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MEDICAL
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MEDICAL

Sixth Edition

MARY P. HARWARD, MD, FACP

Internal Medicine and Geriatrics
Orange, California
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

MEDICAL SECRETS, SIXTH EDITION ISBN: 978-0-323-47872-4

Copyright © 2019 by Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from the
Publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our ar-
rangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found
at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may
be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
ing and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, as-
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contained in the material herein.

Previous editions copyrighted in 2012, 2005, 2001, 1996, 1991.

Library of Congress Cataloging-in-Publication Data

Names: Harward, Mary P., editor.

Title: Medical secrets / [edited by] Mary P. Harward.
Description: Sixth edition. | Philadelphia, PA : Elsevier Inc., [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2017058627 | ISBN 9780323478724 (pbk. : alk. paper)
Subjects: | MESH: Internal Medicine | Examination Questions
Classification: LCC RC58 | NLM WB 18.2 | DDC 616.0076--dc23 LC record available at
https://lccn.loc.gov/2017058627

Executive Content Strategist: James Merritt

Content Development Manager: Louise Cook
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Sharon Corell
Book Designer: Bridget Hoette

Printed in the United States.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To our patients who have shared with us the secrets of
their health and illness.
This page intentionally left blank

     
CONTRIBUTORS

William L. Allen, M. Div, JD Teresa G. Hayes, MD, PhD

Associate Professor Associate Professor
Department of Community Health and Family Medicine Department of Internal Medicine
Program in Bioethics, Law, and Medical Hematology-Oncology Section
Professionalism Baylor College of Medicine
University of Florida College of Medicine Chief
Gainesville, Florida Hematology-Oncology Section
Michael E. DeBakey VA Medical Center
Katherine Vogel Anderson, PharmD, BCACP Houston, Texas
Associate Professor
University of Florida College of Pharmacy and Medicine Nisreen Husain, MD
Gainesville, Florida Director
GI Motility
Rhonda A. Cole, MD, FACG Department of Gastroenterology
Associate Section Chief Baylor College of Medicine
Department of Gastroenterology Houston, Texas
Associate Professor
Department of Internal Medicine Ankita Kadakia, MD
Baylor College of Medicine Assistant Professor of Clinical Medicine
Houston, Texas Division of Infectious Diseases
University of California San Diego Medical
Kathryn H. Dao, MD, FACP, FACR Center – Owen Clinic
Associate Director of Clinical Rheumatology San Diego, California
Baylor Research Institute
Dallas, Texas Henrique Elias Kallas, MD, CMD
Assistant Professor
Nathan A. Gray, MD Departments of Medicine and Aging
Assistant Professor of Medicine University of Florida College of Medicine
Division of General Internal Medicine Gainesville, Florida
Duke University School of Medicine
Durham, North Carolina Alexander S. Kim, MD
Assistant Professor of Medicine
Gabriel Habib, Sr., MS, MD, FACC, FCCP, FAHA Associate Program Director
Professor of Medicine and Cardiology Allergy/Immunology Fellowship Program
Baylor College of Medicine University of California, San Diego
Director of Education and Associate Chief San Diego, California
Section of Cardiology
Michael E. DeBakey VA Medical Center Roger Kornu, MD, FACR
Houston, Texas Affiliated Physician
University of California, Irvine
Eloise M. Harman, MD Irvine, California
Staff Physician and MICU Director
Malcom Randall VA Medical Center R. Anjali Kumbla, MD
Professor Emeritus of Medicine Department of Hematology/Oncology
University of Florida College of Medicine The Southeast Permanente Medical Group
Gainesville, Florida Athens, Georgia
Mary P. Harward, MD, FACP Daniel Lee, MD
Internal Medicine and Geriatrics Clinical Professor of Medicine
Orange, California Division of Infectious Diseases
University of California San Diego Medical
Timothy R.S. Harward, MD, FACS Center—Owen Clinic
Vascular and Interventional Specialists of Orange San Diego, California
County
Orange, California

vii
 viii CONTRIBUTORS

Harrinarine Madhosingh, MD, FACP, FIDSA Eric I. Rosenberg, MD, MSPH, FACP
Attending Physician Associate Professor and Chief
Infectious Disease Division of General Internal Medicine
Central Florida Infectious Disease Specialists Department of Medicine
Assistant Professor University of Florida College of Medicine
Department of Medicine Associate Chief Medical Officer
University of Central Florida University of Florida Health Shands Hospitals
Orlando, Florida Gainesville, Florida
Ara Metjian, MD Abbas Shahmohammadi, MD
Assistant Professor Assistant Professor
Division of Hematology Division of Pulmonary and Critical Care Medicine
Department of Medicine Department of Medicine
Duke University School of Medicine University of Florida College of Medicine
Durham, North Carolina Gainesville, Florida
John Meuleman, MD Damian Silbermins, MD
Geriatric Research, Education, and Clinical Huntington Internal Medicine Group
Center Huntington, West Virginia
University of Florida College of Medicine
Gainesville, Florida Amy M. Sitapati, MD
Clinical Professor of Medicine
Jeffrey M. Miller, MD Chief Medical Information Officer of Population Health
Chief University of California San Diego Health
Division of Hematology/Oncology San Diego, California
Program Director
Hematology/Oncology Fellowship David B. Sommer, MD, MPH
Olive View—UCLA Medical Center Neurology, Movement Disorders
Cedars Sinai Medical Center Reliant Medical Group
Kaiser Sunset Worcester, Massachusetts
Associate Clinical Professor of Medicine Susan E. Spratt, MD
David Geffen School of Medicine at UCLA Associate Professor
Olive View UCLA Medical Center Division of Endocrinology
Los Angeles, California Department of Medicine
Yamini Natarajan, MD Duke University School of Medicine
Assistant Professor Durham, North Carolina
Department of Gastroenterology Adriano R. Tonelli, MD
Baylor College of Medicine Assistant Professor
Michael E. DeBakey VA Medical Center Division of Pulmonary, Allergy, and
Houston, Texas Critical Care Medicine
Catalina Orozco, MD Case Western Reserve University School of Medicine
Rheumatology Associates Cleveland, Ohio
Dallas Texas Whitney W. Woodmansee, MD
Rahul K. Patel, MD, FACP, FACR Endocrinology
Medical Director Mayo Clinic—Jacksonville
PRA Health Sciences Jacksonville, Florida
Dallas, Texas Jason A. Webb, MD, FAPA
Sharma S. Prabhakar, MD, MBA, FACP, FASN Director of Education
Professor and Chief Duke Center for Palliative Care
Division of Nephrology Assistant Professor
Vice-Chair Department of Medicine
Department of Medicine Department of Psychiatry and Behavioral Sciences
Texas Tech University Health Sciences Center Duke University School of Medicine
Lubbock, Texas Durham, North Carolina

