FM_CASES_QUESTIONS
FM_Cases#01:---45 year old female annual exam
QUESTION #1 (Case#1)
A 34-year-old woman who has no past medical problems nor is currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She...
1 fmcasesquestions fmcases01 45 year old female annual exam question 1 case1 a 34 year old woman who has no past medical problems nor is currently taking any medications comes into your office
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FM_CASES_QUESTIONS
FM_Cases#01:---45 year old female annual exam
QUESTION #1 (Case#1)
A 34-year-old woman who has no past medical problems nor is currently taking any medications comes into
your office because she noticed a tender lump in her left breast starting approximately one month ago. She is
worried because she has an aunt who had breast cancer that was BRCA positive. Her periods have been regular
since they started at the age of 12 and occur every 32 days. She is currently menstruating. She has three children
aged 12, 9, and 4. On exam, her BMI is 32 and her other vital signs are stable. On breast exam, you note a
mobile rubbery mass of approximately 1 x 1cm and with regular borders that is tender to palpation.
You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information
provided, which of the following places this patient at increased risk for breast cancer?
A. Age
B. Weight
C. Parity history
D. Family history of cancer
E. Age of menarche
Correct Answer Q1C1 B. Weight has been selected by the expert.
With a BMI of 32, obesity is the one risk factor for this patient based on the information given.
Other risk factors for breast cancer include family history of breast cancer in a first degree relative (mother
or sister - not aunt), prolonged estrogen exposure (menarche before age 12, menopause after 45, advanced
age at first pregnancy), genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast cancer risk
increases with age, and this patient is relatively young), female sex, increased breast density and certain
exposures (diethylstilbestrol, hormone or radiation therapy, heavy smoking).
QUESTION #2 (Case#1)
A 64-year-old woman who is overweight with well-controlled hypertension comes to your office
complaining of a lump in her breast that she noticed while showering. She denies any pain, tenderness,
or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first
child was born when she was 29 and she had her second and last child at the age of 33. She experienced
menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed
away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and
occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of the information provided thus
far puts the patient at decreased risk for breast cancer?
A. Age
B. Weight
C. Age at first birth
D. Age of menarche
E. Age of menopause
Correct Answer Q1C1 E. “Age of Menopause” has been selected by the expert.
The patient experienced menopause at the age of 44, which shortens her time of estrogen exposure, a known risk factor
for the development of breast cancer. Factors associated with decreased breast cancer risk include pregnancy at an early
age, late menarche, early menopause, high parity and medications such as selective estrogen receptor modulators along
with NSAIDs and aspirin. Risk factors for breast cancer include family history of breast cancer in a first degree relative
(mother or sister), prolonged estrogen exposure (menarche before age 12, menopause after 45, advanced age at
pregnancy, obesity after menopause), female sex, genetic predisposition (BRCA 1 or 2 mutation), advanced age (breast
cancer risk increases with age), increased breast density and exposures (diethylstilbestrol, hormone or radiation therapy,
smoking).
, 2
QUESTION #3 (Case#1)
A 63-year old woman comes into your office for her annual preventive exam. She has hypertension and
type 2 diabetes. She is not sexually active and experienced menopause at the age of 52. Her blood
pressure is 125/80 and her physical exam otherwise is within normal limits. You recommend influenza
and zoster vaccination. Her last colonoscopy was eight years ago and her last mammogram one year
ago was normal. She has never had an abnormal Pap smear. At the age of 45 she had a total
hysterectomy for fibroids. You tell her she does not require a Pap smear today because:
She has never had an abnormal Pap smear
She is not sexually active
She had a total hysterectomy for fibroids
She is 63 years old
She experienced menopause more than 10 years ago
CORRECT ANSWER: “C” C has been selected by the expert.
