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Old 06-26-2011
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Question 18-year-old female most appropriate screening test?

An 18-year-old female presents to a family medicine clinic for her annual health maintenance examination. She is presently well and without complaint. Her previous medical history is unremarkable. She currently takes the oral contraceptive pill (OCP) and is allergic to penicillin. She has been smoking since the age of 12 and has been regularly smoking 1 pack per day for the last 5 years. She drinks no more than two bottles of beer on Fridays, Saturdays, and Sundays. At present she is sexually active and uses barrier contraception in addition to OCP. She has had four lifetime sexual partners. A review of her family history reveals that her maternal uncle was diagnosed with hereditary nonpolyposis colorectal cancer at the age of 32, her mother was recently diagnosed with breast cancer at 48, and her father had a myocardial infarction last year at age 49. In addition to performing a Papanicolaou (Pap) smear, what is the most appropriate screening test?
Answer Choices
A. Carbohydrate-deficient transferrin (CDT)
B. Chest X-ray
C. Chlamydia urinary antigen testing
D. Colonoscopy
E. Fasting lipid profile
F. Liver function tests
G. Mammography
H. Oral glucose tolerance test
I. Ultrasound of the breast
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Old 06-26-2011
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That's challenging question!

I'm torn between chlamydia and colonoscopy!
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Old 06-26-2011
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I would say C because she has had 4 sexual partners in the past.
The hereditary nonpolyposis colorectal cancer screening should begin at 20 to 25 years old of age OR 10 years before the onset of the youngest family member. In both cases she should have colonoscopy at age 20 or 22.
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i'm also thinking about chlamydia ... but what about being a smoker and taking OCPs, does the risk starts after 35 yrs ??????
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Old 06-27-2011
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Tell us miss patho the correct answer!

More votes for chlamydia!

Thanks
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Option C (Chlamydia urinary antigen testing) is correct. This is a difficult question, because it requires analyzing many different pieces of information. In this particular case, it is a sexually active teenage girl who is currently smoking, drinking a moderate amount of alcohol, and has a family history of myocardial infarction, breast cancer, and hereditary colon cancer. The U.S. Preventative Services Task Force (USPSTF) recommends that with these risk factors, she requires screening for chlamydia, as well as gonorrhea. The USPSTF recommendations state that all sexually active women younger than age 25 should be screened and that women older than age 25 with risk factors (such as multiple sex partners, previous sexually transmitted diseases [STDs] and inconsistent use of condoms).

Option A (Carbohydrate-deficient transferrin [CDT]) is incorrect. Carbohydrate-deficient transferrin (CDT) has been recently approved as a serum blood test to identify heavy alcohol consumption. Its use is limited, however, because of reduced sensitivity and specificity in particular populations. A rising CDT level is best used as a marker of relapse in chronic alcoholics.

Option B (Chest X-ray) is incorrect. This patient has a 5-year pack per day history already at the age of 18. Although this is concerning and will predispose her to lung cancer, universal chest X-ray (CXR) screening has not been demonstrated to be efficacious. Generally, when asked on the examination whether to perform a CXR as a screen, it will most likely be an incorrect option.

Option D (Colonoscopy) is incorrect. With the diagnosis of hereditary nonpolyposis colon cancer (HNPCC), this patient is at increased risk for colon cancer. Current recommendations suggest that surveillance colonoscopy begin either at age 20 to 25 or 10 years earlier than the earliest age of diagnosis of HNPCC. This patient does not meet either of the criteria.

Option E (Fasting lipid profile) is incorrect. There are widely differing recommendations on the age at which to begin screening with a fasting lipid profile. The U.S. Preventative Services Task Force (USPSTF) recommends beginning screening men at the age of 35 and females at the age of 45 when no other risk factors exist. If there is a family history of diabetes, cardiovascular disease before the age of 50, familial hyperlipidemia, or multiple coronary heart disease risk factors, screening should begin at age 20.

