NMS Q&A Family Medicine

278 NMS Q&A Family MedicineAlthough diabetes is more prevalent in African-Americans,it is not so when matched for weight and age with whiteindividuals. The same can be said for coronary heart diseaseand dyslipidemia. Mitral valve prolapse and hypertrophiccardiomyopathy are not discussed meaningfully inepidemiologic terms.8. The answer is E. African-Americans with hypertensionsuffer earlier onset and a greater incidence of cerebrovasculardisease (strokes) and renal failure as complicationsthan do other group with matched levels of average bloodpressure. Therefore, the therapeutic target for control ofhypertension is set at 125/75 rather than simply settling itfor statistically normal blood pressure, 140/90. Similarly,diabetes mellitus exacts a greater price in accelerateddecremental renal failure for given levels of blood sugarcontrol. Although Mexican Americans and indigenousAmericans have a far greater risk of diabetes for a givenbody mass index, their complication rates are not out ofproportion to their levels of blood sugar control.9. The answer is C. Colonoscopy now and every 3 years ifnegative. A family history of colon cancer in a first-degreerelative (father at age 60) multiplies the lifetime risk ofcolon cancer, normally about 2.5%, 3 times, so this patientnow has a 7.5% chance of colon cancer. Most of the risk inthis circumstance is telescoped into the decades of the 50sand above. Thus, this patient’s chances are higher than7.5%. Colonoscopy, if negative, need not be repeated for3 years because of the long “dwell time” for that cancer.10. The answer is D. Serum PSA and digital rectal examinationstarting at age 50 is the community standard. Thereason the Guide to Preventive Services, published by theUSPSTF, makes no commitment as to screening for prostatecancer is that the PSA is not as specific as would bedesired, given the costs of working up false positives.However, in primary care practice, the great sensitivity ofthe test in a population with low to average risk allowspeace of mind in a vast number of cases for any false positivesthat may emerge, leading to emotional and financialexpense. Moreover, many of the “false positives” who arethus subjected to worry and uncomfortable proceduressuch as needle biopsy of the prostate eventually show upwith prostate cancer after long follow-up.ReferencesJennifer O. Assistant Professor Chicago Medical School. Personalcommunication.Kerlikowske K , Grady D , Barclay J , et al. Effects of age, breastdensity, and family history on the sensitivity of first screeningmammography . JAMA . 1996 ; 276 : 33 – 38.Marwick C . Other voices weigh in on mammography decision .JAMA . 1997 ; 277 : 1027 – 1028 .Miller KE . Preventive care of the middle-aged adult (40–65years) . In: Rudy DR , Kurowski K , eds. Baltimore : Williams &Wilkins , 1997 : 729 – 740 .The Guide to Preventive Services 2009. Recommendations ofthe U.S. Preventive Services Task Force. Agency for HealthcareResearch and Quality.