Screening/Biostatic

Question 1

A 58-year-old female sees you to request testing for a possible vitamin D deficiency. She lives independently and has no health problems except for osteoarthritis. Her BMI is 25 kg/m2 and she has no pain or muscle weakness. After discussing the U.S. Preventive Services Task Force recommendations regarding screening for vitamin D deficiency, she chooses to be tested. A serum 25-hydroxyvitamin D level is 18 ng/mL

Which one of the following would be the most appropriate next step? (check one)
-Explaining to her that there is no accepted cut-off for deficiency, and that the benefits of supplementation with this laboratory result are unclear
- Initiating vitamin D supplementation to decrease the risk of cardiovascular events because her serum 25-hydroxyvitamin D level is <20 ng/mL
-Initiating vitamin D supplementation to decrease the risk of mortality because her serum 25-hydroxyvitamin D level is <20 ng/mL
-Ordering a 1,25-dihydroxyvitamin D study

Answer 1

Explaining to her that there is no accepted cut-off for deficiency, and that the benefits of supplementation with this laboratory result are unclear

There are unclear benefits of vitamin D supplementation with a total serum 25-hydroxyvitamin D level of 18 ng/mL even though this test is considered the best available study of vitamin D status. There are many laboratory assays with poor standardization and no consensus regarding what 25-hydroxyvitamin D level is sufficient or recommended for health optimization. In community-dwelling, nonpregnant individuals without risk factors there is insufficient evidence to support that supplementation decreases all-cause mortality, cardiovascular events, or fractures. A 1,25-dihydroxyvitamin D level would be used to test for rickets and osteomalacia.

Question 2

The specificity of a screening test is best described as the proportion of persons

(check one)
with the condition who test positive
with the condition who test negative
with the condition who test positive, compared to the total number screened
without the condition who test positive
without the condition who test negative

Answer 2

without the condition who test negative

A screening test’s specificity is the proportion of persons without the condition who test negative for that
condition. In other words, it is a measure of the test’s ability to properly identify those who do not have
the disease. Conversely, the sensitivity of a screening test is the proportion of those with the condition who
test positive. The other options listed describe false-negatives, false-positives, and prevalence.

Question 3

A 30-year-old female presents to your office as a new patient and requests a refill of sulfasalazine (Azulfidine) tablets for maintaining remission of her ulcerative colitis. The initial presentation of her disease was in her teenage years and involved inflammation of the entire colon. She was then started on sulfasalazine, which has worked well for controlling her symptoms. She had one flare when she ran out of medicine 7 years ago. She has not seen a gastroenterologist for many years.

Which one of the following is an appropriate management plan for this patient? (check one)
Refill her sulfasalazine and continue usual care unless symptoms recur
Attempt to gradually discontinue the sulfasalazine
Stop sulfasalazine and start azathioprine (Imuran)
Continue sulfasalazine and arrange for colonoscopy to screen for colon cancer
Refer to a colorectal surgeon to discuss colectomy

Answer 3

Continue sulfasalazine and arrange for colonoscopy to screen for colon cancer

Ulcerative colitis (UC) is a lifelong condition that results in a waxing and waning autoimmune inflammation of the colon. Clinical symptoms are inadequate for assessing the need for ongoing therapy. For this reason, once a patient with UC has achieved remission with a specific medication, that medication should be continued indefinitely unless the disease resurfaces. Sulfasalazine is one of the most effective agents for this purpose, is usually well tolerated, and is considered first-line therapy for ulcerative colitis. There is no apparent reason to consider a higher order of therapy (azathioprine) in this patient or to refer her for colectomy. Patients with UC who have had a history of moderate or extensive involvement of the colon, however, are at markedly increased risk for the development of colorectal cancer. Current guidelines recommend beginning screening colonoscopy 10 years after the initial diagnosis and continuing every 2–5 years, with the interval based on the findings.

Question 4

A 50-year-old male comes to your office for a health maintenance visit. He does not have any symptoms today. You last saw him 4 years ago and at that time his BMI was 24 kg/m2, his blood pressure was 124/70 mm Hg, and a lipid panel was normal. Today he tells you that he gained some weight and started smoking due to a stressful job. He is concerned about his risk for cardiovascular disease.

Which one of the following would be the most appropriate screening test for this patient at this time? (check one)
Hypertension screening
An ankle-brachial index
A coronary artery calcium score
An EKG
Abdominal duplex ultrasonography

Answer 4

Hypertension screening

The U.S. Preventive Services Task Force (USPSTF) recommends screening for hypertension with office blood pressure measurement in adults 18 years of age (A recommendation). Adults 40 years of age and those 18 years of age with risk factors should receive annual hypertension screening. Less frequent screening is recommended for adults 18–39 years of age without risk factors. The USPSTF found insufficient evidence to recommend an ankle-brachial index (I recommendation) or a coronary artery calcium score (I recommendation) for cardiovascular screening, even in patients with traditional risk factors such as male sex, older age, current smoking, and overweight/obesity status. Cardiovascular screening with an EKG is not recommended (D recommendation). The USPSTF did not find adequate evidence to suggest that adding a resting or exercise EKG helped guide treatment decisions to reduce cardiovascular events in asymptomatic adults. It identified some evidence that small to moderate harms may exist, such as unnecessary invasive procedures. The USPSTF recommends abdominal duplex ultrasonography (B recommendation) for men 65–75 years of age who have ever smoked, which is usually defined as 100 cigarettes or more in a lifetime. The only appropriate screening test for the patient in this scenario is blood pressure measurement.

Question 5

A 78-year-old male presents to your office for a health maintenance visit at the request of his spouse. He does not have any current symptoms or concerns. He states that he has not seen a physician since he was a teenager. The patient reports breaking his arm as a child but has no other known medical conditions. He has a 30-pack-year history of smoking cigarettes but has not smoked for 10 years. He has one glass of wine with dinner 3–4 times a month and does not use illicit substances. His sexual history consists of sex with only his wife. His family history includes a mother who died of a stroke and a father who died of pancreatic cancer. He walks 2 miles five times a week. His vital signs and a physical examination are normal.

Which one of the following screenings is recommended by the U.S. Preventive Services Task Force for this patient? (check one)
Hepatitis B testing
Prostate-specific antigen testing
Abdominal aortic aneurysm ultrasonography
A DEXA scan
Low-dose CT of the chest

Answer 5

Low-dose CT of the chest

The U.S. Preventive Services Task Force (USPSTF) recommends annual screening for lung cancer with low-dose CT of the chest for men and women ages 50–80 with a 20-pack-year smoking history or more, or patients who currently smoke or have quit smoking in the past 15 years (B recommendation). This patient is 78 years old with a 30-pack-year history and he quit smoking only 10 years ago.

