FM_CASES_QUESTIONS | VERIFIED SOLUTION

FM_CASES_QUESTIONS FM_Cases#01:---45 year old female annual exam QUESTION #1 (Case#1) A 34-year-old woman who has no past medical problems nor is currently taking any medications comes into your office because she noticed a tender lump in her left breast starting approximately one month ago. She is worried because she has an aunt who had breast cancer that was BRCA positive. Her periods have been regular since they started at the age of 12 and occur every 32 days. She is currently menstruating. She has three children aged 12, 9, and 4. On exam, her BMI is 32 and her other vital signs are stable. On breast exam, you note a mobile rubbery mass of approximately 1 x 1cm and with regular borders that is tender to palpation. You appreciate no axillary adenopathy. The rest of her physical exam is unremarkable. Of the information provided, which of the following places this patient at increased risk for breast cancer? A. Age B. Weight C. Parity history D. Family history of cancer E. Age of menarche Correct Answer Q1C1 B. Weight has been selected by the expert. QUESTION #2 (Case#1) A 64-year-old woman who is overweight with well-controlled hypertension comes to your office complaining of a lump in her breast that she noticed while showering. She denies any pain, tenderness, or skin changes. A pertinent review of systems is negative. Menarche began at the age of 10. Her first child was born when she was 29 and she had her second and last child at the age of 33. She experienced menopause at the age of 44. Her mother died of colon cancer when she was 65 and her father passed away from metastatic prostate cancer at the age of 70. She has no history of tobacco use ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of the information provided thus far puts the patient at decreased risk for breast cancer? A. Age B. Weight C. Age at first birth D. Age of menarche E. Age of menopause 2 QUESTION #3 (Case#1) CORRECT ANSWER: “C” C has been selected by the expert. QUESTION #4 (Case#1) A 47-year-old woman comes into your office for a health care maintenance exam. She has hypertension and type 2 diabetes. She is not sexually active and has not yet experienced menopause. There is no family history of cancer. Her blood pressure is 118/78, her BMI is 34 and the remainder of her physical exam is within normal limits. Her vaccinations are up-to-date, she has a PAP smear today and will have labs drawn. According to USPSTF, which of the following is the best recommendation to give her concerning mammography? A. Should have started at age 40 and every year thereafter B. Should have started at age 40 and every 2 years thereafter C. Start at age 50 and every year thereafter D. Start at age 50 and every 2 years thereafter E. Screening mammography is not recommended at this time CORRECT ANSWER: “D”—Start at age 50 and every 2 years thereafter Mammography has a sensitivity of 60-90% for detecting breast cancer and decreases breast cancer mortality. According to the most recent USPSTF guidelines, routine mammography is not indicated for women younger than 50 years old unless they fall into a high-risk category such as women with a BRCA mutation. The USPSTF recommends biennial testing for women between the ages of 50-74 years of age. There is insufficient evidence to assess the benefits versus risk of screenings in women after the age of 75. Other groups such as the American Cancer 3 Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) recommend yearly mammograms starting at age 40, continuing as long as the woman is in good health. QUESTION #5 (Case#1) A 27-year-old woman comes into your office because she heard from her friend about a vaccination against cervical cancer and would like one. She has no medical problems and has had a Mirena IUD for three years. She has an allergy to latex and penicillin. She began having sex at the age of 18 and is currently sexually active with one partner. She occasionally uses condoms. She smokes half a pack of cigarettes per day. Her mother had endometrial cancer several years ago and had a total hysterectomy. Why is the patient not a good candidate for the Gardasil vaccination? A. Age B. Sexual activity C. Mirena IUD D. Allergy to penicillin E. Family history of endometrial cancer F. Tobacco use CORRECT ANSWER: “A”—Age Gardasil is a vaccination against HPV types 6, 11, 16, and 18 approved for females ages 9 to 26. Cervarix protects against serotypes 16, 18, 31 and 45 approved for ages 10 to 25. Both are a series of three shots and recommended for females ages 11-18, optimally before sexual debut or shortly thereafter. The patient above is too old to receive the vaccination. Though vaccination before sexual debut is preferred, sexual activity (choice b) is not a contraindication to Gardasil vaccination. The other choices are not contraindications to vaccinations. FM_Cases#02:---55 yo male annual exam A 55-year-old male with no significant past