How to write a nursing Advanced Health Assessment paper (Solved Case study)

Advanced Health Assessment case study questions: Family Medicine 01: 45-year-old female wellness visit

Author: Thomas Tafelski, DO, and Saudia Mushkbar, MD

INTRODUCTION

CARE DISCUSSION

You are working with Dr. Stephanie Lee at her family medicine clinic. Dr. Lee tells you, “The next patient, Mrs. Payne, is a 45-year-old cisgender female who is here for a health maintenance exam. It looks like she hasn’t had a visit for over five years. When you’re talking with Mrs. Payne, I’d like you to find out if she has any current concerns, update her past medical history, and do a brief review of systems. Then, come on out and tell me what you’ve discovered and we’ll both go in to do the physical exam together.”

TAKING HISTORY

HISTORY

You meet your first patient, Mrs. Payne.

You introduce yourself to Mrs. Payne and begin obtaining her history:

Medical History:

“Do you mind if I ask you a few questions to find out how you are doing?”

Mrs. Payne says, “That sounds fine.”

“What brought you in today?”

“I feel fine, but I know I should get checked out since it’s been a while and I need to have a Pap test and mammogram.”

“I would like to update your medical history. Do you have any chronic medical problems?”

“Well, I don’t really have any medical problems.”

“Have you had any operations?”

“I had my tubes tied shortly after the birth of my last child.”

“Are you on any medications, or are you allergic to any medications?”

“I take an occasional Tylenol or ibuprofen for pain or headache and a multivitamin. I’m not allergic to any medicine as far as I know.”

Social History:

“Have you ever smoked?”

“Yes, I’m afraid I do smoke a pack of cigarettes a week. I keep trying to quit, but I just never seem to be able to do it.”

“Do you drink alcohol?”

“No, I don’t drink any alcohol at all.”

“Have you ever used any recreational drugs?”

“I never tried any illegal drugs. My friends have smoked marijuana but I was always too afraid to try.”

“How much do you exercise?”

“I used to try to walk at lunchtime, but I don’t do that anymore. It just seems like I’ve been too busy to have time to exercise.”

“Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?”

“No, I feel safe.”

Family History:

“How is the health of your family members?”

“My father has high blood pressure and my mother has mild arthritis, but both are in good health. My two sisters are healthy.”

“What about your extended family?”

“I don’t know how my grandparents died, but I think one of them had diabetes. My mom’s sister has breast cancer but is doing well after surgery and chemotherapy.”

Mrs. Payne asks you, “Does having an aunt with breast cancer increase my risk of developing breast cancer? My aunt was diagnosed with breast cancer when she was about 70 years old.”

You were able to reassure Mrs. Payne that the risk is increased only if there is a history in a first-degree relative, such as a parent or sibling.

References

Dicola D, Spaar E. Intimate Partner Violence. Am Fam Physician. 2016;94(8):646-651.

Steiner E, Klubert D, Knutson D. Assessing breast cancer risk in women. Am Fam Physician. 2008;78(12):1361-6.

GYNECOLOGIC HISTORY

HISTORY

OB/GYN:

“How old were you when your periods began?”

“Around 13 or 14.”

“Are your periods usually regular?”

“They have always been regular until the last year, when my menstrual flow has decreased.”

“Can you describe what you mean?”

“My cycles have lengthened and the flow has decreased. I think I might be having hot flashes once in while, too. I’m wondering if I might be going through menopause.”

You tell Mrs. Payne you would like to address this issue in more detail when you return later with Dr. Lee.

“Have you ever had an abnormal Pap test?”

“I had one abnormal Pap test seven or eight years ago. Dr. Lee did a test and took some samples but everything turned out normal. I had another Pap test one year later that was normal. I then had another normal one a few years ago, right?”

“Right. You mentioned having a child. How many times have you been pregnant?”

“I have been pregnant three times, and I have three children.”

BREAST CANCER SCREENING

TESTING

When you ask Mrs. Payne about health maintenance, she says she has never had a mammogram. She tells you, “One of the big reasons I’ve been putting off coming to see Dr. Lee is because I know she will recommend a mammogram. I think I should have one since my aunt had breast cancer and all, even though we just discussed how that shouldn’t increase my risk. But a friend of mine told me her mammogram was very painful. I have done breast self-exams, but not very often. I did notice some tenderness the last time I did my exam.”

You respond, “Let’s talk more about mammograms with Dr. Lee when she comes in. Are there any other issues you’d like to cover today?”

Mrs. Payne indicates that she’s discussed all her concerns with you already. You excuse yourself while Mrs. Payne changes into a gown for her physical exam.

Question

Which of the following is correct regarding breast self-examination? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. Breast self-examination increases the number of biopsies performed.
B. It is recommended to teach females breast self-examination
C. Most females should regularly perform breast self-examination.
D. The practice of regular breast self-examination by trained female patients reduces mortality.

SUBMIT

Answer Comment

The correct answer is A.

In a Cochrane review, females performing breast self-exams were almost twice as likely to undergo a breast biopsy (A).

There was no evidence to suggest reduced mortality in females who utilized breast self-exams (D). Given that harms seemed greater than benefits, breast self-exams are not recommended.

TEACHING POINT

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

Clinical Guidelines:

The U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) do not recommend that physicians teach patients to do breast self-exams (BSEs).

Similarly, in 2015 the ACS made a recommendation against clinical breast exam for screening purposes, citing the extremely low sensitivity rate and high false-positive rate of physician-performed clinical breast exams in asymptomatic patients. The USPSTF did not update its recommendation on breast self-exam in the 2016 revision. However, in 2009 it recommended against teaching breast self-examination.

References

Knutson D, Steiner E. Screening for breast cancer: current recommendations and future directions. Am Fam Physician. 2007;75(11):1660-6.

Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database Syst Rev. 2003;(2):CD003373.

Oeffinger KC, Fontham ET, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599-614.