Patients at increased risk for hepatitis B virus infection should be tested (B recommendation). This patient does not have a history that is high risk for hepatitis B infection, such as needle-sharing, injecting illicit substances, having sex with other men, and HIV infection, so he does not need to be tested at this time. Shared clinical decision-making to discuss the benefits and harms of prostate-specific antigen (PSA) testing in men ages 55–69 years should be considered. This patient’s age makes PSA testing inappropriate (D recommendation).

According to the clinical evidence, one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography demonstrates moderate benefit for males between the ages of 65–75 who have ever smoked or have smoked at least 100 cigarettes (B recommendation). Smoking history is the strongest predictor for AAA (B recommendation). This patient does have a smoking history, but his age is outside the recommended window for AAA screening. According to the USPSTF, there is insufficient evidence to screen men for osteoporosis (I recommendation), so a DEXA scan would not be appropriate.

Question 6

One week after a complete and adequate baseline screening colonoscopy, a 51-year-old female with no history of previous health problems visits you to review the pathology report on the biopsy specimen obtained from the solitary 8-mm polyp discovered in her sigmoid colon. The report confirms that this was a hyperplastic polyp. Her family history is negative for colon cancer.

Which one of the following is the most appropriate interval for follow-up colonoscopy in this patient? (check one)
1 year
2 years
5 years
10 years

Answer 6

10 years

There is substantial evidence that small (<10 mm) hyperplastic polyps found in the rectum or sigmoid colon are not neoplastic. Data obtained from numerous studies provides considerable evidence of moderate quality that individuals with no significant findings other than rectal or sigmoid hyperplastic polyps of this size should be included in the same low-risk cohort as those who have an unremarkable colonoscopy. For patients at low risk the recommended interval between screening colonoscopies is 10 years. Reductions in this interval are recommended for patients with one or two small tubular adenomas (5–10 years) or those with three or more tubular adenomas (3 years); the interval for more extensive disease is best individualized but can be as often as annually in unusual cases.

Question 7

The results of a meta-analysis of lung cancer screening using low-dose CT were as follows: the pooled lung cancer–specific mortality rate in the control group was 2.12%, the estimated lung cancer–specific mortality rate in the screened population was 1.72%, and the absolute risk reduction for lung cancer mortality was 0.4% (2.12% minus 1.72%).

What is the number needed to screen to prevent one death due to lung cancer? (check one)
5
23
47
200
250

Answer 7

250

The absolute risk reduction (ARR) in this meta-analysis was 0.4%. The number needed to screen is the reciprocal of the ARR. The number needed to screen would equal 1 divided by the ARR (1/ARR), or 1/0.004, which equals 250. Based upon this meta-analysis, 250 individuals would need to be screened to prevent one lung cancer death.

Question 8

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? (check one)
Limited life expectancy
Age 76
Quitting smoking within the last 10 years
Recent cardiac procedure

Answer 8

Limited life expectancy

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.

Question 9

A 45-year-old transgender female presents for a health maintenance visit. Her current medications include spironolactone (Aldactone), ethinyl estradiol, and escitalopram (Lexapro). Her blood pressure is within normal range. She transitioned 4 years ago and started estrogen therapy at that time. Her surgical history includes breast augmentation and vaginoplasty. There is no family history of colon, prostate, breast, or cervical cancers.

Which one of the following preventive screenings should you recommend for this patient? (check one)
Breast cancer
Cervical cancer
Colon cancer
Osteoporosis
Prostate cancer

Answer 9

Colon cancer

Family physicians should provide appropriate age-based and organ inventory–based screening recommendations to all patients. Current guidelines from the U.S. Preventive Services Task Force recommend initiating colon cancer screening at age 45 in average-risk individuals. Breast cancer screening in transgender females is complicated by a lack of consensus on screening recommendations in cisgender females and limited evidence. In general, expert guidelines recommend starting breast cancer screening in transgender females at age 50 and after 5–10 years of feminizing hormone therapy. Cervical cancer screening would be a concern in transgender males, not transgender females. Osteoporosis screening is not recommended at this age for a patient of any gender unless there have been concerning fractures or other risk factors. The prostate is not removed during vaginoplasty, but screening is not recommended prior to age 50, if at all.

Question 10

According to the American Diabetes Association, screening should be considered for which one of the following conditions in children with type 1 diabetes mellitus? (check one)
Hypothyroidism
Cystic fibrosis
Cushing syndrome
Systemic lupus erythematosus
Pancreatic pseudocysts

Answer 10

Hypothyroidism

Children with diabetes mellitus are at increased risk for retinopathy, nephropathy, and hypertension. They are also more likely to have immune-mediated disorders such as celiac disease and hypothyroidism. For all children and adolescents with type 1 diabetes mellitus, the American Diabetes Association recommends screening for hypothyroidism, nephropathy, hypertension, celiac disease, and retinopathy. Screening for dyslipidemia should be considered if there is a family history of hypercholesterolemia or cardiac events before age 55.

Question 11

During a routine office visit, a 65-year-old female asks if she should be screened for carotid artery stenosis. The patient has a history of controlled hypertension and hypercholesterolemia, and a family history of stroke. Physical examination of the carotid artery is normal and the patient is asymptomatic.
Which one of the following is consistent with U.S. Preventive Services Task Force and American Heart Association recommendations regarding carotid artery ultrasonography for this patient?
(check one)
She does not need screening ultrasonography at this time
She should have one-time screening ultrasonography now
She should have routine screening ultrasonography now and every 5 years
She should have routine screening ultrasonography now and every 10 years

Answer 11

She does not need screening ultrasonography at this time

The U.S. Preventive Services Task Force and the American Heart Association/American Stroke Association recommend not performing carotid artery screening with ultrasonography or other screening tests in patients without neurologic symptoms because the harms outweigh the benefits. In the general population, screening tests for carotid artery stenosis would result in more false-positive results than true-positive results. This would lead to surgical procedures that are not indicated or to confirmatory angiography. As a result of these procedures, some patients would suffer serious harms such as death, stroke, or myocardial infarction, which outweigh the potential benefit surgical treatment may have in preventing stroke.

Question 12

An 11-year-old female is brought to your office for a routine well child examination. The
American Academy of Pediatrics recommends screening this patient for which one of the
following?

(check one)
Anemia
Diabetes mellitus
Dyslipidemia
HIV

Answer 12

Dyslipidemia

SBecause of concerns about the growing epidemic of obesity in this population, the
American Academy of Pediatrics now recommends screening for elevated serum cholesterol
levels in children 9–11 years of age (SOR C). This patient should also be screened annually
for depression beginning at 11 years of age and continuing through 21 years of age.
Universal screening for iron deficiency anemia is recommended at 12 months of age and
again at 15–30 months of age if the patient is determined to be high risk. HIV screening
is recommended in adolescents 16–18 years of age, and age 21 is now the recommended
starting age for screening for cervical dysplasia. Universal screening for diabetes mellitus
is not recommended for children or adolescents.

