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Parasitic infection d. M alaria e. Hepatitis You are counseling a patient who is planning a trip with his wife to celebrate their 30th anniversary. They are going on an African safari, and wonder about health risks associated with international travel. What would you tell him is the most common cause of death among international travelers? Infections b. Accidents c. Homicide d. Heart disease e. Vascular disease ie, deep venous thrombosis and pulmonary embolus You are performing a physical examination on a student traveling to M exico with her college Spanish class.
The traveler should take trimethoprim-sulfamethoxazole. The traveler should take doxycycline. The traveler should take ciprofloxacin. The traveler should take metronidazole. You are discussing vaccinations for a patient who is traveling internationally. Because of a significant fear of needles, he is unwilling to obtain any vaccination unless it is required. Which of the following is the only mandatory travel vaccine? Yellow fever b. Polio c.
Cholera e. You are reevaluating a year-old woman in your office. You started her on combination oral contraceptives COCs 3 months ago, and at each of three visits since then, her blood pressure has been elevated.
Which of the following is the most appropriate next step?
Discontinue the oral contraceptive and recommend a barrier method. Change to a pill with a higher estrogen component. Change to a pill with a lower estrogen component. Change to a pill with a lower progestin component. Change to a progestin-only pill. You started a year-old woman on COCs 2 months ago. She returns to your office asking to discontinue their use because of side effects.
Statistically speaking, which side effect of COCs is most frequently cited as the reason for discontinuing their use? Nausea b. Breast tenderness c. Fluid retention d. Headache e. Irregular bleeding You are counseling a year-old woman who is interested in starting COC pills. Which of the following is true regarding risks associated with COC use?
Users of COC pills have an increased risk of ovarian cancer. Users of COC pills have an increased risk of endometrial cancer. Users of COC pills have an increased risk of venous thromboembolism. Users of COC pills have an increased risk of hemorrhagic stroke. Users of COC pills have an increased risk of diabetes mellitus.
You are counseling a patient over the phone who has been taking oral contraceptives regularly for 2 years. She therefore missed taking one active pill. She and her husband had intercourse during their trip, and are not interested in being pregnant at this time. Which of the following is most correct? She should ignore the one missed pill. She should take two pills immediately.
She should take two pills immediately and use a backup method of contraception for 7 days. She should use emergency contraception immediately and restart her pills on the following day. She should use emergency contraception immediately and use a different form of birth control for the remainder of her cycle. A year-old obese woman with type 2 diabetes mellitus is asking you about progestin-only pills as a method of contraception.
Progestin-only pills are contraindicated in women with diabetes. Progestin-only pills would increase her risk of thromboembolic events. Progestin-only pills increase her risk for ectopic pregnancy. Progestin-only pills should be taken every day of the month, without a hormone-free period. You are counseling a patient regarding contraception options. She is 36 years old, she smokes one pack of cigarettes daily, weighs lb, and has no medical illnesses.
She is sexually active, but is not in a monogamous relationship. Which of the following is her best contraception option? COC pills b. An intravaginal ring system delivering estrogen and progestin c. A transdermal contraceptive patch delivering estrogen and progestin d.
An injectable form of long-acting progestin e. An intrauterine device IUD A year-old monogamous married woman comes to you for emergency contraception. She and her husband typically use condoms to prevent pregnancy, but when they had sex approximately 36 hours ago, the condom broke. She does not want to start a family at this time.
Which of the following statements is true regarding the use of emergency contraception pills ECPs? She is too late to use ECPs in this case. There are no medical contraindications to the use of ECPs, other than allergy or hypersensitivity to the pill components.
ECPs disrupt the pregnancy, if given within days of implantation. Clinicians should perform a pregnancy test before prescribing ECPs. Genetics and Pharmacogenomics Consider the following pedigree: Assuming that the solid circles indicate that the persons are affected with the condition in question, which of the following is true regarding this condition?
It is autosomal dominant. It is autosomal recessive. It is X-linked recessive. It is X-linked dominant. It is unlikely to be a genetic disorder. Assuming that the solid squares indicate that the persons are affected with the condition in question, which of the following is true regarding this condition?
You are caring for a year-old man with fatigue. Workup revealed hereditary hemochromatosis, an autosomal recessive disorder. Neither of his parents ever showed signs of the disease, though they were never tested while alive. Your patient has one sister. What is the chance that his sister also has hereditary hemochromatosis? No chance b. You are caring for a young family who just had a child with multiple malformations of unknown etiology.
