1. What interviewing skills can help the physician identify all the significant issues to the patient during the visit?
Remaining open-ended and encouraging the patient to “go on” until all the pertinent issues
have been expressed by the patient. Other facilitative techniques to keep the patient talking
include a simple head nod or saying, “and,” or “what else?” Continue these facilitative
techniques until the patient says, “nothing else.” During the opening of the interview, the
physician should listen to the patient’s “list” of the concerns for that visit, without focusing on
specific signs and symptoms at that time. Physicians too often interrupt the patient and
direct the remaining interview, only focusing on what the physician deems important.
A patient may have other, significant issues that are not immediately expressed, and the
physician may miss this “hidden agenda” if the patient is interrupted. Once the patient has
listed the concerns, the patient and physician can then decide which ones will be addressed.
2. How can the physician understand more clearly what the patient is trying to describe?
By rephrasing the response in the physician’s words or simply restating what the patient said.
Sometimes the physician simply needs to ask, “Can you find other words to describe your
pain?” Emotional responses and pain are particularly difficult to put into words.
3. What questions help characterize a symptom?
& Where does the symptom occur?
& What does it feel like?
& When does the symptom occur?
& How is it affected by other things you do?
& Why does the symptom occur (what brings the symptom on)?
& What makes the symptom better?
4. Define “sensitivity” and “specificity” of tests.
& Sensitivity: The percentage of patients who have the disease that is being tested and have
a positive test result
& Specificity: The percentage of patients who do not have the disease and have a negative
test result
5. What are the positive and negative predictive values of tests?
& Positive predictive value: The percentage of patients who have a positive test and have
the disease that is being tested
& Negative predictive value: The percentage of patients who have a negative test and do not
have the disease
6. How are these values calculated?
See Figure 2-1.
Figure 2-1. Calculation of sensitivity, specificity, and predictive value.
7. What is the NNT?
The number needed to treat that quantifies the number of patients who will require treatment with
a therapy (and who will have no benefit) in order to ensure that at least one of the adverse
events that the therapy should prevent does not occur. Most publications now include this number.
There is no absolute NNT that is appropriate for all therapeutic decisions, but it will depend on
the risks of the therapy, the benefits of treatment, and the patient’s goals for treatment.
SCREENING FOR MALIGNANCIES
8. What are the recommendations for colon cancer screening?
The U.S. Preventive Services Task Force (USPSTF) recommends one of three screening
procedures beginning at age 50–75 years. For patients of average risk:
& Annual fecal occult blood test (FOBT) with a sensitive test
& Flexible sigmoidoscopy every 5 years, with sensitive FOBT every 3 years
& Colonoscopy every 10 years
Screening should end at age 85 years, and it is recommended on an individual basis for
patients aged 76–84 years. Immunochemical tests are now currently available for FOBT
screening. Other organizations such as the American Cancer Society and American
Gastroenterology Association have different recommendations.
Levin B, Lieberman DA, McFarland B, et al: Screening and surveillance for the early detection of
colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society,
the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology, CA Cancer
J Clin 58:130–160, 2008.
U.S. Preventive Services Task Force: Screening for colorectal cancer: U.S. Preventive Services Task Force
recommendation statement, Ann Intern Med 149:627–637, 2008.
Rex DK, Johnson DA, Anderson JC, et al: American College of Gastroenterology guidelines for
colorectal cancer screening 2008, Am J Gastroenterol 104:739–750, 2009.
9. What are the guidelines for breast cancer screening?
In 2009, the guidelines for mammography screening from the USPSTF were changed to
allow for more patient and physician discretion for patient selection for breast cancer
screening in women of average risk. The Task Force recommended against routine screening
in women aged 40-49 years and suggested biennial screening (if appropriate and desired
by the patient) for patients aged 50–74 years. The benefits of screening in women > 75 years
old are unknown owing to lack of evidence. Other groups have suggested that women of
average risk continue to receive annual mammograms, starting at an earlier age.
American Cancer Society responds to changes to USPSTF mammography guidelines: The American
Cancer Society guidelines will not change; annual mammography recommended for women 40 and over.
Available at www.cancer.org/docroot/med/content/med_2_1x_american_cancer_society_responds_to_
changes_to_uspstf_mammography_guidelines.asp. Accessed June 12, 2010.
U.S. Preventive Services Task Force: Screening for breast cancer: U.S. Preventive Services Task Force
Recommendation Statement, Ann Intern Med 151:716–726, 2009.
10. How should childhood cancer survivors be screened for breast cancer?
For this group who likely received chest radiation, mammography should begin at age 25
years or 8 years after chest radiation exposure, whichever is earlier. Mammograms should be
continued annually.
Oeffinger KC, Ford JS, Mokowitz CS, et al: Breast cancer surveillance practices among women previously
treated with chest radiation for a childhood cancer, JAMA 301:404–414, 2009.
11. What are the controversies related to prostate cancer screening?
The prostate-specific antigen (PSA) currently used for prostate cancer screening does not
have sufficient evidence to support its routine use in men of average risk for prostate cancer.
False-positive and false-negative PSA tests occur. The evidence is also unclear as to whether
treatment of prostate cancer, when discovered, prolongs life. Prostate cancer screening
decisions should be made on an individual basis. As with mammograms, not all expert
groups concur with the USPSTF recommendations. Currently trials are under way to try to
more clearly identify appropriate prostate cancer screening tests.
Screening for Prostate Cancer, Topic Page. U.S. Preventive Services Task Force, Rockville, MD, 2008,
Agency for Healthcare Research and Quality. Available at http://www.ahrq.gov/clinic/uspstf/uspsprca.htm.
