Colon Cancer Screening in Patients with Family History Referral Guideline

Colon Cancer Screening in Patients with Family History Referral Guideline

Diagnosis/Definition
Simple family history: One or more first degree relative(s) with colon cancer (but not meeting criteria for familial syndromes as below); relative must be < age 60 at time of diagnosis.
Familial syndromes:
Familial adenomatous polyposis (=Gardners) defined by appearance of 100-1000 polyps at endoscopy in the index patient. All first degree relatives are considered at risk (autosomal dominant).
Lynch Syndrome Family defined as three relatives with colon CA, involving at least two generations. One relative must be first degree relative of the other two, and at least one cancer should be diagnosed age <50.
Initial Diagnosis and Management
The family history usually makes the diagnosis in patients at risk.
Ongoing Management and Objectives
When the diagnosis of an at risk patient is made, then periodic referral for colonoscopy according to the schedule below is indicated. No interval testing for occult blood is recommended.
Indications for Specialty Care Referral
Family history of colon CA: Colonoscopy or ACBE/flex-sig every 5 years beginning 10 years younger than youngest affected relative (please include relatives age on consult). Change to average risk screening age 65 if colon always normal.
Familial adenomatous polyposis (=Gardners): Refer patients to GI. First degee relatives: yearly flex-sig ages 10-50.
Lynch Syndrome: First degree relatives: Colonoscopy every two years beginning age 25 (or 5 years younger than youngest affected relative. Colonoscopy should be yearly if adenomas are found.
Criteria for Return to Primary Care
Completion of colonoscopy.

polyps are found throughout the colorectum but Carcinoma occurs in the left side at average age 39!!! polyps are found throughout the colorectum but Carcinoma occurs in the left side at average age 39!!!

**An elementary school teacher born in 1964 presents with a high fever, pneumonia, and a rash which was initially urticarial and then became maculopapular with petechial elements. Because measles has been reported in the community, you strongly consider the diagnosis of atypical measles.

Which one of the following would lend additional support to this diagnosis?

a. The patient has a B-cell immune deficiency disorder
b. The patient received inactivated (formalin-killed) measles vaccine as an infant
c. The measles virus spreads quickly in the school environment via fecal-oral transmission
d. A viral culture of her serum

Answer is B.
This patient has the characteristic features of atypical measles. This illness occurs primarily in individuals who were immunized with the killed measles virus vaccine, which was available from 1963 through 1967. The syndrome of atypical measles presumably represents hypersensitivity in a host who is partially immune. An extremely high measles antibody titer early in the illness is helpful in making the diagnosis, but a viral culture would not be useful. Transmission of measles is primarily via the respiratory tract and associated secretions. Patients with B-cell immunodeficiency are susceptible to recurrent infections with bacterial pathogens. Viral infections are usually not a problem with these patients, although the measles virus does tend to affect the T-cell defense mechanisms.

**24 year-old man complains of facial pain, purulent nasal discharge and fever for 4 days.
PE: tenderness over the right maxilla.

1)What is appropriate initial test

a. X ray of sinus
b. CT of sinus
c. Needle aspiration for culture
d. MRI of sinus

2)The most cost effective antibiotic treatment is

a. Amoxicillin-clavulanate
b. Pen G
c. Dicloxacillin
d. Cefaclor
e. Bactrim

1-A. X-Rays. Some experts argue that one x-ray is adequate for diagnosis of maxillary sinusitis. Single x-rays are not useful, however, in diagnosing frontal and sphenoid sinusitis.
computed tomography (CT) scans and magnetic resonance imaging (MRI) are not accurate for an initial diagnosis of acute sinusitis, but they are useful for diagnosing chronic or recurrent acute sinusitis and difficult cases. CT scans are also used by surgeons as a guide during surgery. They show inflammation and swelling and the extent of the infection, including that in deep hidden air chambers missed by x-rays and nasal endoscopy.

2-E. bactrim.

**A 15 y/o boy has acne not responded to 5% benzoyl peroxide topically. PE reveals inflammatory papules, and moderate comedonal acne.

The FIRST choice of treatment is

a. 10% benzoyl peroxide plus topical erythromycin
b. oral isotretinoin
c. topical clindamycin
d. topical tretinoin plus oral tetracycline

Answer is D. If no improvement occurs, treatment should be intensified by another antibiotics or oral isotretinoin.
A combination of benzoyl peroxide and topical erythromycin is for mild inflammatory acne, it would not be appropriate for this boy.
Topical clindamycin is used in the management of inflammatory , nonscarring acne.
Oral isotretinoin should be reserved for those in whom conventional therapy with oral antibiotics has proven ineffective. Answer is D. If no improvement occurs, treatment should be intensified by another antibiotics or oral isotretinoin.
A combination of benzoyl peroxide and topical erythromycin is for mild inflammatory acne, it would not be appropriate for this boy.
Topical clindamycin is used in the management of inflammatory , nonscarring acne.
Oral isotretinoin should be reserved for those in whom conventional therapy with oral antibiotics has proven ineffective.