FM_CASES_QUESTIONS

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.