Screening Guidelines
A 52-year-old male presents to your office for a routine annual health maintenance examination. He has a past medical history of hypertension and well-controlled type 2 diabetes with a hemoglobin A1c of 6.6%. He is also a chronic tobacco smoker. He requests screening for testicular cancer because his close friend recently died from the disease. Other than colon cancer in his adoptive father, there is no known family history of cancer. Which one of the following is indicated for testicular cancer screening for this patient?
A) No screening
B) An Alpha-fetoprotein level
C) Scrotal ultrasonography now
D) Scrotal ultrasonography at age 55
E) CT of the abdomen and pelvis at age 55
ANSWER: A
Although testicular cancer is the most common solid cancer in men ages 15–34, with effective treatment and an overall survival rate of 97%, the U.S. Preventive Services Task Force recommends against screening for testicular cancer in asymptomatic adolescent or adult males (D recommendation). A detailed history and physical examination should be obtained in symptomatic patients, followed by scrotal ultrasonography if there are positive findings on history and physical examination. Tumor markers and CT of the abdomen and pelvis are required for staging, treatment recommendations, and surveillance, but not for screening purposes.
Which one of the following is the hallmark of proliferative diabetic retinopathy?
A) Blot hemorrhages
B) Cotton-wool spots
C) Drusen
D) Macular edema
E) Neovascularization
ANSWER: E
Diabetic retinopathy is caused by chronic hyperglycemia and is the leading cause of blindness in adults in the United States. Routine screening with a dilated eye examination or retinal imaging performed and interpreted by a skilled clinician shortly after the diagnosis of diabetes mellitus is recommended. Diabetic retinopathy is classified in two stages. Nonproliferative diabetic retinopathy may occur within the first decade following hyperglycemia and is characterized by blot hemorrhages, cotton-wool spots, and retinal vascular microaneurysms. As the number of hemorrhages and microaneurysms increases, normal blood flow is interrupted. Proliferative diabetic retinopathy is the second stage and is characterized by neovascularization, which occurs in response to poor blood flow and retinal ischemia. These new blood vessels are fragile and rupture easily leading to vitreous hemorrhage, fibrosis, and retinal detachment. Drusen are extracellular deposits that accumulate within the macula in macular degeneration, which is unrelated to diabetic retinopathy. Macular edema can occur in both stages of diabetic retinopathy.
A 90-year-old female sees you regularly for follow-up of several chronic medical conditions including systolic hypertension, coronary artery disease, previous ischemic stroke, and heart failure with preserved ejection fraction. Her systolic blood pressure is usually >160 mm Hg while her diastolic blood pressure is usually <50 mm Hg, making management challenging. In managing this patient’s blood pressure, an important physiologic consideration is that coronary artery perfusion is determined by which one of the following?
A) Diastolic blood pressure
B) Systolic blood pressure
C) Mean arterial pressure
D) Pulse pressure
E) Ejection fraction
ANSWER: A
Perfusion of the myocardium occurs during diastole; therefore, the diastolic blood pressure (DBP) determines the coronary artery perfusion pressure. The systolic blood pressure (SBP), mean arterial pressure, pulse pressure (PP), and cardiac ejection fraction do not determine the coronary artery perfusion pressure.
PP is the SBP minus the DBP. The wide PP observed in older patients results from arterial stiffness. This causes an increase in the SBP and PP and a decrease in the DBP. This stiffness results from both arterial structural and functional changes with aging, including wall hypertrophy, calcifications, atheromatous lesions, changes in the extracellular matrix, and impairment of vascular endothelial function and smooth muscle cell reactivity. A wide PP makes it challenging to manage blood pressure with the goal of lowering SBP while ensuring a DBP that maintains coronary artery blood flow and avoids cardiac ischemia.
Guidelines from the American Heart Association, American College of Cardiology, and the American Society of Hypertension recommend that blood pressure should be lowered slowly in patients with an elevated DBP and coronary artery disease with evidence of myocardial ischemia. The guidelines further recommend caution in lowering DBP to <60 mm Hg in patients older than 60 or who have diabetes mellitus.