Nila S. Radhakrishnan, MD
Assistant Professor and Chief
Division of Hospital Medicine
Department of Medicine
University of Florida College of Medicine
Gainesville, Florida
PREFACE

Most of my post-training professional life has been concurrent with the six editions of this book, and I have
seen astounding scientific and therapeutic changes with each new update of Medical Secrets. The chapters
in the sixth edition reflect the many major changes in medical science, prevention, and therapy that have
occurred since the book was first published in 1991. For instance, in the first edition the mortality rate from
Acquired Immunodeficiency Syndrome (AIDS) was cited as 75% at 3 years, and treatment of AIDS as a
chronic disease was not discussed. The sixth edition now notes the 36.9 million people living with Human
Immunodeficiency Virus (HIV) and AIDS and includes questions on preventive treatments. Elsewhere, the
Gastroenterology chapter contrasts the lack of even screening tests for hepatitis C in 1991 with questions
on contemporary effective methods for hepatitis C treatment in 2018. Similar contrasts can be found in
all the chapters. Also noteworthy are the chapters added to later editions on Medical Ethics and Palliative
Medicine, acknowledging the increased presence of these disciplines in everyday medical practice.
The contributor list has also significantly changed since the first edition with new contributors to this
edition adding their fresh perspectives. In addition, Drs. Cole, Habib, and Prabhaker deserve special recog-
nition for faithfully updating their chapters from the first through the sixth editions.
I hope the students using this book will appreciate and acknowledge the perspectives in the previous
editions, yet sense how quickly medicine adapts to new discoveries. Many of the quotes at the beginning of
the chapters reflect the historical context of the disciplines and hopefully may prompt the reader to inves-
tigate the original sources. Perhaps some of the students reading the text today will be future contributors
and remember how medicine was practiced “back during the time of the sixth edition.”

Mary P. Harward, MD, FACP

Orange, California

ix
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CONTENTS

TOP 100 SECRETS 1

CHAPTER 1 MEDICAL ETHICS 5
William L. Allen, M Div, JD

CHAPTER 2 GENERAL MEDICINE AND AMBULATORY CARE 11

Mary P. Harward, MD, FACP

CHAPTER 3 MEDICAL CONSULTATION 40

Eric I. Rosenberg, MD, MSPH, FACP, Nila S. Radhakrishnan, MD, and Katherine Vogel Anderson, PharmD, BCACP

CHAPTER 4 CARDIOLOGY 54
Gabriel Habib, Sr., MS, MD, FACC, FCCP, FAHA

CHAPTER 5 VASCULAR MEDICINE 98

Timothy R.S. Harward, MD, FACS

CHAPTER 6 PULMONARY MEDICINE 109

Abbas Shahmohammadi, MD, Adriano R. Tonelli, MD, and Eloise M. Harman, MD

CHAPTER 7 GASTROENTEROLOGY 140

Rhonda A. Cole, MD, FACG, Nisreen Husain, MD, and Yamini Natarajan, MD

CHAPTER 8 NEPHROLOGY 170

Sharma S. Prabhakar, MD, MBA, FACP, FASN

CHAPTER 9 ACID-BASE AND ELECTROLYTE DISORDERS 197

Sharma S. Prabhakar, MD, MBA, FACP, FASN

CHAPTER 10 RHEUMATOLOGY 220

Roger Kornu, MD, FACR, Kathryn H. Dao, MD, FACP, FACR, Catalina Orozco, MD, and Rahul K. Patel, MD,
FACP, FACR

CHAPTER 11 ALLERGY AND IMMUNOLOGY 258

Alexander S. Kim, MD

CHAPTER 12 INFECTIOUS DISEASES 302

Harrinarine Madhosingh, MD, FACP, FIDSA

CHAPTER 13 A CQUIRED IMMUNODEFICIENCY SYNDROME AND HUMAN IMMUNODEFICIENCY

VIRUS INFECTION 333
Daniel Lee, MD, Ankita Kadakia, MD, and Amy M. Sitapati, MD

CHAPTER 14 HEMATOLOGY 357

Damian Silbermins, MD, and Ara Metjian, MD

CHAPTER 15 ONCOLOGY 399

R. Anjali Kumbla, MD, Jeffrey M. Miller, MD, and Teresa G. Hayes, MD, PhD

CHAPTER 16 ENDOCRINOLOGY 431

Susan E. Spratt, MD, and Whitney W. Woodmansee, MD

xi
 xii CONTENTS

CHAPTER 17 NEUROLOGY 472

David B. Sommer, MD, MPH

CHAPTER 18 GERIATRICS 497

John Meuleman, MD, and Henrique Elias Kallas, MD, CMD

CHAPTER 19 PALLIATIVE MEDICINE 515

Jason A. Webb, MD, FAPA, and Nathan A. Gray, MD
  
TOP 100 SECRETS
These secrets are 100 of the top board alerts. They summarize the most important concepts,
principles, and salient details of internal medicine.

