A 64-year-old woman presents to the physician with the request of being screened for bladder cancer. She feels well and has no complaints, but her sister just passed away from bladder cancer and she would like to determine if she has it as well. She smokes 2 packs of cigarettes per day and drinks 2 to 3 glasses of red wine per day. Physical examination shows an obese woman with wheezing on lung auscultation and an increased expiratory phase.
Which of the following is the most appropriate next step in management based on this patient’s request?
No screening. Although bladder cancer is the second most common urologic cancer, the USPSTF does not recommend screening for bladder cancer. The recommendations are based on the fact that the current screening modalities (UA, cytology, bladder tumor antigen) all have low incidence and very low positive predictive value. Therefore, screening for bladder cancer is not recommended even in those patients at risk for developing the disease (cigarette smoking, industrial chemical exposure, etc.).
A 67-year-old man presents to the physician for his annual health maintenance examination. The patient feels well and has no active complaints. He has a history of type 2 diabetes and hypertension. He smoked a pack of cigarettes per day for 5 years (between the ages of 34 and 39). He drinks 1 to 2 beers per day but denies any illicit drug use. He is up-to-date on his colonoscopy screening and lipid panel screening. He has been reading about abdominal aortic aneurysms and would like to know if he should be screened or not for this disease.
Which of the following is the next step with respect to this patient’s inquiry?
Ultrasound of the abdomen. The USPSTF recommends a single screening ultrasound for abdominal aortic aneurysm (AAA) in men aged 65 to 75 years who have any history of smoking. AAAs are often asymptomatic until they rupture, which has a high mortality rate when this occurs; therefore, screening in this group is highly recommended. Ultrasound is the best modality since it is noninvasive and cost-effective. A surgical intervention is often recommended if the aneurysm grows more than 1 cm per year or if it is bigger than 5.5 cm. Of note, screening is not recommended in women.
A 27-year-old man presents to the physician for a travel medicine appointment. The patient will be visiting several developing countries in North Africa for 2 months as part of an anthropologic research endeavor. The patient has an insignificant past medical history and drinks 2 to 3 beers per week. He has never traveled outside of the United States before. Physical examination is unremarkable.
Which of the following should be offered to this patient at this time?
Hepatitis A vaccine. Travel medicine appointments are critical in order to determine what infectious diseases travelers will be exposed to in their destination. The risk of contracting hepatitis A is pronounced for those travelers going to developing countries and this patient should receive vaccination against hepatitis A. A one-time dose of hepatitis A vaccine offers short-term protection for a young adult; however, a second dose should be administered for long-term immunity. (A) Meningococcal vaccine might be necessary for travelers going to Asia and sub-Saharan Africa, but not North Africa. (B) Pneumococcal vaccine is recommended for young children, those older than 65 years of age, and young adults with certain chronic diseases. (D) Yellow fever vaccine is to protect against a mosquito-borne viral hemorrhagic fever. This is endemic to tropical regions of sub-Saharan Africa and parts of South America.
A 37-year-old HIV positive man presents for a routine visit. He is new to this city as his job relocated him and he is here to establish care. He contracted HIV through intravenous drug use 15 years ago. He is married to his wife of 10 years who is HIV negative. They have a monogamous sexual relationship. The patient is diligent with his HIV medications and endorses “100% safety” with sexual intercourse with his wife to ensure no transmission. The patient reports that he received all his childhood vaccinations and immunizations. He feels well today and has no active complaints.
Which of the following vaccinations is appropriate to offer to this patient today?
Tetanus and diphtheria toxoid booster. It is critically important to understand vaccinations in the HIV positive population. Several vaccines are beneficial to HIV positive patients and several are contraindicated. All HIV positive patients should receive the influenza virus vaccine and the hepatitis B vaccine at diagnosis. Pneumococcal vaccine should also be administered. Furthermore, the meningococcal vaccine, HPV vaccine, and H. influenzae type B vaccine are administered in the same guidelines as all adults. Similarly, patients with HIV should receive a tetanus and diphtheria toxoid booster every 10 years. Since the patient last received vaccines in childhood (>10 years ago), he should receive a tetanus and diphtheria toxoid booster.
(A) Meningococcal vaccine in HIV positive patients is administered according to the same guidelines as all adults (college age, living in dormitories or barracks, asplenic individuals, and certain travel destinations). (B) Hepatitis A vaccine is administered to men who have sex with men. This patient is monogamous with his wife and contracted HIV through intravenous drug use. It actually would be a good idea to give this patient hepatitis A vaccination, but this is not the best answer. (D) No vaccination is inappropriate. The patient should get influenza virus vaccine, the hepatitis B vaccine, pneumococcal vaccine, and tetanus and diphtheria toxoid booster.
A 65-year-old woman presents to the physician for her annual physical examination. The patient is up-to-date on vaccinations and had a mammogram done at her previous appointment 1 year ago that was normal. She had a colonoscopy performed 6 years ago that was normal. The patient is otherwise healthy and reports drinking 1 to 2 glasses of wine per week with her girlfriends at their weekly lunch outing.
Which of the following should be recommended to this patient at her visit today?
Dual-energy x-ray absorptiometry (DEXA). Risk factors for osteoporosis include smoking, family history, low body weight, excessive alcohol use, and secondary organic causes such as premature menopause, among others. Although this patient is not demonstrating risk factors for developing osteoporosis, the USPSTF recommends a one-time screening for osteoporosis in all women aged 65 years or older with DEXA scan of the spine and hips. A bone density with T-score <2.5 standard deviations below the mean is associated with osteoporosis and a T-score between 1 and 2.5 standard deviations below the mean is associated with osteopenia. (A) The patient had a normal mammogram the year before. Mammograms should be performed every 2 years in her age group. (B) The patient had a colonoscopy 6 years ago that was normal. She is due for another colonoscopy in 4 years (reaching the 10-year mark after her previous one). (C) Calcium and phosphorus levels are normal in patients with osteoporosis and have no value in screening for the condition.
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