Tria Tirona M. Breast cancer screening update. Am Fam Physician. 2013;87(4):274-8.

U.S. Preventive Services Task Force. 2016. Final Recommendation Statement: Breast Cancer: Screening – US Preventive Services Task Force. Accessed February 11, 2021.

PHYSICAL EXAM

You begin your physical exam of Mrs. Payne.

After presenting Mrs. Payne’s history and vital signs to Dr. Lee, the two of you knock on the door and reenter the room. After greeting Mrs. Payne, Dr. Lee asks if she minds if you perform the physical examination with Dr. Lee observing. Mrs. Payne assents.

Physical Exam

Vital signs:

Temperature is 37 °C (98.6 °F)
Pulse is 81 beats/minute
Respiratory rate is 12 breaths/minute
Blood pressure is 128/72 mmHg
Weight is 81.6 kg (180 lbs)
Height is 168 cm (66 in)
BMI is 29 kg/m²

General: Mrs. Payne is a well-appearing 45-year-old female.

Head, eyes, ears, nose, and throat (HEENT): All unremarkable. Teeth are in good repair with several fillings and some tobacco staining noted.

Neck: Normal-sized thyroid with no nodules. Trachea is in the midline.

Cardiovascular: Normal S1 and S2 with no murmurs, gallops, or rubs. Pulses are palpable and equal throughout.

Respiratory: Clear with good respiratory excursions. No palpable lymph nodes are noted in the cervical or inguinal regions.

Musculoskeletal: Good muscle development and normal range of motion of all joints.

Neurologic: Cranial nerves are intact; normal strength and sensation; reflexes are equal and symmetrical; normal gait.

DEEP DIVE

References

Erlandson M, Ivey LC, Seikel K. Update on Office-Based Strategies for the Management of Obesity. Am Fam Physician. 2016;94(5):361-8.

Janssen I, Katzmarzyk PT, Ross R. Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health Guidelines. Arch Intern Med. 2002;162(18):2074-9.

BREAST EXAM

PHYSICAL EXAM

TEACHING POINT

Performing a Breast Exam

Although breast exam is not a recommended screening test, it is important to know how to perform it in a patient with symptoms.

A good breast exam consists of both visual inspection and palpation.

Visual inspection:

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.

Palpation:

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.

Vertical strip pattern

When palpating, use the finger pads of the middle three fingers.

Finger pads

Vary pressure (light, medium, and deep) as you complete your exam.

Varied pressure (light, medium, and deep)

Finally, palpate both axillary and supraclavicular lymph nodes.

References

Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999;282(13):1270-80.

Saslow D, Hannan J, Osuch J, et al. Clinical breast examination: practical recommendations for optimizing performance and reporting. CA Cancer J Clin. 2004;54(6):327-44.

PELVIC EXAM

PHYSICAL EXAM

Dr. Lee explains the correct technique for the pelvic exam.

After you have finished the breast exam, you examine Mrs. Payne’s abdomen.

Abdomen:

No hepatosplenomegaly, tenderness, or masses.

Dr. Lee then explains to you the correct technique for a pelvic exam, as Mrs. Payne is due for her Pap test.

TEACHING POINT

Performing a Pelvic Exam

Preparation

First, elevate the head of the exam table to 30 to 45 degrees and assist the patient in placing their heels in the footrests, adjusting the angle and length as needed.
Carefully cover the patient’s abdomen and legs down to their knees with a sheet.
Ask the patient to slide down to the edge of the table and relax their knees outward just beyond the angle of the footrests.

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.

OBTAINING PAP TEST

PHYSICAL EXAM

Image of a normal cervix

Dr. Lee next inspects the cervix and vaginal walls for lesions or discharge before obtaining cytology. “Now I’m going to obtain a sample,” she tells Mrs. Payne.

TEACHING POINT

Obtaining a Pap Test

One common method for collecting the Pap test is to use a spatula and cytobrush, though there are single-collection products available for this purpose as well.

Using the combination involves two steps: 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 test technology allows for later testing of the sample for the presence of human papillomavirus (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.

DEEP DIVE

References

American Cancer Society. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer.. Accessed January 22, 2020

Osayande AS, Bostock WK. Does the use of a lubricant during a Pap smear decrease the accuracy of the test result? Evidence-Based Practice. 2018;21(2):7-8.

Sykes PH, Harker DY, Miller A, et al. A randomised comparison of SurePath liquid-based cytology and conventional smear cytology in a colposcopy clinic setting. BJOG. 2008;115(11):1375-81.

BIMANUAL EXAM, CERVICAL CANCER SCREENING

PHYSICAL EXAM

TEACHING POINT

Performing a Bimanual Exam

Screening for ovarian cancer with a bimanual exam is not recommended, but it 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 nondominant gloved hand and insert them into the patient’s vagina.

Move cervix side to side (laterally) to ensure that it is nontender 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 patients, but are difficult or impossible to feel in obese patients.

Mrs. Payne’s cervix is freely moveable and nontender, and her uterus is normal in size and position. Her ovaries are not palpable.

“Everything is fine,” Dr. Lee tells Mrs. Payne. “We’re going to leave the room for a minute and give you a chance to get dressed, and then we can talk some more when we come back.”

When you have left the room, you tell Dr. Lee that you are a little confused about when Pap tests are recommended, so she reviews the guidelines with you.

TEACHING POINT

Cervical Cancer Screening Guidelines

In 2012, the ACS, the USPSTF, the American College of Obstetrics and Gynecology (ACOG), and the American Society for Colposcopy and Cervical Pathology (ASCCP) came to a consensus on cervical cancer screening.

Since that time, many organizations have updated their recommendations to include the use of high-risk HPV (hrHPV) testing alone. The frequency of testing and age of first use varies.

In 2018, the USPSTF updated their guidelines to recommend that:

At age 21: cervical cancer screening should begin.
Between ages 21 and 29: screening should be performed every three years with cytology alone.
Between ages 30 and 65: screening can be done every five years with high risk HPV (hrHPV) testing alone, every five years with cotesting (hrHPV and cytology), or every three years with cytology alone.

