A 55-year-old man comes into your office for follow-up of a chronic cough.

He also
complains of shortness of breath with activity. He reports that this has been getting
worse over time. As you are interviewing the patient, you note that he smells of
cigarette smoke. Upon further questioning, he reports smoking 1 pack of cigarettes
per day for the past 35 years and denies ever being advised to quit. On examination,
he is in no respiratory distress at rest, his vital signs are normal, and he has no
obvious signs of cyanosis. His pulmonary examination is notable for reduced air
movement and faint expiratory wheezing on auscultation.
➤What would you recommend to this patient?

➤What interventions are available to aid with smoking cessation?

Tobacco Use Summary: A 55-year-old man with a 35 pack/year history of smoking

presents with a chronic cough and progressively worsening dyspnea.
• ➤ Recommendations to this patient: This patient should be advised to quit
smoking; one strategy, using the 5 As,
• ASK about tobacco use
• ADVICE to quit
• ASSESS willingness to quit
• ASSIST in the quit attempt
• ARRANGE follow up

➤ Interventions available to help with smoking cessation: Counseling to quit

smoking along with pharmacologic assistance with bupropion, varenicline, or
nicotine replacement.
A 65-year-old African-American woman presented to the emergency room
complaining of worsening shortness of breath and palpitations for about
1 week. She reports feeling “dizzy” on and off for the past year; the
dizziness is associated with weakness that has been worsening for the
past month. She has been feeling “too tired” to even walk to her backyard
and water her flower bed that she used to do “all the time.” She has been
so dyspneic walking up the stairs at her home that she moved downstairs
to the guest room about a week ago. Review of systems is significant for
knee pain, for which she frequently takes aspirin or ibuprofen; otherwise
the review of systems is negative. She has no significant medical history
and has not been to a doctor in several years. She had a normal well-
woman examination and screening colonoscopy about 5 years ago. She
occasionally has an alcoholic drink and denies tobacco or drug use. She is
married and is a retired shopkeeper. On examination, her blood pressure
is 150/85 mm Hg; her pulse is 98 beats/min; her respiratory rate is 20
breaths/min; her temperature is 98.7°F (37.1°C); and her oxygen
saturation is 99% on room air. Significant findings on examination include
conjunctival pallor, mild tenderness with deep palpation in the epigastric
and left upper quadrant (LUQ) region of the abdomen with normal bowel
sounds, and no organomegaly but a positive stool guaiac test. The
remainder of the examination, including respiratory, cardiovascular, and
nervous systems, was normal.
➤What is the most likely diagnosis?

➤What is your next diagnostic step?

➤What is the next step in therapy?

e ANSWERS TO CASE 9: Geriatric Anemia Summary: A 65-year-old woman with worsening dyspnea on
exertion, fatigue, dizziness, and palpitations. She is found to have conjunctival pallor and guaiac positive
stool.

➤ Most likely diagnosis: Anemia secondary to gastrointestinal bleeding; other considerations should
include new-onset angina, congestive heart failure, and atrial fibrillation.

➤ Next diagnostic step: A complete blood count (CBC) to evaluate for the anemia. To evaluate for the
other conditions on your differential diagnosis list, you should perform an electrocardiogram (ECG) and
cardiac enzymes. A prothrombin time (PT) and partial thromboplastin time (PTT) to look for coagulation
abnormalities would be helpful as well.

➤ Next step in therapy: Admission as an inpatient for further workup, including blood transfusion (if
needed), completion of two more sets of cardiac enzymes, and ECGs. A gastroenterology consult for
esophagogastroduodenoscopy (EGD) and colonoscopy is appropriate because of the positive guaiac
findings.

A 50-year-old Caucasian woman, new to your practice, presents for an

“annual physical examination.” She reports that she is very healthy,
generally feels well and has no specific complaints. She has a history of
having had a “partial hysterectomy,” by which she means that her uterus
and cervix were removed but her ovaries were left in place. The surgery
was performed because of fibroids. She has had a Pap smear every year
since the age of 18, all of which have been normal. She has had annual
mammograms since the age of 40, all of which have been normal. She has
no other significant medical or surgical history. She takes a multivitamin
pill daily but no other medications. Her family history is significant for
breast cancer that was diagnosed in her maternal grandmother at the age
of 72. The patient is married, monogamous, and does not smoke
cigarettes or drink alcohol. She tries to avoid dairy products because of
“lactose intolerance.” She walks 3 miles four times a week for exercise.
Her physical examination is normal.
➤For this patient, how often should a Pap smear be performed for
cervical cancer screening?
➤What could you recommend to reduce her risk of developing
osteoporosis?
➤What is the recommended interval for screening mammography?
Health Maintenance in Adult Female Summary: A 50-year old woman with a history of having had a
hysterectomy for a benign indication comes to your office for a routine health maintenance visit.

➤ Interval for cervical cancer screening: Based upon her history of having a hysterectomy for
benign disease and her overall low-risk status, cervical cancer screening can be discontinued in this
patient.

➤ Interventions to reduce her risk of developing osteoporosis: Supplementation with at least 1200
mg calcium and 400 to 800 IU vitamin D daily; regular weight-bearing exercise.

➤ Recommended interval for screening mammography in a 50-year-old woman: Annual.

