Case 1: Female Annual Exam Flashcards Preview

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Flashcards in Case 1: Female Annual Exam Deck (53):
1

Patient has increased risk of breast cancer if

first degree relative has had breast cancer

2

Does the USPSTF recommend breast self exams?

No

3

Does the USPSTF recommend clinical breast exams?

No

4

Does the ACS recommend clinical breast exams?

Yes - every 3 years for women 20-39 and every year for women > 40

5

Risk factors for HPV transmission (requires sexual contact) and results in squamous cell carcinoma (except DES)

- Early age of intercourse
- multiple sexual partners
- DES exposure in utero
- cigarette smoking
- immunosuppression

6

DES exposure in utero

Given to women until 1971 to prevent miscarriage - caused clear cell adenocarcinoma of vagina

7

Guidelines for cervical cancer screening

- 21 to 29: pap q 3 years
- 30 to 65 pap+co HPV test q 5 years or pap q 3 years
- > 65 stop screening if past 10 years have been normal (2 consecutive negative cotests or 3 consecutive negative pap smears)

Women who have undergone total hysterectomy for benign reasons do not require cervical cancer screening

8

Groups that need more frequent cervical cancer screening (4)

- immunocompromised
- HIV +
- history of CIN 2, 3, cancer
- DES exposure

9

Characteristics of good screening test (6)

- accurate (high sensitivity and specificity)
- detects disease in asymptomatic phase
- minimal associated risk
- reasonable cost
- acceptable to patient
- available treatment of disease

10

Lung cancer screening recommendation

Annual low dose CT scan for 30 pack year history ages 55-80

Must be current smoker or have quit within prior 15 yrs

11

Sensitivity

Higher sensitivity = fewer false negatives

12

Specificity

Higher specificity = fewer false positives

13

Recommendation for ovarian cancer in asymptomatic women

Do not do it!

14

There is ______ evidence regarding whether or not to recommend skin cancer screening

Insufficient

*Skin cancer is most common type of cancer but no screening test is in place

15

ACS breast cancer screening recommendations

40-44: patient's choice to start annual mammograms
45-54: annual mammograms
>55: switch to 2 years or continue annual

16

USPSTF breast cancer screening recommendations

50-74: biennial mammograms

<50: practice shared decision making with patient

17

If there are differences in recommendations, it is important to get

patient's input

18

Breast lump workup

1. History
2. Breast exam (suspicious if hard, immobile, > 2 cm, irregular borders)
3a. if cystic: FNA
3b. if solid: mammography

Use ultrasound to differentiate between cystic and solid if unsure

19

Medications that cause nipple discharge (4)

- antidepressants
- antipsychotics
- some antiHTN
- some opiates

20

If nipple discharge is present, must have further imaging studies (4)

Mammogram or
Ultrasound or
Ductogram or
Biopsy

21

Non modifiable breast cancer risk factors (6)

- increased exposure to breast cancer (menarche before 12, menopause before 65)
- first degree relative with breast cancer
- BRCA1/2
- Advanced age
- Female sex
- Dense breasts

22

Modifiable breast cancer risk factors (5)

- Age at first pregnancy
- DES exposure
- Hormone therapy
- Radiation
- Obesity

23

Protective factors for breast cancer (5)

- pregnancy at early age
- high parity
- late menses
- early menopause
- SERMs or NSAIDs

24

Nutritional recommendation to prevent breast cancer

Do not drink alcohol (smoking doesn't matter)

25

Tdap vaccination for 19-64

Tdap should replace Td if these pts have not received Tdap previously (<18)

26

Obesity = excess estrogen
BMI > 30

- at risk for breast cancer
- protective against menopausal Sx + osteoporosis

27

Menopause

one year without menses
- avg age: 51
between ages 40-60 (earlier in smokers)

Increased risk of cardiovascular disease and osteoporosis (bc of estrogen deficient state)