Since that time, many organizations have updated their recommendations to include the use of high risk HPV (hrHPV) testing alone. The frequency of testing and age of first use varies.

Importantly, it should be noted that the new guidelines stipulate that certain risk groups need to have more frequent screening. They include patients who have 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 females to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and its use was discontinued in 1971.)

Patients older than 65 years who have had adequate screening within the last 10 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.

Patients who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.

Question

Dr. Lee says, “Of course, these recommendations are based, in part, on the risk a patient will develop cervical cancer. So, now I have a question for you: What do you think are the risk factors for developing cervical cancer?” Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Cigarette smoking.
B. Early onset of sexual intercourse.
C. Immunosuppressed patient.
D. Multiple sexual partners.

SUBMIT

Answer Comment

The correct answers are A, B, C, D.

All of the listed factors increase the risk of developing cervical cancer. Patients who smoke (A)are exposed to more cancer-causing chemicals. Early age of sexual intercourse (B) and multiple sexual partners (D) can increase the risk of exposure to HPV. Similarly, patients with weakened immune systems (C) are at higher risk of HPV infections. The persistence of high-risk HPV strains is strongly associated with cervical cancer.

TEACHING POINT

Cervical Cancer Risk Factors

Virtually all cervical cancers are caused by infection with certain high-risk types of human papillomavirus (HPV).

HPV is transmitted via vaginal (or oral) intercourse. Transmission by nonpenetrative genital contact is rare. Therefore, squamous cell carcinoma of the cervix is a disease of sexually active patients. Factors such as age, nutritional status, immune function, and possibly silent genetic polymorphisms modulate the incorporation of viral DNA into host cells.

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 increases the risk by up to fourfold.
Immunosuppression, which also significantly increases the risk of developing cervical cancer.

DEEP DIVE

References

Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol. 2016;128(4):e111-30.

Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic Examination. N Engl J Med. 2007;356:e26. http://www.nejm.org/doi/full/10.1056/NEJMvcm061320. Accessed March 10, 2020.

Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol. 2015;125(2):330-7.

Rerucha CM, Caro RJ, Wheeler VL. Cervical cancer screening. Am Fam Physician. 2018 Apr 1;97(7):441-448.

Riley M, Dobson M, Jones E, Kirst N. Health Maintenance in Women. Am Fam Physician. 2013;87(1):30-7.

Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol. 2012;137(4):516-42.

Smith RA, Andrews KS, Brooks D, et al. Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2019;69(3):184-210.

U.S. Preventive Services Task Force. Final Recommendation Statement: Cervical Cancer: Screening – US Preventive Services Task Force. Accessed March 10, 2020.

CHARACTERISTICS OF A GOOD SCREENING TEST

TESTING

You discuss breast and cervical screening with Dr. Lee.

While you are in the hallway waiting for Mrs. Payne to get dressed, you and Dr. Lee discuss breast and cervical cancer screening. She asks you, “What constitutes a good screening test?”

TEACHING POINT

Characteristics of a Good Screening Test

Accuracy (high sensitivity and specificity)

Sensitivity

· Measures proportion of actual positives that are correctly identified as such (e.g., percentage of sick people identified as having the condition)

· The more sensitive the test, the fewer false negative results.

Specificity

· Measures the proportion of negatives that are correctly identified as such (e.g., percentage of well people identified as not having the condition)

· The more specific the test, the fewer false positives.

Able to detect disease in an asymptomatic phase
Minimal associated risk
Reasonable cost
Acceptable to patient
There is an available treatment for the disease

TEACHING POINT

Pap Test Exemplifies the Characteristics of a Good Screening Test

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 preinvasive state (often a decade or more), and there are effective treatments for preinvasive 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

Dr. Lee asks you what cancers (besides breast and cervical) Mrs. Payne should be screened for. Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. Lung cancer
B. Malignant melanoma
C. Ovarian cancer
D. All of the above
E. None of the above

SUBMIT

Answer Comment

The correct answer is E.

The USPSTF notes there is insufficient evidence to recommend for or against skin cancer screening (B). Currently, the USPSTF recommends against ovarian cancer screening (C). Though Mrs. Payne is a smoker, she is too young to begin lung cancer screening by current standards (A).

TEACHING POINT

Skin Cancer Screening Recommendations

While skin cancer is the most common type of cancer, the USPSTF currently reports that there is insufficient evidence to recommend for or against skin cancer screening.

TEACHING POINT

Lung Cancer Screening Recommendations

As of 2021, the USPSTF recommends annual screening with a low-dose computed tomography (LDCT) scan to screen for lung cancer in patients aged 50 to 80 who have smoked for 20-plus years.

To be considered, the patient should also be currently smoking or have quit within the prior 15 years, or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

TEACHING POINT

Ovarian Cancer Screening Recommendations

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 patients.

References

American Cancer Society. Skin Cancer. Skin Cancer | Skin Cancer Facts | Common Skin Cancer Types. Accessed January 22, 2020.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Obstet Gynecol. 2011;117(3):742-6.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for Skin Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316(4):429-35.

Fletcher R. Clinical epidemiology: the essentials, Edition: 4, illustrated. Philadelphia,PA: Lippincott Williams & Wilkins; 2005.

Moyer VA; U.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-8.

U.S. Preventive Services Task Force. Final Recommendation Statement: Lung Cancer: Screening. March 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening. Accessed March 26, 2021.

Wilt TJ, Harris RP, Qaseem A. Screening for Cancer: Advice for High-Value Care from the American College of Physicians. Ann Intern Med. 2015;162(10):718-25.

SCREENING GUIDELINES

TESTING

Based on Mrs. Payne’s history, you and Dr. Lee have determined that she is at average risk for breast cancer. Dr. Lee tells you that the recommendation regarding when to perform screening mammography varies.

