You are examining a normal term newborn whose mother is hepatitis B virus surface antigen positive. Which of the following protocols is recommended for the child?
Hepatitis B infection is more likely to become chronic when acquired early in life. In 1991, the CDC recommended universal immunization of infants in the United States. The vaccine is given in a three-dose schedule, with the timing dependent on the mother’s hepatitis B surface antigen status. If the mother is hepatitis B surface antigen positive, the first dose of vaccine and a dose of hepatitis B immune globulin must be given within 12 hours of birth. The second dose of vaccine is given at 1–2 months, and the third dose is given at 6 months. For mothers with unknown antigen status, the first dose of vaccine should be given within 12 hours, and maternal blood should be drawn to determine status. If the mother’s surface antigen is positive, the child is given immune globulin as soon as possible, but no later than 1 week of age. For mothers with negative antigen status, the first dose of vaccine is given at 0–2 months, the second at 1–4 months, and the third at 6–18 months.
You are counseling a mother about her child’s immunization schedule. She asks specifically if her child would benefit from the Haemophilus influenzae type b (Hib) vaccine. Which of the following statements is true about this vaccine?
Before the introduction of an effective vaccine, Hib caused invasive disease in about 1 of every 200 children in the United States. Hib meningitis was the most common invasive Hib illness, carried a 2–5% mortality rate, even with appropriate treatment, and up to 30% of survivors developed neurological sequelae. In the first 10 years of the vaccine’s use, the incidence of invasive Hib disease decreased 97%. The vaccine does not reduce the rate of otitis media, as most cases are due to nontypeable H. influenzae. Adverse reactions to the vaccine are very rare. In fact, no serious reactions have been linked to the vaccine. 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.
You are discussing varicella-zoster vaccination with an adult who does not ever remember having chicken pox. Which of the following statements is true?
Varicella-zoster infection is more severe in neonates and adults. The vaccine is less immunogenic in those over the age of 13, and therefore two doses of vaccine are required, given 4–8 weeks apart. 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. No special precautions are necessary for households with immunocompromised persons, unless the person vaccinated develops a rash. Zoster is more common among those with natural infection as opposed to those who were immunized.
An elderly patient that you follow has recently started hemodialysis for chronic renal failure. You know that hepatitis B vaccination is recommended for people on hemodialysis, and find that he is hepatitis B surface antibody negative. Which of the following would be the best guideline to follow in this case?
Hepatitis B vaccination is recommended for nonimmune people who are high risk. Those include men who have sex with men, people with multiple sexual partners, sex industry workers, intravenous drug users, prison inmates, people on hemodialysis, people living in households with hepatitis B virus carriers, health care workers and people from endemic areas. In this question, having surface antibody negativity means that the patient has never been exposed and is nonimmune. The immunization schedule is one injection at time 0, one between 1–2 months after that, and a third injection between 4–6 months after the second.
You are caring for a 23-year-old healthy homosexual male who works as an accountant and lives alone. He had the “typical childhood vaccinations” and provides documentation of his immunization record. He is up to date on tetanus, and was primarily immunized against diphtheria, pertussis, polio, hepatitis B, measles, mumps, rubella, and H. influenzae type b. Which of the following vaccinations is indicated for this patient?
Hepatitis A vaccination is indicated for men who have sex with men or users of illegal drugs. The patient is not at high risk for varicella, and therefore vaccination is not indicated. Meningitis 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, functional asplenia or residents of long term care facilities. An MMR booster is not indicated.
In the prenatal workup for one of your patients, you discover she is rubella nonimmune. When is the best time to vaccinate the patient against rubella?
Congenital rubella syndrome 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. If she is currently pregnant and nonimmune, she should be vaccinated as early in the postpartum period as possible.
An adult is seen in your office after cutting her hand on a clean broken glass in her kitchen. She received her primary tetanus series as a child. The wound is relatively minor, and does not require suturing. Her last tetanus booster was 7 years ago. Which of the following is true?
Adults should receive a Td booster every 10 years. Booster shots are not required for clean, minor wounds. For contaminated or deep wounds, a booster is recommended if the last vaccination was given more than 5 years ago. If the immunization history is unclear, tetanus immune globulin may be indicated for a contaminated wound. DTP and DTaP are not recommended in adults.
You are caring for a woman who would like her children vaccinated against influenza. Her children are ages 4 months, 24 months, and 5 years. Which of the following represents current immunization recommendations for influenza?
Influenza vaccination is recommended annually for children ages 6 months and greater with certain risk factors (asthma, cardiac disease, sickle cell disease, HIV, and diabetes among others). It can be administered to all others wishing to obtain immunity as well. In addition, children between 6–24 months should be offered the vaccine, as they are at substantial risk for hospitalization if infected. In this case, since the mother wishes all her children be vaccinated, only the 4-month-old should be excluded because of age.
You are discussing preventive health screening with a college student. He has no family history of hypertension, coronary artery disease, diabetes, or cancer. At what age would you consider screening for lipid disorders?
Determining which screening tests are appropriate for a patient is difficult, and requires individual judgment based on the clinical situation. The American Academy of Family Physicians has developed clinical preventive services charts based on age alone in low-risk adults, and rank the screen as “strongly recommend,” “recommend,” and “healthy behavior.” Strongly recommended screens are supported by good quality evidence and demonstrate substantial net benefit for the patient. 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.
You are seeing a 58-year-old smoker for a routine health examination. You have counseled him on discontinuing tobacco use, and he is considering that alternative. He denies coughing, shortness of breath, or hemoptysis. Which of the following is a recommended screen for lung cancer in this patient?