What type of testing would be best for identifying the diagnosis? Cytogenetic analysis b. Direct DNA testing c. Biochemical testing d. Protein-specific testing Biostatistics You note that in your practice, a large number of women with a family history of breast cancer in a first-degree relative develop breast cancer themselves.
Given this information, what is the sensitivity of using family history as a predictor of breast cancer in your patient population?
Thirty percent of the people without lung cancer are also smokers. Given this information, what is the specificity using smoking as a predictor of lung cancer? You are determining whether or not to use a rapid streptococcal antigen test to screen for streptococcal pharyngitis. Which of the following statements best describes this situation?
You are reading a medical journal and come across an article about diabetes. The study followed 10, patients over 3 years. At the start of the study, people had diabetes. At the end of the study, additional people developed diabetes.
What was the incidence of diabetes during the study? You are reading a study that compares cholesterol levels in children whose fathers died from an M I with cholesterol levels in children whose fathers died from other causes. What does this value indicate? There was no difference in cholesterol levels between the two groups.
The difference in the cholesterol levels was less than 0. There is a less than 0. If the null hypothesis is true, there is a less than 0. You are considering using a new influenza screening test. You find a study that evaluated patients with this new test.
Of these patients, had the disease. Three hundred of those had positive tests, and of those had a negative test. Of the that did not have the disease, had positive tests, and had negative tests. What is the positive predictive value of this test? You find that many of your patients that have gone to the emergency department with chest pain have a negative set of initial cardiac enzymes. M ost of those with a negative set of initial enzymes did not have a heart attack.
You decide to evaluate of your patients who have gone to the emergency department with chest pain to find out if an initial set of negative enzymes by itself is a good predictor of those that are not having an M I.
Of those patients, 20 of them had acute M Is. Of those 20, 10 had a positive set of enzymes initially.
Of the 80 that did not have an acute M I, none of them had a positive set of initial enzymes. Given this information, what is the negative predictive value of the initial set of cardiac enzymes in your patient population?
The answer is c. Bope, pp ; Mengel, pp Hepatitis B infects approximately 1. Studies have shown that compared to no intervention, treating the infant of a hepatitis B-positive mother with hepatitis B immune globulin within 12 hours of birth, and vaccination, substantially reduces the transmission rate.
Therefore, all mothers should be screened for hepatitis B surface antigen, and if positive, the babies should be treated as described in this question. If the hepatitis status of the mother is unknown, the child should get the vaccine, and the mother should be tested. If the mother is found to be positive, the baby should receive immune globulin within 7 days.
The answer is a. Mengel, pp Prior to the introduction of an effective vaccine, 1 in children developed invasive Hemophilus disease before age 5, often leading to meningitis, hearing loss, or mental retardation.
The vaccine does not reduce the rate of otitis media, as most cases are caused by nontypeable H influenzae. Adverse reactions to the vaccine are very rare. In fact, no serious reactions have been linked to the vaccine, and systemic reactions like fever and irritability are infrequent.
The most common side effects are limited to mild fever, local redness, swelling, or warmth.
The vaccine should not be administered before 6 weeks of age, as immune tolerance to the antigen may be induced. The vaccine may be given with other vaccines. The answer is e. ACIP, ; Mengel, pp Varicella immunization is recommended for adults who have not had evidence of infection or immunization.
US-born people born before are generally considered immune, with the exception of health care workers and pregnant women. While many people who do not remember having chicken pox have serologic evidence of immunity, testing is not necessary, as the vaccine is well-tolerated in those already immune.
While nonimmune pregnant women should not receive the vaccine until after delivery, household contacts of immunocompetent pregnant women do not need to delay vaccination.
Rarely, people receiving the vaccine may develop infection. However, the case is mild, and does not appear to be contagious. ACIP, Hepatitis B vaccination is recommended for adults in various risk categories.
Behavioral risk categories include sexually active persons with more than one sex partner in the last 6 months, persons seeking evaluation or treatment for a sexually transmitted disease, current or recent injection-drug users, and men who have sex with men. Occupational risk categories include health care personnel and public safety workers who may be exposed to blood or body fluids.
M edical risk categories include persons with end-stage renal disease, persons with HIV infection, and persons with chronic liver disease. In this question, having a positive surface antibody means that the patient is immune. If the patient were to be surface antibody negative, the immunization schedule would be one injection at time 0, one between 1 and 2 months after that, and a third injection between 4 and 6 months after the second. Hepatitis A vaccination is indicated for men who have sex with men or users of injection drugs.
