Scenario 1, Part 1 of 2

Jane Morgan, a 34-year-old female sees her internist, Dr. Balfour with a complaint of a pea-sized breast lump. From the patient's history, Dr. Balfour learns that the lump will decrease in size after her periods. Also, Ms. Morgan's grandmother had breast cancer.

Dr. Balfour makes an initial exam at the first visit, and, when he re-examines Ms. Morgan after her menstrual cycle, documents that the lump has decreased.

See medical record

What did Dr. Balfour do to enhance this patient's care? 
Noted the occurrence of breast cancer in the patient's family.
Verified the patients report of the lump's variation in size.

What should Dr. Balfour do to enhance this patient's care? 
Ascertain and document when the lump was first noted, and whether it is persistent or recurring.
Order a mammogram immediately after the initial exam.