness or blood present, slight thin mucus present, consistent with ovulation. Samples taken for Pap smear in standard fashion. No signs of STIs.

Bimanual exam reveals no cervical motion tenderness. Uterus is easily palpable, is firm, and of normal size. It is slightly anteverted. Right ovary is appreciated, no pain present. Left ovary is absent. No pain during exam, no abnormalities noted.

Rectovaginal exam was completed. Rectal tone normal, rectovaginal septum thin and normal. No signs of rectocele. Entire body of rectum examined, no abnormalities found. Hemoccult test was negative.

Allie appears to be perfectly healthy. Prescription given for topical cream, referral for mammogram given. Will reevaluate treatment plan in one year or as needed.