Question 13

Which one of the following is the most common cause of death for African-Americans in the United States? (check one)
Heart disease
Stroke
Cancer
Accidental injuries
Homicide

Answer 13

Heart disease

Heart disease is the leading cause of death in the U.S., and this holds true for both men and women. Among men the only ethnicity for which heart disease is not the most common cause of death is Asian/Pacific Islander.

Question 14

Which one of the following is more common in non-Hispanic whites than in the Hispanic population?
(check one)
Obesity
Osteoporosis
Diabetes mellitus
Hypertension
Neurocysticercosis

Answer 14

Osteoporosis

Many minority populations in the United States, including Hispanics, suffer health care disparities. Some medical problems are also more common in certain populations. In 2009, Hispanics made up approximately 16% of the U.S. population and were the largest minority. This group is projected to make up 30% of the U.S. population by 2050. The rates of obesity and diabetes mellitus in Hispanics are disproportionately higher than those of non-Hispanic whites. Hypertension is closely linked to obesity, and Hispanics have higher rates of hypertension as well. Neurocysticercosis is the most common cause of seizures in Hispanic immigrants. Risk factors for osteoporosis include female gender, non-Hispanic white ethnicity, smoking, and low BMI.

Question 15

In which one of the following populations does the U.S. Preventive Services Task Force support ultrasound screening for abdominal aortic aneurysm?

(check one)
All men age 55–75
Males age 55–75 who currently smoke
Patients of both sexes age 55–75 who currently smoke
Men age 65–75 who have ever smoked
No population group

Answer 15

Men age 65–75 who have ever smoked

The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men age 65–75 who have ever smoked (Grade B recommendation). The USPSTF recommends against routine screening for AAA in women (Grade D recommendation).

Question 16

A new home test is designed to detect a particular type of cancer. The gold standard test for this cancer is a biopsy, but a biopsy is more costly that a urine test, is invasive, and is associted with a number of adverse side effects. To test the effectiveness of the home urine test, 104 people took the test and then agreed to a biopsy. When the study was concluded, 77 people tested negative and 27 tested positive on the urine test. Biopsies were positive in 18 individuals, 8 of whom tested negative on the urine test.

What is the negative predictive value of the home urine test, rounded to a whole number?
(check one)
20%
37%
56%
80%
90%

Answer 16

90%

The results of this urine test were that 10 people had the disease and tested positive (true positives); 8 people had the disease but tested negative (false negatives); 17 people did not have the disease (27 – 10) but tested positive (false positive); 69 people did not have the disease (77 – 8) and tested negative (true negative). The negative predictive value is determined by dividing the true negatives (69) by the total number who tested negative (true plus false negatives = 77). The result is 89.6%, which rounded to a whole number is 90%.

Question 17

A 78-year-old female with advanced dementia is brought to your office by her family for a wellness examination. Other than appearing chronically ill and showing significant cognitive impairment, she has an unremarkable examination.

Which one of the following should be offered to this patient?

(check one)
A clinical breast examination
A Papanicolaou test
Mammography
Colonoscopy
No cancer screening

Answer 17

No cancer screening

The Society of General Internal Medicine does not recommend cancer screening in adults with a life expectancy of less than 10 years. Other organizations have similar recommendations for specific cancers, usually based on a life expectancy of less than 10 years or an age greater than 65. For patients who have had negative screening results for cervical cancer in the past, this screening may be stopped at age 65. For patients who are 76–85 years of age, screening for colorectal cancer and breast cancer should be performed on an individual basis, taking into account the patient’s overall health and screening history.

Question 18

A 27-year-old male requests your advice regarding colon cancer screening. His brother died of colon cancer, which was diagnosed at the age of 40.

You suggest that he begin colonoscopy screening? (check one)
Now
At age 30
At age 40
At age 45
At age 50

Answer 18

At age 30

Average-risk adults should be screened for colon cancer starting at 50 years of age, and high-risk adults either at age 40 or 10 years before the age at which colorectal cancer was diagnosed in the youngest affected relative.

Question 19

Which one of the following is considered to be the highest strength of recommendation by the Strength of Recommendation Taxonomy (SORT) used by family medicine journals? (check one)
Expert opinion
A consensus guideline
A retrospective cohort study
Multiple good quality randomized, controlled trials

Answer 19

Multiple good quality randomized, controlled trials

Family medicine journals, including American Family Physician, The Journal of Family Practice, and The Journal of the American Board of Family Medicine utilize the Strength of Recommendation Taxonomy (SORT) to label key recommendations in clinical review articles. These grades are assigned on the basis of the quality and consistency of available evidence. The Cochrane Collaboration is an extensive database of systematic reviews and clinical trials. A Cochrane review with a clear recommendation warrants a strength of recommendation rating of A. This indicates consistent, good quality, patient-oriented evidence. Consistent findings from at least two randomized, controlled studies or a systematic review/meta-analysis of randomized, controlled trials are also assigned a level A strength of recommendation. Expert opinion and consensus guidelines are assigned a level C strength of recommendation. SORT also includes a grade of 1 to 3 for levels of evidence. Retrospective cohort studies are considered level 2.

Question 20

A 69-year-old male is found to have an infrarenal abdominal aortic aneurysm (AAA) on screening ultrasonography. Which one of the following is most important when determining the risk of his AAA rupturing? (check one)
His age
His sex
His history of hypertension
His history of smoking
The diameter of his aneurysm

Answer 20

The diameter of his aneurysm

The single most important determinant of the risk that an abdominal aortic aneurysm (AAA) will rupture is the diameter of the aneurysm. In men, aneurysm repair is recommended when the aneurysm reaches 5.5 cm in diameter. In women, whose aortas tend to be smaller, the recommended maximum diameter is 5.0 cm. Age, sex, a history of hypertension, and a history of smoking all increase the risk of developing an AAA, but do not increase the risk of rupture.

Question 21

In the U.S., the most common nutritional deficiency is: (check one)
Iron
Vitamin B12
Vitamin D
Calories
Protein

Answer 21

Iron

Iron deficiency is the most common known form of nutritional deficiency. Its prevalence is highest in children and in women of childbearing age (especially pregnant women).