28

Perimenopause

2-8 years - irregular menses, can still get pregnant

29

Perimenopausal Sx (4)

- irregular menses
- hot flashes
- vaginal dryness (water lubricant)
- mood swings

30

Bone health recommendations

1000 mg of calcium for pre menopausal
1200 mg of calcium for post menopausal

Dietary = 3 to 4 servings of dairy

However, increased Ca puts pt at risk for CV disease and kidney stones - currently USPSTF recommends against Ca and Vit D supplementation in healthy pre or post menopausal women

31

Recommendation to avoid osteoporosis

- increase dairy intake
- include weight bearing exercises such as walking into daily routine

32

Osteoporosis screening

>65: DEXA scan
<65: DEXA scan if risk of fracture is = to 65 year old without risk factors (9.3% in 10 years)

33

RFs for osteoporosis (8)

1. Low estrogen state
2. Decreased calcium in diet
3. Lack of physical activity
4. Dementia
5. Family Hx of osteoporotic fracture
6. Personal hx of previous fracture as an adult
7. Smoking
8. Weight

34

Elevated BMI at risk for (6)

- hypertension
- coronary artery disease
- stroke
- osteoarthritis
- type 2 diabetes
- some cancer

35

Dietary guidelines on exercise

75 minutes of vigorous intensity or 150 minutes of moderate intensity/week
+ muscle strengthening 2x/week
Double for more extensive benefits

36

Smoking cessation strategies (9)

- Setting a quit date
- nicotine replacement
- support group
- 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 (identify triggers)
- Throwing away all tobacco and smoking paraphernalia
- Medication

37

One in __ women will have breast cancer before they are __ years old

8, 80

38

Mammography can identify breast cancer ___ to ___ years before detectable on exam

1 to 2 years

39

Adequate cervical specimen

Contains 5000 squamous cells
Has sufficient endocervical cells (columnar epithelial cells just proximal to squamo columnar junction at site of beginning dysplastic changes)

40

Bethesda cytology categories for cervical cancer

ASC: atypical squamous cells
LSIL: low grade squamous intra epithelial lesion
HSIL: high grade squamous intra epithelial lesion
Squamous cell carcinoma

41

3 vaccines for HPV - give all before sexual debut or shortly thereafter. All are 3 doses

1. Gardasil: quadravalent recombinant DNA (HPV4)
2. Cervarix: bivalent vaccine (HPV2)
3. Gardasil 9

42

Gardasil

6, 11 (genital warts)
16, 18 (most cervical cancer)

females & males 9-26

43

Cervarix

16, 18 (most cervical cancers)
31, 45

females 9-25

44

Gardasil 9

6, 11 (genital warts)
16, 18 (most cervical cancer)
31, 33, 45, 52, 58 (15% of cervical cancer)

females & males 9-26

45

Only screen for ovarian cancer in symptomatic patient:

Bimanual exam
Place non gloved hand on abdomen superior to symphysis pubis and feel for uterus between two hands, then move pelvic hand to each lateral fornix and try to capture each between the hands

Ovaries are usually palpable in slender women and not palpable in obese women

46

Mammography benefits

Good screening test that can detect asymptomatic early stage disease

47

Sensitivity of mammography

60-90%
Low sensitivity = mroe false negative results

48

False negative mammography results are more common in

younger women because they have denser breast tissue

49

Radiation exposure in mammography

is negligible

50

Breast MRI

Not recommended for screening in general population of asymptomatic, average risk women

51

Breast MRI indications

- surveillance of women more than 20% lifetime risk of breast cancer (genetic predisposition, mantle radiation for Hodgkin's disease)
- diagnostic tool to identify more completely extent of disease in pt w recent breast cancer diagnosis
- contrast enhanced breast MRI in evaluation of women with breast augmentation in whom mammography is difficult

52

Breast ultrasound

Not recommended for screening purposes
- used for evaluation of suspected abnormalities

53

ASC + but HPV negative

Recommend cotest every 3 years