1. Informed consent is not merely a signature on a form but a process by which the patient and
physician discuss and deliberate the indications, risks, and benefits of a test, therapy, or procedure
and the patient’s outcome goals.
2. Patients should participate in informed consent, even if they have impaired memory or communi-
cation skills, whenever they have sufficient decision-making capacity.
3. Decision-making capacity is determined by assessing the patient’s ability to (1) comprehend the
indications, risks, and benefits of the intervention; (2) understand the significance of the underlying
medical condition; (3) deliberate the provided information; and (4) communicate a decision.
4. Many states now have specific physician-signed order forms to indicate a patient’s end-of-life
preferences for resuscitation and intensity of care.
5. All adults need one dose of tetanus, diphtheria, pertussis (Tdap) vaccine in place of one booster
dose of tetanus-diphtheria (Td) vaccine to improve adult immunity to pertussis (whooping cough).
6. Zoster vaccine is indicated for adults ≥ 60 years old even if they have had an episode of herpes
zoster infection.
7. Adolescent girls and boys should begin human papillomavirus (HPV) vaccine at age 11–12 to
prevent HPV infection and reduce cervical cancer risk. Those who start at a later age can “catch
up” through age 21 (men) or age 26 (women).
8. High-risk patients and those 65 years and older should receive two types of pneumococcal
vaccine: pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine
(PCV23) at least 12 months apart.
9. Antibiotic prophylaxis before dental procedures is recommended only for patients with (1) signifi-
cant congenital heart disease; (2) previous history of endocarditis; (3) cardiac transplantation; and
(4) prosthetic valve.
10. “Routine” preoperative testing is not helpful to reduce surgical risk. Laboratory and procedural
tests should be ordered to address the acuity or stability of a medical problem or to investigate an
abnormal symptom or physical sign identified during the consultation.
11. Preoperative consultation should include identification of risk factors for postoperative venous
thromboembolism and appropriate treatment.
12. Patients undergoing major surgery who are at risk of adrenal suppression may need glucocorti-
coid therapy in the perioperative period. Some patients, though, may just need close monitoring
postoperatively for signs of adrenal insufficiency.
13. “Tight” control of diabetes with target blood sugar of 80–110 mg/dL may not be beneficial
postoperatively.
14. Metformin should be held and renal function closely monitored for patients undergoing surgery or
imaging procedures involving contrast agents.
15. Asking the patient about personal and family history of bleeding episodes associated with minor
procedures or injury is as effective in identifying bleeding diatheses as measuring coagulation
studies.
16. Noninvasive stress testing has the best predictive value for detecting coronary artery disease
(CAD) in patients with an intermediate (30–80%) pretest likelihood of CAD and is of limited value in
patients with very low (<30%) or very high (>80%) likelihood of CAD.
17. Routine use of daily low-dose aspirin (81–325 mg) can reduce the likelihood of cardiovascular
disease in high-risk patients with known CAD, diabetes, stroke, or peripheral or carotid vascular
disease.
18. Routine daily low-dose aspirin use is associated with an increased risk of gastrointestinal bleeding,
which can be reduced through the use of proton pump inhibitors.
19. Right ventricular infarction should also be considered in any patient with signs and symptoms of
inferior wall myocardial infarction.

1
2 TOP 100 SECRETS

20. D iabetes is considered an equivalent of known CAD, and treatment and prevention guidelines for
diabetic patients are similar to those for patients with CAD.
21. Patients with congestive heart failure (CHF) and left ventricular ejection fraction (LVEF) < 35% with
class II or III New York Heart Association (NYHA) symptoms should be considered for implantable
cardiac defibrillator.
22. Consider aortic dissection in the differential diagnosis of all patients presenting with acute chest or
upper back pain.
23. Increasing size of an abdominal aortic aneurysm (AAA) increases the risk of rupture. Patients with
AAA greater than 5 cm or aneurysmal symptoms should have endovascular or surgical repair.
Smaller aneurysms should be followed closely every 6 to 12 months by computed tomography (CT)
scan.
24. Patients presenting with pulselessness, pallor, pain, paralysis, and paresthesia of a limb likely have
acute limb ischemia due to an embolus and require emergent evaluation for thrombolytic therapy
or revascularization.
25. Patients with symptoms of transient ischemic attack are at high risk of stroke and require urgent
evaluation for carotid artery disease and treatment that may include antiplatelet agents, carotid
endarterectomy, statin drugs, antihypertensive agents, and anticoagulation.
26. All patients with peripheral arterial disease and cerebrovascular disease should stop smoking.
27. Asthma, chronic obstructive pulmonary disease (COPD), CHF, vocal cord dysfunction, and upper
airway cough syndrome (UACS) can all cause wheezing.
28. Inhaled corticosteroid therapy should be considered for asthmatic patients with symptoms that
occur with more than intermittent frequency.
29. Pulmonary embolism cannot be diagnosed by history, physical examination, and chest radiograph
alone. Additional testing such as d-dimer level, spiral chest CT scan, angiography, or a combination
of these tests will be needed to effectively rule in or rule out the disease.
30. Sarcoidosis is a multisystem disorder that frequently presents with pulmonary findings of abnor-
mal chest radiograph, cough, dyspnea, or chest pain.
31. Hepatitis C virus infection can lead to cirrhosis, hepatocellular carcinoma, and severe liver disease
requiring liver transplantation. Routine screening for infection is helpful for certain high-risk groups
including those born in the United States between 1945 and 1965.
32. Travelers to areas with endemic hepatitis A infection should receive hepatitis A vaccine.
33. Celiac sprue should be considered in patients with unexplained iron-deficiency anemia or
osteoporosis.
34. In the United States, gallstones are common among American Indians and Mexican Americans.
35. Esophageal manometry may be needed to complete the evaluation of patients with noncardiac
chest pain that may be due to esophageal motility disorders.
36. The estimated glomerular filtration rate (eGFR) is now routinely reported when chemistry panels
are ordered and can provide a useful estimate of renal function.
37. Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) use should be
evaluated for all diabetics, even those with normotension, for their renoprotective effects.
38. Diabetes is the most common cause of chronic kidney disease (CKD) in the United States, followed
by hypertension.
39. When erythrocyte-stimulating agents are used for the treatment of anemia associated with CKD
and end-stage renal disease, the hemoglobin level should not be normalized but maintained at
11–12 g/dL.
40. Almost 80% of patients with nephrolithiasis have calcium-containing stones.
41. Hyponatremia can commonly occur after transurethral resection of the prostate.
42. Thrombocytosis, leukocytosis, and specimen hemolysis can falsely elevate serum potassium
levels.
43. Intravenous calcium should be given immediately for patients with acute hyperkalemia and elec-
trocardiographic changes.
44. Hypoalbuminemia lowers the serum total calcium level but does not affect the ionized calcium.
45. Hypokalemia, hypophosphatemia, and hypomagnesemia are common findings in alcoholics who
require hospitalization.
46. Lupus mortality rate is bimodal in distribution. It peaks in patients who die early from the disease
or infection and again in patients who die later in life from cardiovascular diseases.
47. Inflammatory arthritis is characterized by morning stiffness, improvement with exercise, and
involvement of small joints (although large joints may also be involved).
 TOP 100 SECRETS 3