Occupational indications include persons working with hepatitis A virus HAV -infected primates or with HAV in a research laboratory setting. M edical indications include chronic liver disease and persons that receive clotting factor concentrates. The patient is not at high risk for varicella, and therefore vaccination is not indicated. M eningitis vaccination is indicated for those with functional asplenia or travelers to endemic areas.
College students can be counseled about the vaccination, especially if they are living in a dormitory. Pneumococcal vaccination is only indicated for those with chronic diseases and functional asplenia or residents of long-term care facilities.
An M M R booster is not indicated. The answer is d. Bope, pp Rubella is normally a mild self-limited illness, but infection during pregnancy can result in fetal death or congenital defects known as congenital rubella syndrome CRS.
CRS is devastating, and rubella immunity is important for women considering pregnancy. If a woman is found to be rubella nonimmune, vaccination should not occur if she is pregnant or planning pregnancy in the next 4 weeks. Although the vaccine is contraindicated in pregnancy, inadvertent vaccination is not an indication for therapeutic abortion.
If the patient is currently pregnant and nonimmune, she should be vaccinated as early in the postpartum period as possible. McPhee, pp Increasing reports of pertussis among US adults has stimulated vaccine development for older persons.
A tetanus-diphtheria five-component acellular pertussis vaccine Tdap is available, and recommended for adults aged 19 to 64 to replace the next booster dose of tetanus. Influenza is a highly contagious viral infection.
Influenza vaccination is recommended annually for children aged 6 months and older. The minimum age for vaccination with the trivalent inactivated influenza vaccine TIV is 6 months, but the minimum age for the live, attenuated influenza vaccine LAIV is 2 years.
In this case, since the mother wishes all her children be vaccinated, only the 4-month-old should be excluded because of age. The influenza vaccine is recommended for all persons aged 6 months and older. The minimum age for LAIV is 2 years, so that vaccine would be inappropriate for the child in this question.
The minimum age for TIV is 6 months. It is recommended that practitioners administer two doses of vaccine separated by at least 4 weeks to children between the ages of 6 months and 8 years who are receiving the seasonal influenza vaccine for the first time, or who were vaccinated for the first time during the previous influenza season, but only received one dose.
This recommendation states that all healthy children aged 24 to 59 months who have not completed their primary immunization for PCV7 be given one dose of PCV7. The HPV vaccination is recommended for all adult women younger than 26 years of age who have not completed the vaccine series. History of genital warts or an abnormal Pap test are not, by themselves, evidence of prior infection with all HPV subtypes, and are not reasons to avoid vaccination.
Persons who are sexually active but not in monogamous relationships are at risk for infection, and should therefore be immunized if they meet criteria. The quadrivalent HPV vaccination has been shown to be highly immunogenic, safe, and well-tolerated in females aged 9 to 26 in studies.
To be most effective, the vaccine should be given before a female becomes sexually active. It can be administered when a patient has an abnormal Pap test or when a woman is breast-feeding. It can also be given when a patient is immunocompromised because of a disease or medication.
It is not recommended for use during pregnancy. The vaccine was recently approved for use in males aged 9 to 26 to reduce the likelihood of genital warts. As in women, it is most effective if administered before exposure to HPV through sexual contact. The answer is b. Of the vaccines listed, only the Tdap is indicated in this patient. According to guidelines, the Tdap vaccine should be administered to patients 65 years and older who have close contact with an infant aged less than 12 months.
The Tdap vaccine should be administered regardless of the interval since the most recent Td-containing vaccine. People born before do not need to be vaccinated with an M M R, as they are considered immune. People born before are considered immune to varicella, and therefore do not need vaccination. Although she has a medical indication for the pneumococcal polysaccharide vaccine, she had her first shot before the age of Therefore, she should get a onetime revaccination 5 years after her initial vaccination.
Intranasal influenza should only be used in healthy adults younger than the age of The herpes zoster vaccination is currently recommended for adults 60 years of age or older regardless of whether or not they report a prior episode of herpes zoster. The vaccination is not approved for persons younger than the age of 60, though trials are currently underway to assess safety and efficacy in younger age groups.
AAFP, Determining which screening tests are appropriate for a patient is difficult, and requires individual judgment based on the clinical situation. It is strongly recommended that men are screened for lipid disorders at age 35, even in the absence of other risk factors. Screening would occur earlier in the presence of diabetes, a family history of heart disease by age 50, or with other risk factors.
