1: 45-year-old woman annual exam

Question 1

Familial Breast Cancer Risk

Answer 1

A patient has an increased risk of breast cancer if a first-degree relative has had breast cancer. A first-degree relative is a parent or a sibling

Question 2

Breast Self-Exam and Clinical Breast Exam - Effectiveness and Recommendations

Answer 2

The USPSTF does not recommend breast self-exams (BSE’s)

Similarly, the USPSTF concludes there is insufficient evidence to assess the additional benefits and harms of clinical breast exam (CBE) beyond screening mammography in women 40 years or older, while ACS recommends that CBE should be part of a periodic health exam about every three years for women in their 20s and 30s and every year for women 40 and over.

Question 3

Classification of Overweight and Obesity in Adults

Answer 3

Classification
BMI (kg per m2)
Risk of comorbidities

Underweight
< 18.5
Low

Normal range
18.5 to 24.9
Average

Overweight
25.0 to 29.9
Mildly increased

Obese
> 30.0

Class I
30.0 to 34.9
Moderate

Class II
35.0 to 39.9
Severe

Class III (morbid obesity)
> 40.0
Very Severe

Question 4

Waist circumference is also important to consider

Answer 4

In adults with a BMI of 25 to 34.9 kg/m^2, a waist circumference greater than 102 cm (40 in) for men and 88 cm (35 in) for women is associated with a greater risk of hypertension, Type 2 diabetes, and dyslipidemia and CHD.

Question 5

Performing a Breast Exam

Answer 5

A good breast exam consists of both visual inspection and palpation

Question 6

Visual inspection

Answer 6

With patient sitting upright on the exam table, have her lower her gown to her waist so the breasts can be fully visualized.

Look for symmetry in shape and assess skin changes, including any erythema, retractions, dimpling, or nipple changes
Ask the patient to lift her hands overhead to accentuate any retraction or dimpling

Question 7

Palpation:

Answer 7

For the palpation portion of the exam, ask patient to lie back on the exam table and place her hands over her head, thus flattening the breast tissue on the chest wall.

Carefully examine each breast using a vertical strip pattern.

When palpating, use the finger pads of the middle three fingers…… and varied pressure (light, medium and deep) as you complete your exam

Finally, palpate both axillary and supra-clavicular lymph nodes.

Question 8

Performing a Pelvic Exam

Answer 8

Preparation
External inspection and palpation
–Look for any redness, swelling, lesions or masses.
–Inspect the labia, the folds between them, and the clitoris, paying attention to any redness, swelling, lesions, or discharge.
Speculum exam

Question 9

Cervical Cancer Screening Guidelines

Answer 9

At age 21: cervical cancer screening should begin.

Between ages 21 and 29: screening should be performed every three years.

Between ages 30 and 65: screening can be done every five years if co-tested for HPV (preferred) or every three years with cytology alone (acceptable).

Question 10

risk groups need to have more frequent screening

Answer 10

women with compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or have been exposed to diethylstilbestrol (DES) in utero

Question 11

Cervical Cancer Risk Factors

Answer 11

Sexual behaviors associated with an increased cervical cancer risk include:

Early onset of intercourse
A greater number of lifetime sexual partners

Other risk factors include:

Diethylstilbestrol (DES) exposure in utero.
Cigarette smoking, which is strongly correlated with cervical dysplasia and cancer, independently increasing the risk by up to fourfold.
Immunosuppression, which also significantly increases the risk of developing cervical cancer.

Question 12

The Pap test generally shows one of the following:

Answer 12

normal results
low-grade squamous epithelial cells (LSIL)
high-grade squamous epithelial cells (HSIL)
atypical glandular cells of undetermined significance (AGUS)
atypical squamous cells of undetermined significance (ASC-US)

Question 13

Characteristics of a Good Screening Test

Answer 13

1. Accuracy (high sensitivity and specificity)
2. Able to detect disease in an asymptomatic phase
3. Minimal associated risk
4. Reasonable cost
5. Acceptable to patient
6. Have an available treatment for the disease

Question 14

Lung Cancer Screening Recommendations

Answer 14

As of 2013, the USPSTF recommends annual screening with a low-dose CT scan to screen for lung cancer in patients ages 55 to 80 who have smoked for 30-plus years.

