AFP journal review

1. AFP journal review Jiyo Shin M.D. Emory Family Medicine

2. May 15 2010 • Nursing Home Care : Clinical Aspects • Diagnosis and Initial Management of Acute HIV Infection • Primary Care of Adult Survivors of Childhood Cancer

3. Nursing Home Care

6. Tai Chi

7. Cont’

10. Level of evidence

13. Cont’

14. Cont’

15. Cont’

17. Review Question • 1. Methicillin-resistant Staphylococcus aureus (MRSA) infection is diagnosed in a nursing home resident. Which one of the following statements about infection control is correct?  (check one) A. Handwashing is the most important measure for controlling infection. B. Resident-to-resident contact is a major mode of MRSA transmission. C. Cultures should be performed in all residents for surveillance purposes. D. The resident’s room should be thoroughly decontaminated. • Answer A

18. Review Question • 2. Which of the following are goals of palliative care for nursing home residents in the early stages of disease ?  (check all that apply) • A. Discussing prognosis. • B. Discussing the patient’s expectations for treatment. • C. Providing educational material. • D. Encouraging focus on completing important tasks. • Answer : A,B,C

19. Review Question • 3. Which of the following statements about advance directives in a nursing home are correct?  (check all that apply) • A. Most residents have an advance directive in place when admitted to a nursing home. • B. Nursing homes are required to offer residents information about advance care planning. • C. Advance directives should include discussions about hospital transfers. • D. A surrogate can be selected to make health care decisions if the resident is unable to do so • Answer : B,C,D

20. Review Question • 4. Which one of the following situations warrants antimicrobial treatment for urinary tract infection in a nursing home resident?  (check one) • A. Bacteria identified in the urine of an asymptomatic patient. • B. Negative urine culture results in a symptomatic patient with a white blood cell count of greater than 10,000 cells per mm3 (10.00 x 109 per L). • C. Positive urine culture results in a symptomatic patient with positive leukocyte esterase test result. • D. Positive nitrite test result in an asymptomatic patient who has not received urine culture. • Answer : C

21. Review Question • 5. A woman with non–insulin-dependent diabetes mellitus and dementia is admitted to the nursing home. She has little interest in food. Which of the following are the best interventions to ensure weight maintenance and optimal nutritional status?  (check all that apply) • A. Strict American Diabetes Association diet. • B. Liberal, culturally appropriate diet. • C. Feeding tube placement. • D. Frequent, small feedings. • Answer : B,D

22. Review Question • 6. A nursing home resident with normal cognitive function has had several incontinence episodes and is willing to cooperate with therapy. Which of the following interventions are appropriate?  (check all that apply) • A. Scheduled toilet habit training. • B. “Check-and-change” program. • C. Prompted voiding. • D. Catheterization • Answer : A, C

23. Acute HIV infection

24. Acute HIV infection

25. R Rash : erythematous maculopapular exanthem

26. Quick Review • Likelihood ratio for a positive result (LR+) tells you how much the odds of the disease increase when a test is positive. • Likelihood ratio for a negative result (LR-) tells you how much the odds of the disease decrease when a test is negative. • The likelihood ratio of a positive test result (LR+) is sensitivity divided by 1- specificity. • The likelihood ratio of a negative test result (LR-) is 1- sensitivity divided by specificity.

31. Review Question • 7. Which one of the following tests is considered the most useful diagnostic marker for acute human immunodeficiency virus (HIV) infection?  (check one) • A. p24 antigen. • B. CD4 lymphocyte count. • C. HIV RNA viral load. • D. Enzyme-linked immunosorbent assay (ELISA). • E. HIV genotype. • Answer : C

32. Review Question • 8. A 28-year-old patient presents with symptoms of myalgias, lymphadenopathy, and mucocutaneous ulcerations. The ELISA is negative, and the patient’s HIV RNA viral load is above 100,000 copies per mL. Which one of the following statements about the patient’s condition is correct?  (check one) • A. The results likely represent a false positive. • B. The patient has a long-standing HIV infection. • C. The patient has an acute HIV infection. • D. A transient increase in CD4 lymphocyte count would confirm the diagnosis • Answer : C

33. Review Question • 9. Which of the following statements about management of acute HIV infection are correct?  (check all that apply) • A. Patients should be counseled on effective risk reduction strategies. • B. Current evidence suggests that combination antiretroviral therapy initiated during acute infection leads to long-term improvement in HIV-related outcomes. • C. HIV antibody and RNA viral load testing should be repeated within four to six weeks in patients with low viral loads to rule out a false-positive result. • D. Short-term hospitalization for monitored induction therapy is recommended in most patients • Answer : A,C

34. Primary Care of Adult Survivors of Childhood Cancer

35. Late Effects

36. Cont’

37. Cont’

38. Cont’

39. Cont’

40. Cont’

42. Take home point • The Children’s Oncology Group’s long-term followup guidelines are available at http://www.survivorshipguidelines.org

43. Review Question • 10. A 25-year-old woman who was diagnosed with Wilms tumor at four years of age had previously received a chemotherapy regimen that included doxorubicin (Adriamycin) for six months. Which one of the following secondary morbidities would most likely occur in this patient?  (check one) • A. Cataracts. • B. Osteoporosis. • C. Cardiomyopathy. • D. Peripheral neuropathy • Answer : C

44. Review Question • 11. A 47-year-old childhood cancer survivor comes to the office as a new patient for a routine examination without any medical records. Which of the following would be important in the care of this patient?  (check all that apply) • A. Work with the patient’s previous physicians to create a Summary of Cancer Treatment form. • B. Consult the long-term follow-up guidelines from the Children’s Oncology Group to determine proper screening tools for future management. • C. If the patient does not recall prior treatments, just proceed with routine health maintenance. • D. Use patient risk factors (e.g., age, sex, lifestyle choices) to help create a future follow-up and monitoring plan for the patient • Answer : A,B,D

45. Finally Tomato Tomato !

46. References • 1. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing • Home Survey: 2004 overview. Vital Health Stat 13. 2009;(167):1-155. • 2. American Academy of Family Physicians. Practice Profile I Survey. • June 2008. http://www.aafp.org/online/en/home/aboutus/specialty/ • facts/5.html. Accessed February 16, 2010. • 3. Unwin BK, Porvaznik M, Spoelhof GD. Nursing home care: part II. clinical • aspects. Am Fam Physician. 2010;81(10):1229-1237. • 4. Dimant J. Roles and responsibilities of attending physicians in skilled and more in AFP journal 2010 May 15