The patient described above underwent a total hysterectomy (total removal of the uterus and cervix with or
without oophorectomy) for benign reasons (fibroids). USPSTF guidelines recommend against continued
cervical cancer screening in patients whose uterus has been removed for benign disease and evidence showed
cytologic screening to be very low yield and poor evidence that screening to detect vaginal cancers improves
health outcomes in women after hysterectomy for benign disease. Cervical cancer screening should begin at the
age of 21 and women between the ages of 65 and 70 who have had three or more normal Pap tests in the past
ten years may choose to stop cervical cancer screening. Not being sexually active; age 63; only having had
normal PAP smears and years since menopause are not reasons to stop screening for cervical cancer.
QUESTION #4 (Case#1)
A 47-year-old woman comes into your office for a health care maintenance exam. She
has hypertension and type 2 diabetes. She is not sexually active and has not yet
experienced menopause. There is no family history of cancer. Her blood pressure is
118/78, her BMI is 34 and the remainder of her physical exam is within normal limits. Her
vaccinations are up-to-date, she has a PAP smear today and will have labs drawn.
According to USPSTF, which of the following is the best recommendation to give her
concerning mammography?
A. Should have started at age 40 and every year thereafter
B. Should have started at age 40 and every 2 years thereafter
C. Start at age 50 and every year thereafter
D. Start at age 50 and every 2 years thereafter
E. Screening mammography is not recommended at this time
CORRECT ANSWER: “D”—Start at age 50 and every 2 years thereafter
Mammography has a sensitivity of 60-90% for detecting breast cancer and decreases breast cancer mortality.
According to the most recent USPSTF guidelines, routine mammography is not indicated for women younger than
50 years old unless they fall into a high-risk category such as women with a BRCA mutation. The USPSTF
recommends biennial testing for women between the ages of 50-74 years of age. There is insufficient evidence to
assess the benefits versus risk of screenings in women after the age of 75. Other groups such as the American Cancer
, 3
Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) recommend yearly
mammograms starting at age 40, continuing as long as the woman is in good health.
QUESTION #5 (Case#1)
A 27-year-old woman comes into your office because she heard from her friend about a
vaccination against cervical cancer and would like one. She has no medical problems and
has had a Mirena IUD for three years. She has an allergy to latex and penicillin. She
began having sex at the age of 18 and is currently sexually active with one partner. She
occasionally uses condoms. She smokes half a pack of cigarettes per day. Her mother
had endometrial cancer several years ago and had a total hysterectomy. Why is the
patient not a good candidate for the Gardasil vaccination?
A. Age
B. Sexual activity
C. Mirena IUD
D. Allergy to penicillin
E. Family history of endometrial cancer
F. Tobacco use
CORRECT ANSWER: “A”—Age
Gardasil is a vaccination against HPV types 6, 11, 16, and 18 approved for females ages 9 to 26. Cervarix protects
against serotypes 16, 18, 31 and 45 approved for ages 10 to 25. Both are a series of three shots and recommended for
females ages 11-18, optimally before sexual debut or shortly thereafter. The patient above is too old to receive the
vaccination. Though vaccination before sexual debut is preferred, sexual activity (choice b) is not a contraindication
to Gardasil vaccination. The other choices are not contraindications to vaccinations.
FM_Cases#02:---55 yo male annual exam
A 55-year-old male with no significant past medical history presents for a routine
physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35-
pack-year tobacco history since the age of 20. He indicates that his wife and children
have urged him to quit smoking for the last few months. When you ask him if he has
considered quitting, he replies, "I just don't see what the big deal is!" Which stage of
change best describes this patient at this time?
A. Precontemplation
B. Contemplation
C. Preparation
D. Action
E. Maintenance
ANSWER:--A Precontemplation
Based on this man's response, it appears he has not actively considered quitting
smoking despite his family's concern. All stems refer to a different stage in the
, 4
Transtheoretical stages of change model. Given that he has not actively contemplated
quitting, the best stage to describe this patient at this time would be the
Precontemplation stage and not any of the other responses.
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