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GeneralPrinciplesMain.1-10Q1A57-year-oldwomancomestothephysicianforafollow-upvisitregardingherlowerbackpain.Sheoriginallypresentedlastmonthwithsignificantcontinuouslowerbackpainthatwasworseatnightandwouldawakenherfromsleep.Shetriedover-the-counteribuprofen,withnoreliefofhersymptoms.Whenherpainpersisted,thepatientwasscheduledformagneticresonanceimagingofherback.Thereportreturnedtodayandshowsfindingsconsistentwithmetastaticlesionsinherspine.Thesourceoftheprimaryneoplasmremainsundetermined.Thepatienthasnotyetbeentoldaboutthefindingsandiswaitinginaprivateroom.Whichofthefollowingisthemostappropriatenextstepininitiatingaconversationabouthercondition?A.Haveyouconsideredwhetheryouwanttoknowthetestresults,regardlessoftheoutcome?B.I'msorrytohavebadnewsaboutyourtestresults;itseemsthatcancerhasmetastasizedtoyourback.C.Itlookslikeyouhavecancerinyourback,andweshouldbeabletodosomethingaboutitwithradiationandchemotherapy.D.Thetestresultsarenotgood.Doyouwanttoknowthem?E.Whatdoyouthinkisgoingonwithyourback?A1Correctanswer:EBreakingbadnewsisoneofthemostdifficultsituationsaphysicianwillencounter.Asensitiveyethonestapproachmustbeusedtomakethepatientfeelmorecomfortable.OnesuchapproachistheSPIKESmethod(Table),whichinvolvesaseriesof6sequentialsteps.Inthefirststep,settingthestage,itishelpfultoaskifthepatientwouldlikethecompanyoffamilyorfriendsbeforethediscussionbegins.Ifthepatientdoesnotknowthephysician,itisalsoappropriatetoexplainthephysician'sroleinsubsequentcare.Thenextstepistoassessthepatient'sperceptionofwhathashappenedandgetanideaofhis/hervocabularyandcomprehensionofmedicalfacts,itwouldbeappropriatetoaskthispatientaboutherbacktodeterminehowsheperceiveshercondition.Thephysicianshouldtheninvitethepatienttoreceiveadditionalinformationanddetermineifhe/shewishestoknowtheresults.Ifthepatientdeclinestoheartheresults,thisrequestshouldbehonored.ChoiceAwouldbeconsideredaninvitationforthepatientandwouldbeappropriateafterthequestioninChoiceE.Oncethediagnosishasbeenstated,thepatient'sfeelingsshouldbeexploredandsupportshouldbeprovided,itisalsoImportanttoletthepatientaskquestionsbutnotoverloadhim/herwithtoomuchinformation.Finally,Itisimperativetoclearlyoutlinethetreatmentplanandprognosis.Thisinformationmayneedtoberepeatedlater,aftertherealityofthesituationhasbeenabsorbed.(ChoiceB)Immediatelystatingthediagnosisisnotanappropriatewaytobeginthediscussionwiththepatientbecausehe/shewillhavedifficultyadaptingtothenews.Also,itisbettertousesimplervocabularyratherthanmedicalwordssuchasmetastasized.(ChoiceC)Itistooearlytostatethatthispatienthascancerinherbackandthenjumpstraighttotreatmentoptions.Thephysicianshouldpauseafterdeliveringthediagnosisandseehowthepatientreactsasthereisusuallysomedegreeofshockand/ordenial.(ChoiceD)Itisimportanttomakethepatientfeelateasebeforestatingthediagnosis.Beginningthediscussionwith“Thetestresultsarenotgoodisnotappropriate.Educationalobjective:Whenbreakingbadnews，aphysicianshouldfirstsetthestageandassessthepatient'scomprehensionbeforedeliveringthenewsinanempatheticyetcomprehensiblemanner.Q2A70-year-oldwomancomestothephysicianforaroutinepreventivevisit.Shehasnospecificcomplaintsandfeelswell.Thepatientisaretiredschoolteacher,livesalone,anddoesnotsmoke.Shedrinksalcoholoccasionally.Otherthananemergencyappendectomy40yearsago;shehasnosignificantpastmedicalhistory.Thepatienttakesnomedicationsandhasnopersonalorfamilyhistoryofcancerorheartdisease.Shehadanormalmammogram,Papsmear,andlipidpanelatherexamination2yearsago.Acolonoscopy7yearsagoshowednolesions.Whichofthefollowingstudiesismostappropriateatthisvisit?A.Chestx-rayB.ColonoscopyC.ElectrocardiogramD.LipidprofileE.MammographyF.PapsmearA2Correctanswer:ETheUSPreventiveServicesTaskForcerecommendsbiennial(every2years)screeningmammographyforwomenage50-74years.Routinemammographyisnotnecessarybeyondage75，althoughscreeningforthoseage75-85maybeindividualized.Otherrecommendedscreeningproceduresaresummarizedinthetable.(ChoiceA)Chestradiographyisnotrecommendedforlungcancerscreeninginasymptomaticindividualsasithaslowsensitivityandspecificityfordetectingearly-stagecancersthatareamenabietotreatment.Forpatientswithasignificantsmokinghistory,screeningwithlow-dosecomputedtomographyhasbeenadvocated,butprotocolsarenotwidelystandardized.(ChoiceB)Patientsshouldbeofferedscreeningforcoloncanceratage50-75witheitherannualfecaloccultbloodtestingorcolonoscopyevery10years.Morefrequentcolonoscopyisnotrecommendedasthebenefithasnotbeenproventooutweighthepotentialrisk.(ChoiceC)Althoughsomeexpertsadvisescreeninghigh-riskpatientsforasymptomaticcoronaryarterydiseasewithrestingelectrocardiography,thereisnoevidencetosupportitsroutineuseinpatientsataveragerisk.(ChoiceD)TheTaskForcerecommendsroutinecholesterolscreeninginmenataverageriskforcoronaryarterydiseasebeginningatage35andinwomenatincreasedriskbeginningatage45.Theidealagetodiscontinuescreeningisnotknown,buttheyieldlikelydecreasesinelderlypatientswithconsistentlynormallipidresults.A5-yearintervalismostcommonlyrecommended,andthereislikelylittlebenefitfrommorefrequ