You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.

1a) Identify two (2) additional questions that were not asked in the case stud 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.

For each system examin in this case;
2a) Explain the reason the provider examin each system.
2b) Describe how the examM 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 examM findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examin 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’

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.



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.”

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.



“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.”


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.


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.


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.


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.


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


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.


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.


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.


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.


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?”

Characteristics of a Good Screening Test

1. Accuracy (high sensitivity and specificity)


· 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.


· 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.

2. Able to detect disease in an asymptomatic phase

3. Minimal associated risk

4. Reasonable cost

5. Acceptable to patient

6. There is an available treatment for the disease


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.


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.


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.


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.


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


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.


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.


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.


Breast Cancer Screening Studies



Mammography is a good screening test that can detect asymptomatic early stage disease, and there is good evidence that mammography decreases breast cancer mortality.


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.


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.


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.

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.”




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.


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.


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.


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


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.


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.

· 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.”



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.”


“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!


“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.


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


· 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).


The Bethesda System for Reporting Cervical Cytology

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

1. 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.”

2. General categorization of results

Is there any evidence of intraepithelial lesion or malignancy?

3. 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.


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.


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.

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