You diagnose hand-foot-and-mouth disease in a 5-year-old male. His parents ask when he can return to kindergarten. You advise that if he feels well enough to participate, he may return
A) 5 days after the onset of symptoms
B) when afebrile and there are no mouth sores causing drooling
C) when afebrile as long as all skin lesions can be covered with a dressing
D) when afebrile and all skin lesions have crusted over
ANSWER: B
Hand-foot-and-mouth disease (HFMD) is very common among children younger than 10 years of age, and is very easily spread by fecal-oral, oral-oral, and respiratory droplet routes. As the disease is ubiquitous and has a very low complication rate, the CDC recommends allowing children to return to school or day care when they are afebrile, feel well enough to participate, and are not actively drooling with mouth lesions. There is no specific time course that must be followed, and the status of skin lesions does not affect return to school.
You provide care for a 65-year-old female who has metastatic breast cancer. She would like to consider simple treatments and/or admissions, but wishes to avoid any further surgeries, heroic procedures, transfers to the ICU, or intubation. Which one of the following forms should you recommend as most beneficial for directing her end-of-life care?
A) Cardiopulmonary resuscitation (CPR) directives B) A living will
C) A medical power of attorney
D) Physician Orders for Life-Sustaining Treatment (POLST)
ANSWER: D
Physician Orders for Life-Sustaining Treatment (POLST) forms are a portable order set signed by the provider and either the patient or the surrogate to direct care across various settings (including EMS, residential retirement facilities, nursing homes, emergency departments, and inpatient settings) at the end of life. The form is typically printed on bright-colored cardboard to make it easier to locate by EMS, with scanned versions available for electronic medical charts. It describes the patient’s wishes for cardiopulmonary resuscitation (CPR) and indicates the levels of care desired including full treatment, limited or selective interventions, and comfort-focused care. It is the best way to direct end-of-life patient care and respect diverse wishes. POLST forms are more useful than CPR directives because they describe broader end-of-life treatment choices. A living will is applicable only under the narrow conditions of a terminal or persistent vegetative state. A medical power of attorney is useful but does not convey values and wishes.
A 42-year-old male sees you for a routine health maintenance examination. He has no symptoms, no high-risk behaviors, and no past medical history. The physical examination is unremarkable. He has had no health care screenings since a sports preparticipation evaluation at age 14. Which one of the following screenings should you recommend for this patient at this time?
A) Carotid stenosis
B) Glaucoma
C) HIV
D) Testicular cancer
E) Vitamin D deficiency
ANSWER: C
The U.S. Preventive Services Task Force recommends that all adolescents and adults between the ages of 15 and 65 be screened for HIV (A recommendation). Screening for carotid stenosis and for testicular cancer is not recommended (D recommendation). The evidence for glaucoma screening and vitamin D deficiency is unclear and no recommendation has been made.
A 60-year-old male with recently diagnosed squamous cell lung cancer presents to the emergency department with generalized weakness and altered mental status. He has a temperature of 36.9°C (98.4°F) and a blood pressure of 134/78 mm Hg. His pulse rate is 100 beats/min and regular. A physical examination reveals confusion and dry oral mucosa. An EKG reveals sinus rhythm with first-degree atrioventricular block and a short ST segment. Aside from his known lung mass, imaging studies including head CT and a chest radiograph are normal. Laboratory studies, including a CBC, comprehensive metabolic panel, and lactate level, are normal except for a serum calcium level of 14.0 mg/dL (N 8.0–10.0) and a creatinine level of 1.4 mg/dL (N 0.7–1.3). Which one of the following is the most important first step to address his hypercalcemia? A) A 2-liter intravenous fluid bolus with normal saline B) Furosemide, 40 mg intravenously C) Methylprednisolone (Solu-Medrol), 125 mg intravenously D) Pamidronate, 90 mg intravenously E) Placement of a large bore central venous dialysis catheter
ANSWER: A
This patient presents with malignant hypercalcemia, which in this case is most likely due to parathyroid hormone–related peptide (PTHrP) production from his squamous cell lung cancer. The first step in management is to correct the volume depletion that is associated with the hypercalcemia, which commonly occurs due to the combined effects of anorexia, nausea/vomiting, and nephrogenic diabetes insipidus. This often leads to extreme dehydration followed by a decreased glomerular filtration rate, which reduces the kidneys’ ability to excrete calcium, thereby compounding the electrolyte disturbance. An initial 2-liter intravenous fluid bolus in this case would be an appropriate first step. Once the volume status has been addressed and renal function is stabilized, additional treatment options may include loop diuretics such as furosemide, corticosteroids such as prednisone or methylprednisolone, and/or bisphosphonates such as pamidronate, depending on the clinical circumstances. In patients with severe chronic kidney disease or acute, life-threatening hypercalcemia, calcium may be removed via dialysis, although preparing for imminent dialysis would not be appropriate for this patient.