The USPSTF has found that CT scanning, chest x-ray, and sputum cytology can detect lung cancer at an earlier stage than no screening at all, but also found no evidence that any screening strategy actually improves mortality.
Therefore, no screening is recommended for this patient. Of the interventions listed above, only prescribing folic acid has been shown to be beneficial prior to pregnancy. It will decrease the chance of neural tube defects in the baby. The other interventions should be done early in the pregnancy to ensure good pregnancy outcome. The American Academy of Family Physicians recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 and continuing until age The risk and benefits of these screening methods vary.
When there is a family history of colon cancer, it is generally recommended to start screening 10 years before the cancer was found in the family member, or at age 50, whichever is sooner. M ammographic screening has been shown to decrease mortality from breast cancer.
However, screening interval and recommendations have changed based on evidence review. There is a stronger recommendation that women between the age of 50 and 74 should get screening mammograms every 2 years. Therefore, in this question, the correct answer is to begin routine screening at age The issues surrounding breast self-examination BSE remain controversial. While it is true that most breast cancers are found by women not by mammography or by clinical breast examination , the American Academy of Family Physicians AAFP and the USPSTF have reviewed the evidence and found that a significant number of additional imaging procedures and biopsies were performed for women performing BSE than control participants.
Prior to , there was insufficient evidence to recommend for or against teaching or performing BSE. There is evidence supporting DRE and PSA testing as a prostate cancer screen, but concerns exist regarding false-positive tests and any actual reduction in mortality that is gained from doing the tests. Therefore, AAFP feels the evidence is insufficient to recommend for or against routine prostate cancer screening in men younger than 75 years. In patients who are interested in screening, physicians should discuss the potential benefits and harms with the patients before making a decision to test.
There is a strong recommendation from AAFP for cervical cancer screening at least every 3 years for women who have ever had sex and have a cervix. However, the optimal age at which to begin screening is less clear. Indirect evidence, coupled with the natural history of HPV infection, indicates that screening can safely be delayed until 3 years after the onset of sexual activity or age 21, whichever comes first.
Guidelines for low-risk women indicate that Pap testing should be conducted at least every 3 years in women who have ever had sex and still have a cervix. The guidelines regarding when to discontinue testing are not as clear. The American Cancer Society recommends discontinuing screening at age 70, but also notes that a woman who has had three or more documented normal, technically satisfactory Pap tests, and has had no abnormal Pap tests in the last 10 years can safely stop screening.
The AAFP and the USPSTF recommend against routine referral for genetic counseling or routine genetic testing for breast cancer mutations when women do not meet specific high-risk criteria.
In non-Ashkenazi Jewish women, high-risk criteria are: Ashkenazi Jewish women should be offered testing if any first-degree relative or two second-degree relatives on the same side of the family are diagnosed with breast or ovarian cancer. Since the patient in this question does not meet the criteria, she should not be offered testing. The purpose of the preoperative evaluation is to identify and manage risk. The primary care physician is frequently asked to perform this evaluation on surgical patients.
All surgeries involve some level of risk, and the evaluation allows the patient to balance the risks involved in surgery against the potential benefits, and allows the physician to minimize risks before, during, and after the procedure. Potential surgical complications involve infectious wound infections, pneumonia, urinary tract infections, bacterial endocarditis, and sepsis , cardiac myocardial infarction, cardiac arrest, pulmonary edema, and complications of congestive heart failure , pulmonary pneumonia, atelectasis, bronchitis, respiratory failure , thrombosis peripheral venous thromboembolism, arterial thrombosis adverse reactions to anesthesia, gastrointestinal ulcer disease, ileus, hyperemesis , and psychologic delirium, exacerbation of existing psychiatric disease complications.
Of the complications listed, cardiac events are the events that are most likely to be lethal. Pulmonary complications are most likely to be seen in children and are common in obese patients, but are less likely to be lethal. The preoperative workup should include a risk assessment of the type of surgery being performed.
As a general rule, preoperative workups should be more thorough for patients undergoing higher risk surgeries. There are three categories of risk: They generally do not require additional cardiac preoperative testing. High-risk procedures have high anticipated blood loss and include aortic or peripheral vascular surgery. The American College of Cardiology and the American Heart Association have printed guidelines for preoperative cardiac evaluation. If a patient has no known heart disease, the evaluator should look at clinical predictors for heart disease.