Question 22

A 23-year-old gravida 3 para 1 at 28 weeks’ gestation whose blood type is O-negative is antibody positive (D antibody) on a routine 28-week screen. Which one of the following best describes the clinical significance of this finding? (check one)
The fetus HAS hemolytic disease and requires appropriate monitoring and treatment
The fetus is AT RISK for hemolytic disease only if the biological father is Rh-negative
The fetus is AT RISK for hemolytic disease only if the biological father is Rh-positive
The current fetus is NOT at risk for hemolytic disease, but subsequent pregnancies may be at risk

Answer 22

The fetus is AT RISK for hemolytic disease only if the biological father is Rh-positive

When a person is Rh negative, this indicates that they do not have type D antigen on their red blood cells. If a woman is exposed to Rh D antigen–positive red blood cells, she can have an immune response of variable strength. This may occur in the setting of pregnancy (transplacental fetomaternal transfusion), or exposure outside of pregnancy (e.g., transfusion with mismatched blood). If a maternal antibody screen for D antigen is positive, this indicates that the current fetus MAY be at risk for hemolytic disease. The level of risk is determined by the antibody titer. For example, an antibody titer of 1:4 poses much less risk to the fetus than a titer of 1:64. Determination of the blood type of the father is helpful if paternity is certain. If the father is homozygous Rh negative, there is no risk of alloimmunization to the fetus and the fetus is NOT at risk for hemolytic disease. In this scenario, maternal sensitization occurred either from a prior pregnancy with a different partner or from another source (e.g., transfusion). If the father is heterozygous or homozygous Rh positive, then the fetus IS at risk. If paternity is uncertain, a polymerase chain reaction can be performed on 2 mL of amniotic fluid or 5 mL of chorionic villi to accurately determine the fetal Rh status.

Question 23

A 58-year-old white male has a negative screening colonoscopy. He has no symptoms and no family history of colon carcinoma. His next screening colonoscopy should be scheduled in (check one)
1 year
3 years
5 years
10 years

Answer 23

10 years

The evidence supports a 10-year interval for colonoscopy in patients less than 80 years old. For patients with a family history of colon cancer a 5-year interval is recommended, or 3 years if benign polyps are found. Screening in patients over 80 years old is controversial.

Question 24

The most common stress fracture in children involves which one of the following bones? (check one)
Calcaneus
Tibia
Fibula
Tarsal navicular
Metatarsal

Answer 24

Tibia

Tibial fractures are the most common lower extremity stress fractures in both children and adults, accounting for about half of all stress fractures.

Question 25

You are considering how useful a new treatment might be in preventing stroke. A well designed study is reported with 200 patients in the treated group and 200 patients in the untreated group. The study finds a 5-year risk of stroke of 3% in the treated group versus 5% in the untreated group. Assuming this study is valid and applicable to your patient population, how many patients would you have to treat for 5 years to prevent one stroke (number needed to treat, or NNT)? (check one)
400
200
100
50
25

Answer 25

50

The relative risk reduction (RRR) is the proportional decrease in disease incidence in the treated group relative to the incidence in the control group. In this example the 3% incidence in the treated group is 40% less than the 5% incidence in the control group: (5%–3%)/5% = 40%. The absolute risk reduction (ARR) is the difference between the incidence of disease in the treatment group and the incidence in the control group. In this example the ARR is 5% minus 3% = 2%. The number needed to treat (NNT) equals the reciprocal of the ARR: 1/.02 = 50. The RRR is not a very useful statistic in clinical practice. It amplifies small differences and makes clinically insignificant findings appear significant because it essentially ignores the baseline risk of the outcome event. The ARR provides a more useful measure of clinical effect. It answers the question “How much will I decrease my patient’s risk of an adverse outcome by this treatment?” The NNT is also very useful for clinicians, as it answers the question, “How many patients will I need to treat to prevent one adverse outcome?”

Question 26

A new drug treatment is shown to reduce the incidence of a complication of a disease by 50%. If the usual incidence of this complication were 1% per year, how many patients with this disease would have to be treated with this medication for 1 year to prevent one occurrence of this complication? (check one)
20
50
100
200
500

Answer 26

200

Considering relative risk reduction without also considering the absolute rate can distort the importance of a therapy. A useful way to assess the importance of a therapy is to determine the number-needed-to-treat for that therapy. To calculate this number, the percentage of absolute risk reduction of a particular therapy is divided into 100. In the case in question, the absolute risk reduction would be 0.5% (0.5x.01). Thus, the number-needed-to-treat for the example cited would be 200 (100/0.5).

Question 27

A U.S. Preventive Services Task Force “D” recommendation indicates
(check one)
high certainty that the net benefit is substantial
high certainty that the net benefit is moderate
moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits
that the decision to provide the service should be based on professional judgment and patient preferences
that current evidence is insufficient to assess the balance of benefits and harms of the service

Answer 27

moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits

A “D” recommendation means the U.S. Preventive Services Task Force (USPSTF) recommends against
the service. There is moderate or high certainty that the service has no net benefit or that the harms
outweigh the benefits. An “I” recommendation means the USPSTF concludes that the evidence is lacking,
of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. A “C”
recommendation means the USPSTF recommends selectively offering or providing this service to
individual patients based on professional judgment and patient preferences. There is at least moderate
certainty that the net benefit is small. A “B” recommendation means the USPSTF recommends the service.
There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit
is moderate to substantial. An “A” recommendation means the USPSTF recommends the service and there
is high certainty that the net benefit is substantial. The highest levels of evidence and most recent evidence
available are used by the USPSTF in making all of its recommendations.

Question 28

Of the following, which one is the most common adverse event to complicate the hospital course of patients age 65 and over? (check one)
Falls
Wound infections
Drug-related events
Procedure-related events
Anesthesia-related events

Answer 28

Drug-related events

It has been observed that drug-related problems are the most common type of adverse event, and for hospitalized patients the rate of these events increases with the patient’s age. One study showed that in patients who are >65 years of age, the number of events per 1000 discharges was 11.46 for drug-related events, 6.15 for wound infection, 3.85 for procedure-related events, 3.19 for falls, and 0.09 for anesthesia-related events.

Question 29

Information derived from which one of the following provides the best evidence when selecting a specific treatment plan for a patient? (check one)
Meta-analyses
Prospective cohort studies
Expert opinion
Consensus guidelines

Answer 29

Meta-analyses

In general, the strongest evidence for treatment, screening, or prevention strategies is found in systematic reviews, meta-analyses, randomized controlled trials (RCTs) with consistent findings, or a single high-quality RCT. Second-tier levels of evidence include poorer quality RCTs with inconsistent findings, cohort studies, or case-control studies. The lowest quality of evidence comes from sources such as expert opinion, consensus guidelines, or usual practice recommendations.

Question 30

A 24-year-old female presents for her annual examination. She is single and has had several male sexual partners during the past year. You include screening for chlamydial infection in your evaluation, and the test is reported as positive. She is asymptomatic. Which one of the following is true concerning this situation? (check one)
Failure to treat this patient would place her at higher risk of later infertility
Only sexual partners with whom she has been active during the last 2 weeks need to be treated
She should avoid sexual intercourse for 1 month after treatment
Use of barrier methods of contraception increases her risk for repeat infection

Answer 30

Failure to treat this patient would place her at higher risk of later infertility

It is recommended that sexually active women under the age of 25 years be screened routinely for Chlamydia trachomatis. Treatment of asymptomatic infections in women reduces their risk of developing pelvic inflammatory disease, tubal infertility, ectopic pregnancy, and chronic pelvic pain. A 1-gram dose of oral azithromycin is an appropriate treatment, including during pregnancy. Sexual contacts during the preceding 60 days should be either treated empirically or tested for infection and treated if positive. The patient should avoid sexual intercourse for 7 days after initiation of treatment. Consistent use of barrier methods for contraception reduces the risk of C. trachomatis genital infection.

