NMS Q&A Family Medicine

Care and Prevention of the Older Adult, Age 65 and Older 281Examination Answers1. The answer is C. Patients over 65 years of age withmore than 50 moles should be examined on a regularbasis for melanoma. Even that conclusion is an inference,not a definite position statement in the 2009 Guide. Suchan inference could be drawn as well from the Guide’sacknowledgment that other high-risk categories include(65 years old) fair skinned people, those with histories offrequent sun burning in the past, and family histories ofmelanoma. The Guide acknowledges the high-risk statusof moles’ shapes (asymmetrical), colors (variegated), andsizes ( 6 mm) but implies that these characteristics arecriteria for treatment, not screening. Their general positionis that they cannot, based on “the balance of benefitsand harms,” recommend for or against total body professionalor self-examination for basal cell and squamouscell carcinomas and cutaneous melanomas.2. The answer is C. Ask standardized screening questionsfor alcoholism such as the CAGE questionnaire. Sets ofstandardized alcoholic screening questions are a moresensitive indicator than just asking about alcohol consumption.Cerebellar function impairments may be subtleand only manifest with acute intoxication. Patientsvary in their propensities to develop alcoholic hepatitisand telangiectasias, even for a given amount and durationof alcohol consumption. An elevated aspartate aminotransferaselevel is a nonspecific indicator of hepatocellulardamage, which is not necessarily present inalcoholism. The other choices yield positive results but ata much later stage of alcoholism than the CAGE questionnaire,assuming it is done with a low threshold for suspicion.(CAGE is an acronym taken from the followingitems: C, cutting down; A, annoyed by criticism of others;G, guilty about drinking; E, (need) eye opener.)3. The answer is B. CRC screening is indicated in thishypothetical 65-year-old patient. The lifetime incidenceof CRC in people of average risk is 2.5%. It is safe to saythat for a cancer whose incidence in the population accelerateswith age and that the over 60 age group has survivedheart disease, accidents, and so on, the incidence ofCRC would be expected to be significantly higher than2.5% in this cohort. There are at least five methodsapproved by the American Gastroenterology Associationwith the gold standard being colonoscopy. Mammogramshould be done yearly beginning at the age of 40 yearsuntil at least the age of 65 as has occurred in this patient.The pneumococcal vaccine is generally indicated once ortwice in the adult lifetime. Her hysterectomy was forbenign disease and she does not need Pap smears. A favorablelipid profile on a postmenopausal female need not berepeated frequently unless there has been a materialchange in the patient’s living style and weight.4. The answer is B. Bulimia nervosa. Pure bulimia is anovereating disorder, without, in its pure form, purging orvomiting. Thus, weight loss is not a part of the syndrome.Actually, part of the addiction, if it occurs at all, is due to astimulant effect of nicotine. This results in an amphetaminelikeeffect so that one of the complications of smoking cessationis weight gain. All the other diseases mentioned in thechoices occur at significantly greater incidence in smokersas compared to nonsmokers. For the slender postmenopausalwoman of Celtic origin, osteoporosis is a significantrisk, multiplied 1.5 to twofold in a cigarette smoker.5 . The answer is A. A spouse. Relatives, especiallyspouses, are most likely to be the abusers. They may beactively or passively abusive.6. The answer is D. 160/80, if in a steady state, fits thedefinition of isolated systolic hypertension (ISH). This ismore likely in the older age group. Thiazide diuretics aremost effective in salt/water retention conditions; namely,the low renin end of the hypertensive spectrum. Impliedis that ISH is a low renin state. It is well known that ifbeta-adrenergic blocking agents are used in the oldest agegroup, a greater dosage is required. Thus, being anti-reninagents, they are less effective because renin played a lesssignificant part in ISH as compared to the broad spectrumof the remainder of hypertension.7. The answer is A. Flexible sigmoidoscopy and FOBTsare the least likely to prevent disease in a patient who hasa life expectancy of 5 to 10 years. Blood pressure controlcan prevent strokes; thyroid-stimulating hormone canunearth hypothyroidism in the absence of typical symptoms,especially in an elderly person; urinalysis can revealsubclinical urinary tract infection. The up-and-go testcan rule out the possibility that the patient may be physicallyunable to care for himself alone. The test consists ofasking the patient to arise from a sitting position withoutthe use of his or her hands, walk 10 ft (3 m), and return tothe originally sitting site and position. If the patient canperform this satisfactorily in 10 seconds, then he or sheis assumed to be physically able. If the activity requiresmore than 30 seconds, then the patient very likely willrequire physical assistance at home.8. The answer is D. Preparing caregiver(s) and the familyfor management and socioeconomic issues for a patientwith imminent AD is worthwhile in the view of most