You are playing in a community league soccer tournament and are asked to evaluate a 30-year-old female. She was in her usual state of health when she suddenly began having difficulty breathing while playing soccer. She tells you that she has had similar episodes in the past. Treatment with an albuterol (Proventil, Ventolin) inhaler does not improve her symptoms. On examination you note dyspnea with audible inspiratory wheezing but no increased work of breathing, and she has an oxygen saturation of 98%. Which one of the following is the most likely diagnosis?
A) Anaphylaxis
B) Exercise-induced asthma
C) Foreign body aspiration
D) Laryngeal edema
E) Vocal cord dysfunction
ANSWER: E
Vocal cord dysfunction occurs when the vocal cords close when they should be open, particularly during inspiration. It should be suspected in patients who develop sudden, severe dyspnea that presents with inspiratory stridor or wheezing and is not associated with hypoxia, tachypnea, or increased work of breathing. It is most common in women ages 30–40. Anaphylaxis and foreign body aspiration would be unlikely without an antecedent trigger. Exercise-induced asthma usually presents with expiratory wheezing and responds to the use of an albuterol inhaler. Laryngeal edema is usually preceded by signs of illness.
Which one of the following is the most appropriate timing to initiate the use of fluoride varnish in infants and children to prevent dental caries?
A) At age 6 months if their primary water source is deficient in fluoride
B) At age 6 months and then four times yearly
C) At age 6 years and then four times yearly
D) When the first primary tooth erupts and then twice yearly
E) When the first permanent tooth erupts and then four times yearly
ANSWER: D
Fluoride helps to prevent tooth decay and is an important aspect of good oral care. Family physicians can impact oral health, which directly affects overall health, by incorporating this into their routine practice. Fluoride varnish should be applied when the first primary tooth erupts. It should then be applied twice yearly in all infants and young children (SOR B). Also, if the patient’s primary water source is deficient in fluoride, then fluoride supplements should be prescribed for children beginning at 6 months of age.
An 82-year-old female in your palliative care service who has stage 4 breast cancer is experiencing frequent episodes of delirium. Her pain is well controlled on long-acting oral opioid therapy. Additionally, no other reversible causes of delirium are noted. Her delirium is not responding to conservative measures, and her family asks if there are any medications that can effectively manage her symptoms. Which one of the following should you recommend?
A) Alprazolam (Xanax)
B) Diazepam (Valium)
C) Melatonin
D) Risperidone (Risperdal)
ANSWER: D
The first step in managing delirium in end-of-life care is to assess for any reversible or treatable causes, including uncontrolled pain, constipation, urinary retention, infections (e.g., urinary tract infections), and medication side effects. Antipsychotic medications, such as haloperidol and risperidone, are recommended if conservative measures fail to control the symptoms of delirium. Benzodiazepines should be used with caution as they can worsen delirium, especially in older patients. Melatonin is not indicated in the management of delirium.
A 65-year-old female with end-stage renal disease, who has been on dialysis for 2 years, presents for a health maintenance examination. She has a history of diabetes mellitus and hypertension and does not want to be considered for renal transplantation. Which one of the following would be the most appropriate cancer screening for this patient?