medical history presents for a routine physical exam. He last saw a doctor five years ago. Social history is remarkable for a 35- pack-year tobacco history since the age of 20. He indicates that his wife and children have urged him to quit smoking for the last few months. When you ask him if he has considered quitting, he replies, "I just don't see what the big deal is!" Which stage of change best describes this patient at this time? A. Precontemplation B. Contemplation C. Preparation D. Action E. Maintenance ANSWER:--A Precontemplation Based on this man's response, it appears he has not actively considered quitting smoking despite his family's concern. All stems refer to a different stage in the 4 Transtheoretical stages of change model. Given that he has not actively contemplated quitting, the best stage to describe this patient at this time would be the Precontemplation stage and not any of the other responses. QUESTION#2 A 55-year-old male with a past medical history that includes hypertension, Chronic Obstructive Pulmonary Disease (COPD), and hyperlipidemia presents to clinic as a new patient for a general physical exam. History reveals that he has been smoking a pack of cigarettes daily since age 20. He drinks two beers daily. He is intermittently noncompliant with his medications. Review of the state immunization database reveals that the only immunization he has received as an adult was a tetanus diphtheria shot administered 12 years ago. Which of the following vaccine combinations would be most appropriate for this patient? A. Influenza, Meningococcal, and Zoster B. Influenza, Pneumococcal, and Tda C. Influenza, Zoster, and Tda D. Meningococcal, Pneumococcal, and Tda E. Meningococcal, Pneumococcal, and Zoster CORRECT ANSWER B Influenza, Pneumococcal, & Tda Because this man has a diagnosis of COPD and smokes cigarettes, both annual Influenza and Pneumococcal vaccination are indicated. Because his last tetanus immunization was over 10 years ago and because he has not had a booster pertussis shot as an adult, a one-time TdaP is recommended. At this time meningococcal vaccine is recommended for adolescents and young adults and not indicated for this patient. Zoster vaccine is recommended to all adults at age 60 or older QUESTION#3 A 55-year-old male comes to the clinic for a visit. He has read about the dangers of being overweight and inquires about which category he fits into. He is 5' 10'' (1.78 m) and weighs 220 lbs (100 kg), BMI = 31.6. Which of the following categories most accurately describes the patient based on his BMI? A. Underweight B. Ideal C. Overweight D. Obese E. Morbidly (very severely) obese QUESTION#4 A 55-year-old white male with a family history of melanoma presents to the clinic for evaluation of a skin lesion on his back which appeared three months ago. His wife first alerted him to it, hasn't noticed it change and he has not noticed any symptoms associated with it. Physical examination reveals a 7 mm uniformly black macule that is symmetrically round with sharply demarcated borders on his upper back near the right shoulder. Which of the following characteristics would most justify it being biopsied today? A. Symmetry B. Borders C. Color D. Diameter E. Location CORRECT/BEST ANSWER D.) DIAMETER Using the ABCDE mnemonic, this nevus is not Asymmetrical, does not have irregular Borders, does not display Color variation and he does not describe any Evolution or change or symptoms. The only positive is that its Diameter is 6 mm, which is considered a red flag supporting biopsy. Location is not considered a predictive factor for melanoma. QUESTION#5 A 55-year-old male with no significant past medical history and generally healthy behaviors presents to clinic for a health care maintenance exam. He says, "I'd like to get tested for all types of cancer." He does not have any family history of cancer. Review of systems is negative for any symptoms of prostate cancer, such as urinary frequency, urgency, retention, hematuria, weight loss, or back pain. Based on current US Preventive Services Task Force guidelines, which of the following is the most appropriate recommendation to give this man concerning screening for prostate cancer? A. PSA testing is recommended B. Referral for prostate biopsy under ultrasound is an option C. The benefits and risks of screening for prostate cancer are uncertain D. Recommend against PSA screening E. First, check a digital rectal examination CORRECT/BEST ANSWER D.) Recommend AGAINST PSA screening The US Preventive Services Task Force - at the time of printing, April 2014 - recommends against screening using PSA testing because the risks of harm of detecting and treating asymptomatic prostate cancer outweigh the known benefits. Digital rectal exam, prostate biopsy, and transrectal ultrasound are not recommended as screening tests either. FM_Cases#03:---INSOMNIA Ms. Marcos is a 65-year old Latina woman with a past medical history of Type 2 diabetes, hypertension, and hypercholesterolemia who presents with six months of insomnia despite self-medication with acetaminophen, diphenhydramine, and herbal remedies. She is 5' 2" and weighs 250 lbs. When considering a differential diagnosis, which one of the following is a common cause of insomnia in the elderly? A. Sleep Apnea B. Pneumonia C. Chronic sinusitis D. Asymptomatic coronary artery disease E. Hypoparathyroidism The correct answer is A, sleep apnea. Sleep apnea occurs in 20% to 70% of elderly patients. Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep. Some of the other most common causes of insomnia in the elderly are: 1. Environmental problems such as noise or uncomfortable bedding which are not conducive to sleep. 2. Drugs, Alcohol, and Caffeine such as over-the-counter, alternative, and certain recreational drugs. 3. Parasomnias such as restless leg syndrome/periodic leg movements/REM sleep behavior disorder. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively. 4. Disturbances in the sleep-wake cycle such as jet lag or shift work. 5. Psychiatric disorders such as primary depression and anxiety 6. Symptomatic cardiorespiratory disease (asthma, COPD, heart failure) 7. Pain or pruritus 8. Gastroesophageal reflux disease (GERD) due to heartburn, throat pain or breathing problems. 9. Hyperthyroidism The elderly frequently do not present with typical symptoms such tachycardia or weight loss, and therefore further laboratory studies may be required to detect this problem. Mrs. Anderson is a 60-year-old white female who comes in to clinic as a walk in appointment. She is tearful and is carrying a box of tissues in her hand. She says she doesn't know why but she has been very sad of late. She reports trouble falling asleep and staying asleep. She used to be the head of her Bridge club, but quit two weeks ago and doesn't feel like going out anymore. She also says she has lost interest in walking her dog, and now just allows him to use the doggie door to let himself out. She also says she feels weak and fatigued and no longer has the energy to do her gardening or shopping. She spends most of her day on the sofa crying while watching TV. She also reports a greatly diminished appetite. She denies suicidal or homicidal ideation, but she does have a history of a previous suicide attempt following her divorce seven years ago for which she was hospitalized. A recent CBC, CMP, CXR, TSH, U/A and CT of the head were all within normal limits. How long do the above symptoms need to be present in order to make the diagnosis of Major Depressive Disorder? A. One week B. Two weeks C. Four weeks D. Five weeks E. Eight weeks Correct Answer: B Depressed mood or anhedonia and at least five of the following eight criteria must have been present for two weeks or longer. (Mneumonic = SIG E CAPS) » Sleep Insomnia or hypersomnia nearly every day » Interest: (loss of) Anhedonia (loss of interest or enjoyment) in usual activities » Guilt Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) » Energy (decreased) Fatigue or loss of energy nearly every day » Concentration (decreased) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) » Appetite (increased or decreased) » Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) » Suicidal ideation Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Mr. Jones is an 82-year-old white male who presents to the office for his six-month chronic disease visit. His diabetes and hypertension are controlled on his usual home medications. He reports that his wife died four weeks ago, and he is now experiencing insomnia most days of the week and fatigue and loss of energy nearly every day; is not showering or shaving; has diminished concentration while playing chess with his neighbor; and is also experiencing loss of appetite but no weight loss. He denies any suicidal ideation and has no previous suicide attempts. Mr. Jones says he often hears his wife's voice while going to bed. He says he goes to church to pray and this helps him. You are trying to determine if your patient's symptoms are normal bereavement or if you should diagnose and treat him for Major Depressive Disorder (MDD). Which feature of Mr. Jones’ case would suggest MDD rather than a normal grief reaction ? A. Insomnia B. Change in appetite C. Lack of attention to hygiene D. Hearing wife's voice E. Fatigue Ms. Rogers is a 75-year-old female who was found unresponsive in her house by her neighbor who had come over to help clean her house. An empty unlabeled pill container was found next to her on the bathroom floor. She was rushed to the ER, stabilized and is now in ICU on a mechanical ventilator. Which of the following are true regarding suicide in the elderly? A. Elderly persons attempting suicide are more likely to be married and living with their spouse. B. Elderly persons attempting suicide usually report good sleeping habits. C. Suicidal behaviors increase with age, but rates of