“We all struggle to keep up with the constantly changing recommendations,” Dr. Lee tells you. “I follow the USPSTF guidelines. They review cancer screening as well as health maintenance issues in general. The USPSTF guidelines are strictly evidence-based and probably eliminate some of the bias brought to the table by specialists. A nice feature of the USPSTF guidelines is that they also review the guidelines from other organizations.”

Dr. Lee further observes that, in Mrs. Payne’s age group, even though the most common cancers are breast, lung, and colorectal cancers, screening for them is not necessarily suggested.

TEACHING POINT

Recommendations for Breast Cancer Screening Mammography

U.S. Preventive Services Task Force

Biennial screening mammography for females aged 50 to 74 years

(Grade B recommendation)

The 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)

American Cancer Society

Females aged 45 to 54 should get mammograms every year.

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

Females aged 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.

American College of Radiology

For females at average risk, < 15% lifetime risk of breast cancer, annual screening with mammography or digital breast tomosynthesis is recommended starting at age 40.

*As of 2018, The American College of Radiology (ACR) has classified African American females as high risk.

(ACR Appropriateness Category: Usually Appropriate)

Most guidelines do not recommend routine mammography for females younger than 40 unless they fall into a high-risk category, such as females with a known BRCA mutation.

TEACHING POINT

Shared Decision-Making in the Setting of Conflicting Guidelines

Part of a clinician’s job is to help patients make informed decisions that incorporate their personal and family history/risk factors and personal health beliefs. Clinicians 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.

References

American Cancer Society. Breast Cancer Early Detection and Diagnosis | How To Detect Breast Cancer. Accessed January 22, 2020.

American College of Radiology. ACR Appropriateness Criteria: Breast Cancer Screening. Accessed May 29, 2018.

American College of Radiology. New ACR and SBI Breast Cancer Screening Guidelines Call for Significant Changes to Screening Process. Accessed January 22, 2020.

Mandelblatt JS, Cronin KA, Bailey S, et al. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. 2009 Nov 17;151(10):738-47.

Siu AL; U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279-96.

EVALUATION OF BREAST LUMP

TESTING

Dr. Lee tells you that breast-related concerns like lumps and discharge are common in primary care practice.

TEACHING POINT

Evaluating a Breast Lump

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
Any change in size of the lump (especially ask whether the lump changes in size according to phase of the menstrual cycle)

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

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

Diagnostic tests:

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.

Follow-up:

If the workup suggests that the lesion is benign (which the vast majority are), close follow-up with regular breast exams and mammography is indicated.

DEEP DIVE

References

Primary care guide to managing a breast mass: step by step workup. http://www.medscape.com/viewarticle/443381_9. Accessed January 22, 2020.

Salzman B, Collins E, Hersh L. Common Breast Problems. Am Fam Physician. 2019;99(8):505-514.

EVALUATION OF NIPPLE DISCHARGE

TESTING

TEACHING POINT

Evaluation of Nipple Discharge

Reasons for nipple discharge may be physiologic or pathologic:

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)

A comprehensive history and breast exam are necessary to evaluate the discharge.

For example, it is important to know if the discharge appears milky, purulent, or bloody. Palpate nipples and check for any discharge.

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

Mammogram
Ultrasound
Ductogram and/or
Biopsy

Consider hormonal testing to exclude endocrinological reasons. If discharge is milky, check the prolactin level.

Review and discontinue any medications that may be the cause.

References

Salzman B, Collins E, Hersh L. Common Breast Problems. Am Fam Physician. 2019;99(8):505-514.

BREAST IMAGING

TESTING

Next, you and Dr. Lee review breast cancer screening. The most commonly used screening tool is mammography. Physician breast exam has not been shown in studies to meet the screening criteria.

TEACHING POINT

Breast Cancer Screening Studies

Mammography

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 females, as 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.

Breast MRI

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

May be indicated in the surveillance of females 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 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.

Breast Ultrasound

USPSTF guidelines says there is insufficient evidence to use this for screening in females with dense breasts. The American College of Radiology (ACR) notes that it increases breast cancer detection in females with dense breasts but also increases the risk of false positives. This tool is generally used for evaluation of suspected abnormalities.

Question

What are the risk factors for developing breast cancer in the general population? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Age
B. Excessive alcohol intake
C. Family history of breast cancer in first-degree relative
D. Genetic factors
E. Postmenopausal obesity
F. Prolonged exposure to estrogen

SUBMIT

Answer Comment

The correct answers are A, B, C, D, E, F.

All increase the risk of breast cancer. Age (A) and excessive alcohol (B) increase risk. Genetic factors (D), such as the BRCA1 and 2 mutations, as well as other genes, can increase risk. Prolonged exposure to estrogen (F), which may increase from excess adipose tissue in obese females, is another risk factor.

TEACHING POINT

Risk Factors for Breast Cancer

Understanding modifiable and nonmodifiable factors that increase or decrease breast cancer risk allows physicians to counsel females appropriately.

Nonmodifiable risk factors include:

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 females, and age is often the only known risk factor.)
Female sex
Increased breast density

Other hormonal risk factors include:

Advanced age at first pregnancy
Exposure to diethylstilbestrol
Estrogen therapy

Environmental factors include:

Therapeutic radiation
Obesity in postmenopausal females
Excessive alcohol intake
Smoking

Factors associated with decreased breast cancer rates include:

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.

No convincing evidence supports the use of dietary interventions for the prevention of breast cancer, with the exception of limiting alcohol intake.

Calculating the risk using the Gail criteria is helpful in individualizing recommendations for mammogram.

So far, it appears that Mrs. Payne is at average risk of breast cancer since she is 45 years old. But she does not have a first-degree relative with breast cancer, prolonged exposure to estrogen, excessive alcohol intake, or known genetic factors.

References

American College of Radiology. ACR Appropriateness Criteria. Accessed January 22, 2020.

Kispert S, McHowat J. Recent insights into cigarette smoking as a lifestyle risk factor for breast cancer. Breast Cancer (Dove Med Press). 2017;9:127-132.

