Fm Cases - Case 1

Front 1

Breast Sef-examinations

Back 1

1. Breast self-examination actually increases the number of biopsies performed

2. Patients who choose to perform self-examination should be trained in technique

3. Self breast exam allows motivated women to be in control of their health care

Front 2

Visual inspection of Breast

Back 2

1. symmetry

2. erythema

3. retractions/dimpling (lift hands overhead to accentuate any retraction or dimpling)

4. nipple changes

Front 3

Palpation of breast

Back 3

1) place hands over head -> flattening the breast tissue on the chest wall

2) Examine each breast using a vertical strip pattern using finger pads

3) palpate both axillary and supraclavicular lymph nodes.

Front 4

squamo-columnar junction

Back 4

area of the endocervix where there is rapid cell division and where dysplastic cells originate

Front 5

Pap -test

Back 5

Use cytobrush to get sample from

1) ectocervix (body of donut)

2) squamo-columnar junction of endocervix (the hole of donut)

Front 6

Bimanual Exam

Back 6

1) Lubricate index finger

2) Palpate cervix ensuring it's nontender& mobile

3) Place non-gloved hand on abdomen, superior to symphysis pubis, feel for uterus between your two hands (provides sense of size and position)

4) feel for ovaries

Front 7

Cervical Cancer Screening Guidelines

Back 7

• 21 y.o. = Begin cervical cancer screening

• Between 21-29 y.o. = perform every 3 years

• Between 30-65 y.o. = every 3 years w/ cytology alone OR every 5 years if co-test for HPV
• certain risk groups need Frequent testing

Front 8

Risk groups needing more frequent

Cervical Cancer Screening

Back 8

♀'s with

1) compromised immunity (e.g. HIV+)

2) history of cervical intraepithelial neoplasia grade 2, 3 or cancer

3) exposure to diethylstilbestrol (DES) in utero (DES = nonsteroidal estrogen once given to pregnant ♀ to prevent miscarriages but linked to clear cell adenocarcinoma of the vagina

Front 9

Who can stop cervical cancer screening

Back 9

> 65 y.o. ♀'s with adequate screening within the last ten years

Adequate screening = 3 consecutive normal pap tests with cytology alone or two normal pap tests if combined with HPV testing

Women who underwent total hysterectomy for benign reasons

Front 10

Risk factors for developing cervical cancer

Back 10

Virtually all cervical cancers are caused by infection with certain high-risk types of HPV

1) Early onset of sexual intercourse

2) Multiple sexual partners

3) Cigarette smoking & DES exposure in utero

4) Immunosuppression

Front 11

Characteristics of a Good Screening Test

Back 11

1) High sensitivity and specificity

2) Able to detect disease in an asymptomatic phase (this is why people die from lung cancer b/c no good screening test in asymptomatics)

3) Minimal risk (don't hurt patient with test)

4) Affordable (Reasonable cost)

5) Acceptable to patients (not super unpleasant)

Front 12

sensitivity

Back 12

• 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 (b/c it is catching almost all positives and even some negatives)

Front 13

Specificity

Back 13

• 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 (b/c it identifies most negatives correctly as negatives )

Front 14

Why is pap smear good screening test

Back 14

1) relatively inexpensive

2) easy to perform

3) acceptable to patients

4) Cervical cancer has long asymptomatic pre-invasive state (> 10 years)

5) effective treatments for pre-invasive disease

* Sensitivity only between 30-80% and a specificity of 86-100% but cervical cancer ↓ markedly b/c all other factors good

This means = that if you have + result, you almost certainly have Cervical cancer b/c specificty very good (captures all the true negatives). The problem is that if your result is Negative, you might still have Cervical Cancer b/c low Sensitivity (Only catches 30-80% of true positives)

Front 15

When to screen for ovarian cancer?

Back 15

Only in symptomatic Women

Front 16

When to screen for Endometrial cancer?

Back 16

Only post-menopausal women with unexpected symptoms bleeding or spotting

OR women with high risk for hereditary non-polyposis colon cancer (HNPCC)-> screening should be offered with endometrial biopsy beginning at age 35

Front 17

When to screen for lung cancer?