Question 31

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? (check one)
A 24-year-old female with a BMI of 26 kg/m2
A 36-year-old male with a BMI of 27 kg/m2
A 52-year-old female with a BMI of 22 kg/m2
A 72-year-old male with a BMI of 32 kg/m2
An 84-year-old female with a BMI of 40 kg/m2

Answer 31

A 36-year-old male with a BMI of 27 kg/m2

The U.S. Preventive Services Task Force (USPSTF) recommends that all nonpregnant adults ages 35–70 who are overweight (BMI ≥25 kg/m2) or obese (BMI ≥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 (SOR B).

Question 32

A randomized, controlled study of 300 participants tested the effectiveness of a new medication to reduce breast cancer–related deaths. Within 2 years of treatment, 15 out of 150 participants with breast cancer in the treatment group died, while 60 out of the 150 participants in the control group died.

Based on this study, what is the number needed to treat to prevent one breast cancer–related death? (check one)
2
3
5
10
15

Answer 32

3

The number needed to treat (NNT) is the number of patients who need to be treated with a specific medication to prevent one negative outcome or to achieve one positive outcome. It is the inverse of the absolute risk reduction (ARR), which is the difference in risk between participants in the control group and the treatment group. The closer the NNT is to 1, the more effective the new treatment is versus the placebo.

Event rate in the control group (CER) = 60/150 = 0.4
Event rate in the experimental group (EER) = 15/150 = 0.1
Absolute risk reduction (ARR) = CER – EER = 0.4 – 0.1 = 0.3
NNT = 1/ARR = 3.33

Question 33

The American Academy of Pediatrics recommends measuring a child’s hemoglobin level at what age? (check one)
6 months
12 months
18 months
2 years
5 years

Answer 33

12 months

Multiple reports have associated iron deficiency with impaired neurodevelopment and it is therefore
essential to ensure adequate iron intake. Based on expert opinion, the American Academy of Pediatrics
recommends measuring a child’s hemoglobin level at 12 months of age.

Question 34

A 27-year-old male took a COVID-19 rapid antigen test at home prior to coming to your office and reports that it was negative. Which one of the following pretest probability factors increases the likelihood that the test results were falsely negative? (check one)
No clinical signs or symptoms of COVID-19 infection
No known exposure to a person with COVID-19 infection
Clinical signs or symptoms that are best explained by an alternative diagnosis such as influenza
A high prevalence of COVID-19 infection in the community
Chlordiazepoxide (Librium)

Answer 34

A high prevalence of COVID-19 infection in the community

Pretest probability is the estimated likelihood of disease prior to testing. A false-negative result occurs when the test result is negative, but the person does, in fact, have the disease. False-negative test results are more common when the pretest probability is high. Factors that increase the pretest probability of COVID-19 infection include a positive exposure history, having clinical signs or symptoms of COVID-19 infection, not having an alternative diagnosis to explain the symptoms, and a higher prevalence of infection in the community. Therefore, false-negative results occur more frequently when the prevalence of infection in a community is high (i.e., ≥20%) and consideration should be given to verification of the results.

Question 35

A 53-year-old male presents for follow-up after a routine screening colonoscopy. He is healthy and takes no medications, and his family history is negative for colon cancer. During a thorough, relatively easy colonoscopy to the cecum, two rectal polyps measuring 0.7 mm were removed, both of which were found to be hyperplastic on pathologic analysis. His next surveillance colonoscopy should be in (check one)
1 year
3 years
5 years
7 years
10 years

Answer 35

10 years

Risk factors for proximal neoplasia include high-grade dysplasia, three or more adenomas, adenomas with villous features, and an adenoma ≥1 cm in size. For patients with one or more of these findings, follow-up colonoscopy in 3 years is recommended. The clinical benefit of follow-up surveillance colonoscopy in patients with one or two small adenomas has never been demonstrated. Distal hyperplastic polyps are not markers for proximal or advanced neoplasia. Patients with this finding on colonoscopy should be considered to have a normal colonoscopy and the interval until the next colonoscopy should be 10 years.

Question 36

Overdiagnosis is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm during the patient’s lifetime. Which one of the following interventions has the best likelihood of reducing overdiagnosis? (check one)
Broadening the criteria for diagnosis of a condition
Creating financial incentives for more testing
Focusing screening efforts on populations at highest risk for a disease
Redefining risk factors as pre-diseases
Using more sensitive screening tests

Answer 36

Focusing screening efforts on populations at highest risk for a disease

Overdiagnosis is a consequence of a health system that seeks to diagnose disease before it is clinically evident in the hope of intervening to improve morbidity and mortality. The benefits of a system in which disease is detected early and health is improved must be balanced against the drawbacks in which patients are more often labeled as “sick” and engage in treatments that may cause harm without always resulting in benefit. Focusing screening efforts on populations most at risk of a disease will result in more true positive test results and the identification of patients more likely to benefit from intervention.

Examples of lack of benefit include the identification of an indolent cancer that would never have spread or caused harm (e.g., low-grade prostate cancer detected via prostate-specific antigen screening) and improvements in technology leading to increased sensitivity for the detection of disease for which there is a lack of clarity in what to treat or not treat (e.g., improvements in CT scanning technology resulting in an increased sensitivity for diagnosing small pulmonary emboli, including those that are clinically unimportant). Other examples of overdiagnosis include changes in the definition of chronic kidney disease that lead to an increase in the number of patients labeled with this diagnosis, few of whom will progress to end-stage disease, and defining prediabetes as a disease rather than as a risk factor for a disease when only about one-third of patients with prediabetes will progress to diabetes over 10 years.

Question 37

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? (check one)
No screening
A skin survey
A Papanicolaou smear
Mammography
Colonoscopy

Answer 37

No screening

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.

Question 38

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? (check one)
Carotid stenosis
Glaucoma
HIV antibody
Testicular cancer
Vitamin D deficiency

Answer 38

HIV antibody

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.

Question 39

The most common identifiable cause of skin and soft-tissue infections presenting to metropolitan emergency departments is: (check one)
Staphylococcus epidermidis
Streptococcus pneumoniae
Pseudomonas aeruginosa
methicillin-resistant Staphylococcus aureus (MRSA)
Bacillus cereus

Answer 39

methicillin-resistant Staphylococcus aureus (MRSA)

Recent clinical experience has shown that methicillin-resistant Staphylococcus aureus (MRSA) is the most
common identifiable cause of skin and soft-tissue infections among patients presenting to emergency
departments in 11 U.S. cities. The other responses should be considered in evaluating these infections,
but they are not as common as MRSA infections.