Nattinger AB, Mitchell JL. Breast Cancer Screening and Prevention. Ann Intern Med. 2016;164(11):ITC81-ITC96.

Steiner E, Klubert D, Knutson D. Assessing breast cancer risk in women. Am Fam Physician. 2008;78(12):1361-6.

IMMUNIZATIONS

THERAPEUTICS

Dr. Lee asks, “What other important health maintenance issues do we need to address?”

You suggest checking Mrs. Payne’s immunization status. You both review Mrs. Payne’s chart and then visit the CDC immunization information website (PDF). Seeing that Mrs. Payne’s last tetanus shot was over 10 years ago, you recommend she get a Tdap now. Also, since she is a smoker, you recommend she receive the pneumovax vaccine today. She should receive a flu vaccine every fall.

“Okay. Is there anything else we should talk with Mrs. Payne about when we go back?” You feel you should address Mrs. Payne’s smoking, her excessive weight, her lack of exercise, and osteoporosis prevention. Dr. Lee agrees.

TEACHING POINT

Immunization: Tdap

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.

DEEP DIVE

References

Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE. Diagnosis and management of osteoporosis. Am Fam Physician. 2015;92(4):261-8.

MENOPAUSE

MANAGEMENT

Dr. Lee discusses menopause with Mrs. Payne.

When you reenter the room, Dr. Lee reassures Mrs. Payne, “Your physical exam was normal. However, I have several suggestions and recommendations I would like to discuss with you. But first let’s talk a bit about menopause, since I’m told you have some concerns.”

TEACHING POINT

Menopause

Timing

On average, patients with ovaries reach menopause at age 51, but menopause can start earlier or later. A few patients start menopause as young as 40, and a very few as late as 60. Those 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 patient has not menstruated for 12 straight months can menopause be confirmed.

Perimenopause

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.

Symptoms

Menopause affects each person differently. Some 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 clinician 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 patient’s libido may also change.

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

DEEP DIVE

References

Dennerstein L, Dudley EC, Hopper JL, Guthrie JR, Burger HG. A prospective population-based study of menopausal symptoms. Obstet Gynecol. 2000;96(3):351-8.

Baill IC and Castiglioni A. Health maintenance in postmenopausal women. Am Fam Physician. 2017 May 1:95(9):561-570.

Gold EB, Bromberger J, Crawford S, et al. Factors associated with age at natural menopause in a multiethnic sample of midlife women. Am J epidemic. 2001;153(9):865-74.

Hill DA, Crider M, Hill SR. Hormone therapy and other treatments for symptoms of menopause. Am Fam Physician. 2016 Dec 1;94(11):884-889.

Riley M, Dobson M, Jones E, Kirst N. Health Maintenance in Women. Am Fam Physician. 2013;87(1):30-7.

WebMD. Slideshow: All About Menopause and Perimenopause. http://www.webmd.com/menopause/slideshow-menopause-overview. Accessed January 22, 2020.

OSTEOPOROSIS

MANAGEMENT

Dr. Lee asks you if Mrs. Payne has any risk factors for osteoporosis. “Yes,” you reply. “She is a smoker.”

TEACHING POINT

Recommendations for Osteoporosis Prevention

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

Calcium Intake

Calcium supplementation for osteoporotic fracture prevention has raised concerns that it may increase the risk of atherosclerotic vascular disease and kidney stones. However, it is unclear from the present data whether intake of dietary calcium versus calcium supplementation increases cardiovascular risk or the risk for kidney stones. A USPSTF 2018 recommendation statement concluded that current evidence is insufficient to assess the risks and benefits of calcium and vitamin D supplementation for the prevention of fractures in premenopausal and noninstitutionalized postmenopausal patients. Therefore the USPSTF is currently recommending against 1,000 mg or less of calcium and 400 IU or less vitamin D supplementation in community-dwelling postmenopausal patients.

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.

TEACHING POINT

Recommendations for Osteoporosis Screening

For females 65 and older, screening with dual energy x-ray absorptiometry (DEXA) is recommended.
For females under 65, 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 female without additional risk factors (9.3 percent over 10 years). These recommendations are being reviewed by the USPSTF.

Question

Which of the following are risk factors for osteoporosis? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. African American heritage
B. BMI > 30
C. Early menopause
D. History of previous fracture as an adult
E. Sedentary lifestyle

SUBMIT

Answer Comment

The correct answers are C, D, E.

Early menopause (C) leads to lower exposure to estrogen. Weight-bearing exercise is protective, so being sedentary (E) increases the risk of osteoporosis. A prior fracture (D) is associated with an increased risk of osteoporosis.

Higher BMI (B) seems to be protective by increasing estrogen levels. African American adults (A) are at lower risk of osteoporotic fracture than Caucasian adults, and have higher bone mineral density in population-based studies.

TEACHING POINT

Osteoporosis Risk Factors

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

It should be noted that African American women are much less likely than Caucasian women to be offered screening for osteoporosis and are more likely to die of complications of a hip fracture. The persistence of a belief that African American patients are not at risk of osteoporosis may contribute to these disparities.

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

References

Baill IC and Castiglioni A. Health maintenance in postmenopausal women. Am Fam Physician. 2017 May 1:95(9):561-570.

Cauley JA. Defining ethnic and racial differences in osteoporosis and fragility fractures. Clin Orthop Relat Res. 2011 Jul;469(7):1891-9.

Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE. Diagnosis and management of osteoporosis. Am Fam Physician. 2015;92(4):261-8.

U.S. Preventive Services Task Force. Final Recommendation Statement: Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: Preventive Medication – US Preventive Services Task Force. Accessed January 22, 2020.

WEIGHT MANAGEMENT

MANAGEMENT

TEACHING POINT

Body Mass Index (BMI)

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.

Dr. Lee moves on to the next topic. “I’d like to talk next about your weight,” she tells Mrs. Payne. “By losing 5 to 10 percent of your body weight, you can significantly reduce your risk of diabetes, hypertension, and cardiovascular disease.”