48. P atients with autoimmune disorders who smoke should be counseled to quit because tobacco has
recently been linked to precipitation of symptoms and poorer prognosis.
49. Most rheumatologic diseases are diagnosed via clinical criteria based on thorough history, physical
examination, and selective laboratory testing and imaging.
50. Early diagnosis of an inflammatory arthritis leads to intervention and improved clinical outcomes
because there are many disease-modifying therapies available.
51. The most common immunoglobulin (Ig) deficiency is IgA deficiency, which can cause a false-
positive pregnancy test.
52. Intranasal steroids are the single most effective drug for treatment of allergic rhinitis. Deconges-
tion with topical adrenergic agents may be needed initially to allow corticosteroids access to the
deeper nasal mucosa.
53. ACE inhibitors can cause dry cough and angioedema.
54. Beta blockers should be avoided whenever possible in patients with asthma because they may
accentuate the severity of anaphylaxis, prolong its cardiovascular and pulmonary manifesta-
tions, and greatly decrease the effectiveness of epinephrine and albuterol in reversing the
life-threatening manifestations of anaphylaxis.
55. Patients with persistent fever of unknown origin should first be evaluated for infections, malignan-
cies, and autoimmune diseases.
56. Viruses are the most common causes of acute sinusitis; therefore, antibiotics are ineffective,
unless symptoms are persistent (>10 days) or relapse after improvement.
57. Rocky Mountain spotted fever (RMSF) occurs through North and Central America with concentra-
tion in the southeastern and south central U.S. states with increasing incidence in Arizona (on
Indian reservations). Empiric therapy for RMSF should be considered within 5 days of symptom
onset for patients with febrile illnesses and a history of a tick bite who have been in these regions
in the spring or summer (May to September).
58. Asplenic patients (either anatomic or functional) are susceptible to infections with encapsulated
organisms (Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis) and
should receive appropriate vaccinations for these organisms in addition to up-to-date childhood
vaccinations. Needed vaccinations should be administered 14 days before elective splenectomy, if
possible.
59. Allergic bronchopulmonary aspergillosis (ABPA) occurs in asthmatics and is evident by recurrent
wheezing, eosinophilia, transient infiltrates on chest radiograph, and positive serum antibodies to
Aspergillus.
60. Chagas disease, caused by Trypanosoma cruzi, can cause cardiomyopathy, cardiac arrhythmias,
and thromboembolism.
61. Human immunodeficiency virus (HIV) infection is preventable and treatable but not curable.
62. Routine HIV testing should be considered for all patients aged 13–65 years.
63. A fourth-generation Ag/Ab combination enzyme immunoassay (EIA) is needed for diagnosis of
acute primary HIV infection.
64. HIV-infected patients with undetectable viral loads can still transmit HIV.
65. HIV-infected patients with tuberculosis are more likely to have atypical symptoms and present with
extrapulmonary disease.
66. All patients with HIV infection should be tested for syphilis, and all patients diagnosed with syphilis
(and any other sexually transmitted disease) should be tested for HIV.
67. The presence of thrush (oropharyngeal candidiasis) indicates significant immunosuppression in an
HIV-infected patient.
68. Transferrin saturation and ferritin are effective screening tests for hemochromatosis.
69. Methylmalonic acid can be helpful in the diagnosis of vitamin B12 deficiency in patients with low
normal vitamin B12 levels.
70. Patients with chronic hemolysis should receive folate replacement (1 mg/day).
71. Chronic lymphocytic leukemia is the most common leukemia in adults and is often found in those
older than 70 years.
72. Patients with antiphospholipid syndrome have an antiphospholipid antibody and the clinical occur-
rence of arterial or venous thromboses or both, recurrent pregnancy losses, or thrombocytopenia.
73. Solid tumor staging often uses American Joint Commission on Cancer (AJCC) TNM staging
(T = tumor size and areas of invasion; N = regional nodal status; and M = distant metastases).
74. Each type of cancer is driven by different mutations and abnormal checkpoints for which many
new, targeted immunotherapeutics have been developed.
4 TOP 100 SECRETS

75. D ifferential diagnosis when evaluating possible malignancy should always ensure an accurate
treatment plan and may require multiple biopsies and other procedures prior to diagnosis.
76. Tobacco and alcohol use are significant risk factors for head and neck cancers.
77. The treatment plan for a malignancy is often chemotherapy but may include surgical oncology,
radiation oncology, and palliative medicine.
78. The best initial screening test for evaluation of thyroid status in most patients is the thyroid-
stimulating hormone (TSH). The exceptions are patients with pituitary and hypothalamic dysfunction.
79. Patients with type 1 and type 2 diabetes mellitus (DM) should be screened at regular intervals for
the microvascular complications of retinopathy, neuropathy, and nephropathy.
80. Closely examine the feet of diabetic patients regularly, looking for ulcerations, significant callous
formation, injury, and joint deformities that could lead to ulceration. Check dorsalis pedis and
posterior tibial pulses to detect reduced blood flow and sensation with a monofilament.
81. Erectile dysfunction and decreased libido in men and amenorrhea and infertility in women are the
most common symptoms of hypogonadism.
82. Hyperparathyroidism is the most common cause of hypercalcemia.
83. Ataxia can be localized to the cerebellum.
84. Gait dysfunction, urinary dysfunction, and memory impairment are symptoms of normal-
pressure hydrocephalus.
85. In the appropriate setting, thrombolysis can markedly improve the outcome of stroke. Prompt
initiation of thrombolytic therapy is essential.
86. The sudden onset of a severe headache may indicate an intracranial hemorrhage.
87. Optic neuritis can be an early sign of multiple sclerosis.
88. Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for insomnia,
particularly for older adults.
89. Older adults are particularly susceptible to the anticholinergic effects of multiple medications,
including over-the-counter antihistamines.
90. Anemia is not a normal part of aging, and hemoglobin abnormalities should be investigated.
91. Decisions regarding screening for malignancies in the elderly should be based not on the age
alone but on the patient’s life expectancy, functional status, and personal goals.
92. Systolic murmurs in the elderly may be due to aortic stenosis or aortic sclerosis.
93. Delirium in hospitalized patients is associated with an increased mortality risk.
94. When delirium occurs, the underlying cause should be thoroughly evaluated and treated.
95. Pneumonia is the most common infectious cause of death in the elderly.
96. Patients with life-limiting or serious illness can be referred for palliative care at any point in their
illness process, regardless of prognosis.
97. A stimulant laxative should always be prescribed whenever opiates are prescribed for chronic pain
management to manage opiate-induced constipation.
98. Patients can discontinue hospice care if their symptoms improve or their end-of-life goals change.
99. Opiates are the first line treatment for severe dyspnea at the end of life.
100. Opioid analgesics are available in many forms including tablets to swallow or for buccal applica-
tion, oral solutions, lozenges for transmucosal absorption, transdermal patches, rectal supposito-
ries, and subcutaneous, intravenous, or intramuscular injection administration.
 CHAPTER 1
MEDICAL ETHICS
William L. Allen, M Div, JD

I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or
wrong them.
Attributed to Hippocrates
4th-Century Greek Physician
  