A) No screening
B) A skin survey
C) A Papanicolaou smear
D) Mammography
E) Colonoscopy
ANSWER: A
Routine cancer screening is not recommended for patients with end-stage renal disease with limited life expectancy who are not candidates for kidney transplantation. In the Choosing Wisely campaign, the American Society of Nephrology recommends avoiding routine cancer screenings for patients who are receiving dialysis who are not candidates for kidney transplantation. The U.S. Preventive Services Task Force has concluded that the current evidence is insufficient to assess the balance of benefits and risks of visual skin examination for skin cancer screening.
Which one of the following medications commonly causes hyponatremia in the elderly?
A) Amlodipine (Norvasc)
B) Amoxicillin
C) Atorvastatin (Lipitor)
D) Escitalopram (Lexapro)
E) Spironolactone (Aldactone)
ANSWER: D
A possible side effect of SSRIs is hyponatremia, which is more pronounced in the elderly. This fact is particularly pertinent in elderly patients with poorly controlled psychiatric illness who are more inclined to psychogenic polydipsia, which also leads to hyponatremia. Amlodipine is known to cause peripheral edema, dizziness, and medication-induced hepatitis. Amoxicillin causes eosinophilia and ALT and AST elevations. Atorvastatin causes elevations in ALT, AST, and creatine kinase levels. Spironolactone causes hyperkalemia and hyperuricemia, but it is not known to cause hyponatremia.
A 60-year-old female presents to the emergency department after developing confusion with severe headache and nausea. Shortly after arrival she has a generalized tonic-clonic seizure lasting less than 30 seconds. She has a blood pressure of 220/130 mm Hg, a pulse rate of 85 beats/min, and an oxygen saturation of 98% on room air. Cardiac enzymes are negative. Noncontrast CT of the head is negative for hemorrhage and contrast CT of the chest and abdomen reveals no aortic dissection. Based on guidelines from the American Heart Association, the patient’s blood pressure is lowered by approximately 20% during the first hour of treatment. Assuming the patient remains clinically stable, the goal over the next 2–6 hours is to lower her blood pressure to A) 130/90 mm Hg
B) 140/90 mm Hg
C) 150/100 mm Hg
D) 160/100 mm Hg
E) 170/100 mm Hg
ANSWER: D
This patient is having a hypertensive emergency with encephalopathy and the goal is to lower her blood pressure by no more than 25% in the first hour. Over the next 2–6 hours, her blood pressure should be lowered to 160/100 mm Hg. After that level is achieved, her blood pressure may be cautiously lowered to normal over the ensuing 24–48 hours. Lowering blood pressure too aggressively can lead to cerebral ischemia and should be avoided.
A 9-year-old male has persistent severe depression despite cognitive behavioral therapy. Which one of the following medications is approved by the FDA for the treatment of major depressive disorder in this age group?
A) No antidepressant medications
B) Bupropion (Wellbutrin)
C) Escitalopram (Lexapro)
D) Fluoxetine (Prozac)
E) Sertraline (Zoloft)
ANSWER: D Only two medications, escitalopram and fluoxetine, are approved by the FDA for the treatment of major depressive disorder in children and adolescents. Fluoxetine is approved for treatment in children age greater or equal to 8 while escitalopram is only approved for use in children age greater or equal to 12. Bupropion and sertraline are not approved by the FDA for the treatment of major depressive disorder in children.
A 48-year-old female with alcohol use disorder presents to your clinic 2 days after she has stopped drinking alcohol. She reports some mild anxiety, sweating, and insomnia. On examination her vital signs are stable and she does not have a tremor. She has no history of alcohol withdrawal–related seizures or delirium. Which one of the following medications is most appropriate for treating her alcohol withdrawal syndrome?