A 75-year-old white man presents for a health maintenance check-up. The

patient has stable hypertension but has not seen a physician in more than
2 years. He denies any particular problems. He lives alone. He takes an
aspirin a day and is compliant with his blood pressure medication
(hydrochlorothiazide). His son fears that his father is either experiencing a
stroke or getting Alzheimer disease because his father is having trouble
with speech discrimination and understanding what family members are
saying during social events. The son reported no noticeable weakness or
gait impairment. On physical examination, the patient’s blood pressure
was 130/80 mm Hg. Examination of the ears showed no cerumen
impaction and normal tympanic membranes. His general examination is
normal. Laboratory studies are normal
. ➤What is the most likely diagnosis?
➤What is the next step
Summary: A 75-year-old man who presents with loss of speech discrimination and
complains of difficulty understanding speech and conversation in noisy areas
➤Most likely diagnosis: Presbycusis.

➤ Next step: Presbycusis is a diagnosis of exclusion. Hearing aids are underused in

presbycusis but are potentially beneficial for most types of hearing loss, including
sensorineural hearing loss. Consequently, referral to an audiologist for testing and
consideration of amplification with a hearing aid may be an important next ste

A 45-year-old man presents to the clinic with a cough productive of

purulent sputum of 3-week duration. He says that he had just gotten over
a cold a few weeks prior to this episode. He occasionally has fevers and
he coughs so much that he has chest pain. He reports having a mild sore
throat and nasal congestion. He has no history of asthma or of any chronic
lung diseases. He denies nausea, vomiting, diarrhea, and any recent
travel. He denies any smoking history. On examination, his temperature is
98.6°F (37.0°C), his pulse is 96 beats/min, his blood pressure is 124/82
mm Hg, his respiratory rate is 18 breaths/min, and his oxygen saturation is
99% on room air. Head, ears, eyes, nose, and throat (HEENT) examination
reveals no erythema of the posterior oropharynx, tonsillar exudates, or
significant tonsillar swelling. Neck examination is negative. The chest
examination yields occasional wheezes but normal air movement is noted.
➤What is the most likely diagnosis?
➤What is your next step?
➤What are some common noninfectious causes of cough?
A 45-year-old man, who has no history of lung disease and does not
smoke, with 3 weeks of productive cough following an upper respiratory
infection.
➤ Likely diagnosis: Acute bronchitis.
➤ Next step: Bronchodilators, analgesics, antitussives; antibiotics have
not been consistently shown to be beneficial. The illness is usually self-
limited.
➤ Common noninfectious causes of cough: Asthma, chronic obstructive
pulmonary disease (COPD), malignancy, postnasal drip,
gastroesophageal reflux disease (GERD), medication side effect (eg,
angiotensin-converting enzyme inhibitors), congestive heart failure.

A 38-year-old woman presents to the office with complaints of weight loss, fatigue,
and insomnia of 3-month duration. She reports that she has been feeling gradually
more tired and staying up late at night because she can’t sleep. She does not feel
that she is doing as well in her occupation as a secretary and states that she has
trouble remembering things. She does not go outdoors as much as she used to and
cannot recall the last time she went out with friends or enjoyed a social gathering.
She feels tired most of the week and states she feels that she wants to go to sleep
and frequently does not want to get out of bed. She denies any recent medication,
illicit drug, or alcohol use. She feels intense guilt regarding past failed relationships
because she perceives them as faults. She states she has never thought of suicide,
but has begun to feel increasingly worthless. Her vital signs and general physical
examination are normal, although she becomes tearful while talking. Her mental
status examination is significant for depressed mood, psychomotor retardation, and
difficulty attending to questions. Laboratory studies reveal a normal metabolic panel,
normal complete blood count, and normal thyroid functions.
➤What is the most likely diagnosis?

➤What is your next step?

➤What are important considerations and potential complications of management?

Major Depression Summary: This is a 38-year-old woman with depression. At least
one of the symptoms must be either depressed mood or loss of interest or pleasure.
➤Most likely diagnosis: Major depression.
➤ Next step: Evaluate the patient for suicidal risk, begin pharmacologic and
psychotherapeutic management.
➤ Important considerations and potential complications: Rule out other medical
diagnoses such as hypothyroidism, anemia, and infectious processes that could
mimic some symptoms of depression; verify that no substance abuse or use is taking
place; screen for bipolar disorder and inquire about a family history of mood
disorders; investigate and address suicidal ideations; review any recent medication
changes for agents that may contribute to these symptoms (eg, β-blockers, steroids,
sedatives, chemotherapy agents).

A 33-year-old woman presents with a complaint of headaches. She has had

headaches since she was a teenager but they have become more debilitating
recently. The episodes occur once or twice each month and last for up to 2 days.
The pain begins in the right temple or at the back of the right eye and spreads to
the entire scalp over a few hours. She describes the pain as a sharp, throbbing
sensation that gradually worsens and is associated with severe nausea. Several
factors aggravate the pain, including loud noises and movement. She has taken
several over-thecounter medications for the pain, but the only thing that works is
going to sleep in a quiet, darkened room. A thorough history reveals that her mother
suffers from migraine headaches. Her vital signs, general physical examination, and a
thorough neurologic examination are all within normal limits.
➤What is the most likely diagnosis?

➤What imaging study is most appropriate at this time?

➤What are the most appropriate therapeutic options?

A 33-year-old woman presents with headaches that are throbbing and over her right
eye. Her headaches have occurred since she was a teenager and have progressively
worsened. She has not found relief from over-thecounter preparations.
➤Most likely diagnosis: Migraine without aura.
➤Most appropriate imaging study: No imaging is indicated at this time as there are
no “red flag” symptoms or signs.

➤ Most appropriate therapy: A “triptan”