M ajor clinical predictors would require coronary artery evaluation prior to surgery, and include unstable coronary syndromes, decompensated congestive heart failure CHF , significant arrhythmias, or severe valvular disease.
Intermediate clinical predictors include mild angina, a prior M I, compensated CHF, diabetes, and renal insufficiency. In a patient with poor functional capacity, noninvasive testing is recommended.
In the question above, the patient has diabetes an intermediate clinical predictor and poor functional capacity. Therefore stress testing is recommended. Recent coronary revascularization is a risk for poor perioperative outcomes.
People with clinically important coronary artery disease should defer noncardiac procedures until 6 months after revascularization, when possible. If surgery is necessary within 6 months after revascularization, repeated evaluation of the coronary arteries is necessary prior to surgery.
In this case, because the surgery is elective, the patient should defer the surgery until 6 months has elapsed from the time of coronary revascularization. If the patient is asymptomatic at that time, the patient may be able to proceed to surgery without reassessment. Asymptomatic patients who have had a normal stress test in the past 2 years, bypass surgery in the past 5 years, or angioplasty in the past 5 years are unlikely to have developed significant new disease.
Current recommendations are that these people may proceed to surgery without further cardiac workup. However, some experts suggest screening ECG should be done in patients older than 55 or with known cardiac disease. Assessment of left ventricular function such as an echocardiogram is not recommended, as it will unlikely change the perioperative management of the patient.
Pulmonary complications from surgery are most common in surgeries that are anatomically close to the diaphragm. Preexisting respiratory disease increases the change of bad outcomes, and smoking is a risk factor for pulmonary problems after surgery.
Despite this, chest x-ray is not indicated as a routine baseline test for patients undergoing surgery. It may be indicated for the evaluation of physical examination abnormalities or reported symptoms of dyspnea or cough, but it is unhelpful in the absence of these symptoms.
Pulmonary function testing is useful for demonstrating the status of asthma or chronic obstructive pulmonary disease COPD prior to surgery, but would not be an effective routine test in the absence of these diagnoses or symptoms leading one to suspect these diagnoses. Pulse oximetry or arterial blood gasses are rarely useful in the preoperative patient without symptoms.
M ore than 50 million Americans travel abroad each year. M ost morbidity and mortality related to international travel is caused by common preventable health concerns, not by unusual diseases. It is followed by upper respiratory infection URI , viral syndromes, skin conditions, parasitic infections, malaria, hepatitis, and other more rare infections.
Heart disease is the most common cause of death while traveling, likely because it is such a common cause of death in general. While traveling people engage in risky behavior that they otherwise might not indulge in.
Dangerous recreation activities, increased drinking, driving in foreign countries all contribute to causing accidents. Discussing accident prevention is therefore the key when counseling patients planning to travel abroad.
M ost of the times, the condition is self-limited. The CDC does recommend using common sense regarding food and water, eating nothing unless it is boiled, peeled, or cooked. Yellow fever is the only legally required immunization and then, only for some countries. A single inactivated polio vaccine IPV booster is recommended for adult travelers who have had primary polio immunization, but who will be traveling to an area where polio is endemic.
Cholera and typhus are generally not required immunizations for travelers. Hepatitis A is the most common vaccine-preventable illness acquired by travelers, but vaccination is not required. South-Paul, pp In some patients, COCs cause a small increase in blood pressure. This risk increases with age. Both estrogen and progestin are known to cause blood pressure elevations, so changing formulations of COC or using progestin-only pills may not lead to problem resolution.
Once COCs are discontinued, blood pressure usually returns to normal within 3 months. Side effects of COCs include androgenic effects hair growth, male pattern baldness, nausea. Weight gain is thought to be a common side effect, but multiple studies have failed to show it to be a statistically significant side effect. The side effect most frequently cited as the reason for stopping the use of COCs is irregular bleeding. It is common in the first 3 months of use and generally diminishes over time.
The use of COC pills is associated with a threefold risk of venous thromboembolism. COCs have a protective effect against ovarian cancer and endometrial cancer. The risk of hemorrhagic stroke is not increased by the use of COCs, and they have not been shown in studies to impact carbohydrate metabolism in a statistically significant way.
It is important to counsel patients appropriately if they miss an oral contraceptive pill. If an active pill is missed at any time, and no intercourse has occurred in the past 5 days, two pills should be taken immediately and a backup method should be used for 7 days.