completed suicides dont. D. Approximately 75% of the elderly who commit suicide had visited a primary care physician within the preceding month, but their symptoms went unrecognized. E. Firearms are the most common means of suicide in the elderly. • Respiratory rate: 18 breaths/minute • Oxygen saturation: 95% • Blood pressure: 152/84 mmHg • Weight: 325 lbs • Body Mass Index: 41 kg/m2 Today, her physical exam is significant for thinning hair, poor dentition, a systolic murmur heard at the left upper sternal border, an obese abdomen, and bilateral knee stiffness and pain on range of motion exam. Remainder of the physical exam is within normal limits. Which laboratory tests or studies can be done to rule out medical causes of insomnia, fatigue, and depression? A. Chest-X Ray B. CBC, CMP, and TSH C. HgbA1c, lipid panel, urine microalbumin D. CT head without contrast E. MRI brain with contrast FM_Cases#04:---Sports Injury QUESTION #1 A 41-year-old male with no significant past medical history is brought to the Emergency Department after falling to the ground in the middle of a pick-up basketball game with friends. He did not lose consciousness nor hit his head when he fell. As he landed on the ball of his foot after having taken a shot, he recalls hearing a popping sound followed by immediate pain in the posterior right ankle. On physical exam, the posterior right ankle is edematous and palpation is tender. He is unable to plantarflex his right foot. What is the most likely diagnosis of his current condition? A. Ankle ligament sprain B. Calcaneal fracture C. Achilles tendon rupture D. Ankle tendonitis E. Ankle arthritis CORRECT ANSWER:--- C. Achiles Tendon Rupture This is a classical description of an acute rupture of the achilles tendon. Middle-aged males are more commonly affected than other groups. The mechanism does not describe inversion injury making an ankle ligament sprain less likely and there is no direct trauma making fracture less likely. There is no history of overuse or chronicity making arthritis and tendonitis less likely. QUESTION #2 A 19-year-old female with no significant past medical history is involved as the driver in a motor vehicle accident and brought to the Emergency Department by EMS. She is complaining of severe pain in her right lower extremity that has been worsening since the accident. In addition, she has started to notice what she describes as "burning and tingling" in her right foot. On physical exam, her right calf is edematous and tender with tense overlying skin. There is no swelling or tenderness of the right foot or ankle but the right dorsalis pedis and posterior tibial artery pulses are barely palpable. She cannot confirm light touch of the foot and cannot wiggle her toes on command. What is the next best step in the management of this patient? A. Reassurance and icepacks q 2 hours B. Immobilize leg and ankle with a cast C. Urgent EMG of the right lower extremity D. Diagnostic imaging of right foot and ankle E. Emergent fasciotomy CORRECT ANSWER:--- E. Emergent Fasciotomy This clinical scenario describes acute compartment syndrome which is a vascular emergency. Emergent fasciotomy is the treatment of choice to relieve pressure in the calf and, if not performed, the limb could be lost due to acute ischemia. While emergent radiographs of the tibia and fibula are appropriate to evaluate for co-existent fracture, x- rays of the foot and ankle are not indicated. Reassurance, ice packs, urgent EMG and immobilization are all incorrect treatments and place the patient at risk of serious permanent adverse outcome. QUESTION #3 A 21-year-old female with no significant past medical history experienced an inversion- type injury to her right ankle while playing soccer a day prior to presentation. She remembers immediate pain and swelling but was able to weight bear and limp of f the field. She has noticed some significant swelling which is mostly still present. She has been icing the ankle since the injury as her coach recommended. Pain is still present near the lateral malleolus. Physical exam reveals that the lateral right ankle is edematous with purplish bruising, bilateral pulses are good and the patient had good sensation and motor function in both feet about equally. Palpation of the posterior edge of the lateral malleolus elicits significant pain from the patient. What is the next best step in the management of this patient? A. Reassurance B. Immobilize with cast or splint C. X-ray imaging of right ankle D. Emergent fasciotomy E. Rest, ice, Ibuprofen, compression and elevation and re-evaluate in one week CORRECT ANSWER:--- C. X-rya imaging of the Right Ankle Based on the Ottawa Ankle Rules, tenderness of the lower 6 cm of the posterior lateral malleolus may predict fracture and justifies X-ray imaging of the ankle. Tenderness of the lower anterior lateral malleolus, on the other hand, is very common in ligamentous injury such that x-rays are not warranted. Bec