ETHICAL PRINCIPLES AND CONCEPTS

1. Define the following terms in relation to the patient and physician-patient
relationship: beneficence, nonmaleficence, autonomy, and justice.
•  Beneficence: The concept that the physician will contribute to the welfare of the patient through
the recommended medical interventions
•  Nonmaleficence: An obligation for the physician not to inflict harm upon the patient
•  Autonomy: The obligation of the physician to honor the patient’s right to accept or refuse a
recommended treatment, based on respect for persons
•  Justice: The obligation of the physician to avoid treating patients differently by providing
better care or privileges to favored patients or by discriminating against less favored patients,
especially on grounds of race, ethnicity, sex, sexual orientation, religion, creed, socioeconomic
status, or disability
2. What is fiduciary duty?
An obligation of trust imposed upon physicians requiring them to place their patients’ best interests
ahead of their own interests and, as the patient’s advocate, to protect patients from exploitation or
neglect of others in the health care system.
3. What is conflict of interest?
A situation in which one or more of a professional’s duties to a client or patient potentially conflicts
with the professional’s self-interests or when a professional’s roles or duties to more than one patient
or organization are in tension or conflict.
4. How should conflicts of interest be addressed?
• Avoided, if possible
• Disclosed to institutional officials or to patients affected
• Managed by disinterested parties outside the conflicted roles or relationships
5. What is conscientious objection?
Refusal to participate in or perform a procedure, prescription, or test grounded on a person’s sincere
and deeply held belief that it is morally wrong.

6. What is a conscience clause?

A provision in law or policy that allows providers with conscientious objections to decline participation
in activities to which they have moral objections, under certain conditions and limitations. The scope
of the allowance should only protect the provider’s conscience, not deny a patient legitimate care.

7. Describe futility.
The doctrine that physicians are not required to provide treatment if there will be no medical benefit
from it. It has become a very controversial term in recent times, in part because of inconsistency
in definition and usage. In the narrowest definition, “futility” may refer to physiologic futility or the
inability of a treatment or intervention to support bodily functions such as circulation or respiration
or reverse the ultimate decline and cessation of these functions. More often, though, futility refers
to the very low likelihood of an intervention succeeding in restoring physiologic function or health.
5
 6 MEDICAL ETHICS

Patients and physicians may disagree about the level of probability that could be considered
futile, though. Most health care institutions will establish policies for guidance in resolving such
disagreements.

INFORMED CONSENT
8. How should one request “consent” from a patient?
Consent is not a transitive verb. Sometimes a medical student or resident is instructed to “go
consent the patient,” implying that consent is an act that a health professional performs upon a
passive recipient who has no role in the action other than passive acceptance. A health professional
seeking consent from a patient should be asking the patient for either an affirmative endorsement of
an offered intervention or a decision to decline the proposed intervention.
9. What is consent or mere consent?
Consent alone, without a sufficiently robust level of information to justify the adjective “informed.”
Although “mere consent” may avoid a finding of battery (which is defined as harmful or offensive
physical contact with a person without that person’s consent), it is usually insufficient permission for
the physician to proceed with a procedure or treatment.
10. What is informed consent?
Consent from a patient that is preceded by and based on the patient’s understanding of the proposed
intervention at a level that enables the patient to make a meaningful decision about endorsement or
refusal of the proposed intervention.
11. What are the necessary conditions for valid informed consent?
• Disclosure of relevant medical information by health care providers
• Comprehension of relevant medical information by patient (or authorized representative)
• Voluntariness (absence of coercion by medical personnel or institutional pressure)
12. What topics should always be addressed in the discussion regarding informed
consent (or informed refusal)?
• Risks and benefits of the recommended intervention (examination, test, or treatment)
• Reasonable alternatives to the proposed intervention and the risks and benefits of such alternatives
   • The option of no intervention and the risks and benefits of no intervention

K EY POIN T S: IN F ORM ED C O N S E N T
1. Informed consent involves more than a signature on a document.
2. Before beginning the informed consent process, the physician should assess the patient’s capacity
to understand the information provided.
3. The physician should make the effort to present the information in a way the patient can compre-
hend and not just assume the patient is “incompetent” because of difficulty in understanding a
complex medical issue.
4. The patient’s goals and values are also considered in the informed consent process.

13. What are the different standards for the scope of disclosure in informed consent?
• Full disclosure: Disclosure of everything the physician knows. This standard is impractical, if not
impossible, and is not legally or ethically required.
• Reasonable person (sometimes called “prudent person standard”): Patient-centered standard of
disclosure of the information necessary for a reasonable person to make a meaningful decision
about whether to accept or to refuse medical testing or treatment. This standard is the legal
minimum in some states.
• Professional practice (also called “customary practice”): Physician-centered standard of disclo-
sure of the information typically practiced by other practitioners in similar contexts. Sometimes
the professional practice standard is the legal minimum in states that do not acknowledge the
reasonable person standard.
• Subjective standard: Disclosure of information a particular patient may want or need beyond
what a reasonable person may want to know. This is not a legally required minimum but is ethi-
cally desirable if the physician can determine what additional information the particular patient
might find important.
 Medical Ethics  7

14. What are the exceptions to the obligation of informed consent?

• Implied consent: For routine aspects of medical examinations, such as blood pressure, tempera-
ture, or stethoscopic examinations, explicit informed consent is not generally required, because
presentation for care plausibly implies that the patient expects these measures and consent may be
reasonably inferred by the physician. Implied consent does not extend to invasive examinations or
physical examination of private or sensitive areas without explicit oral permission and explanation of
purpose.
• Presumed consent: Presentation in the emergency room does not necessarily mean that emergency
interventions are routine or that the patient’s consent is implied. The justification for some exception
to informed consent is that most persons would agree to necessary emergency interventions; there-
fore, consent may be presumed, even though this presumption may turn out to be incorrect in some
instances for some patients. Such treatment is limited to stabilizing the patient and deferring other
decisions until the patient regains capacity or an authorized decision maker has been contacted.
15. What should you do when a patient requests the physician to make the decision
without providing informed consent?
When a patient seems to be saying in one way or another, “Doctor, just do what you think is best,” it
is appropriate to make a professional recommendation based on what the physician believes to be in
the patient’s best medical interests. This does not mean, however, that the patient does not need to
understand the risks, benefits, and expected outcomes of the recommended intervention. This type
of request is sometimes referred to as requested paternalism or waiver of informed consent. The
physician should explain, in terms of risks and benefits of a recommended intervention, the reasons
he or she recommends the intervention and why it would seem to be in the patient’s best medical
interest and then ask the patient to endorse it or to decline it.
16. What is a physician’s obligation to veracity (truthful disclosure) to patients?
In order for patients to have an accurate picture of their medical situation and what clinical
alternatives may best meet their goals in choosing among various medical tests or treatments or to
decline medical intervention, patients must have a truthful description of their medical condition. Such
truthful disclosure is also essential for maintaining patient trust in the physician-patient relationship.
Truthful disclosure, especially of “bad news,” however, does not mean that the bearer of bad news
must be brutal or insensitive in the timing and manner of disclosure.
17. Define therapeutic privilege.
A traditional exception to the obligation of truthful disclosure to the patient, in which disclosures
that were thought to be harmful to the patient were withheld for the benefit of the patient. In recent
decades, this exception has narrowed almost to the vanishing point from the recognition that most
patients want to know the truth and make decisions accordingly, even if the truth entails bad news.
Nevertheless, some disclosures may justifiably be withheld temporarily, such as when a patient is
acutely depressed and at risk of suicide. Ultimately, however, with appropriate medical and social
support, the patient whose decisional capacity can be restored should be told the information that had
been temporarily withheld for her or his benefit.