Question 40

A 53-year-old male undergoes colon cancer screening with multitarget stool DNA testing (Cologuard). The result is negative and you are composing a message to send to his online patient portal to discuss the results.

Which one of the following would be the most appropriate screening strategy for this patient? (check one)
Fecal immunochemical testing (FIT) now
FIT in 1 year
Colonoscopy now
Repeat multitarget stool DNA testing in 3 years
Repeat multitarget stool DNA testing in 5 years

Answer 40

Repeat multitarget stool DNA testing in 3 years

The recommended interval for colon cancer screening with multitarget stool DNA testing is 3 years at minimum, with the U.S. Preventive Services Task Force recommending an interval of 1–3 years. If the screening is positive, proceeding with a colonoscopy is recommended. Fecal immunochemical testing (FIT) has an annual screening interval if the test is negative, and colonoscopy is recommended if the FIT is positive. Colonoscopy for patients without risk factors should be performed every 10 years, or sooner if indicated by pathology results or risk factors.

Question 41

A 53-year-old female sees you for a routine health maintenance visit. The patient reports that she is newly menopausal and asks you about osteoporosis screening. Her past medical history includes morbid obesity, and her family history includes type 2 diabetes in her mother and hypertension in her father. The patient is a nonsmoker and rarely consumes alcohol. Her only medication is loratadine (Claritin), 10 mg daily.

Which one of the following would you recommend regarding osteoporosis screening for this patient? (check one)
No screening now or in the future, and calcium supplementation only
No screening now or in the future, and calcium and vitamin D supplementation
Radiography of her hip and lumbar spine now
A DEXA scan now
A DEXA scan at age 65

Answer 41

A DEXA scan at age 65

For women with no risk factors, the U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in women 65 years and older with bone measurement testing such as DEXA to prevent osteoporotic fractures (grade B recommendation). The USPSTF recommends screening for osteoporosis with DEXA in postmenopausal women younger than age 65 who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (B recommendation). Factors associated with an increased risk of osteoporosis include smoking, excessive alcohol consumption, low body weight, and a parental history of hip fracture. This patient is not at increased risk for osteoporosis, so a DEXA scan at age 65 would be most appropriate. Calcium and vitamin D supplementation to prevent osteoporosis are no longer routinely recommended. Plain radiography would not be recommended as screening for osteoporosis.

Question 42

At what age should a patient at average risk be switched from a universal screening strategy for colon cancer to a more individualized strategy? (check one)
45
55
65
75
85

Answer 42

75

Although national guidelines vary, it is generally advised to start routine colon cancer screening between ages 45 and 50, and to screen with a more individualized approach between ages 75 and 85. Factors to consider include life expectancy, the patient’s overall health, whether the patient has been screened previously, and patient preference. Most guidelines recommend stopping colon cancer screening in patients older than 85 years or when their life expectancy falls below 10 years (SOR B).

Question 43

Which one of the following would be most appropriate regarding screening for nonalcoholic fatty liver disease? (check one)
No routine screening for any patients
Routine screening for patients with obesity
Routine screening for patients with hypothyroidism
Routine screening for patients with polycystic ovary syndrome
Routine screening for patients with type 2 diabetes

Answer 43

No routine screening for any patients

Routine screening for nonalcoholic fatty liver disease (NAFLD) is not recommended for any patients, even those considered to be at high risk. The highest risk factor for NAFLD is obesity, and other risk factors include type 2 diabetes and metabolic syndrome. There is emerging evidence that HIV, hypothyroidism, polycystic ovary syndrome, obstructive sleep apnea, and genetic variation of the PNPLA3 gene are likely risk factors as well. NAFLD is usually discovered with the incidental finding of elevated liver enzymes. An AST/ALT ratio >1.5 is suspicious for excessive alcohol use, while a ratio of 0.8 is more likely due to NAFLD.

If NAFLD is suspected, the first step is to obtain a detailed history, particularly for hepatotoxic medications and alcohol use. Drugs that can be problematic include chemotherapy medications, amiodarone, aspirin, corticosteroids, cocaine, NSAIDs, tetracyclines, and valproic acid. The next step is to evaluate for hepatitis B and C infection and measure ferritin and iron levels, lipids, and a fasting glucose level or hemoglobin A1c. If these are negative, then ultrasonography of the liver should be ordered.

Question 44

A 54-year-old female sees you for a wellness examination. Her last screening mammography 10 years ago revealed dense breasts but was otherwise normal.

A past history of which one of the following would indicate the need for MRI of the breasts? (check one)
Very dense breasts
Morbid obesity
Combination estrogen/progesterone therapy for the last 3 years
Chest radiation for Hodgkin’s disease
Radioiodine treatment for Graves disease

Answer 44

Chest radiation for Hodgkin’s disease

MRI of the breasts should be reserved for women at very high risk for breast cancer such as those with genetic mutations, a history of breast irradiation, or a very high-risk family history. Women who had chest radiation therapy during childhood or adolescence, generally for Hodgkin’s disease, are at an extremely high risk for breast cancer.

Question 45

A 32-year-old Yazidi female from Iraq is brought to your office to establish care. She is a refugee who was relocated 2 weeks ago.

Which one of the following would be appropriate at this visit? (check one)
Having a family member who speaks English serve as an interpreter
Screening for posttraumatic stress disorder
Hepatitis B vaccine
Varicella vaccine

Answer 45

Screening for posttraumatic stress disorder

A full history and physical examination are indicated for all refugees within 30 days of arrival in the United States, with a professional medical interpreter if needed (SOR C). In addition to addressing medical needs, the focus should be on emotional support and barriers to health care access (SOR C). All refugees should be screened for depression, anxiety, and posttraumatic stress disorder (SOR C). They should also be screened for anemia, hypertension, impaired fasting glucose, nutritional deficiencies, tuberculosis, and COPD (SOR C). If there is no vaccination documentation, routine vaccines should be provided except for varicella and hepatitis B. Serology should be performed before these vaccines are administered (SOR C).

Question 46

In the development of clinical guidelines, which one of the following is rated as the strongest and highest-quality evidence? (check one)
Evidence from randomized, placebo-controlled studies
Evidence from nonrandomized, double-blind, placebo-controlled studies
Evidence from nonrandomized, double-blind, crossover, placebo-washout–controlled studies
Evidence obtained from well-designed cohort or case-control analytical studies from more than one center or research group

Answer 46

Evidence from randomized, placebo-controlled studies

Randomized, controlled studies yield stronger evidence than other types of studies, especially case-control or cohort studies, because randomization provides the greatest safeguard against unanticipated study bias. Evidence obtained from randomized, controlled studies is considered level 1 (strongest) by the U.S. Preventive Services Task Force. Evidence obtained from nonrandomized, controlled studies is considered level 2a; well-designed case-control and cohort studies are considered level 2b; and reports of expert committees or respected authorities are considered level 3 (weakest).

