Her abdomen is soft with mild suprapubic tenderness to palpation. She has no organomegaly, masses, guarding, or rebound tenderness. Normal female genitalia. Vagina pink, no discharge, cervix without lesion. Bimanual exam reveals no cervical motion tenderness, a normal sized anterverted, anteflexed uterus which is non-tender, no adnexal pain or masses.
Rectovaginal exam reveals no tenderness or masses, stool is hemoccult negative.
Include in this section an assessment of the patient's data and your conclusions. When a patient has several active problems, assess each one separately. Include a differential diagnoses for each undifferentiated problem with supporting evidence for each diagnosis. Record what health maintenance is needed. For patients who have been treated for some time, write an assessment of the patient's response to treatment.