To be considered, the patient should also be currently smoking or have quit within the prior 15 years.

Question 15

Cervical Cancer Screening Guidelines

Answer 15

At age 21: cervical cancer screening should begin.

Between ages 21 and 29: screening should be performed every three years.

Between ages 30 and 65: screening can be done every five years if co-tested for HPV (preferred) or every three years with cytology alone (acceptable).

Question 16

Cervical Cancer Screening Guidelines risk groups need to have more frequent screening

Answer 16

They include women with compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or have been exposed to diethylstilbestrol (DES) in utero (DES is a nonsteroidal estrogen that was given to pregnant women to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and was discontinued in 1971).

Question 17

Women older than 65 years Cervical Cancer Screening Guidelines

Answer 17

who have had adequate screening within the last ten years may choose to stop cervical cancer screening. Adequate screening is three consecutive normal pap tests with cytology alone or two normal pap tests if combined with HPV testing.

Question 18

Pap Test Exemplifies the Characteristics of a Good Screening Test

Answer 18

The Pap test fits into the definition of a good screening test because the test is relatively inexpensive, easy to perform, and acceptable to patients.

Cervical cancer has a long asymptomatic pre-invasive state (often a decade or more), and there are effective treatments for pre-invasive disease.

Although the Pap test has a sensitivity of only between 30% and 80% and a specificity of 86% to 100%, cancer deaths from cervical cancer decreased markedly in the U.S. after the Pap test was introduced.

Question 19

Skin Cancer Screening Recommendations

Answer 19

While skin cancer is the most common type of cancer, the USPSTF is currently reviewing guidelines regarding screening. Presently, the draft statement states that current evidence is insufficient to assess if there is more harm or benefit to visual skin cancer screening in adults. The USPSTF is also currently evaluating if there is any benefit in providing behavioral counseling for skin cancer prevention.

Question 20

Lung Cancer Screening Recommendations

Answer 20

As of 2013, the USPSTF recommends annual screening with a low-dose CT scan to screen for lung cancer in patients ages 55 to 80 who have smoked for 30-plus years.

To be considered, the patient should also be currently smoking or have quit within the prior 15 years.

Question 21

Ovarian Cancer Screening Recommendations

Answer 21

The USPSTF, the American College of Obstetricians and Gynecologists, and the American College of Physicians all recommend against routine screening for ovarian cancer in asymptomatic women.

Question 22

Recommendations for Breast Cancer Screening Mammography: American Cancer Society

Answer 22

Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be considered.

Women age 45 to 54 should get mammograms every year.

Women age 55 and older should switch to mammograms every two years, or have the choice to continue yearly screening.

Question 23

Recommendations for Breast Cancer Screening Mammography: US Preventive Services Task Force

Answer 23

Biennial screening mammography for women age 50 to 74 years (Grade B recommendation)

Decision to start regular, biennial screening mammography before age 50 should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms
(Grade C recommendation)

Question 24

Shared Decision-Making in the Setting of Conflicting Guidelines

Answer 24

Part of a physician’s job is to help patients make informed decisions that incorporate their personal and family history/risk factors and personal health beliefs. Physicians need to be aware of the different guidelines. It is important to present the pros and cons of different recommendations and guide patients in a shared decision- making process. In situations where there are differences in recommendations, it is important to get the patient’s input.

Question 25

Evaluating a Breast Lump

Answer 25

First, take a good history from the patient, including:
Precise location of the lump;
How it was first noticed (accidentally, by breast self-examination, clinical breast examination, or mammogram);
How long it has been present;
Presence of nipple discharge; and
Any change in size of the lump. (Especially ask whether the lump changes in size according to phase of the menstrual cycle.)