Option F (Liver function tests) is incorrect. This patient's alcohol intake is within the recommended weekly guideline, as she is drinking no more than two standard alcoholic drinks a day and no more than six in a week. Generally, laboratory tests are less useful in screening for alcohol abuse than structured questionnaires, such as the cut down (on drinking), annoyance, guilt (about drinking), (need for) eye opener (CAGE) questionnaire.

Option G (Mammography) is incorrect. Mammography would be of little use before the age of 35 to 40.

Option H (Oral glucose tolerance test) is incorrect. Oral glucose tolerance tests are rarely used to diagnose diabetes, because of the difficulty performing the test. The preferred method in virtually all individuals except pregnant females is to use a fasting plasma glucose. Also, there are no current guidelines as to when screening for diabetes should begin.

Option I (Ultrasound of the breast) is incorrect. This patient does not have a clinical indication for ultrasound evaluation of the breast.

High-yield Hit 1
Sexually Transmitted Diseases and Pelvic Inflammatory Disease
The health impact of sexually transmitted diseases (STDs) is disproportionately borne by women. Women are more easily infected than men by most STDs. Diagnosis is more difficult in women because the acute infection may be asymptomatic, and serious sequelae such as pelvic inflammatory disease (PID), infertility, perinatal and neonatal morbidity and mortality, and cervical carcinoma may result. Anyone engaging in sexual intercourse is at risk for acquiring a STD. For treatable infections such as chlamydia, gonorrhea, or syphilis, it is crucial to treat all sexual contacts of infected individuals. Clinics providing care solely to women should either alter their normal daily operation and treat male contacts or make arrangements for the appropriate treatment of male sexual partners. Chapter 106 provides specific treatment recommendations for infection with individual pathogens.

From Cecil Essentials of Medicine 6E by Andreoli et al
High-yield Hit 2
Screening strategies for some organisms are effective in detecting the presence of infection in largely asymptomatic populations. Because 75% of women with Chlamydia trachomatis infections are asymptomatic and 20 to 40% of infected women may develop PID, screening for C. trachomatis is an important strategy to control morbidity. Adolescents are at particular risk, because it is estimated that 1 in 10 are infected with this organism. Frequent screening for C. trachomatis is recommended for sexually active adolescents and for women ages 20 to 24, particularly if the woman does not use barrier contraceptives or has new or multiple sexual partners. Treatment of infected pregnant women prevents transmission of C. trachomatis to infants at delivery. Individuals treated for chlamydia should be advised to abstain from sexual intercourse for 7 days after a single-dose regimen or until a 7-day regimen is completed.

From Cecil Essentials of Medicine 6E by Andreoli et al
High-yield Hit 3
With infection by Neisseria gonorrhoeae, a large proportion of women are also asymptomatic, and 10 to 40% of untreated women develop PID. Although less common than C. trachomatis, gonorrhea rates have increased in adolescents in many geographic regions. Therefore, screening is an important strategy for control of this infection. All women at high risk for STDs should be screened periodically. Women at especially high risk include but are not limited to the following groups: (1) sexually active adolescents, (2) women with a past history of gonorrhea, (3) prostitutes, and (4) homeless women.
Syphilis is a curable disease that increased dramatically among women of all ages from 1985 to 1990. Female adolescents had twice the rate of syphilis as their male counterparts for the year 1993. African American women have rates of syphilis seven times that observed in the female population as a whole. Congenital syphilis is a catastrophic neonatal infection that is largely preventable. Serologic screening of all pregnant women should be performed. However, because one third of women giving birth to infants with congenital syphilis have had no prenatal care, and one half of mothers of infected infants will have had a negative serologic test in the first trimester of pregnancy, repeat serologic testing at delivery is indicated in high-risk patients. All infants whose mothers test positive for syphilis should be treated, as should sexual contacts of the mother.
HIV screening should be routinely offered to all pregnant women, because many HIV-infected women are asymptomatic, and appropriate treatment of the HIV-infected mother reduces maternal-infant HIV transmission by at least 67% (see Chapter 107). Counseling about the risk posed by heterosexual contact, particularly with partners who use intravenous drugs, as well as the protective effect of condoms, should be a normal part of routine health care for both men and women.
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