Back 17

Only patients 55-65 years old with 30-pack-history of smoking by low-dose CT scan

Front 18

US Preventive Services Task Force

Recommendations for Breast Cancer Screening Mammography

Back 18

Biennial screening mammography for women aged 50-74 years
(Grade B recommendation)

Amer. Cancer Society: Yearly mammograms starting at age 40 and continuing

Front 19

Evaluating a Breast Lump: History

Back 19

take a good history from the patient, including:

1) Precise location of lump

2) How first noticed (accidentally/breast self-exam/clinical breast exam/mammogram)

3)How long it has been present?

4) Presence of nipple discharge

5) Any change in size of the lump (is lump changing in size according to menstrual cycle)

Front 20

Evaluating a Breast Lump: Physical Exam

Back 20

Certain characteristics on physical exam increase suspicion of malignancy.

- Single, hard, immobile lesion of ~ 2 cm or Larger

- Irregular borders

Front 21

Evaluating a Breast Lump: Diagnostic tests

Back 21

If feels cystic -> aspiration can be attempted and the fluid sent for cytology

If feels solid -> mammography is the next step

Ultrasound can be helpful in distinguishing solid mass from a cystic lesion

Front 22

Evaluation of Nipple Discharge

Back 22

Physiologic:

• Pregnancy
• Excessive breast stimulation

Pathologic:

• Prolactinoma
• Breast cancer
  -Intraductal papilloma
  -Mammary duct ectasia -Paget's disease of the breast (malignantccancer of nipple/areola)
• -Ductal carcinoma in situ
• Hormone imbalance
• Injury or trauma to breast
• Breast abscess
• Use of medications (e.g. antipsychotics, some antidepressants/antihypertensive/opiates)

Front 23

What to ask about Nipple Discharge?

Back 23

Ask if discharge appears milky (check prolactin levels), purulent or bloody (more likely cancerous)

Front 24

Tests for milky discharge

Back 24

Exclude endocrinological reasons, then consider:

• Mammogram
• Ultrasound
• Ductogram, and/or
• Biopsy

Front 25

Mammography Benefits

Back 25

1) good screening test that can detect asymptomatic early stage disease

2) good evidence that mammography decreases breast cancer mortality

Front 26

Mammography Risks

Back 26

1) false positive -> unnecessary procedures

2) false negative -> gives false sense of security

Low sensitivity (60% and 90%) means more false negative results

3) Small radiation exposure

4) Discomfort

Front 27

Breast MRI

Back 27

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 (BRCA1/BRCA2) OR Hx of mantle radiation for Hodgkin’s Dz.

Potential diagnostic tool to identify extent of Dz. in patients w/ recently diagnosed breast cancer

Contrast-enhanced breast MRI may help in evaluation of patients w/ breast augmentation b/c mammography is difficult

Front 28

Breast Ultrasound

Back 28

Not recommended for screening

Used for evaluation of suspected abnormalities

Front 29

Risk factors for developing breast cancer in the general population?

Back 29

• Breast cancer in first-degree relative
• Prolonged exposure to estrogen (menarche before age 12 or menopause after age 45)
• Genetic predisposition (BRCA 1/2 mutation)
• Advanced age
• Increased breast density (Breast and connective tissue are denser than fat) - probably b/c the more breast cells/connective tissue cells, the greater the chance that one of them will become neoplastic, while adipocytes in breast do not become malignant cells b/c they are pretty quiescent
• Therapeutic radiation and
• Obesity - more estrogen release
• Advanced age at first pregnancy
• Exposure to diethylstilbestrol - synthetic nonsteroidal estrogen that was used to prevent premature labor
• Hormone Replacement Therapy

Front 30

Factors associated with decreased cancer rates

Back 30

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

Front 31

Breast cancer: EtOH and Smoking

Back 31

limiting alcohol intake helps But smoking DOes NOT Increase risk of breast cancer.

Front 32

Osteoporosis

Back 32

spinal or hip bone mineral density (BMD) of 2.5 standard deviations or more below the mean for healthy, young women (T-score of −2.5 or below) as measured by dual energy x-ray absorptiometry (DEXA).