Question 26

Evaluating a Breast Lump…The next step is a thorough breast exam: Certain characteristics on physical exam increase the suspicion of malignancy.

Answer 26

For example, the presence of a single, hard, immobile lesion of approximately 2 cm or larger with irregular borders increases the likelihood of malignancy.

Question 27

Evaluating a Breast Lump: Diagnostic tests:

Answer 27

If it feels cystic, aspiration can be attempted and the fluid sent for cytology. Fine needle aspiration is a procedure family physicians can do in the office.
If it feels solid, mammography is the next step.
Ultrasound can be helpful in distinguishing a solid mass from a cystic lesion.

Question 28

Evaluation of Nipple Discharge

Answer 28

Physiologic:
Pregnancy
Excessive breast stimulation

Pathologic:
Prolactinoma
Breast cancer
> Intraductal papilloma
> Mammary duct ectasia
> Paget disease of the breast
> Ductal carcinoma in situ
Hormone imbalance
Injury or trauma to breast
Breast abscess
Use of medications (e.g., antidepressants, antipsychotics, some antihypertensives and opiates)

Question 29

If a discharge is present, the patient needs further evaluation by imaging studies:

Answer 29

Mammogram Ultrasound Ductogram and/or Biopsy

Question 30

Risk Factors for Breast Cancer: Non-modifiable risk factors include:

Answer 30

Family history of breast cancer in a first-degree relative (i.e., mother or sister)
Prolonged exposure to estrogen, including menarche before age 12 or menopause after age 45
Genetic predisposition (BRCA 1 or 2 mutation)
Advanced age (The incidence of breast cancer is significantly greater in postmenopausal women, and age is often the only known risk factor.)
Female sex
Increased breast density

Question 31

Risk Factors for Breast Cancer:

Other hormonal risk factors include:

Answer 31

Advanced age at first pregnancy
Exposure to diethylstilbestrol
Hormone therapy

Question 32

Risk Factors for Breast Cancer

Environmental factors include:

Answer 32

Therapeutic radiation
Obesity
Excessive alcohol intake

Question 33

Factors associated with decreased breast cancer rates include:

Answer 33

Pregnancy at an early age Late menarche
Early menopause
High parity
Use of some medications, such as selective estrogen receptor modulators and, possibly, nonsteroidal anti- inflammatory agents and aspirin.

Question 34

Immunization: Tdap

Answer 34

Tetanus, diptheria, and acellular pertussis (Tdap) should replace a single dose of Td for adults age 19 through 64 who have not received a dose of Tdap previously.

Question 35

Menopause

Timing

Answer 35

On average, women reach menopause at 51. But, menopause can start earlier or later. A few women start menopause as young as 40, and a very few as late as 60. Women who smoke tend to go through menopause a few years earlier than nonsmokers. The timing of an individual’s menopause cannot be predicted. Only after a woman has not menstruated for 12 straight months can menopause be confirmed.

Question 36

Perimenopause

Answer 36

The gradual transition to menopause is called perimenopause. The ovaries don’t abruptly stop; they slow down. During perimenopause it is still possible to get pregnant. The ovaries are still functional, and ovulation may occur, although not necessarily on a monthly basis. Perimenopause can last from two to eight years.

Question 37

Symptoms

Answer 37

Menopause affects each woman differently. Some women reach menopause with little to no trouble; others experience severe symptoms that drastically hamper their lives. Menstrual irregularity is the hallmark of perimenopause. Patients should be advised to call their provider if their menses come very close together, if the bleeding is heavy, or if the bleeding lasts more than a week.

Other perimenopausal symptoms due to estrogen deficiency include:

Hot flashes: Hot flashes are brief feelings of heat that may make the face and neck flushed and cause temporary red blotches to appear on the chest, back, and arms. Sweating and chills may follow. Hot flashes vary in intensity and typically last between 30 seconds and 10 minutes. Dressing in light layers; using a fan; getting regular exercise; avoiding spicy foods and heat; and managing stress may help.

