OEQ/MEQ Life Stages 2

· Lab values that suggest the patient is not taking medications as prescribed · An inability to teach back the correct way to take medications. Non-adherence may be due to LHL because patients may not have understood what you wanted them to do. A patient who becomes angry or makes an excuse to leave the office when confronted with forms to fill out. Having to leave may be more 'socially acceptable' than admitting they cannot fill out the forms

Additional clues for Limited Health Literacy

Description: Provides a suite of levels of care that allows older adults to remain in the same community for the rest of their lives. This tiered approach accommodates residents' changing needs over time Admission Criteria: -Age, typically >60 -Most CCRCs require ADL independence at time of admission -Ability to pay $$$$$ Healthcare services: -Included Typical Services: Services are broad as CCRCs typically encompass independent living (single family home/apt/condo), assisted living facility, and custodial care. payment Out of pocket and the most expensive option for long term care. Typically includes large entrance fees and monthly payments

Continuing Care Retirement Community (CCRC) Description Admission Criteria Healthcare services Typical Services payment

c. Use a teach to goal technique when reviewing how to take his medications. Use a teach to goal technique when reviewing how to take his medications. With the teach to goal technique, the provider determines a measurable target comprehension goal—for example, ensuring that the listener can accurately explain three critical concepts. In the teach-to-goal technique, rounds of teach-back or other methods of confirming listener comprehension are repeated until the listener exhibits mastery of the learning goal. Options a, b, and d would not provide Mr. M with the opportunity to demonstrate his understanding of the plan or goals of treatment. Verbally telling Mr. M about the diuretic dose, and educating him about salt restriction have been tried previously in various forms. Charting his weight would require understanding of both why it's important and how to do the charting, which would likely be an ineffective next step in preventing future CHF exacerbations.

Mr. M is a 75-year-old man (he/him) who presents to the hospital for a congestive heart failure (CHF) exacerbation. This is his third exacerbation in 2 months. When asked about his medication regimen, he states he is uncertain how to take his diuretic or what it's for. He does check his weight periodically but doesn't understand why since the problem is with his heart. He has received numerous patient handouts in the past about heart failure, weight gain, and a low sodium diet, but he doesn't understand how all of it relates to each other. You administer a health literacy screening tool, and his score suggests a high likelihood of limited health literacy. Which should you do upon hospital discharge when discussing his CHF treatment plan to help prevent future CHF exacerbations? Select one: a. Tell him in simple language that you're doubling the dose of his diuretic. b. Provide him a chart to log his weight. c. Use a teach to goal technique when reviewing how to take his medications. d. Give him a handout that lists low-salt foods.

Definition: Postural or orthostatic hypotension is diagnosed as a fall in systolic blood pressure of at least 20 mm Hg and/or diastolic blood pressure of at least 10 mm Hg within 3 min of standing.

Definition: Postural or orthostatic hypotension is

Often as providers, we are faced with gray areas when helping to make the best decisions on where a patient should live. These decisions are complex with diverse factors to consider, such as: patient and family preferences, financial considerations, location and proximity to loved ones, and bed availability. In all the patient cases, there is intentionally no clear description about the patient's financial situation, as various scenarios affect a patient's monthly income; however financial considerations are a key component in determining where older adults live.

Difficulty selecting options for patients

Delirium prevention trials demonstrated the effectiveness of intervention protocols in six areas: 1) orientation and cognitive stimulation for those with cognitive impairment, 2) early mobilization to avert immobilization, 3) interventions to prevent sleep deprivation, 4) communication methods and adaptive equipment (particularly eyeglasses and hearing aids) for vision and hearing impairment, 5) avoiding/monitoring use of problematic medications in older adults, including those with adverse side effects (antihistamines, benzodiazepines, antipsychotics, anti-nausea, overactive bladder agents, and muscle relaxants), and 6) managing pain. In Mrs. H's case, you could encourage/facilitate mobilization as soon as appropriate after surgery to reduce deconditioning, ensure she has her glasses and hearing aids, and minimize sleep deprivation by avoiding overnight vital sign checks, reducing nighttime noise, and overnight medication administration.

Given her health history, what measures would you take to prevent post-op delirium in Mrs. H?

· You can refer patients to social work services who can help low income patients connect to IHSS (in-home support services) for assistance with ADLs/IADLs. Social work can also help patients navigate their environment by connecting them with transportation resources such as paratransit. · You can refer to home health services which can provide patients with skilled needs with therapy/monitoring at home (ex: PT, OT, skilled nursing). · You should also make sure patients have the assistive devices they need to navigate their environments (both inside and outside their home). This may require a referral to home health services to evaluate the home environment and recommend the appropriate equipment. · As a provider, it is also important to consider consolidating appointments and referrals where possible to minimize the number of times patients have to travel/leave their homes. Also consider utilizing telehealth when possible and appropriate.

How might you tailor your future care to mitigate SES and physical environmental barriers?

c. Hydrocele Hydroceles are the most common source of progressive, mild scrotal swelling. As hydroceles are fluid filled sacs around the testicle they typically transilluminate and make palpation of the testicle and epididymis difficult. Testicular neoplasms are most common in men in their 20s and 30s and are associated with a hard mass within the testicular parenchyma that does not transilluminate. Varicoceles do not typically cause swelling and are often described as a palpable mass that feels like "a bag of worms" superior to the testicle. Inguinal hernias do not typically transilluminate as they contain bowel or omentum. Epididymorchitis is typically painful and associated with voiding concerns; a reactive hydrocele may form in the setting of infection but the absence of pain in this scenario makes this diagnosis less likely.

