A 65-year-old man presents for a routine health maintenance examination. The patient endorses moderate wheezing and shortness of breath. He has smoked 3 packs of cigarettes per day for the past 40 years and is being treated for COPD. He drinks 3 to 4 beers per day. The patient has a family history of pancreatic cancer (his brother passed away from pancreatic cancer 2 years ago). He would like to be screened today for pancreatic cancer.
Which of the following is the screening test of choice for pancreatic cancer?
No screening recommendations. Although pancreatic cancer has a high mortality rate (up to 98% 5-year mortality), no blood test or imaging modality have been shown to be effective in screening for pancreatic cancer in asymptomatic patients. It usually presents at an advanced or metastatic stage and presents with several vague nonspecific symptoms. Interestingly, close to 8% of patients with pancreatic cancer have a family history, so much research is being devoted to finding a screening test. (B) This is the screening test for abdominal aortic aneurysm (AAA). (D) CA 19 to 9 is a protein specific to the pancreatic cancer cells, but is not useful as a screening marker. Rather it is best implemented as a marker of response to treatment.
A 29-year-old woman presents for a routine health maintenance examination. She feels well and other than some mild dyspnea with exertion has no active complaints. She reports that she is concerned about getting colon cancer since her father died at the age of 47 from advanced colon cancer (after being diagnosed at the age of 46). She wants to know when she should be screened for colon cancer.
Which of the following is the most appropriate screening for this woman?
Colonoscopy at age 36. According to both the USPSTF and the American Cancer Society, the recommend screening for colorectal cancer is between the ages of 50 and 75 years with sigmoidoscopy every 5 years, colonoscopy every 10 years, or annual fecal occult blood testing. The most sensitive and specific test is colonoscopy. For those at high risk, particularly those with an affected first-degree relative, screenings begin at the age of 40 or 10 years before the age the relative was diagnosed. In this case, the patient’s father was diagnosed at the age of 46, so she should get her first colonoscopy at the age of 36 (46 minus 10). (C) Colonoscopy at the age of 40 is recommended in high-risk patients (unless the age of the affected relative is lower than 50 at which point screenings should begin earlier (subtract 10 from the age). (D) Colonoscopy at age 50 is the right answer for screening of a patient with average risk of developing colon cancer.
A 59-year-old woman suffers from traumatic brain injury and is admitted to the intensive care unit. She is unresponsive to commands and a gastrostomy tube is placed for feedings.
Which of the following is the best way to prevent decubitus ulcers in this patient?
Reposition patient every 2 hours. Decubitus ulcers, also known as pressure ulcers, are localized injuries to the skin that usually occur over a bony prominence as a result of pressure. Patients at risk are those that are critically ill and suffering from immobility, poor nutrition, and sensory impairment secondary to diabetes or other two states. The best way to prevent decubitus ulcer formation is to reposition the patient every 2 hours (the point at which tissue damage occurs is 2 hours after entering a new position). (A) Antibiotics would be helpful in treating infected ulcers, but not recommended to prevent decubitus ulcers. (C) Pneumatic compression devices are used to prevent deep venous thromboses in patients with venous insufficiency. (D) On the contrary, air and foam mattresses should be used to prevent decubitus ulcers since they sufficiently distribute pressure over a larger area.
A 41-year-old woman with HIV presents for routine examination. She feels well and has no active complaints. Her recent CD4 count is 550/mm3 and her viral load is 3,000 copies/mL. Routine titers are drawn and show that the patient has no immunity against mumps or measles.
Which of the following is the next best step in the management of this patient?
Administer the measles, mumps, rubella (MMR) vaccine today. Given that patients with HIV are at significant risk for several infections, they should receive several vaccinations at the time of diagnosis (influenza, hepatitis B, pneumococcal). Nonetheless, several live vaccines are contraindicated in patients with HIV. The MMR vaccine is one of the live vaccines; however, it can be administered to HIV positive patients with a CD4 count of 200/mm3 or greater (and without evidence of AIDS-distinguishing illness). The reason that the live MMR vaccines is administered to HIV positive patients is that measles can be life-threatening to HIV positive patients. Live vaccines that are always contraindicated in HIV positive patients are BCG, anthrax, oral typhoid, oral polio, intranasal influenza, and yellow fever vaccines.
A 3-year-old boy presents to the physician and is diagnosed with Bordetella pertussis. His mother endorses that he has had several unpredictable coughing episodes. He is given azithromycin for treatment. He lives in the same house with his parents and two sisters (ages 5 and 7). All family members are current on their immunizations.
Which of the following is the recommended treatment for his family members?
Administer azithromycin to all family members. Bordetella pertussis is very contagious and is transmitted via respiratory secretions and droplets. Treatment is with a macrolide antibiotic (azithromycin, clarithromycin, or erythromycin) and should be initiated as soon as possible to shorten the course. Even though immunization can prevent the vast majority of pertussis cases, exposed family members can still develop symptoms since immunity wanes over time. (A, C, D) As a result, prophylactic antibiotics (macrolides) are recommended for all close contacts regardless of vaccination status. Furthermore, close contacts who are not fully immunized should also receive the pertussis vaccination.
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