Question 47

Of the following, which one is the greatest risk factor for developing knee osteoarthritis as an older adult? (check one)
A sedentary lifestyle
Cigarette smoking
Low socioeconomic status
Male sex
Obesity

Answer 47

Obesity

Because debilitating knee osteoarthritis is a frequent health concern in older adults, physicians should try to identify and possibly modify factors that increase the risk for this condition. Pooled data from many large studies has been sufficient to clearly identify several major risk factors for the development and progression of osteoarthritis of the knees. Overweight and obesity have consistently been found to approximately double the risk for developing knee osteoarthritis. Other factors that have been identified as risk factors include female sex, advancing age (50–75 years of age), and previous trauma. Smoking, inactivity, moderate physical activity, and socioeconomic status have not been shown to affect one’s risk for developing knee osteoarthritis. However, any of these factors in the extreme may be detrimental to joint health in general.

Question 48

The U.S. Preventive Services Task Force recommends screening all adults for obesity and offering intensive, multicomponent behavioral interventions to patients with a BMI ≥30 kg/m2. This recommendation is based on trials that show that behavioral weight-loss interventions for overweight and obese patients with elevated plasma glucose levels reduce the incidence of diabetes mellitus by 30%–50% over 2–3 years and the number needed to treat is 7.

What is the absolute risk reduction for developing diabetes, based on these trials? (check one)
1/7
1/5
1/0.7
1/0.2
1/0.02

Answer 48

1/7

The number needed to treat (NNT) is defined as the number of people who would need to receive an intervention in order for one person to benefit. It is the inverse of the absolute risk reduction (ARR). The ARR is the difference in risk for a disease without and with an intervention. The correct formula for calculating NNT is 1/ARR.

Question 49

A patient is evaluated and admitted through the emergency department with nausea and vomiting after receiving chemotherapy 1 day earlier. The admission diagnosis is dehydration and acute kidney injury. Over the next 2 days the patient’s condition progressively declines. The diagnosis is changed to sepsis with multiple organ failure about 48 hours after admission. Antibiotics are not started in a timely manner. Upon review, it is felt that the diagnosis of sepsis and initiation of antibiotics could have been considered earlier in the hospital course.

Which one of the following cognitive processes most likely contributed to the diagnostic error? (check one)
Anchoring bias
Commission bias
Hindsight bias
Omission bias
Outcome bias

Answer 49

Anchoring bias

Diagnostic error is important because it is very common. Anchoring bias, also known as premature closure, is defined by the Agency for Healthcare Research and Quality as relying on an initial diagnostic impression despite subsequent information to the contrary. This is the most frequent single cause of diagnostic error. In this case, once the diagnosis of dehydration and acute kidney injury were made, clinicians became “anchored” to that diagnosis and did not consider other possibilities until much later.

Hindsight bias and outcome bias occur when looking back at a case while knowing the result and outcome. Commission and omission bias relate to the tendency toward action rather than inaction and the tendency toward inaction rather than action, respectively.

Question 50

A 60-year-old male sees you for a routine health maintenance visit. One of the patient’s friends recently underwent screening for an abdominal aortic aneurysm (AAA), and he asks if he should be screened. He is asymptomatic, has never smoked, and has no other risk factors.

Which one of the following does the U.S. Preventive Services Task Force advise with regard to AAA screening for this patient? (check one)
There is insufficient evidence to recommend for or against screening
He does not require screening now or in the future
He should not be screened now, but should have abdominal duplex ultrasonography in 5 years
He should have abdominal duplex ultrasonography now, with no future screening
He should have abdominal duplex ultrasonography now and in 5 years

Answer 50

He does not require screening now or in the future

The U.S. Preventive Services Task Force (USPSTF) recommends screening for abdominal aortic aneurysm in men between the ages of 65 and 75 who have ever smoked (B recommendation). This should be performed one time, using abdominal duplex ultrasonography. There may be a small benefit for screening men who have never smoked, and the USPSTF recommends selectively offering screening to this group (C recommendation). The evidence is insufficient to assess the benefits and harms in women who have ever smoked (I recommendation), and the USPSTF recommends against screening for women who have never smoked (D recommendation).

Question 51

A 50-year-old female undergoes screening colonoscopy and a 1.2-cm polyp is discovered and removed. She is told that it is benign but she is concerned about her future risk for developing colon cancer.

Which histologic type of colonic polyps >1.0 cm in size has the highest likelihood of becoming malignant? (check one)
Hamartomatous polyps
Hyperplastic polyps
Inflammatory polyps
Tubular adenomas
Villous adenomas

Answer 51

Villous adenomas

Colon cancer arises from adenomatous polyps, and generally requires at least 5 years of growth before malignant transformation. Villous adenomas carry a threefold increased risk for becoming malignant compared with other adenomatous types such as tubular or tubulovillous adenomas. The larger the polyp the greater the chance of malignancy, although malignant polyps <1.5 cm are rare. Hamartomas (juvenile polyps) and inflammatory polyps (often associated with inflammatory bowel disease) are benign. Hyperplastic polyps are the most common histologic type by far, but only rarely become cancerous.

Question 52

A 21-year-old female asks you about Papanicolaou (Pap) testing recommendations. You determine she is at average risk for cervical cancer and recommend which one of the following? (check one)
Pap testing without HPV co-testing now and in 1 year if results are normal
Pap testing without HPV co-testing now and in 3 years if results are normal
Pap testing with HPV co-testing now and in 3 years if results are normal
Pap testing with HPV co-testing now and in 5 years if results are normal
HPV testing only, now and in 5 years if results are normal

Answer 52

Pap testing without HPV co-testing now and in 3 years if results are normal

Family physicians should be familiar with age-appropriate cancer screening recommendations. Deaths from cervical cancer have been significantly reduced through screening. HPV testing is not recommended for screening in average-risk women younger than 30 years old. Cytology without HPV testing is recommended for screening every 3 years for an average-risk 21-year-old female.