CONFIDENTIALITY
18. What is medical confidentiality?
The private maintenance of information relating to a patient’s medical and personal data without
unauthorized disclosure to others. Maintaining the confidential status of patient medical information is
crucial not only to trust in the physician-patient relationship but also to the physician’s ability to elicit
sensitive information from patients that is crucial to adequate medical management and treatment.
The Health Information Portability and Accountability Act (HIPAA, a federal statute) as well as most
state statutes provide legal protections for patients’ personally identifiable health information (PHI),
but the professional ethical obligation of confidentiality may exceed these minimal protections or
apply in situations not clearly addressed by HIPAA or state statutes.
19. What are recognized exceptions to patient medical confidentiality?
• Duty to warn (Tarasoff duty): A basis for justifying a limited exception to the rule of patient
confidentiality when a patient of a psychiatrist makes an explicit, serious threat of grave bodily
harm to an identifiable person(s) in the imminent future. The scope of this warning is limited to
the potential victim(s) or appropriate law enforcement agency, and the health care provider may
divulge only enough information to convey the threat of harm.
 8 MEDICAL ETHICS

• Reporting of communicable disease to public health authorities (but not others).

• Reporting of injuries from violence to law enforcement.
• Reporting of child or elder abuse to protective social service authorities.
20. What is the obligation to veracity to nonpatients?
Physicians are not obligated to lie to persons who inquire about a patient’s confidential information,
but they may be required simply to decline to address such requests from persons to whom the
patient has not granted access.

DECISION-MAKING CAPACITY
21. How do physicians assess decision-making capacity in patients?
Whereas most adult patients should be presumed to have intact decisional capacity, some patients may be
totally incapacitated for making their own medical decisions. Totally incapacitated patients will generally
be obvious cases, such as unconscious or sedated patients. But decisional capacity is not an all-or-
nothing category, so it is not uncommon for patients to have variable capacity depending on the status of
their condition and the complexity of the particular decision at hand. Thus, one crucial aspect of assessing
decisional capacity is to determine whether the patient can comprehend the elements required for valid
informed consent to the particular decision that needs to be made. Patients with mood disorders, such as
acute depression, however, may be incapacitated by their mood, even if they comprehend the information.
22. What are common pitfalls in assessing patient decisional capacity or
competence?
If one uses the outcome approach, the patient’s capacity is determined based on the outcome of the
patient’s acceptance of the physician’s recommendation. The physician may incorrectly assume that
the refusal of a recommended treatment indicates incapacity. Refusal of a recommended treatment
is not adequate grounds to conclude patient incapacity. Nor is patient acceptance of the physician’s
recommendation an adequate means of assessing patient capacity. An incapacitated patient may
acquiesce to recommended treatment, whereas a capacitated patient may refuse the physician’s
best medical advice. If one uses the status approach, patients with a history of a mental illness
or memory impairment may be considered incapacitated. Psychiatric conditions or other medical
conditions that can result in incapacity may have resolved or may be under control with appropriate
therapy that mitigates the condition’s impact on patient capacity for decision making. Patients with
memory impairment or dementia may also be able to express wishes regarding treatment. Patients
who can express a clear preference should have that expression seriously regarded as assent or
dissent, even if an authorized decision maker makes the legally sufficient informed consent or refusal.
23. What is the best approach to assessing patient capacity?
The functional approach, which determines the patient’s ability to function in a particular context to
make decisions that are authentic expressions of the patient’s own values and goals. Determining whether
a patient is capacitated for a particular medical decision entails assessing whether the patient is able to:
• Comprehend the risks and benefits of the recommended intervention, risks and benefits of
reasonable alternative intervention, and the risks and benefits of no intervention.
• Manifest appreciation of the significance of his or her medical condition.
• Reason about the consequences of available treatment options (including no treatment).
• Communicate a stable choice in light of his or her personal values.
Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N
Engl J Med. 2007;357:1834–1840.
24. What is involuntary commitment?
Assignment of a person to an inpatient psychiatric facility without patient consent when the
appropriate criteria are met. These patients must be unable to provide informed consent owing to
a mental illness and, owing to the same mental illness, pose a danger to themselves or to others.
Similarly, patients who are seriously impaired by substance abuse may be involuntarily admitted to
detoxification units or to longer term rehabilitation facilities.
25. What are assent and dissent?
Assent is the obligation prospectively to explain medical interventions in language and concepts the
patient can comprehend even if the patient is deemed to be not capable of full informed consent,
such as children or mentally impaired adults. The patient’s agreement is elicited, even though the final
decision requires parental, guardian, or other legally authorized decision maker’s permission.
 Medical Ethics  9

Conversely, dissent is the obligation to take seriously the refusal of children or mentally impaired
adults when they are opposed to medical interventions or placements, unless the recommendations
are so crucial to the patient’s well-being that their dissent must be overridden to avert serious
deterioration or harm to their interests.