Front 33

Osteopenia

Back 33

spinal or hip BMD between 1 and 2.5 standard deviations below the mean (T-score between -1 and -2.5).

Front 34

Menopause: Timing

Back 34

On average, women reach menopause at 51

A few start as young as 40, and a very few as late as 60

Smokers tend to start earlier than non-smokers

Can not be predicted

Front 35

When can menopause be confirmed?

Back 35

Only when woman has not menstruated for 12 straight months

Front 36

Perimenopause

Back 36

The gradual transition to menopause

- Ovaries don't abruptly stop; they slow down

- Still possible to get pregnant

- Ovaries still functional, & ovulation may occur intermittently (not monthly basis)

- Perimenopause can last from two to eight years.

Front 37

Menopause Symptoms expectation

Back 37

Menopause affects each woman differently

Some have no troubles, others have severe symptoms that drastically hamper their lives

Menstrual irregularity is the hallmark of perimenopause
(should call provider if their menses come very close together, if the bleeding is heavy, or if the bleeding lasts more than a week-> b/c could be cancer )

Front 38

Menopause symptoms due to estrogen deficiency

Back 38

1) Hot flashes - 30 seconds to ten minutes of heat with possible flushing of face and neck & temporary red blotches on chest, back, & arms

- Sweating and chills may follow

What helps? Dress in light layers, use fan, regular exercise, avoiding spicy foods & heat, and manage stress

2) Vaginal Dryness - intercourse uncomfortable, use lubricant, libido might change

3) Mood Swings - Mood swings, especially Depression, are common

Front 39

Role of Estrogen in Osteoporosis

Back 39

Estrogen has benefits for bones and heart

Bones: causes apoptosis of osteoclasts and blocks IL-6 (IL-6 stimulates osteoclasts)

Heart: vasodilatory effects cause lower BP -> less vascular damage (that is why women get CHD when post-menopausal)

Front 40

Calcium Intake

Back 40

premenopausal women: need ~1000 mg of calcium daily

postmenopausal women: need 1500 mg of calcium daily

Front 41

Dairy calcium content

Back 41

300 mg of calcium

8 oz. of yogurt

milk 1 cup

1.5 ounces of cheese

Front 42

Danger of Calcium supplementation for osteoporotic fracture prevention

Back 42

Increase the risk of atherosclerotic vascular disease as well as for kidney stones

USPSTF says to increase dairy intake & including weight bearing exercises such as walking into a daily routine

Front 43

Recommendations for Osteoporosis Screening

Back 43

- Women >65 years old, screen with DEXA

- women <65 years old - DEXA screening recommended if fracture risk > or equal to that of a 65-year-old white woman without additional risk factors (9.3 percent over 10 years) - use calculator

Front 44

Risk factors for osteoporosis

Back 44

Early menopause

Lack of physical activity

Obesity (BMI >30 (B)) -> high estrogen level and can be protective against menopausal symptoms and osteoporosis

White race

Family history of osteoporotic fracture

Personal history of previous fracture as an adult

Front 45

elevated BMI are at greater risk of developing

Back 45

1. High blood pressure
2. Coronary artery disease
3. Stroke
4. Osteoarthritis
5. Some cancers, and
6. Type 2 diabetes

Front 46

Recommended Physical activity

Back 46

Most recommend 20-30 minutes of moderate activity five to seven days a week

Some research suggests the need for > 30 minutes of physical activity to aid with weight loss

Front 47

Stages of Change Model

Back 47

Pre-contemplation Stage
Not even consider change. "in denial" Do not believe advice applies to them

Contemplation Stage
During the contemplation stage, patients are ambivalent about changing. Consider difficulties and benefits of change

Preparation Stage
prepare to make a specific change.

experiment with small changes as their determination increases (e.g. sampling low-fat foods)

Action Stage
At this point patients take definite action to change.

Maintenance Stage
This is the stage of continued commitment to sustaining new behavior. Physician should plan for follow up support and also discuss coping with relapse.

Relapse
Resumption of old behavior. Trigger for relapse should be evaluated. Motivation and barriers need to be reassessed and stronger coping strategies developed.