12. When should screening begin for cervical cancer?
At age 21 years or within 3 years after the onset of sexual activity, whichever is sooner.
A Papanicolaou (Pap) smear is the appropriate screening test. After two or three negative
Pap smears, the screening interval may be lengthened to every 3 years. The USPSTF
recommends ending screening in women after age 65 years if they have had appropriate
routine screening.
Screening for Cervical Cancer, Topic Page. U.S. Preventive Services Task Force, Rockville, MD, 2003,
Agency for Healthcare Research and Quality. Available at www.ahrq.gov/clinic/uspstf/uspscerv.htm.
13. Do women who have had a total hysterectomy (with cervix removal) for nonmalignant reasons need Pap smears?
No. The yield of finding significant disease in this population is low.
14. Is there an effective screening test for ovarian cancer?
No, not at this time, although this is an area of active research. Although the pelvic
examination, transvaginal ultrasound, and the tumor marker CA-125 have all been used as
screening tests, none has been shown to reduce death from the disease.
15. What is the role of chest x-rays and computed tomography (CT) scans in lung cancer screening?
The National Cancer Institute is currently sponsoring the National Lung Screening Trial (NLST) to
evaluate this question. Early results suggest that screening may reduce lung cancer mortality by
20%. CT scanning is probably helpful. Early results from the NLST suggest a 20% reduction in
lung cancer mortality in subjects screened with CT scans. The NLST compares the efficacy of
chest x-ray and CT scan in early cancer detection. The data are currently undergoing further
analysis.
Available at: http://www.cancer.gov/nlst/updates
CARDIOLOGY
16. What is the first step to evaluate a patient with an initial blood pressure (BP) reading of 150/90 mmHg?
Confirm that the BP was measured under the right conditions with:
& The patient seated comfortably in a chair
& The patient’s legs uncrossed
& Support of patient’s back and arm for BP measurement
& All clothing removed that covers the area of the cuff placement
& Middle of the cuff on the upper arm at the midpoint of the sternum
& Allowance of approximately 5 minutes after the patient is seated comfortably before measuring the BP
& Adequate cuff size for the patient’s arm (cuff bladder length is 80% and width is 40% of the patient’s arm circumference)
& Measurement of the BP in both arms if initial visit
Pickering TG, Hall JE, Appel LJ, et al: Recommendations for blood pressure measurement in humans
and experimental animals: Part 1: Blood pressure measurement in humans: A statement for professionals
from the Subcommittee of Professional and Public Education of the AHA Council on HBP, Circulation 111:697–716, 2005.
17. What can cause a difference in BP between the right and the left arm?
Arterial occlusion in the arm with the lower BP. “Normal” BP difference should be
< 10 mmHg. The arm with the higher reading should be used for future measurements.
18. Should systolic BP between 120 and 139 and/or diastolic BP between 80 and 89 be treated?
Yes, with lifestyle modification. BP readings such as these are called “prehypertension” and
are associated with increased risk of cardiovascular events. Pharmacologic therapy should be
initiated if the BP increases to the hypertensive range (systolic 140 or diastolic 90).
19. What lifestyle modifications are helpful for reducing BP?
& Weight loss (to body mass index [BMI] of 18.5–24.9)
& Salt restriction (<6 g sodium chloride or <2.5 g sodium)
& Limited alcohol use (12 oz of beer, 5 oz of wine, 1.5 oz of 80-proof whiskey)
& Stress management
& Smoking cessation
& Regular aerobic exercise
& Low–saturated fat diet rich in fruits and vegetables
U.S. Department of Health and Human Services: Your guide to lowering your blood pressure with DASH. National Heart, Lung, and Blood Institute. NIH Publication No. 06-4082. Originally printed 1998.20. What are the risks of prehypertension?
Revised April 2006. Available at: www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf.
Coronary artery disease, myocardial infarction, and death from a cardiovascular event.
21. What is the initial laboratory evaluation of newly diagnosed hypertension (HTN)?
& Glucose
& Hematocrit
& Fasting lipid panel
& Potassium
& Creatinine
& Calcium
& Electrocardiogram
22. How can the patient’s history identify secondary HTN due to medications and other substance use?
Ask the patient about use of:
& Over-the-counter medications: decongestants, stimulants, appetite suppressants, nonsteroidal anti-inflammatory drugs (NSAIDs), and caffeine
& Prescription medications: NSAIDs, corticosteroids, antidepressants (venlafaxine, desvenlafaxine, bupropion), cyclosporine, oral contraceptive pills (OCPs)
& Illicit drug use (acute and chronic): cocaine, amphetamines, stimulants, MDMA (3,4- methylenedioxymethamphetamine or ecstasy), PCP (phencyclidine), cannabis (marijuana), and herbal designer drugs
& Alcoholism: alcohol history, CAGE questionnaire (see Question 155), family history of
alcoholism
23. How can the patient’s history identify secondary HTN due to an endocrine disorder?
Ask the patient about:
& Cushing’s syndrome: weight gain, central obesity, easy bruising, “moon” facies, abdominal striae.
& Hyperthyrodism: weight loss, tachycardia, nervousness
& Hypothyroidism: weight gain, fatigue, constipation, dry skin
& Pheochromocytoma: labile HTN, sweating, headache, palpitations
& Hyperaldosteronism: fatigue, muscle weakness due to low potassium
24. List two elements in the history that may suggest secondary HTN due to sleep apnea.
Snoring and daytime sleepiness. (See also Chapter 6, Pulmonary Medicine.)
Aucun commentaire:
Enregistrer un commentaire