Family Med. Aquifer 1
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.
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.
A. Breast self-examination increases the number of biopsies performed.
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.
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.
,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.
When palpating, use the finger pads of the middle three fingers.
Vary pressure (light, medium, and deep) as you complete your exam.
Finally, palpate both axillary and supraclavicular lymph nodes.
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 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.
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