ADVANCE DIRECTIVES
26. What is an advance directive?
A generic term for any of several types of patient instructions, oral or written, for providing guidance
and direction in advance of a person’s potential incapacity. The instructions and authorization in
an advance directive do not take effect until the person loses decisional capacity and the advance
directive ceases to be in effect if or when the patient regains capacity.
27. What are the types of advance directives?
Designation by a capacitated patient of the person the patient chooses to make medical
decisions during any period when the patient is incapacitated, whether during surgery, temporary
unconsciousness, or mental condition, as well as irreversible condition of lost decisional capacity.
The decisions the designated person can make include withholding or withdrawal of treatment in
life-limiting circumstances. This type may variously be called a “durable power of attorney for health
care,” a “surrogate health care decision maker,” or a “proxy health care decision maker.”
A living will is a formal expression of a patient’s choices about end-of-life care and
specifications or limitations of treatment, either with or without the naming of a person to reinforce,
interpret, or apply what is expressed to the patient’s current circumstances.
28. Who are statutorily authorized next-of-kin decision makers?
If a patient has not made a living will or designated a person to make decisions during periods of
patient incapacity, state statutes determine the order of priority for persons related to or close to the
patient to assume the role of making medical decisions on the patient’s behalf. These are typically
called “surrogates” or “proxies,” but they differ from decision makers designated by the patient in
the way they are selected, and, in many cases, they bear a greater burden of demonstrating that they
know what the patient would want.
29. What are the standards of decision making for those chosen either by the patient
or by statute to make decisions for the incapacitated patient?
•  Substituted judgment: The decision the patient would have made if she or he had not been in-
capacitated. In some cases, this will not be the same as what others may think is in the patient’s
best interest.
•  Best interest: Choosing what is considered most appropriate for the patient. If there is sub-
stantial uncertainty about what the patient would have chosen for herself or himself, then the
traditional best interest standard is the appropriate basis for decision making.

END-OF-LIFE ISSUES
30. What are end-of-life care physician orders?
Orders that give direction regarding interventions at the time of death or cardiopulmonary arrest.
Patient-directed measures such as advance directives or statutory next-of-kin decisions should be
the basis for underlying medical decisions that entail informed consent or refusal issues at the end
   of life.

K EY POIN T S: E N D - OF-L I F E I S S UES

1. Patients should be encouraged to discuss their wishes for end-of-life care with family members or
close friends and physicians while still able to clearly express these wishes.
2. Forms such as Preferences of Life-Sustaining Treatment can designate the patient’s specific
requests to accept or decline therapies at the end of life.
3. Patients are frequently unaware of the numerous, complex therapies related to end-of-life care
and may not be able to write down what is wanted. Designation of a surrogate decision maker with
whom the patient discusses her or his values and goals related to end-of-life care can also ensure
the patient’s choices will be respected.
 10 MEDICAL ETHICS

31. How are end-of-life care orders written?

• Do not resuscitate (DNR) or do not attempt resuscitation (DNAR): An order written by the
attending physician to prevent emergency cardiopulmonary resuscitation (CPR) for a patient who
has refused CPR as a form of unwanted treatment. The decision of an incapacitated patient’s
authorized decision maker may also be a basis for a written DNR order by the physician.
• Physician Orders for Life-Sustaining Treatment (POLST): Similar to the concept of DNR,
but broadened to include all aspects of end-of-life care based on the choices of the patient or
authorized decision maker, including withholding or withdrawal of care and palliative measures.
Many states now have statutory acknowledgment that a properly executed POLST form, signed
by a physician, should be followed by all health care providers for the patient. Available at
www.polst.org. Accessed October 27, 2016.
32. What is brain death?
The term used to replace the traditional definition of death by cessation of heartbeat and respiration.
In the legally operative definition of this term, it refers to whole brain death, cessation not only of
higher cortical function but of brainstem function as well.
33. What is physician aid-in-dying?
The provision of a lethal amount of a medication that the patient voluntarily takes to end his or her life.
Oregon, Washington, California, New Mexico, and Vermont have established legislation to allow these
prescriptions, and other states are considering the issue. Montana, based on court ruling, also allows
physician aid-in-dying.

Bibliography
1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. Oxford: Oxford University Press; 2012.
2. Jonsen A, Siegler M, Winslade W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 8th ed.
New York: McGraw-Hill Education; 2015.
3. Lo B. Resolving Ethical Dilemmas. A Guide for Clinicians. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.
GENERAL MEDICINE AND

CHAPTER 2
AMBULATORY CARE
Mary P. Harward, MD, FACP

When I see a new patient, I find it valuable, at the first meeting, consciously to look at the hands. Clues to
diseases in the nervous system, heart, lung, liver, and other organs can be found there…. In medicine, a hand
is never merely a hand; symbolically it is much more. That is why the “laying on of hands” is so important for the
physician and patient.
John Stone (1936–2008)
“Telltale Hands” from
In the Country of Hearts: Journeys in the Art of Medicine, 1990
  
It’s the humdrum, day-in, day-out everyday work that is the real satisfaction of the practice of medicine; … the
actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of
their lives, when they were being born, when they were dying, watching them die, watching them get well when
they were ill, has always absorbed me.
William Carlos Williams (1883–1963)
“The Practice” from
The Autobiography of William Carlos Williams, 1951
  

LISTENING TO THE PATIENT

1. What interviewing skills can help the physician identify all the significant issues
for the patient?
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 can 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 at that visit and which ones can be deferred to future visits.
2. How can the physician understand more clearly what the patient is trying to
describe?
By rephrasing the patient’s 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?

11
12 General Medicine and Ambulatory Care

EVALUATING THE TESTS

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 result and have
the disease that is being tested
• Negative predictive value: The percentage of patients who have a negative test result and do
not have the disease
6. How are these values calculated?
See Fig. 2.1.

Disease:
Present Absent

a = True positive
+ a b
b = False positive
Test result
c = False negative
- c d d = True negative

Sensitivity = a = Percentage of patients who have the disease and test

a+c positive
Specificity d= = Percentage of persons who do not have the disease
b+d and test negative (True-Negative).
Positive = a = Percentage of patients who test positive and actually do
predictive value a + b have the disease.
Negative = d = Percentage of patients who test negative and really do
predictive c +d not have the disease.
value

Fig. 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 (with possibly no benefit to an individual patient) in order to ensure that at least one patient
benefits from the therapy, usually defined as no occurrence of the adverse event or events that the
therapy should prevent. 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. In general, the higher the NNT, the less effective
the therapy.

SCREENING FOR MALIGNANCIES

8. What are the recommendations for colon cancer screening?
The U.S. Preventive Services Task Force (USPSTF) recommends performing at least one of multiple
screening procedures beginning at age 50 years and continuing through age 75 years. For patients
of average risk who are asymptomatic, the physician may consider:
 General Medicine and Ambulatory Care  13

• gFOBT (guiac-based fecal occult blood test): Every year

• FIT (fecal immunochemical test): Every year
• FIT-DNA (multitargeted stool DNA test): Every 1–3 years
• Colonoscopy: Every 10 years (if no polyps on previous colonoscopy)
• CT (computed tomography) colonography: Every 5 years
• Flexible sigmoidoscopy: Every 5 years
• Flexible sigmoidoscopy with FIT: Flexible sigmoidoscopy every 10 years + FIT every year
Screening is not recommended after age 86 years. For patients aged 76–84 years, individual
health, risk factors, and previous findings at screening should be considered before recommending
screening procedure. Other organizations such as the National Comprehensive Cancer Care Network
and American Gastroenterology Association have different recommendations.
Burt RW, Cannon JA, David DS, et al. Colorectal cancer screening. J Natl Compr Conc Netw.
2013;11:1538–1575.
Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for
colorectal cancer screening 2009. Am J Gastroenterol. 2009;104:739–750.
U.S. Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, et al.
Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.
JAMA. 2016;315:2564–2575.
9. What are the guidelines for breast cancer screening?
The most recent guidelines (2016) from the USPSTF for screening asymptomatic women with
conventional mammography are summarized as:

Age Recommendation
40–49 years (y) Individual decision made by the woman based on her preferences
50–74 y Every 2 years
≥75 y No recommendation because of insufficient evidence

The USPSTF based these recommendations after review of the available evidence that mammograms
reduce mortality and morbidity risks. The recommendations also considered the potential harms from
screening including false-positive results and unnecessary biopsies. These guidelines are regularly
updated. The American Cancer Society (ACS) recommends beginning annual screening at age 45 and
continuing until age 55. Biennial screening should begin at age 55.
Oeffinger KC, Fontham ET, Etzioni R, et al. Breast cancer screening for women at average risk:
2015 guideline update from the American Cancer Society. JAMA. 2015;314:1599–1614.
U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task
Force Recommendation Statement. Ann Intern Med. 2016;164:279–297.
10. How should childhood cancer survivors be screened for breast cancer?
For this group who 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. 2009;301:404–414.
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.
U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Servicess
Task Force Recommendation Statement. Ann Intern Med. 2012;157:120–135.
Wolf AM, Wender RC, Etzioni RB, et al. American Cancer Society guideline for the early detection
of prostate cancer: update 2010. CA Cancer J Clin. 2010;60:70–98.
14 General Medicine and Ambulatory Care

12. When should screening begin for cervical cancer?

At age 21 years. A Papanicolaou (Pap) smear every 3 years is the appropriate screening test. If women
aged 30 to 65 years wish to undergo screening less frequently, the interval can be extended to every
5 years with the use of a Pap smear and human papillomavirus (HPV) tests. The USPSTF recommends
ending screening in women after age 65 years if they have had appropriate routine screening.
U.S. Preventive Services Task Force, Moyer VA. Screening for cervical cancer: U.S. Preventive
Services Task Force Recommendation Statement. Ann Intern Med. 2012;156:880–891.
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 scans in lung cancer
screening?
Although chest x-rays are not effective for lung cancer screening, the National Lung Screening Trial
(NLST) showed that annual low-dose chest CT (LDCT) scans showed a reduction in lung cancer and
all-cause mortality rate for patients who are:
• Age 55–79 years
• Current smoker OR former smoker who quit within the past 15 years
• Smoker for at least 30 pack-years (currently or former)
• Asymptomatic
The USPTF recommends continuing screening until age 80 and discontinuing screening when a
significant life-limiting illness develops or the patient has not smoked for 15 years. Centers for Medicaid
and Medicare Services (CMS) covers LDCT for those meeting the above criteria and are 55–77 years old.
National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-
cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395–409.
U.S. Preventive Services Task Force: Lung cancer screening. Available at: https://www.uspreventiv
eservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening; December, 2013.
[accessed 22.01.17].

CARDIOLOGY
16. What is the first step to evaluate a patient with an initial blood pressure (BP)
reading of 150/90 mm Hg?
Confirm that the BP was measured under the right conditions including:
• Comfortable seating in a chair
• Uncrossed legs, feet resting on the floor
• Support of patient’s back and arm for BP measurement
• No clothing covering the area of the cuff placement
• Middle of the cuff placed on the upper arm across from the midpoint of the sternum
• Waiting 5 minutes after the patient is seated comfortably (and remaining quiet) before measur-
ing 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)
• Recording at least two measurements 30 seconds apart
• Measurement of the BP in both arms at initial visit
Multiple measurements at different times of the day (and possibily different settings) should be
done to confirm the elevated BP. Home and work site measurements and ambulatory BP recordings
are also helpful for hypertension confirmation.
LeBlond RF, Brown DD, Suneja M, et al. DeGowin’s Diagnostic Examination. 10th ed. New York:
McGraw-Hill; 2015.
17. What can cause a difference in BP between the right and the left arm?
Arterial occlusion in the arm with the lower BP (subclavian artery stenosis), thoracic outlet syndrome,
or aortic dissection. “Normal” BP difference should be <10 mm Hg. The arm with the higher reading
should be used for future measurements. Sometimes no cause is found.
 General Medicine and Ambulatory Care  15

18. Should systolic BP between 120 and 139 mm Hg and/or diastolic BP between 80
and 89 mm Hg 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 mm Hg or diastolic ≥90 mm Hg).
Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA.
2003;289:2560.
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of
high blood pressure in adults: report from the panel members appointed to the Eighth Joint National
Committee (JNC 8). JAMA. 2014;311(5):507–520.
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 spirits daily)
• Stress management
• Smoking cessation
• Regular aerobic exercise
• Low–saturated fat diet rich in fruits and vegetables
U.S. Department of Health and Human Services. National Heart, Lung, and Blood Institute. NIH
Publication: How is high blood pressure treated? Available at: https://www.nhlbi.nih.gov/health-
topics/high-blood-pressure#Treatment.
20. What are the risks of prehypertension?
Coronary artery disease, myocardial infarction, and death from a cardiovascular event.
21. What is the initial laboratory evaluation of newly diagnosed hypertension (HTN)?
• Fasting blood glucose
• Complete blood count
• Total and HDL (high-density lipoprotein) cholesterol
• Potassium
• Creatinine, blood urea nitrogen (BUN)
• Calcium, albumin
• Urinalysis
• 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 (methylphenidate), appetite sup-
pressants, nonsteroidal anti-inflammatory drugs (NSAIDs), and caffeine
•  Prescription medications: NSAIDs, corticosteroids, antidepressants (venlafaxine, desvenla-
faxine, bupropion), cyclosporine, oral contraceptive pills (OCPs), estrogen and progesterone
preparations, erythropoietin, vascular growth factor antagonists
•  Illicit drugs (acute and chronic): Cocaine, amphetamines, stimulants, MDMA (3,4-methylene­
dioxymethamphetamine, or ecstasy), PCP (phencyclidine), cannabis (marijuana), and herbal
designer drugs
•  Alcohol: Alcohol history, CAGE questionnaire (see Question 156), family history of alcoholism
23. How can the patient’s history identify secondary HTN due to an endocrine
disorder?
Ask the patient about:
•  Cushing 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, and Chapter 17, Neurology.)
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