A) Atenolol (Tenormin)
B) Chlordiazepoxide
C) Diazepam (Valium)
D) Gabapentin (Neurontin)
E) Valproate
ANSWER: D
Patients at minimal risk of developing severe or complicated alcohol withdrawal who can safely be treated in an outpatient setting include those who are <65 years of age and who have no history of alcohol withdrawal–related seizures or delirium, no multiple prior withdrawal episodes, no comorbid illness, and no marked autonomic hyperactivity on presentation. Mild symptoms of alcohol withdrawal syndrome include mild to moderate anxiety, sweating, and insomnia but no tremor. Moderate symptoms include moderate anxiety, sweating, and insomnia with mild tremor. Severe symptoms include severe anxiety and moderate to severe tremor but no confusion, hallucinations, or seizures that are indicative of complicated alcohol withdrawal symptoms. For patients with alcohol withdrawal syndrome who have mild symptoms and minimal risk of developing severe or complicated alcohol withdrawal, a nonbenzodiazepine anticonvulsant such as gabapentin or carbamazepine is recommended. Benzodiazepines are first-line treatment for moderate alcohol withdrawal syndrome, and -blockers can be used as adjunctive therapy with benzodiazepines. Valproate should not be used as monotherapy for withdrawal.
You are instructing a new medical assistant in preordering laboratory studies for upcoming patients. You have a series of patients with appointments for physical examinations in the next week. Based on U.S. Preventive Services Task Force guidelines, which one of the following patients should have a screening fasting glucose level or hemoglobin A1c?
A) A 24-year-old female with a BMI of 26 kg/m2
B) A 36-year-old male with a BMI of 27 kg/m2
C) A 52-year-old female with a BMI of 22 kg/m2
D) A 72-year-old male with a BMI of 32 kg/m2
E) An 84-year-old female with a BMI of 40 kg/m2
ANSWER: B
The U.S. Preventive Services Task Force (USPSTF) recommends that all nonpregnant adults ages 35–70 who are overweight (BMI greater or equal 25 kg/m2 ) or obese (BMI greater or equal 30 kg/m2 ) be screened for diabetes mellitus and prediabetes with a fasting glucose level, hemoglobin A1c, or glucose tolerance test (B recommendation). In 2021, the age of screening was decreased from 40 to 35. In addition to the above recommendations, patients with a family history of diabetes or a personal history of gestational diabetes or polycystic ovary syndrome should be considered for screening at a younger age. In patients who belong to groups with high rates of diabetes such as American Indian/Alaska Native, Asian American, Black, Hispanic/Latino, or Native Hawaiian/Pacific Islander, screening can also start at a younger age. The recommended interval for screening is every 3 years. Routine screening for prediabetes and diabetes in persons over the age of 70 is not a current recommendation. While the risk of prediabetes and diabetes increases with age, patients older than 70 with prediabetes have a low likelihood of progressing to diabetes. More commonly, they either maintain prediabetes status or regress to normoglycemia
A 42-year-old male with a history of chronic low back pain managed with extended-release morphine sulfate (MS Contin) comes to your office to discuss fatigue. Among other causes, you consider the impact that long-term opioid therapy may have on the endocrine system. Which one of the following endocrine conditions is most commonly associated with long-term opioid therapy?
A) Hyperprolactinemia
B) Hypocortisolism
C) Hypogonadism
D) Hypoparathyroidism
E) Hypothyroidism
ANSWER: C
Long-term opioid therapy is associated with several endocrine conditions, the most common of which is hypogonadism. A 2020 systematic review and meta-analysis that included 52 studies on the endocrine effects of opioids found hypogonadism in 69% of male patients. Lower androgen levels were also found in women, while estradiol was not affected. Menstrual cycle disorders were noted in 87% of premenopausal women taking opioids chronically. Seven of the included studies assessed prolactin levels, which were elevated in 40% of participants. Adrenal insufficiency was noted in 24% of patients. Parathyroid disorders were not included in this manuscript and have not been reported to have an association with opioid use. Two included studies showed lower free T4 levels in those taking opioids, with an estimated incidence of 34%.
A 55-year-old male with oxygen-dependent COPD plans to visit family 2000 miles away. For the last year, his COPD has been well controlled on medications and oxygen at 2 L/min. He wants to travel by commercial airline. Which one of the following would be the most appropriate advice for this patient regarding air travel?