Question 53

In the development of clinical guidelines, which one of the following is rated as the strongest and highest-quality evidence? (check one)
Evidence from randomized, placebo-controlled studies
Evidence from nonrandomized, double-blind, placebo-controlled studies
Evidence from nonrandomized, double-blind, crossover, placebo-washout–controlled studies
Evidence from well designed cohort or case-control analytical studies from more than one center or research group
Evidence based on reports of expert committees or opinions of respected authorities in the appropriate specialty area

Answer 53

Evidence from randomized, placebo-controlled studies

Randomized, controlled studies yield stronger evidence than other types of studies, especially case-control or cohort studies, because randomization provides the greatest safeguard against unanticipated study bias. Evidence obtained from randomized, controlled studies is considered level 1 (strongest) by the U.S. Preventive Services Task Force. Evidence obtained from nonrandomized, controlled studies is considered level 2a, well-designed case-control and cohort studies are considered level 2b, and reports of expert committees or respected authorities are considered level 3 (weakest).

Question 54

A 69-year-old female presents with postmenopausal bleeding. You consider whether to begin your evaluation with transvaginal ultrasonography to assess the thickness of her endometrium.

In evaluating the usefulness of this test to either support or exclude a diagnosis of endometrial cancer, the most useful statistic is the (check one)
likelihood ratio
number needed to treat
prevalence
incidence
relative risk

Answer 54

likelihood ratio

There has been a large increase in the number of diagnostic tests available over the past 20 years. Although tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for harm. In addition, the characteristics of a particular test and how the results will affect management and outcomes must be considered. Clinically useful statistics for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratio.

The likelihood ratio indicates how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5–10 greatly increase the likelihood of disease, and those less than 0.1–0.2 greatly decrease it. In the example given, if the patient’s endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%.

The number needed to treat is useful for evaluating data regarding treatments, not diagnosis. Prevalence is the existence of a disease in the current population, and incidence describes the occurrence of new cases of disease in a population over a defined time period. The relative risk is the risk of an event in the experimental group versus the control group in a clinical trial.

Question 55

A 58-year-old male comes to your office for a routine health maintenance examination. He has smoked 1 pack of cigarettes per day for the last 35 years.

The U.S. Preventive Services Task Force recommends which one of the following lung cancer screening strategies for this patient? (check one)
A chest radiograph annually
Low-dose CT annually
Sputum cytology every 3 years
Bronchoscopy every 5 years

Answer 55

Low-dose CT annually

Lung cancer is the leading cause of cancer-related deaths in the United States and the third most common cause of death overall. Smoking causes approximately 85% of all U.S. lung cancer deaths. Thirty-seven percent of U.S. adults are current or former smokers. While nearly 90% of people diagnosed with lung cancer will die from the disease, early-stage non–small cell lung cancer has a better prognosis and can be treated with surgical resection. The largest randomized, controlled trial of low-dose CT (LDCT) for lung cancer detection, the National Lung Screening Trial, enrolled 50,000 people age 55–74 with at least a 30-pack-year smoking history and showed a reduction in lung cancer mortality of 16% and a reduction in all-cause mortality of 6.7%. Based on this study and several other randomized, controlled trials, the U.S. Preventive Services Task Force has concluded that LDCT has a high sensitivity and an acceptable specificity for the detection of lung cancer in high-risk persons. The other testing modalities listed have not been validated as acceptable screening strategies for lung cancer.

Question 56

A 32-year-old obese female from Saudi Arabia presents with muscle aches. Her clothing limits sun exposure and you decide to test her for vitamin D deficiency.

Which one of the following is the most appropriate test for this condition? (check one)
Calcium
Alkaline phosphatase
25-hydroxyvitamin D
1,25-dihydroxyvitamin D
Parathyroid hormone

Answer 56

25-hydroxyvitamin D

Recommendations to screen for vitamin D deficiency apply only to patients at risk and not to the general population. This patient’s obesity and her clothing style, which limits sun exposure to the skin, puts her at increased risk. Additionally, this patient’s muscle aches may be a symptom of vitamin D deficiency. The recommended test for this condition is a 25-hydroxyvitamin D level. A 1,25-dihydroxyvitamin D level is recommended to monitor, not diagnose, certain conditions. Parathyroid hormone, calcium, and alkaline phosphatase levels are poor indicators of vitamin D status.

Question 57

According to recommendations by the U.S. Preventive Services Task Force, physicians should screen all adolescents and adults for which one of the following disorders? (check one)
Bipolar disorder
Generalized anxiety disorder
Major depressive disorder
Posttraumatic stress disorder
Schizophrenia

Answer 57

Major depressive disorder

Due to the disease prevalence and impact, effectiveness of screening instruments, and benefits of available treatment, the U.S. Preventive Services Task Force (USPSTF) recommends screening for major depressive disorder when adequate systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The USPSTF has made no recommendations regarding screening for bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, or schizophrenia.

Question 58

An 11-year-old female is brought to your office for a routine well child examination. The American Academy of Pediatrics recommends screening this patient for which one of the following?
(check one)
Anemia
Diabetes mellitus
Dyslipidemia
HIV

Answer 58

Dyslipidemia

Because of concerns about the growing epidemic of obesity in this population, the American Academy of Pediatrics now recommends screening for elevated serum cholesterol levels in children 9–11 years of age (SOR C). This patient should also be screened annually for depression beginning at 11 years of age and continuing through 21 years of age. Universal screening for iron deficiency anemia is recommended at 12 months of age and again at 15–30 months of age if the patient is determined to be high risk. HIV screening is recommended in adolescents and adults 15–65 years of age (A recommendation). Age 21 is now the recommended starting age for screening for cervical dysplasia. Universal screening for diabetes mellitus is not recommended for children or adolescents.

Question 59

Which one of the following community health programs best fits the definition of secondary
prevention? (check one)
An antismoking education program at a local middle school
Blood pressure screening at a local church
A condom distribution program
Screening patients with diabetes mellitus for microalbuminuria

Answer 59

Blood pressure screening at a local church

Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition. Examples include childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex. Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications. Examples include routine Papanicolaou tests and screening for hypertension, diabetes mellitus, or hyperlipidemia. Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications. Examples include screening patients with diabetes for microalbuminuria, rigorous treatment of diabetes mellitus, and post–myocardial infarction prophylaxis with β-blockers and aspirin.

Question 60

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? (check one)
No screening
An α-fetoprotein level
Scrotal ultrasonography now
Scrotal ultrasonography at age 55
CT of the abdomen and pelvis at age 55

Answer 60

No screening

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.

Question 61

A 12-year-old female is brought to your office for a routine well child examination. The U.S. Preventive Services Task Force recommends screening this patient for which one of the following? (check one)
Anemia
Depression
Diabetes mellitus
Dyslipidemia
HIV

Answer 61

Depression

The U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adolescents and adults starting at age 12. The USPSTF states that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in children 6–24 months of age (I recommendation) and does not offer recommendations regarding other age groups. There are no USPSTF recommendations regarding universal screening for diabetes mellitus in children or adolescents. The American Academy of Pediatrics now recommends screening for dyslipidemia in children once between 9 and 11 years of age, but the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years of age (I recommendation). HIV screening is recommended in adolescents and adults 15–65 years of age (A recommendation).