A 39-year-old man presents for his annual physical examination. He has a history of asthma, pre-hypertension, and Gilbert syndrome. The patient smokes a pack of cigarettes per day, but is pleased because he has cut it down from 2.5 packs per day. He has smoked since the age of 20. The patient is motivated at this visit to seek assistance in smoking cessation.
Which of the following medications can help him quit smoking in both the short and long term?
Bupropion. Bupropion is a drug primarily used as an atypical antidepressant and is used in smoking cessation. It is the most commonly used medication in increasing short- and long-term smoking cessation rates. Of note, varenicline is another smoking cessation medication that is thought to be even more effective than bupropion in short- and long-term smoking cessation rates. Varenicline acts via partial agonism of nicotinic acetylcholine receptors. Nicotine-replacement therapy, either alone or in addition to bupropion or varenicline, can also be used and may be more effective than using either medication alone. Bupropion is unique compared to the other antidepressant drugs in that it has no sexual side effects. It should not be used in bulimic patients and those at risk of seizures because it can lower the seizure threshold. (A) Propranolol is a nonselective β-blocker used in several clinical contexts, but not in smoking cessation. (B) Buspirone is an anxiolytic psychoactive drug and is primarily used to treat generalized anxiety disorder. Some researchers postulate some efficacy of buspirone in smoking cessation but data is still limited. (D) Paroxetine is an SSRI used in depression; SSRIs have not been shown to work for smoking cessation.
A 9-year-old boy presents with his mother for a health evaluation. They just moved from China and the mother reports that her family has experienced many deaths from cancer and she is concerned about her child’s health. Physical examination reveals a healthy boy with unremarkable findings. Laboratory values are all within normal limits.
Which of the following vaccines can be given to this patient to reduce his risk of developing cancer?
Hepatitis B vaccine. Of the four choices, only hepatitis B vaccine can diminish the risk of developing cancer. Chronic hepatitis B infection can cause hepatocellular carcinoma (HCC). In parts of Asia, chronic hepatitis B infection is most often caused by vertical transmission from mother to child. In the United States, however, it is most often contracted through blood (needlesticks, sexual intercourse, etc.). Vaccination against hepatitis B ensures that the virus is never contracted and therefore prevents the development of HCC. Importantly, there are two infections that increase the rate of cancer for which there are vaccines: Hepatitis B and HPV. (A, C, D) The other choices no not protect against any cancers.
A 69-year-old woman presents for a routine physical examination. The patient feels well and has no active complaints today. She has never smoked and does not drink alcohol. The patient has an insignificant past medical history and says she feels “blessed” because everyone in her family has “died of old age.” Two years ago at her last appointment, the patient had a mammogram (normal result), Pap smear (normal result), and lipid panel. She had a colonoscopy 8 years previously that showed no lesions or polyps.
Which of the following should be performed at this visit?
Mammogram. According to the USPSTF, mammograms should be performed every 2 years for women between the ages of 50 and 74. Furthermore, beyond the age of 75, routine mammograms are not recommended and should only be performed in case-by-case situations. This patient received her last mammogram 2 years ago and therefore is due for another. (A) Colonoscopy should be performed every 10 years between the ages of 50 and 75. This patient had a normal colonoscopy 8 years ago. (B) Lipid panel screening should be performed in men starting at 35 years (average risk) and in women starting at 45 years (average risk). Performing lipid screening every 5 years is currently recommended. This patient had a lipid panel 2 years ago. (D) Pap smears can be discontinued at the age of 65 if the patient received adequate screening up to that age without evidence of premalignancy/malignancy.
A 29-year-old medical student is injured via needlestick while drawing blood from a patient with chronic hepatitis B. The patient received his final hepatitis B vaccination of the series 8 years ago. The patient had his titers checked before clinical rotations 6 months ago and was found to be positive for anti-hepatitis B surface antibodies (HBsAb).
Which of the following is the best next step in the management of this patient?
Reassurance. This patient demonstrates immunity to hepatitis B (positive for HBsAb) and therefore reassurance should be offered. Immunity to hepatitis B occurs when anti-hepatitis B surface antibodies (HBsAb) develop against the recombinant hepatitis B surface antigen. Given the patient’s documented hepatitis B vaccination and positive titers for HBsAb, reassurance is appropriate. (A, C) If the patient had unknown vaccination history, he should receive both HBIG (passive immunity) and hepatitis B vaccine (active immunity). (B) The patient has documentation already revealing positivity for HBsAb. Therefore, a hepatitis B panel is unnecessary. The patient should be tested for HIV and HCV as well, and HIV postexposure prophylaxis should be considered.
A 60-year-old man presents for his annual physical examination. The patient feels well and has no active complaints. The patient takes atorvastatin for hyperlipidemia. The patient has no family history of cancer. His blood pressure is 128/64 mmHg and his pulse is 82/min. A digital rectal examination is performed and shows an enlarged, smooth prostate. Fecal occult blood test is negative. The patient had a colonoscopy 7 years ago that was normal. His lipid panel was within normal limits at his last visit 1 year ago.
Which of the following is the best next step in managing this patient?
Conversation with the patient regarding PSA testing. The current guidelines for prostate cancer screening are slightly controversial. The USPSTF currently does not recommend screening with PSA for any age. The USPSTF justifies this recommendation by citing the high rate of false positives, causing further unnecessary tests and procedures that lead to significant pain and side effects (impotence and incontinence). Although several associations differ with respect to prostate screening guidelines, screening decisions should be discussed with the patient so he can decide based on the known risks and benefits of screening with PSA.
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