“How do you feel about your weight at this point?”

“I weigh too much. I would feel better physically and emotionally if I could only lose about 10 or 20 pounds. But I don’t know where to start.”

“Well, we are here to help you with that,” offers Dr. Lee. Can you tell me what you would eat in a typical day?”

Mrs. Payne lists her daily diet for you: “Well, I usually skip breakfast because mornings are so chaotic, plus I know I don’t really need to eat more than I do. For lunch, I eat a sandwich or leftover pasta, an apple or orange, and I drink water. I also have a weakness for a couple of cookies after lunch to keep me going through the day. For dinner, I try to cook lean meats, and we usually have rice with it. Again, I drink water. My family likes strawberries and blackberries. We try to eat something like that when it’s available. And, we have cake or ice cream for dessert. At night, while I’m watching TV is my weakness—I’ll often eat some chips or have another helping of dessert.”

“Alright, you are making some excellent choices by eating two fruits a day, choosing lean meats, and drinking water. I would like to continue to see you doing these things.”

You tell Mrs. Payne about some additional nutritional approaches to a healthier diet.

“Do you think you could try any of these changes?”

Mrs. Payne says, “I could start eating breakfast, buy whole wheat stuff, and decrease my desserts to three servings weekly.”

“That would be excellent,” Dr. Lee concludes. “Let’s follow up on these goals at our next visit.”

TEACHING POINT

Nutrition

The website Choose My Plate provides good information on healthy eating.

Current recommendations are to eat a varied, nutrient-dense diet consisting of fruits, vegetables, low-fat or fat-free dairy, protein, oils, and grains (at least half being whole grains). In addition, sodium, saturated fats, and added sugars should be limited.

Use the MyPlate Checklist Calculator to find out the number of calories needed to maintain versus lose weight. Based on the calories, check the MyPlate Daily Checklist for guidance on a well-balanced diet.

Reducing portion size can also be very helpful.

DEEP DIVE

References

Kant Ak, Andon MB, Angelopoulos TJ, Rippe JM. Association of breakfast energy density with diet quality and body mass index in American adults: National Health and Nutrition Examination Surveys, 1999-2004. Am J Clin Nutr. 2008;88(5): 1396-404.

Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer B, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008.

Rubin R. Is breakfast really your most important meal? https://www.webmd.com/diet/news/20140902/breakfast-importance#1. Accessed January 22, 2020.

Rubin R. Does Skipping Breakfast Lead to Weight Loss or Weight Gain? JAMA. 2019;321(19):1857–1858.

U.S. Department of Agriculture. Welcome to MyPlate | ChooseMyPlate. www.choosemyplate.gov. Accessed January 22, 2020.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. https://health.gov/sites/default/files/2019-09/2015-2020_Dietary_Guidelines.pdfAccessed August 16, 2021.

World Health Organization. Diet, nutrition and the prevention of chronic diseases: Report of the joint WHO/FAO expert consultation. WHO Technical Report Series, No. 916 (TRS 916). http://www.who.int/dietphysicalactivity/publications/trs916/download/en/. Published 2003. Accessed January 22, 2020.

Zhang L, Cordeiro LS, Liu J, Ma Y. The association between breakfast skipping and Body Weight, Nutrient Intake, and Metabolic Measures among Participants with Metabolic Syndrome. Nutrients. 2017;9(4):384. Published 2017 Apr 14.

EXERCISE

MANAGEMENT

Dr. Lee reminds Mrs. Payne that increasing her physical activity would also assist weight loss.

“What type of activity do you enjoy?”

“I used to walk during my lunch hour, but I’ve gotten away from it. I could start doing that again.”

TEACHING POINT

Physical Activity and Weight Loss

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.

References

Jakicic JM, Otto AD. Physical activity considerations for the treatment and prevention of obesity. Am J Clin Nutr. 2005;82(1 Suppl):226S-229S.

Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25 Suppl 3: 1-72.

U.S. Department of Agriculture. Physical Activity | ChooseMyPlate. https://www.choosemyplate.gov/resources/physical-activity. Accessed January 22, 2020.

U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington DC: U.S. Department of Health and Human Services; 2018. https://health.gov/paguidelines/second-edition/. Accessed January 22, 2020.

SMOKING CESSATION

MANAGEMENT

Dr. Lee discusses smoking cessation with Mrs. Payne.

“Now I’d like to talk about smoking,” continues Dr. Lee.

“Have you thought about quitting?”

“I’ve tried to quit smoking a few times but was never able to make it stick. I’d like to quit for good.”

Turning to you, Dr. Lee says, “It sounds like Mrs. Payne is at the ‘preparation stage’ according to the transtheoretical model for change.”

Mrs. Payne declines assistance with medication to help her stop smoking.

When discussing smoking cessation, it is a good idea to start with the five “A’s”: ask, advise, assess, assist, arrange. With Mrs. Payne, you have asked and assessed. Fortunately, Mrs. Payne is interested in quitting, but typically you would want to advise as well. Since Dr. Lee has noted the patient is in the preparation stage but does not want to use medication, you can provide her with some of the other smoking cessation strategies below. Make sure to arrange for follow up!

More information on the five A’s can be found on the Agency for Healthcare Quality and Research website.

TEACHING POINT

Smoking Cessation Strategies

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

DEEP DIVE

References:

Searight HR. Counseling patients in primary care: evidence-based strategies. Am Fam Physician. 2018 Dec 15:98(12):719-728.

SCREENING RECOMMENDATIONS

MANAGEMENT

“Now, I’ve just got a few more loose ends we need to tackle at this appointment. Since your last tetanus shot was over 10 years ago, I’d like you get a Tdap shot today. In 10 years, you will need a Td.”

Dr. Lee turns to you and asks,

“Is there any blood work we should order on Mrs. Payne today?”