If intercourse occurred in the previous 5 days, emergency contraception should be used immediately and pills should be restarted the following day. A backup method should be used for 5 days.
There is no need to change contraceptive method. Progestin-only pills prevent conception through suppression of ovulation, thickening of cervical mucus, alteration of the endometrium, and inhibition of tubal transport.
The effectiveness of this method is dependent on consistency of use. In fact, if a pill is taken even after 3 hours, an alternative form of contraception should be used for 48 hours. There is no hormone-free period with these pills, and they should be taken every day.
The pills do not carry an increased risk for thromboembolism, and the World Health Organization has reported this form of contraception to be safe for women with a history of venous thrombosis, pulmonary embolism, diabetes, obesity, or hypertension. Nursing women can use this pill, but there is FDA approval for use in others as well.
In general, progestin-only pills protect against ectopic pregnancy by lowering the chance of conception. Therefore, users should be aware of the symptoms for ectopic pregnancy. Oral contraceptive pills containing estrogen and progestin components are contraindicated in smokers older than 35 years, because of an increased risk of thromboembolic events.
An intravaginal ring or transdermal patch that releases estrogen and progestin is also contraindicated in smokers older than 35 years for the same reason. Women who use IUDs for contraception are at higher risk for acquiring a sexually transmitted infection and developing pelvic inflammatory disease PID as compared to women who use barrier or other hormonal birth control methods, and patients should be screened carefully.
An injectable long-acting progestin would therefore be the best choice in this woman. Emergency contraception is appropriate when no contraception was used including cases of sexual assault , or when there is contraceptive failure.
They should be used within 72 hours of intercourse, well before implantation implantation occurs days after intercourse. ECPs involve limited hormonal exposure, and therefore have not been shown to increase the risk of venous thromboembolism, stroke, or M I. In fact, there are no medical contraindications to the use of emergency contraception pills. They do not disrupt an already implanted pregnancy and do not cause birth defects.
There is no need to perform a pregnancy test when prescribing. The pedigree shown is for an autosomal dominant condition. As the pedigree shows, males and females in the family are equally affected, and parents are transmitting the gene to their offspring vertical inheritance. X-linked recessive traits affect more males than females, and X-linked dominant traits affect more females than males.
The pedigree shown is for an X-linked recessive condition. As the pedigree shows, the condition affects more males than females, and inheritance is through the maternal side of the family diagonal inheritance. All daughters of an affected male are carriers, and none of his sons are affected. If this were an autosomal dominant condition, males and females would be equally affected, and parents would transmit the gene to their offspring. If this were an autosomal recessive trait, horizontal inheritance would be present, with multiple children being affected from unaffected parents.
If it were X-linked dominant, more females would be affected than males. Cytogenetic analysis is a microscopic study of the chromosomes and is used to identify abnormalities in chromosome number, size, or structure.
It is commonly ordered when patients are suspected of having a recognizable chromosomal syndrome trisomy 21 and in newborns with multiple malformations of unknown etiology or with ambiguous genitalia. Direct DNA testing is indicated for patients affected or predisposed to a condition for which the gene change that causes the condition has been identified cystic fibrosis.
Biochemical tests identify or quantify metabolites or enzymes to measure activity, and are commonly used to diagnose and monitor disorders of metabolism.
Linkage analyses identify genetic sequences that are physically in close proximity to a disease gene of interest. Rosner, pp Sensitivity is thought of as the probability that a symptom is present given that the person has the disease. Specificity can be thought of as the probability that the symptom is not present given that a person does not have a disease.
A false-negative is defined as a person who tests negative, but who is actually positive. Sensitivity is defined as the probability that the test would be positive, given that the person has strep throat. The specificity is the probability that the test would be negative if the person does not have strep. The false-positive rate is defined as the percent of people who test positive, but are actually negative.
The positive predictive value is the probability that a person has an illness, given that the test is positive. The incidence of a disease is the probability that a person with no prior disease will develop a new case of the disease over a specific time period. In this case, people developed diabetes. In the study, only people began with no prior disease. The prevalence is the probability of having a disease at a specific point in time, and is obtained by dividing the number of people with the disease by the number of people in the study.
The p value for any hypothesis test is the level at which we would be indifferent between accepting or rejecting the null hypothesis given the sample data at hand.
