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.
BILAN MASCULIN DE STERILITE Au Maroc l’homme est impliqué dans 50 à 60% des infécondités du couple I/ Interrogatoire 1. La durée de l’infertilité : c’est la durée pendant laquelle le couple a eu des rapports sans contraception et sans qu’il y ait eu une grossesse ; plus cette durée est longue et plus le risque d’infertilité est grand ; 1 an est la durée communéme
CONHECIMENTOS GERAIS 04. O princípio da rede regionalizada e hierarquizada de servi- 01. De acordo com a Constituição Federal: Título VIII – Cap II, Seção II – Saúde, compete ao sistema único de saúde –(A) responsabilização dos municípios pela atenção primá-ria, dos estados pela atenção secundária e da esferafederal pelas instituições de ensino superior e de as