Vaginal dryness: This can make intercourse uncomfortable. A water-soluble lubricant may be recommended. A woman’s libido may also change.

Mood swings: Mood swings, especially depression, are common during perimenopause and menopause. Women should let their provider know if they are experiencing this, so that resources and support may be found.

Question 38

Recommendations for Osteoporosis Prevention

Answer 38

Before menopause, estrogen offers some protection against heart disease and osteoporosis. This protection is lost when estrogen levels ebb with menopause.

Calcium Intake:
For bone health, it is recommended that pre-menopausal women need approximately 1,000 mg of calcium daily while post-menopausal women need 1,200 mg of calcium daily.

Only a small amount of calcium is found in a normal diet if we exclude dairy products. To meet these needs, three or four servings of dairy products are required. For instance, 8 ounces of yogurt (228 gm) or milk (1 cup = 236 ml), or 1.5 ounces of cheese can provide around 300 mg of calcium.

At this time the most prudent recommendation would be to try to increase intake of dairy and try to include weight- bearing exercises such as walking into a daily routine.

Question 39

Recommendations for Osteoporosis Screening

Answer 39

For women > 65 years old, screening with dual energy x-ray absorptiometry (DEXA) is recommended.

For women < 65 years old, the USPSTF recommends using the World Health Organization’s Fracture Risk Assessment Tool to risk-stratify. Screening with DEXA is recommended if the risk of fracture is greater than or equal to that of a 65-year-old white woman without additional risk factors (9.3 percent over 10 years).

Question 40

Osteoporosis Risk Factors

Answer 40

Risk factors for osteoporosis are mainly due to low estrogen states.

Low estrogen states may be caused by early menopause (i.e., before age 45 years), prolonged premenopausal amenorrhea, and low weight and body mass index.

Lack of physical activity and inadequate calcium intake (which could be attributable to poor nutrition or alcoholism) are also associated with osteoporosis.

Other risk factors include:
Family history of osteoporotic fracture
Personal history of previous fracture as an adult Cigarette smoking
White race

Obesity (BMI >30) is associated with a high estrogen level and can be protective against menopausal symptoms and osteoporosis.

Question 41

Body Mass Index (BMI)

Answer 41

Body mass index (BMI) is an estimate of body fat. Individuals with elevated BMI are at greater risk of developing several diseases, including:
High blood pressure
 Coronary artery disease Stroke
Osteoarthritis
Some cancers 
Type 2 diabetes

Older age, a sedentary lifestyle, and smoking cigarettes increase the risk of developing these diseases even more.

Question 42

Physical Activity and Weight Loss

Answer 42

Physical activity has been shown to benefit a variety of common disease including obesity, diabetes, hypertension, and depression. For adults to achieve “substantial health benefits,” the 2015-2020 Dietary Guidelines recommend getting 150 minutes of moderate-intensity exercise, 75 minutes of vigorous intensity exercise, or a combination of both per week. For more “extensive” benefits, double that amount is recommended. At least two days a week, strengthening exercises involving all muscle groups should be incorporated into exercise.

Lifestyle modifications (e.g., taking the stairs instead of the elevator or walking short distances instead of driving) seem to be easier to adhere to than more structured activities such as going to a fitness class. Encouraging patients to participate in physical activities they enjoy may help to increase exercise. Having an exercise partner or including family is another way to stay motivated and increase physical activity.

Question 43

Smoking Cessation Strategies

Answer 43

Setting a quit date
Using nicotine replacement
Joining a support group
Calling 1-800-QUIT-NOW
Choosing an activity to substitute for smoking (e.g., taking a walk or chewing sugarless gum when the urge to smoke occurs)
Making a list of the reasons why it is important to quit smoking and keeping it handy to refer to
Keeping track of where, when, and why you smoke (helps identify smoking triggers to avoid)
Throwing away all tobacco and smoking paraphernalia (i.e., ashtrays, lighters, anything else associated with the smoking habit)
Taking medication

Question 44



Breast Cancer Epidemiology & Screening Via Mammography

Answer 44

Epidemiology
One in eight women will have breast cancer before they are 80 years old. The risk of developing breast cancer is related to age.