A) Choosing another mode of transit
B) Flying first class only
C) Continuing his oxygen flow rate at 2 L/min during the flight
D) Lowering his oxygen flow rate to 1 L/min during the flight
E) Doubling his oxygen flow rate to 4 L/min during the flight
ANSWER: E
Commercial airline carriers typically permit Federal Aviation Administration–approved portable oxygen compressors. Patients whose usual oxygen requirements are <4 L/min are advised to double the flow rate during the flight. Conditions such as bullous lung disease, cystic fibrosis, and severe COPD may require the Hypoxia Altitude Simulation Test to determine in-flight oxygen requirements prior to air travel. It would not be appropriate to recommend this patient choose another mode of transit, fly first class only, continue his current oxygen flow rate, or lower his oxygen flow rate.
An 8-year-old female is brought to your office by her parents for follow-up 6 months after you recommended a DASH diet and 1 hour of physical play daily to address her BMI and blood pressure, which were both greater than the 95th percentile for her age and height. Her mother also has a history of obesity and hypertension. The patient otherwise has an unremarkable past medical history. Although she has lost 1.4 kg (3 lb) her blood pressure remains at 125/77 mm Hg. You diagnose stage 1 hypertension and recommend management with medication. In addition to a CBC; electrolyte, BUN, and creatinine levels; a urinalysis; and a lipid panel, you recommend
A) no further testing
B) serum or urine catecholamine measurement
C) renal Doppler ultrasonography
D) CT angiography of the kidneys
E) echocardiography
ANSWER: E
Echocardiography should be performed to assess for cardiac target end-organ damage, such as left ventricular hypertrophy, when medication is being considered in children with hypertension. Evaluation for secondary causes of hypertension is not needed in children >6 years of age with stage 1 hypertension if they are overweight or have a positive family history of hypertension and there are no physical examination findings indicative of a secondary cause. Renal imaging, catecholamine and steroid levels, and renin activity are indicated in children <6 years of age or patients with stage 2 hypertension (greater or equal 95th percentile plus 12 mm Hg systolic or diastolic blood pressure or greater or equal 140/90 mm Hg, whichever is lower).
A 52-year-old male presents to your office because of increasing difficulty hearing conversations in social settings over the past 6 months. On examination the finger rub test is positive on the left ear. A Rinne test is positive on the left ear and negative on the right ear. A Weber test lateralizes to the left ear. Which one of the following is the most likely etiology of this patient’s hearing loss?
A) Conductive hearing loss
B) Sensorineural hearing loss
C) Meniere disease
D) Ototoxic medication
E) Presbycusis
ANSWER: A
This patient notes progressive hearing loss and has a positive finger rub test on the left, which indicates the left ear is affected. The Rinne test measures bone conduction compared to air conduction in which air conduction should be greater than bone conduction. A positive test indicates that bone conduction is greater and is indicative of conductive hearing loss. When the Weber test lateralizes to the bad ear, this indicates conductive hearing loss. If the Weber test lateralizes to the good ear, then this indicates sensorineural hearing loss. This patient has conductive hearing loss, not sensorineural hearing loss. Both Meniere disease and ototoxic medications cause a sensorineural hearing loss. Presbycusis is age-related hearing loss that is typically bilateral and sensorineural.
A 76-year-old male presents to your office for evaluation. He has a history of worsening New York Heart Association class IV heart failure and is on maximum medical therapy. He had a left ventricular assist device (LVAD) placed 6 months ago. He has a 50-pack-year smoking history and started smoking one pack a day at age 15. He quit smoking 10 years ago when he was diagnosed with heart failure. He asks you to schedule lung cancer screening with low-dose CT, which he has received annually for the last 10 years. According to the U.S. Preventive Services Task Force, which one of the following is an indication to discontinue screening for lung cancer in this case?
A) Limited life expectancy
B) Age 76
C) Quitting smoking within the last 10 years
D) Recent cardiac procedure
ANSWER: A
Lung cancer is the leading cause of cancer-related death in the United States. It is estimated that 90% of cases are related to tobacco exposure. Effective lung cancer screening programs are thought to reduce lung cancer–related morbidity and mortality via early detection in persons at high risk. The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose CT in adults ages 50–80 who have a 20-pack-year smoking history. Eligible individuals include those who currently smoke or have quit within the past 15 years. In this case, this patient’s New York Heart Association class IV heart failure refractory to medical and surgical therapy limits his life expectancy and screening should be discontinued. The lack of ability or willingness to have curative lung surgery would also be an indication to discontinue lung cancer screening. A recent cardiac procedure is not an indication to discontinue screening for lung cancer.
