HEALTH MAINTENANCE SMALL GROUP DISCUSSION

Track D, September 17, 2015.

Case #1:
Maria is a 66 years old G3P3 Caucasian woman with history of HTN (tx with
enalapril), bronchial asthma (tx with albuterol, inhaled steroids and intermittently
with short courses of oral steroid), and diabetes type 2 (tx with Metformin). She
weighs 105 lbs and her height is 54. She has history of a vaginal hysterectomy at
53 years old due to symptomatic pelvic relaxation. She smokes half a pack of
cigarettes per day since age 22. Her last gyn visit was 3 years ago, when she had a
pap smear done that was negative for dysplasia; she denies history of any previous
abnormal pap smear. She had a colonoscopy at age 51 due to chronic diarrhea that
resolved; no pathology was identified during this study. Her last mammogram was
2 years ago. Her last vaccine was the influenza vaccine 5 years ago. The patients
family history is pertinent for diabetes, hypertension and breast cancer in one of her
sisters (diagnosed at age 67).
What health maintenance screening tests and recommendations are indicated in
this patient and why?
1. General Recommendations
a. Clinical physical breast exam, pelvic exam.
b. Check BP, blood glucose levels, HbAc1. Counsel patient on importance
on daily screening of glucose and BP.
c. Counsel for smoking cessation.
d. Low BMI; nutritional consultation and recommend vit D and Ca.
e. Influenza, DTaP, Zoster and Pneumococco vaccine.
2. Cervical cancer
a. Does not need anymore screening due to: Age >65 with normal pap
smear and no hx of dysplasia and a previous hysterectomy.
3. Osteoporosis
a. Risk factors: smoking, low BMI, taking short courses of steroids,
Caucasian, post menopause. Recommend DXA, Vit D and Ca, and
weight-bearing exercises.
4. Breast cancer
a. Risk factors: female age >65, first-degree relative. Recommend
clinical physical breast exam and mammography annually, monthly
manual examination. Age >65 increases risk by 4x.
5. Ovarian cancer
a. Does not require genetic testing; no symptomatology and no further
risk factors.
6. Colorectal cancer
a. Risk factors: Age>50, but no family hx. Recommend colonoscopy since
last one was >10years ago. Recommend follow-up in 10 years.

Case #2:
Cristina is a 19 years old G0 adolescent with history of bronchial asthma and
hypoglycemia. She denies history of surgeries or toxic habits. She has been
sexually active since age 15 and has had 3 partners. She refers she uses condoms
most of the time and denies history of any sexually transmitted infection. The
patients menarche was 4 years ago. This is her first gyn visit and is presenting
with a complaint of primary dysmenorrhea. Her last vaccines were at age 12 and
included the meningococcal and tetanus vaccines.
What health maintenance screening tests and recommendations are indicated in
this patient and why?
7. General Recommendations
a. Clinical physical breast exam, pelvic exam.
b. Counsel patient on safe sex practices, contraceptives and domestic
violence.
c. Order bHCG, VDRL, chlamydia, gonorrhea, HIV.
d. Order pelvic sonogram to R/O PCOS, Endometriosis, cysts.
e. Check fasting plasma glucose.
f. Recommend folic acid.
8. Cervical cancer
g. Do not recommend pap smear; age <21. Follow-up at 21.
h. HPV vaccine.
9. Osteoporosis
i. Counsel on taking Vit D, Calcium, and regular excersice.
10.Breast cancer
j. Clinical physical examination.
11.Ovarian cancer
k. Does not require genetic testing; no symptomatology and no further
risk factors.
12.Colorectal cancer
l. Do not recommend screening until age 50. Inquire about family hx.

Case #3:
Melissa is a 35 years G2P1A1 patient without history of any medical condition. The
patients surgical history includes a cesarean section 2 years ago. Her last pap
smear was 2 years ago; she denies history of any abnormal cytology. Maria denies
any toxic habits and has been in a monogamous relationship with her husband for 8
years. Her family history is pertinent for her parental grandmother diagnosed with
breast cancer at age 68; she also mentions that her younger sister was removed a
benign breast tumor in her 20s. Her last vaccine was at age 18 when she was going
to start college.
What health maintenance screening tests and recommendations are indicated in
this patient and why?
13.General Recommendations
a. Clinical physical breast exam, pelvic exam.
b. Recommend influenza, DTaP vaccines; no HPV vaccine.
c. Offer HIV screening.
d. Offer HPV testing.
14.Cervical cancer
e. No pap smear recommended, recommended once every 3 years after
age >21. Recommend HPV testing every 5 years along with pap smear.
15.Osteoporosis
f. No screening. Counsel on taking Vit D, Ca and regular exercise.
16.Breast cancer
g. Family hx of breast cancer is not significant to merit genetic testing.
Recommend manual examination and follow-up checks.
17.Ovarian cancer
h. Does not require genetic testing; no symptomatology and no further
risk factor.
18.Colorectal cancer
i. Do not recommend screening until age 50. Inquire about family hx.

Case #4:
Delia is a 38 years old G0 obese patient with history of HTN (tx with diuretics),
hirsutism and hypothyroidism (tx with synthroid). She denies any surgeries or toxic
habits. Her menses are very irregular, occurring only 3-4 times each year. She has
been living with her current for over 5 years and despite using no contraception she
has not been able to get pregnant. Her last pap smear was 1 year ago; 5 years ago
she was treated with a LEEP due to CIN 2,3. At age 27 she was treated with
radiotherapy due to a thyroid carcinoma. Her family history is pertinent for a sister
with endometrial carcinoma diagnosed at age 41, an aunt diagnosed with breast
cancer at age 43 and her mother diagnosed with breast cancer at age 49. She had
an influenza vaccine last year during flu season and had a tetanus toxoid booster 7
years ago.
What health maintenance screening tests and recommendations are indicated in
this patient and why?
19.General Recommendations
j. Clinical physical breast exam, pelvic exam.
k. Order TSH, check BP, glucose levels.
l. Order transvaginal sonogram to R/O PCOS
20.Cervical cancer
m. Recommend routine cytology screening (pap smear) and HPV testing
every 5 year, including now, for at least 20 years after first CIN 2,3
positive pap smear, reevaluate at age 65.
21.Osteoporosis
n. No screening. Counsel on taking Vit D, Ca and regular exercise. Risk
factor of hypothyroidism, counsel for screening starting at age 65.
22.Breast cancer
o. Family hx of breast cancer is significant; recommend genetic testing for
BRCA 1&2 gene mutation and other genetic mutations, if patient is
positive for mutations, annual breast MRI would be advised. Order
mammogram. Follow-up with twice yearly clinical breast examinations.
Instruct for manual self-examination and self-awareness.
23.Ovarian cancer
p. Order transvaginal sonogram to rule out.
24.Colorectal cancer
q. Do not recommend screening until age 50. Inquire about family hx.