Routine breast cancer screening
Risk Factors: No personal history of breast cancer, no family history of breast or ovarian
cancer, non-smoker, normal weight, physically active.
Sarah presents for her routine annual wellness visit. She is due for a mammogram as part of her
breast cancer screening, in accordance with the guidelines which recommend mammography
starting at age 45 for women at average risk. She has no breast symptoms such as lumps, pain, or
discharge. Her last mammogram was 2 years ago, and she reports no issues during self-breast
exams.
Assessment:
Age: 48 (within the age range for routine screening)
No symptoms or risk factors (family history, genetic mutations, etc.)
No physical findings of concern during the clinical breast exam (CBE).
For women at average risk of breast cancer, mammography every 1-2 years is recommended.
Sarah is advised to continue routine screening.
Plan:
1. Mammogram Screening:
oDiscussed the importance of routine breast cancer screening starting at age 45 for
women with average risk and recommended mammogram as the appropriate
screening tool.
oProvided information on how the procedure works, including the use of
compression to obtain clear images and the duration of the exam.
oExplained that mammograms are essential for early detection of breast cancer,
which can be treated more effectively when caught early.
2. Scheduling the Procedure:
oSarah was given a referral to the radiology department for scheduling her
mammogram.
oProvided instructions on how to prepare for the mammogram, including avoiding
deodorants, lotions, or powders on the day of the exam as these can interfere with
imaging.
3. Follow-Up:
oSarah will follow up with the PCP after receiving her mammogram results. If the
results are normal, she will be scheduled for her next screening in 1-2 years.
oIf there are any abnormalities detected, she will be referred to a specialist for
further evaluation, such as ultrasound or biopsy.
4. Patient Education:
oEmphasized the importance of regular screenings even without symptoms, as
early-stage breast cancers may not present with noticeable signs.