“I think a lipid profile and fasting glucose would be indicated.”

Dr. Lee agrees.

“I’d like you to schedule a follow-up appointment so we can go over your lab results and your progress with your lifestyle goals,” She tells Mrs. Payne.

Dr. Lee asks her, “Do you have any questions about our recommendations?”

“No, you both have answered all my questions. I am going to try to start eating breakfast regularly, increasing my exercise, and try getting out and walking daily. I’ll work on cutting back smoking as well. Thanks for all your help,” Mrs. Payne says as she shakes hands with both of you and heads out the door.

References

American Diabetes Association. Standards of Medical Care in Diabetes – 2019. Diabetes Care. 2019; 42, (S1): S1-S6. https://care.diabetesjournals.org/content/42/Supplement_1/S1. Accessed January 22, 2020.

Siu AL; U S Preventive Services Task Force. Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2015;163(11):861-8.

TEST RESULTS: PAP

MANAGEMENT

On your last day with Dr. Lee, you see Mrs. Payne is on the schedule to follow up on her lab results. Before going into the room, you review her results with Dr. Lee:

Fasting glucose: 86 mg/dl

Lipids:

Total cholesterol 183 mg/dl
HDL 52 mg/dl
LDL 121 mg/dl
Triglycerides 137 mg/dl

Using her blood pressure from her initial visit and current cholesterol results, the atheroslerotic cardiovascular disease (ASCVD) risk calculator shows that Mrs. Payne’s 10-year risk is 2.6 percent. For more required information about risk factors for ASCVD, read the Aquifer Cholesterol Guidelines Module.

Pap test results: Satisfactory; with evidence of ASC-US; HPV negative on co-testing.

Dr. Lee reviews with you the current way cervical cytology is reported via the Bethesda System. Since you know that infection with specific types of HPV is required for the development of cervical cancer and high-grade cervical lesions, you are reassured by the fact that Mrs. Payne’s Pap is negative for HPV. You and Dr. Lee also take a look at the recommendations to follow-up on Mrs. Payne’s Pap test results. Because of her ASC-US and HPV negative findings, the current recommendation is to retest in 3 rather than 5 years. (See guidelines below).

TEACHING POINT

The Bethesda System for Reporting Cervical Cytology

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

Specimen adequacy

In order to be “adequate,” the Pap test 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.”

General categorization of results

Is there any evidence of intraepithelial lesion or malignancy?

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.

TEACHING POINT

Recommendations for Management of Abnormal Cervical Cancer Screening Test

The Society for Colposcopy and Cervical Pathology (ASCCP) has published detailed management guidelines for abnormal Pap and HPV tests. They can be found at the link below:

Consensus Guidelines for Managing Abnormal Cervical Cancer Screens & CIN/AIS

References

Massad LS, Einstein MH, Huh WK, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2013;17(5 Suppl 1):S1-S27.

Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;287(16):2114-9.

HPV VACCINE

THERAPEUTICS

Dr. Lee gives Mrs. Payne the good news on her tests.

You and Dr. Lee enter the room and greet Mrs. Payne. She says she had already received the report that her mammogram was normal. Dr. Lee also tells her that her blood sugar was normal and that her cholesterol was at the recommended level. She tells her that her Pap test had only a mild abnormality but that there is little risk of cancer and recommends a repeat co-testing in three years. She would not recommend waiting for five years, as she did with this Pap. Mrs. Payne thanks you both for the good news.

Aware that Mrs. Payne has a young daughter, you volunteer to tell her about the HPV vaccine.

The CDC notes that as of 2017, only the 9-valent will be available in the U.S. Another important change is that the HPV series is considered complete after two doses in patients who receive the first dose before age 15 and the second dose at least five months after the first (ideally six to 12 months apart). See an overview of the HPV vaccine recommendations for clinicians.

The vaccines can be expensive, and patients should be advised to check with their individual insurance carrier about coverage.

References

Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination — Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405–08.

LIFESTYLE CHANGE MANAGEMENT

MANAGEMENT

Dr. Lee notices Mrs. Payne’s weight: “I see that you have lost two pounds since your last visit.”

“Well, I tried. I have taken your advice and started to eat breakfast and have cut back on sweets and portion size. I have been able to walk three times a week,” replies Mrs. Payne.

“Good job! Keep up the good work,” applauds Dr. Lee.

Dr. Lee poses her last question: “And how are you doing with smoking cessation?”

“Great! I’m down to only one or two cigarettes a day! By the next time you see me I may have stopped smoking altogether!” Mrs. Payne exclaims.

Dr. Lee offers encouragement and says she would like to see her again in three weeks to monitor her progress.

Mrs. Payne thanks you both and says she will really try to continue to make the changes to her lifestyle.

This is the final page of the case. We value your perspective on the learning experience. After completing three required feedback ratings you can finish the case and access the case summary.

Assignment

DOMAIN: HISTORY
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.

DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.

DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable’

DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.

