Microsoft word - 2010-2011 clerkship handbook 4-201

POINT OF CARE CLINICAL QUESTIONS FORM

Name of Student: Happy Family Medicine Student
Name of Preceptor: Very Happy Preceptor Date: Question # 1:
Type of Question: (circle one) Screening x Diagnosis Prognosis Treatment
Electronic Knowledge Resources Used:
Preferred – practice using these evidence-based sites first:
DynaMed X ___ Cochrane ___X___ USPSTF___X__, PEPID: _____ TRIP Database _____
Others:
UpToDate ___X____

The patient: 41 y.o. female presents with a fibro adenoma in her R breast. This lesion was found on a routine
self exam. The patient underwent mammography and two ultrasounds to follow up the status of this “lump,”
in her breast.
Clinical Question: (about a specific patient(s) seen with Preceptor):
The patient: 41 y.o. female presents with a fibro adenoma in her R breast. This lesion was found on a routine
self exam. The patient underwent mammography and two ultrasounds to follow up the status of this “lump”
in her breast. Are self breast exams a recommended screen for breast cancer?

Who posed this question?
______ Preceptor
__X___ Student
_______ Patient
Written Answer to Specific Patient Related Question
There is no length requirement; you will be graded on the accuracy of the answer and the appropriateness of
your search. Include references.
Self breast exams have little to no impact on breast cancer mortality. Studies have shown no reduction in
breast cancer mortality in patients who perform self exams versus controls. In fact, regular self exams pose a
possibility of some harm because patients are more likely to undergo breast biopsies for benign lesions
detected on self exams. Results are based on two large population based studies of a total of 388,535 women
from Russia and Shanghai; these results showed no statistical difference in breast cancer mortality in women
who preformed self exams versus those who do not.
Results (with details):
“Two large population-based studies (388,535 women) from Russia and Shanghai that compared breast self-
examination with no intervention were included. There was no statistically significant difference in breast
cancer mortality, relative risk 1.05 (95% confidence interval (CI) 0.90 to 1.24) (587 deaths in total). In
Russia, more cancers were found in the breast self-examination group than in the control group (relative risk
1.24, 95% CI 1.09 to 1.41), while this was not the case in Shanghai (relative risk 0.97, 95% CI 0.88 to 1.06).
Almost twice as many biopsies (3406) with benign results were performed in the screening group compared
to the control group (1856, relative risk 1.88. 95% CI 1.77 to 1.99.”
Authors’ conclusions and the answer to our question:
Data from two large trials do not suggest a beneficial effect of screening by breast self-examination. Instead,
the data shows that self breast exams have a potential for harms. Based on a review of the literature, breast
self examination cannot be recommended. Also, evidence suggests that mammography screening every 12-
33 months is very effective in significantly reducing breast cancer mortality.
Brief Summary of Answer to the Question and how it applies to the specific patient: 41 year old female
with a fibro adenoma found in her R breast on self-exam. The lesion is completely benign lesion discovered
by chance. She underwent a mammogram and two ultrasounds which showed a benign lesion and no further
need for intervention. The patient went through unnecessary anxiety and tests all because of the result of an
incidental finding. While it is reassuring for the patient to find out that what she has is “not cancer,”
unwarranted testing simply adds to the cost of medical care without offering significant benefits.

References:
Gaskie S. Nashelsky J Journal of Family Practice. 2005 Sep, 54(9):803-4.
http://www.ahraq.gov/clinic/uspstf/uspsbrca.htm
Thomas DB, Gao DL. Ray RM, et al. Randomized trial of breast self-examination in Shanghai: final results.
J Natl Cancer Inst 2002:94:1445-1457
Barton MB. Harris R. Flecher SW, the rational clinical examination. Does this patient have breast
cancer? The screening clinical breast examination: Should it be done? How? JAMA 1999;282:1270-1280.
Kosters JP, Gotzsche PC Regular self-examination or clinical examination for early detection of breast cancer.
Cochrane Database Syst Rev 2003;(2):CD003373.


POINT OF CARE CLINICAL QUESTIONS FORM

Name of Student: Happy Family Medicine Student
Name of Preceptor: Very Happy Preceptor Date: Question # 1:
Type of Question: (circle one) Screening x Diagnosis Prognosis Treatment X
Electronic Knowledge Resources Used:
Preferred – practice using these evidence-based sites first:
DynaMed X ___ Cochrane ___X___ USPSTF___X__, PEPID: _____ TRIP Database _____
Others:
UpToDate ___X____

Clinical Question: (about a specific patient(s) seen with Preceptor):
29 year old male presents for an annual exam. He c/o toenail onychomycosis. He has had it for a year and
has tried to treat it topically with OTC cream. It went awa for a few months ago but now it is back. He would
like to get treatment for it. How effective are oral treatments for toenail onychomycosis.
Who posed this question?
______ Preceptor
___X__ Student
_______ Patient
Written Answer to Specific Patient Related Question
There is no length requirement; you will be graded on the accuracy of the answer and the appropriateness of
your search. Include references.
A meta-analysis analyzed a total of 36 RCT studies and estimated the cure rate of toenail onychomycosis using oral agents
terbinefine, itraconazole (pulse or continuous), fluconazole, and griseofulvin. Mycological cure was defined as negative KOH and
negative culture. Clinical response was defined as visually cleared infection or marked improvement. Terbinafine and itraconazole
are the most effective in treating onychomycosis in short term studies. A meta analysis found the following mycological cure rates
in randomized controlled trials.
Oral Drug
Another study of 151 patients compared the long term efficacy of terbinafine and itraconazole. The study looked at the relapse rate
between the two drugs and then gave an additional 12 weeks of terbinafine daily. They then follow up on these patients for the nect
5 years (median 54 months). The results indicated that subjects treated with terbinafine had a mycological cure rate of 46% and the
itraconazole cure rate was only 13%. A total of 74 patients were then treated with terbinafine. They found that after retreatment
92% of the double terfinafine patients had a mycological cure vs. 85% of those initially treated with itraconazole and then
terfinafine. The authors concluded that terbinafine had better initial cure rates as well as significantly less relapse rate than
itraconazole and those patients can benefit from treatment if they relapse.
Brief Summary of Answer to the Question and how it applies to the specific patient:
Onychomycosis is very difficult to treat and relapses frequently. Of the various medications, oral terbinafine
seems to be the most effective way to treat onychomycosis. My preceptor and I cultured a piece of the
patient’s toenail to confirm it to be a fungal infection. The best treatment after my research for this patient, if
the culture is positive, is for him to take terbinafine 250 mg daily for 3-4 months. It would not be surprising
if he relapses within a few years. If he does, we can then retreat again with 12 weeks of terbinafine.
References
Goldstein Ao, Goldstein BG, Onychomycosis. In: UpToDate, Dellavalle RP, Levy ML (ed.), UpToDate,
Waltham, MA 2009.
Gupta AK; Ryder JE; Johnson Am Cumulative meta-analysis of systemic antifungal agents for the treatment
of onychomycosis. Br J Dermatol 2004 Mar; 150(3)L537-44.
Sigurgeirsson, B, Olasffon, JH, Steinsson, JB, et al. Long-term effectiveness of treatment with terbinafine vs
itraconazole in onychomycosis: a 5-year blinded prospective follow-up study. Arch Dermatol 2002: 138:353.

Source: http://familymedicine.uchicago.edu/Content/POC%20Clin%20Ques%20Forms%201-2.pdf