Case 2

A 52-year old woman has recently moved to your city and you are listed as part of her health plan. She comes to your office because she feels she is in need of a general “check-up”. She does not have any complaints but she has a long tobacco history and this is what she is most concerned about. She has not seen a physician (nor has she had any testing) since she was treated for pyelonephritis 7 years ago.

1. What should be done on physical examination? Is there any evidence that a complete physical exam on a well patient is beneficial?
    
2. What screening tests and/or procedures will you recommend? Do you need additional history to determine which tests you should recommend? (Consult the above reading assignments to answer these questions. The consumer oriented sites http://www.ahrq.gov/ppip/healthywom.htm may also help.)
    
3. During the visit you find out that she has not had a pelvic exam or Papanicolou smear since the birth of her last child. She reports that she has not had a period in several years, is not currently sexually active, and so she does not see any reason to go through the discomfort and embarrassment of a pelvic exam. How would you counsel her? What is the likelihood of a false positive test on a Pap smear and what are the consequences of such a result?
    
4. When you recommend a mammogram, she reports that she does not have any pain in her breasts and does not see the need for this test. Several of her friends have had to undergo extra ultrasounds and biopsies because they had abnormal mammograms. She does not want something like this to happen to her because of the stress it will cause. She has also heard that the radiation from mammograms can cause cancer. How would you respond? What if she were 60 years old? What if she were 30 years old?