The U.S. preventive services task force 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.
You are seeing a healthy 26-year-old woman for a routine health visit. She mentions that she and her husband are thinking about starting a family soon. She has never been pregnant before. Which of the following interventions has been shown to have a clear beneficial outcome at this time?
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.
You are discussing cancer screening with a patient. Her father was diagnosed with colorectal cancer at age 72. When should you recommend she begins colorectal cancer screening?
In general, colorectal cancer screening should begin at age 50. In cases where there is a family history of colorectal cancer, the screen should begin 10 years before the cancer was diagnosed in the family, or at age 50, whichever is sooner.
You are discussing cancer screening with a female patient. She has no family history of breast cancer. At what age should she start getting routine mammograms?
Mammograms (with or without clinical breast examinations) have clearly been shown to reduce mortality associated with breast cancer. Guidelines vary, but the U.S. Preventative Services Task Force recommends routine mammography every 1–2 years beginning at age 40.
In a routine examination, a 33-year-old woman asks you about self-breast examination as breast cancer screening method. Which of the following best represents current recommendations for breast self-examination (BSE)?
The American Academy of Family Physicians has concluded that there is insufficient evidence to recommend for or against using BSE as a screening modality. Evidence is poor that BSE reduces mortality, and there is fairly strong evidence that BSE is associated with an increased risk for false-positive results and biopsies. Due to limitations in published and ongoing studies, the balance between benefits and harm is not known.
A 52-year-old man comes to your office for a complete physical examination. He is interested in prostate cancer screening. Which of the following best represents current guidelines for prostate cancer screening?
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, the American Academy of Family Physicians feels the evidence is insufficient to recommend for or against routine prostate cancer screening. In patients who are interested in screening, physicians should discuss the potential benefits and harms with the patients before making a decision to test.
You are seeing a 40-year-old healthy man for a routine health examination. He is completely healthy, takes no medications, and has no abnormal physical examination findings. What are the current recommendations regarding obtaining a screening electrocardiogram (ECG) as part of his routine physical?
The American Academy of Family Physicians recommends against the routine use of the ECG as part of periodic health or preparticipation examinations in asymptomatic adults. There is no evidence that the use of ECG screening improves mortality or identification of asymptomatic disease.
During an appointment to discuss acne, you find that your 16-yearold female patient has become sexually active. According to current guidelines, when should you begin cervical cancer screening on this patient?
There is a strong recommendation from the American Academy of Family Physicians 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 unknown. Some recommend that screening should start at the onset of sexual activity or at age 18, whichever comes first. However, 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.
You are seeing a 55-year-old patient for her annual physical examination. She has been married to her husband for 32 years and has never had sex with anyone else during the marriage. She has never had an abnormal Papanicolaou (Pap) smear. At what age is it appropriate to discontinue Pap screening on this patient?
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. However, the yield of the Pap test is low in women who have been previously screened at age 65. 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.
A 76-year-old male patient of yours is undergoing a left knee replacement for severe arthritis, and you are asked to perform his presurgical clearance. His past medical history is significant for episodic rate-controlled atrial fibrillation, a stroke at age 72 (from which he recovered fully), and uncontrolled hypertension. Last year, an echocardiogram showed he had severe aortic stenosis, but he has elected not to undergo surgical repair. He reports that he is sedentary, and is not able to walk up one flight of steps carrying his groceries without stopping to rest. His blood pressure upon evaluation is 168/92. Which of the described features are clinical predictors of increased perioperative cardiovascular risk for this surgery?
Family physicians are often asked to perform preoperative evaluations for their patients. The purpose of these evaluations is to identify risks for poor outcomes that may not be immediately apparent to the surgeon. In 2002, the American College of Cardiology and the American Heart Association summarized clinical predictors for increased perioperative cardiovascular risk. They found that advanced age, a rhythm other than sinus rhythm (atrial fibrillation), uncontrolled hypertension and low functional capacity were not proven to independently increase perioperative cardiovascular risk in low or intermediate risk surgeries. However, severe heart valve disease was a major predictor of perioperative risk. Other major predictors are acute myocardial infarction (MI) (within 7 days), recent MI (between 8–30 days), unstable or severe angina, decompensated heart failure, high grade A/V block, symptomatic arrhythmias with underlying heart disease, and supraventricular arrhythmias with a poorly controlled ventricular rate.
You are concerned about the cardiac risks of several of your patients undergoing surgical procedures, and are considering further cardiac testing in the preoperative period. Which of the following surgical procedures is considered to have a low surgery-specific risk, and generally does not require additional preoperative cardiac testing, if the patient does not have clinical predictors of increased cardiac risk?
When evaluating a patient’s risk for undergoing a surgical procedure, the family physician must look at the patient-specific clinical variables, the patient’s exercise capacity, and the risk of the surgical procedure being performed. High-risk surgical procedures are those with a risk of cardiac death greater than 5%, and include emergent operations, aortic or other major vascular surgeries, peripheral artery surgery, or prolonged surgeries with large anticipated fluid shifts. Intermediate risk procedures have a risk of cardiac death between 1–5% and include carotid endarterectomies, head and neck surgeries, intrathoracic and intraperitoneal surgeries, orthopedic surgeries and prostate surgeries. Low risk procedures have a risk of cardiac death less than 1% and generally do not require additional cardiac preoperative testing. They include endoscopic procedures, superficial procedures, cataract surgeries, and breast surgery
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