Screening
The earlier breast cancer is detected, the higher the chances of successful treatment and a cure. Mammography can help find cancer one or two years before breast cancer may be felt by breast self-exam. Guidelines regarding breast cancer screening differ, and for women between the ages of 40 to 50 with average risk, the decision should be individualized. Mammograms are very safe.

Method: To obtain a mammogram (an x-ray image of the breasts), each one is separately pressed between two plates. Breast compression allows the radiologic technologist to take an image of all the breast tissue. It also holds the breast still and allows use of a lower dose of x-ray. It may be uncomfortable while the breast is being pressed between the plates, but compression lasts only a few seconds. Patients may want to schedule their mammogram for the time when their breasts are least likely to be tender (usually about a week after completing a period).

Question 45

The Bethesda System for Reporting Cervical Cytology

Answer 45

Using this system of reporting, cervical cytology pathology results are given in three categories:

1. Specimen adequacy
   In order to be “adequate,” the Pap smear must contain over 5,000 squamous cells and have sufficient endocervical cells. (Endocervical cells are columnar epithelial cells found just proximal to the squamo-columnar junction, the site of beginning dysplastic changes.) If they are present, it shows that you have sampled the transformation zone, and therefore the specimen is “adequate.”
2. General categorization of results
   Is there any evidence of intraepithelial lesion or malignancy?
3. Interpretation of results
   Either the Pap is negative for intraepithelial lesion or malignancy, or there is evidence of epithelial abnormalities. Epithelial abnormalities are further divided into four categories.

Atypical squamous cells (ASC): Some abnormal cells are seen. These cells may be caused by an infection or irritation or may be precancerous.

Low-grade squamous intraepithelial lesion (LSIL). LSIL may progress to a high-grade lesion but most regress.

High-grade squamous intraepithelial lesion (HSIL). This is considered a significant precancerous lesion.

Squamous cell carcinoma.

Question 46

Recommendations for Immunization Against HPV

Answer 46

There are three vaccines that effectively protect women against the viruses that cause approximately 75 percent of cervical cancers:
Gardasil
Cervarix
Gardasil 9

Question 47

Gardasil

Answer 47

-quadravalent recombinant DNA vaccine (HPV4)
-HPV serotypes protected against:
6, 11 (cause genital warts)
16 and 18 (cause most cervical cancers)
-females and males age 9 to 26
-Number of doses 3
-before sexual debut or shortly thereafter

Question 48

Cervarix

Answer 48

-bivalent vaccine (HPV2)
-16 and 18 (cause most cervical cancers)
31 and 45
-females age 9 to 25
-Number of doses: 3
-before sexual debut or shortly thereafter

Question 49

Gardasil 9

Answer 49

• HPV serotypes protected against: 6, 11 (anogenital), 16, 18 (most cervical cancer), 31, 33, 45, 52, 58 (~15% cervical cancer)
• females & males ages 9-26 yrs
• 3 doses
• before sexual debut or shortly thereafter

Question 50

Performing a Pelvic Exam

Answer 50

Preparation—-
First, elevate the head of the exam table to 30 to 45 degrees and assist the patient in placing her heels in the stirrups, adjusting the angle and length as needed.

Carefully cover the patient’s abdomen and legs down to her knees with a sheet.

Ask patient to slide down to the edge of the table and relax her knees outward just beyond the angle of the stirrups.

External inspection and palpation—-
Look for any redness, swelling, lesions or masses.

Inspect the labia, the folds between them, and the clitoris, paying attention to any redness, swelling, lesions, or discharge.

Speculum exam—–
Use a warm and lubricated speculum for the examination. (There is some controversy about whether gel- based lubricants distort cytologic assessment. For this reason, the speculum is lubricated with warm tap water or a thin layer of gel lubricant, avoiding the tip of the speculum. You should know what is recommended by the laboratory in your area.)