It can also be thought of as the probability of obtaining a test statistic as extreme or more extreme than the actual test statistic obtained, given that the null hypothesis is true. It does not reflect the absolute difference in the data between groups and the correctness of the data in the sample.
The positive predictive value refers to the probability that a positive test correctly identifies an individual who actually has the disease.
The negative predictive value is the probability that a negative test correctly identifies an individual who does not have the disease. Doctor-Patient Issues Questions Communication You are performing a medical interview with a patient and having some difficulty obtaining accurate information regarding the events that brought him into the office.
Which of the following physician communication tactics leads to the collection of the most accurate information? Controlling the interview with more directive questions b.
Using medical terms that the physician feels the patient can understand c. Using open-ended questions You were involved in a minor motor vehicle accident on the way to work. As a result, you saw your first patient of the morning more than 1 hour after the scheduled appointment time. When you walk in, he appears extremely angry. Which of the following alternatives is the most patient-centered way to approach this situation?
Explain what happened so that he will understand why you are late. Apologize for the delay and efficiently take care of his problem.
Explore the reasons for his anger if he brings it up. Help the patient understand that his anger should be directed at his illness, not at you. You are having trouble caring for a year-old woman with uncontrolled diabetes. Which of the following is the most effective way to measure her adherence to the prescribed medical regimen? Ask her if she is taking her medications.
Look for a reduction in her blood glucose measurements in subsequent visits. Have her bring in her medications so that you may perform pill counts. M easure serum blood levels of her medications. Ask her specific questions about her medication names, dosages, and administration times.
You are seeing a year-old woman who has smoked for 50 years. You want her to quit, and are considering different communication tactics to use in the discussion. Which of the following is likely to be the most powerful motivator?
Point out the positive results that can be expected if she complies with your advice. Point out the consequences of not following your advice. Provide data. Ask about her experience with the illness that she is at risk for. A year-old man is following up to discuss the results of laboratory tests you did at his complete physical examination 1 week ago.
His human immunodeficiency virus HIV screen was positive, and you need to tell him this news.
Which of the following is the most appropriate approach? Begin the session by inquiring about his understanding of HIV. Ensure you schedule enough time to discuss treatment goals and options. M ake sure he brings a support person into the room before you disclose the test results.
Regarding patient education and counseling, which of the following statements is true? Patients usually understand and remember most information from their physician.
Patients commonly believe that physicians give them too much information. Patients are more likely to make behavior changes if they are given several options for change from which to choose. Physician eye contact does not improve patient recall.
Patients feel patronized when physicians repeat information. You are treating a year-old Chinese immigrant. You diagnose type 2 diabetes, but the patient is reluctant to make the dietary changes necessary to help treat the condition, as much of her high glycemic index diet is culturally based. Which of the following is the most culturally appropriate approach? Ask to involve her Americanized children in future communication to help encourage the changes.
Since her culture believes that health is a balance between yin and yang, tell her that the dietary changes you suggest will restore this balance.
Organize an appointment with the patient and a diabetes educator who can better take the time and explain the etiology and dietary regimen necessary for diabetes.
Use a Chinese interpreter to ensure your message is being heard appropriately. You are caring for a patient originally from M exico and are communicating with the help of a Spanish-speaking interpreter. Which of the following statements is true regarding the effective use of an interpreter? Ask the interpreter to explain your statements, when necessary. Arrange seats in a triad, and speak slowly, facing the interpreter.
Act as if the interpreter is not present, speaking to the patient normally. Use as many nonverbal gestures as possible. If you get an unexpected response, repeat the same question over again. You are interacting with a patient who has emigrated from Russia. The patient is not complying with the treatment plan you outlined for his hyperlipidemia.
Which of the following is the most effective way to improve this situation? Speak with Russian colleagues to better understand the Russian culture. Refer the patient to a physician from the same cultural background as the patient.
Study the Russian culture as it relates to illness and healing, and offer alternatives for treatment consistent with the cultural norms. Examine the beliefs of Russian culture and use these beliefs to convince the patient to comply with treatment. You are working at a medical office whose population includes a large proportion of Native American patients.
Which of the following health issues has a higher prevalence in this population than in other American population groups? Hypertension b. Coronary artery disease c. Obesity d. Asthma e.
Tuberculosis You are working in an office that provides care to a large population of homeless patients. Which is true about medical illnesses in homeless children as compared with other groups of children? Homeless children are more likely to develop type 2 diabetes. Homeless children experience a higher number of ear infections. Homeless children are more likely to have chronic illness.