A 37-year-old male sees you for a routine health maintenance examination. He is morbidly obese with a BMI of 42 kg/m2 . In addition to his obesity diagnosis, his past medical history is significant for diabetes mellitus, hypertension, hyperlipidemia, GERD, and bilateral knee osteoarthritis, which are all adequately controlled with oral medications. His father died of a myocardial infarction (MI), and the patient is worried about his risk of dying of an MI like his father, since they share a similar body habitus and comorbidities. He is concerned about his weight and has researched metabolic surgical interventions on the internet. He is overwhelmed with the options and is seeking your guidance. Given his medical conditions, which one of the following surgical options is the recommended intervention?
A) Adjustable gastric band
B) Sleeve gastrectomy
C) Roux-en-Y gastric bypass
D) Biliopancreatic diversion with a duodenal switch
ANSWER: C
In obese patients with a medical history of GERD, a Roux-en-Y gastric bypass is preferred over sleeve gastrectomy (SOR A). Adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion all function by limiting the physical size of the stomach. This has a potential for exacerbating GERD symptoms, despite anticipated significant weight loss. This patient meets criteria for metabolic surgery due to a diagnosis of morbid obesity, in addition to comorbidities such as diabetes mellitus and hypertension.
A 71-year-old male who resides at sea level travels to Colorado for a vacation. He spends the first night in a resort at 2700 m (8858 ft) above sea level. He notes a headache and sleeps poorly. The next morning he is somewhat nauseated and lightheaded, but feels well enough to proceed with his plans and ascends to his campsite at 4000 m (13,123 ft). During the first evening at the campsite, friends note that he is confused and having difficulty with his balance. Which one of the following diagnoses best explains his symptoms at the campsite?
A) Acute mountain sickness
B) High-altitude cerebral edema
C) High-altitude headache
D) High altitude–induced central sleep apnea
E) High-altitude pulmonary edema
ANSWER: B
This patient likely had a high-altitude headache on arrival, central sleep apnea during his first night in the hotel, and acute mountain sickness by the next morning. None of these conditions are life-threatening, and proper acclimatization would have been helpful. The addition of ataxia and confusion to his symptom list points to high-altitude cerebral edema, which can progress to coma and death. Immediate descent is indicated. Symptoms of high-altitude pulmonary edema include cough with pinkish sputum, respiratory distress, and cyanosis.
A 12-year-old transgender female accompanied by her mother comes to your office to discuss persistent gender dysphoria. The patient has been in counseling for 2 years along with her family, who is supportive of her gender identity. The patient’s mother asks about puberty blockers. In discussing GnRH analogs with her, you note that the current recommendation for beginning this medication is when she is at which Tanner stage of development?
A) 1
B) 2
C) 3
D) 4
E) 5
ANSWER: B
The 2022 World Professional Association for Transgender Healthcare (WPATH) standards of care recommends that in eligible adolescents, pubertal suppression may begin at Tanner stage 2. Treatment prior to the onset of puberty is not recommended. Tanner stage 1 is prepubescent and Tanner stage 2 is the initial pubescent stage. It is not necessary and may be harmful to wait for further pubertal stages before initiating puberty blockers in an eligible transgender adolescent.
For patients with terminal pancreatic cancer, lung cancer, or metastatic melanoma, which one of the following is the potential increase in life expectancy from receiving hospice care?
A) No increase
B) 3 months
C) 6 months
D) 9 months
E) 12 months
ANSWER: B
Multiple retrospective cohort studies from 2007, 2014, and 2015 have demonstrated an increased life expectancy of up to 3.3 months for patients with terminal cancer, specifically terminal pancreatic cancer, lung cancer, and metastatic melanoma, who received 3 or more days of hospice care. Some benefit was noted in patients with even 1 day of hospice care (SOR B). This extended life expectancy associated with hospice care was not observed in patients with terminal prostate or breast cancer. Family physicians should present the option of home hospice care to such patients early in their prognosis.