Inform the patient that you are about to begin the speculum exam.

Expose the introitus by spreading the labia from below using the index and middle fingers of the non- dominant hand (peace sign).

Insert the speculum at a 45-degree angle, pointing slightly downward being careful to avoid contact with the anterior structures.

Once past the introitus, rotate the speculum to a horizontal position and continue insertion until the handle is almost flush with the perineum.

Open the “bills” of the speculum 2 or 3 cm using the thumb lever until the cervix can be visualized between the bills.

Question 51

Obtaining a Pap Test

Answer 51

The sample is obtained using an extended tip spatula and then a cytobrush.

First, the spatula is rotated several times to obtain a sample from the ectocervix. The cytobrush is then inserted into the os and rotated 180 degrees.

Care is taken to make sure that the squamo-columnar junction (the area of the endocervix where there is rapid cell division and where dysplastic cells originate) is adequately sampled.

The sample is then placed into a liquid medium.

Using the liquid-based system over the conventional Pap smear technology allows for later testing of the sample for the presence of human papilloma virus (HPV) if the Pap comes back abnormal.
(Currently two liquid-based systems are approved by the FDA. You should check with your lab to find out which system is preferred.)

Once the sample is obtained, let the patient know the speculum is about to be withdrawn.

Then, withdraw the speculum slightly to clear the cervix, loosen the speculum and allow the “bills” to fall together, and continue to withdraw while rotating the speculum to 45 degrees.

Question 52

Performing a Bimanual Exam

Answer 52

Screening for ovarian cancer with a bimanual exam is not recommended, however this is the technique you would use should you need to do the exam for a symptomatic patient.

First, explain to your patient what you are going to do.

Next, apply lubricant (e.g., K-Y jelly) to the index and middle fingers of your non-dominant gloved hand and insert them into the patient’s vagina.

Move cervix side to side (laterally) to ensure that it is non-tender and mobile.

Place your non-gloved hand on the abdomen just superior to the symphysis pubis, feeling for the uterus between your two hands. This gives you an idea of its size and position.

Then, moving your pelvic hand to each lateral fornix, try to capture each ovary between your abdominal and pelvic hands. The ovaries are usually palpable in slender, relaxed women, but are difficult or impossible to feel in obese women.

Question 53

Recommendations for Management of Abnormal Cervical Cancer Screening Test

Answer 53

Note: Women with ASC-US and negative HPV testing are recommended repeat co-testing in three years.

Question 54

Breast Cancer Screening Studies: Mammography

Answer 54

Benefits:
Mammography is a good screening test that can detect asymptomatic early stage disease, and there is good evidence that mammography decreases breast cancer mortality.

Risks:
As with any other screening test, there is a potential for false positive results (leading to unnecessary procedures) or false negative results (giving patients a false sense of security). The sensitivity of mammography is between 60% and 90%. Low sensitivity means more false negative results. False negative results are more common in younger women since denser breast tissue makes it harder to find abnormalities on x-rays.

Mammography is a radiograph which involves some radiation exposure. However, modern mammography systems use extremely low levels of radiation, usually about 0.1 to 0.2 rad per x- ray, which is minimal and provides negligible risk.

Also, mammograms can be uncomfortable for patients.

Question 55

Breast Cancer Screening Studies: Breast MRI

Answer 55

Not recommended for screening the general population of asymptomatic, average-risk women.

May be indicated in the surveillance of women with more than a 20% lifetime risk of breast cancer (for example, individuals with genetic predisposition to breast cancer by either gene testing or family pedigree, or individuals with a history of mantle radiation for Hodgkin’s disease).

May be used as a diagnostic tool to identify more completely the extent of disease in patients with a recent breast cancer diagnosis.

Contrast-enhanced breast MRI may be indicated in the evaluation of patients with breast augmentation in whom mammography is difficult.

Question 56

Breast Cancer Screening Studies: Breast US

Answer 56

Not recommended for screening purposes. This tool is used for evaluation of suspected abnormalities.