Homeless children are more likely to have depression. Homeless children are more likely to have attention-deficit disorders. You are working in an office that serves a large uninsured population. Which of the following is true regarding this population as compared to the privately insured population? This population has fewer chronic health conditions. This population has a lower mortality rate. This population has a better general health status. This population has a better mental health status.
This population has a higher rate of chronic disease among children. You are evaluating health disparities in your community and using mortality rates as a measure of overall health. Which of the following population subgroups in the United States has the lowest mortality rate at each age of the lifespan?
African Americans b. Hispanic Americans c. Native Americans d. Asian Americans e. Non-Hispanic white You are evaluating a Hispanic patient with multiple somatic complaints and suspect a mental health disorder. Which of the following is true regarding mental health disparities in the United States today? M ental health disorders are diagnosed less frequently in minority populations than in non-Hispanic white patients. It is uncommon for minority groups to express mental health disorders via somatization.
M inority patients are more likely to be misdiagnosed than nonminority counterparts. M inorities who maintain cultural practices and resist involvement in the dominant culture have better mental health.
Culture is less of a factor in mental health than in other organic syndromes or illnesses. Ethics and Professionalism You are taking care of a year-old woman with a urinary tract infection.
You prescribe trimethoprim-sulfamethoxazole Bactrim for her infection, but forget to ask about her allergies. Which of the following fundamental principles of medical professionalism has been violated? The principle of primacy of patient welfare b. The principle of patient autonomy c. The principle of social justice d. The principle of professional competence e.
The principle of honesty with patients You are working with a physician who is treating a patient for hypertension. The patient has a documented allergy to angiotensin-converting enzyme inhibitors, and you note that the physician is prescribing them. You assume that the physician knows best, and do not let the physician know of the potential mistake.
What professional responsibility have you violated? Commitment to honesty with patients b. Commitment to professional competence c. Commitment to maintaining appropriate patient relationships d. Commitment to improving quality of care e. Commitment to maintaining trust You are working as a student in the emergency room. After a cardiac arrest and a prolonged attempt at resuscitation, a patient dies. The attending physician asks if you would like to gain experience by practicing intubations on the patient who has died.
You feel that this relates to one of your professional responsibilities, to maintain clinical competence, and consider the offer. Which fundamental principle of professionalism and ethics would be violated if you do this? The principle of patient welfare b. The principle of honesty with patients e.
The principle of maintaining trust There are other health care providers in the elevator. What professional responsibility has your senior resident violated? Commitment to maintaining trust b. Commitment to improving quality of care c. Commitment to professional competence d.
Commitment to scientific knowledge e. Commitment to patient confidentiality One of your patients is 6 months pregnant, and is found to have a medical condition that, if left untreated, will be life-threatening to both her and the fetus.
She believes that God will take care of her and the baby, and she refuses medical intervention offered to her. Which of the following best describes the principle of patient autonomy in this case?
She has no right to refuse the intervention, based on the fact that her decision is lethal to both her and her unborn infant. She has no right to refuse the intervention, based on the fact that her decision is lethal to her infant. She has the right to refuse the intervention regardless of the condition. She has the right to refuse the intervention, only if the father of her baby agrees. She has the right to refuse the intervention if she is found competent to make the decision.
You are caring for a year-old man with metastatic cancer. He thoroughly understands his condition, and realizes that he has only a few months to live.
Tell her the truth about the situation because she has a right to know. Tell her the truth because you have the legal obligation to do so.
Consult the ethics committee to help you make the decision. You are caring for a patient who has suffered with amyotrophic lateral sclerosis ALS for several years.
During the past month, she has been hospitalized twice with aspiration pneumonia and has required mechanical ventilation. She was admitted to the hospital again 4 days ago with difficulty in breathing and was found to have another pneumonia.
She is not responding to volume or pressers. Her creatinine rose today to 5. Which of the following statements is most accurate regarding her situation? The patient is terminally ill and the physician should recommend withdrawal of support. The patient is terminally ill, but the physician cannot withdraw intervention as it would hasten death. To simulate the time constraints imposed by the qualifying examinations for which this book is intended as a practice guide, the student or physician should allot about one minute for each question.
After answering all questions in a chapter, as much time as necessary should be spent in reviewing the explanations for each question at the end of the chapter. Attention should be given to all explanations, even if the examinee answered the question correctly.
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Tuesday, April 16, Free Medical Books — Arslan Library. Share