Advanced Health Assessment case study SOLVED

Domain: History
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
The first question that was not asked is the marital status of the patient. “What is your current marital status?”
The second question that should have been asked is sex and the use of multiple sex partners. “Do you have other sex partners or do you know if your partner has multiple sex partners?”
1b) Explain your rationale for asking these two additional questions.
Asking about the marital status is important for the healthcare provider to understand the type of family support available in case of a major diagnosis like cancer. The second question focusing on sexual partners is crucial to understanding the patient’s sex life and the risk for STDs. For example, having multiple sexual partners is a risk factor for cervical cancer because it increases the chances of HPV infection. These questions could have added more details to the patient’s history and for guiding health education practices.
1c) Describe what the two (2) additional questions might reveal about the patient\’s health.
Marital status structures the entire adult life course is observed to influence the psychological and physical well-being of the patient. Since the visit was all about wellness, this question could help reveal the psychological well-being of the patient and the support available from the family. The second question about multiple sexual partners could reveal the risk for STDs and other conditions like cervical cancer that may result from HPV infections.
Domain: Physical exam
2a) Explain the reason the provider examined each system.
The systems examined during the assessment included the cardiovascular, respiratory, musculoskeletal, and reproductive systems. The assessment of the cardiovascular system was crucial to determine any heart problems that could indicate health issues. Based on the patient’s BMI, it was important to assess the risk for heart conditions. Assessment of the respiratory system enabled the provider to ascertain breathing problems that could indicate underlying medical conditions. The musculoskeletal system was assessed to determine problems with bones and joints that could reflect health problems like osteoporosis and osteoarthritis. Based on the patient’s age, it was important to observe any musculoskeletal issues that could result from hormonal changes during premenopause and menopause.
As part of routine physical examination for women, breast examination is recommended to screen for breast cancer. Part of Mrs. Payne’s assessment involved breast examination to detect any lumps that could indicate breast cancer. Breast examination was important for the patient because she complained of breast tenderness. Lastly, the patient’s examination focused on the genitourinary system where a pelvic examination was done. The reason for the examination was due to her past history of abnormal pap smear results that could indicate cervical cancer. Additionally, screening for cervical cancer is recommended every five years for women between the age of 30 to 65 years (Committee on Practice Bulletins, 2016). The physical examination and review of systems helped in obtaining subjective data that guided the course of treatment of the patient.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient\’s age, describe what exam findings could be abnormal.
The first examination performed on the patient was the breast exam that revealed results. Normal findings should reveal a bean bag-shaped breast with the nipple centrally located. There should be no swelling or tenderness except in the weeks before and during menstruation. There should be no lumps in the breast tissue or abnormal discharge from the nipples.
The second examination done during the visit was a pelvic exam that involved inspection of the genitalia and the cervix. Normal findings should reveal a warm and moist vagina with no foul-smelling discharge. Normal pap smear results should indicate the absence of HPV and be negative for intraepithelial lesion or malignancy (Koliopoulos et al., 2017). Regarding the bimanual examination results, normal finings should indicate a mobile non-tender cervix that rules out cervicitis and other diseases. The ovaries should be palpable and reduced in size based on the age of the patient. There should be no tenderness on palpation.
2c) Describe the normal findings for each system.
The first part during examination focuses on constitutional symptoms and vital signs. The normal findings should reveal Blood pressure: 90/60 mm Hg to 120/80 mm Hg, Respiration: 12 to 18 breaths per minute, Pulse: 60 to 100 beats per minute, Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C). Assessment of the patient revealed findings within the normal limits. The second part involved assessment of the head, eyes, ears, nose, and throat (HEENT) that revealed unremarkable results. The neck was of the normal size, midline trachea, and thyroid with no nodules. The cardiovascular system revealed normal S1 and S2 heart sounds with no murmurs, gallops, or rubs. The respiratory system was clear with good respiratory excursions while the musculoskeletal system revealed a normal range of motion. Neurologically, the assessment revealed equal reflexes, intact cranial nerves, and normal gait.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
The tools that would be used to examine the patient include a speculum, examination light, spatula, and cytobrush to sweep the cells from the cervix.
DOMAIN: ASSESSMENT (Medical Diagnosis)
3a, 3b, and 3c are not applicable because the study describes a wellness visit.
Domain: Laboratory & diagnostic tests
4a) What labs should be ordered in the case?
Laboratory investigations will include cervical cytology and HPV testing following a pap smear or examination under a microscope with an automated liquid-based pap cytology test (Jin, 2018). These tests involve analyzing the presence of high-risk types of HPV and the presence of abnormal cells in the cervix.
4b) Discuss what lab results would be abnormal.
A positive pap test means that there is the presence of unusual cells in the endocervix (Koliopoulos et al., 2017). It means that high-risk HPV was found but does not necessarily mean the patient has cervical cancer. Possible abnormal findings after a pap test include ASC-US, AGC, LSIL, ASC-H, HSIL, AIS, or cervical cancer.
4c) Discuss what the abnormal lab values indicate.
A positive pap test does not mean the presence of cervical cancer. For example, atypical squamous cells of undetermined significance (ASC-US) are the most common abnormal finding that means some cells are abnormal but it is not clear if the changes are caused by HPV infection (National Cancer Institute, 2021). Follow-up tests may be necessary for the patient after abnormal pap test results.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
There is no medical diagnosis for the patient because it is a wellness visit.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.
Following an initial pap test, it is recommended to have another test done after three years. Secondly, an HPV test is recommended every 5 years or an HPV/pap cotest could be done every five years (US Preventive Services Task Force (USPSTF), 2018). It is advisable for women in this age bracket to do HPV tests because it provides more reliable results compared to pap tests.

References
Committee on Practice Bulletins. (2016). Practice bulletin no. 168: Cervical cancer screening and prevention. (2016). Obstetrics and Gynecology, 128(4), e111–e130. https://doi.org/10.1097/AOG.0000000000001708
Jin J. (2018). Screening for Cervical Cancer. JAMA, 320(7), 732.
https://doi.org/10.1001/jama.2018.11365
Koliopoulos, G., Nyaga, V. N., Santesso, N., Bryant, A., Martin-Hirsch, P. P., Mustafa, R. A., Schünemann, H., Paraskevaidis, E., & Arbyn, M. (2017). Cytology versus HPV testing for cervical cancer screening in the general population. The Cochrane Database of Systematic Reviews, 8(8), CD008587. https://doi.org/10.1002/14651858.CD008587.pub2
National Cancer Institute. (2021). Cervical cancer: Next steps after an abnormal cervical cancer screening test: Understanding HPV and pap test results.
https://www.cancer.gov/types/cervical/understanding-abnormal-hpv-and-pap-test-results
US Preventive Services Task Force. (2018). Cervical cancer: Screening.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening

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How to write a nursing Advanced Health Assessment paper (Solved Case study)

How to write a nursing Advanced Health Assessment paper (Solved Case study)

Advanced Health Assessment case study SOLVED

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