Mr. Patel, a 60-year-old man (he/him) presents to his primary care provider with a complaint of swelling in his left testicle. He first noticed the swelling one week ago. He does not recall an inciting event. The swelling has remained stable and is mildly uncomfortable but not acutely painful. He denies pain, weight loss or night sweats. On exam, the left side of the scrotum is enlarged but not tender and no hard masses are noted. The left side epididymis is not palpable. The scrotum transilluminates on the left side. What is his most likely diagnosis? Select one: a. Testicular neoplasm b. Varicocele c. Hydrocele d. Inguinal hernia e. Epididymorchitis

IADLs refer to tasks that are not necessary for fundamental daily life, but are necessary in order to live independently in the community. IADLs include: • Housekeeping • Laundry • Food preparation • Shopping • Medication management • Finance/money management • Using a telephone • Driving/utilizing transportation options

Instrumental Activities of Daily Living (IADLs):

Description: Skilled Nursing Facilities contain both sub-acute rehab beds (short term stay) for skilled care performed by nurses and therapists, AND custodial beds (long term stay). Therefore, residents may live in a SNF indefinitely OR live there temporarily for intensive rehabilitation prior to returning home. The term "nursing home" generally refers to a facility that has only custodial beds Admission Criteria FOR LONG TERM/CUSTODIAL CARE: -Dependent in most (3+) ADLs FOR SUBACUTE REHAB: -Must have need for skilled care. Examples of skilled care include: rehab therapy, wound care, catheter care. This care is provided by therapists and nurses. Healthcare services -Skilled care -Condition specific care -Hospice / end of life services at some locations -Doctors on call Typical Service Social activities ADL/IADL assistance included Regulation: State & Federal Regulations Also known as: -Nursing Home Care and Rehabilitation -Convalescent hospital/home -Rest Home payment: Skilled care: State Medicaid programs have different rules that determine when skilled care is medically necessary and payable by Medicaid. -Custodial care: Out of pocket or may be covered by MediCal

Skilled Nursing Facilities (SNFs) Description Admission Criteria Healthcare services Typical Services Regulation Also known as Payment

a. Endometrial hyperplasia The correct answer is "endometrial hyperplasia." A gland:stroma ratio of 1:1 is abnormal, and indicates increased gland density, which may be seen in a variety of conditions including endometrial hyperplasia, endometrial carcinoma, and endometrial polyps. Gland density lower than 1:5 may be seen in a variety of conditions including exogenous progestin effect or age-related endometrial atrophy.

The normal ratio of glands:stroma in the endometrium is 1:5. On microscopic examination of an endometrial biopsy, you observe a gland:stroma ratio of 1:1. Of the choices below, which biological state is the most likely explanation for this finding? Select one: a. Endometrial hyperplasia b. Variant of normal endometrium c. Age-related endometrial atrophy

Mrs. H's risk factors for falling include: · History of falls · Poor vision · Severe knee arthritis · Decreased muscle strength · Slow Timed Up and Go score

Three months later, Mrs. H is brought to the emergency department by ambulance after sustaining a fall. She is diagnosed with a left hip fracture and has agreed to undergo surgical repair. What risk factors for falling does Mrs. H have, based on her clinic history and physical exam?

Innate Immune Response o Decreased ability of memory T cells and memory B/plasma cells to expand o Lower levels of cytokine production by the T cells o Dysregulated cytokine production that shifts toward Th2-type response · Adaptive Immune Response o Decrease in naive B and T cell production rate compromises the ability to respond to novel antigens o Decrease production of antibodies by B cells and plasma cells o Decrease diversity of the B-cell repertoire with age o Accumulation of memory B and T cell populations that are more restricted and depend on an individual's prior lifetime antigen exposures Because of how immunosenescence affects the immune system, both viral and bacterial infections can have increased severity and long-term sequelae in older people.

What changes occur to the immune system with aging?

When patients' needs are not adequately met, even with adaptive equipment and environmental modifications, consider the following factors in determining whether they should move to a different setting: 1) What are the patient's needs? In particular, consider IADL/ADL needs 2) What are the patient and family's preferences? 3) What can the patient afford? 4) Do you have concerns about the patient's safety or ability to manage their medical conditions?

What factors would you consider in determining whether patient should move to a residential model of care?

Mrs. H would like to remain at home, is independent in her ADLs, but is dependent is some IADLs. In this scenario, she could receive primary medical care through a Housecalls program; she would qualify given that it is extremely taxing for her to leave her home. She could also hire a caregiver to assist with her grocery shopping, housekeeping, and laundry. She does not have any ADL needs and would not qualify for a PACE program.

What is one potential "model of care" solution that would allow for Mrs. H to both remain in her home and meet her needs? How might this model meet her needs?

Definition of frailty: frailty is a common geriatric syndrome defined as a state of increased physiological vulnerability to stressors (e.g., extremes of heat and cold, infection, physical injury, changes in medication). Conceptually, frailty is an expression of a critical mass of physiologic impairments. Importance of assessing frailty in older adult surgical candidates: Because surgery is essentially an acute stressor to the body, frail patients have poor surgical outcomes. It is strongly associated with postoperative complications such as hospital readmission, discharge to nursing home, and greater risk of mortality. Frailty assessment in the preoperative setting helps to identify and risk stratify patients to better inform the surgeon and the patient regarding the risk of postoperative complications.

What is the definition of frailty and why is it particularly important to assess in older adult surgical candidates?

a. Increases cancer risk in both breasts The correct answer is "Increases cancer risk in both breasts." Lobular neoplasia is a spectrum of changes that includes atypical lobular hyperplasia (ALH) and lobular carcinoma in-situ (LCIS). These changes represent a clonal growth of cells that originate from the lobule of the breast. Although LCIS includes the term "carcinoma" in the name, it is generally interpreted as an indeterminate lesion or marker of breast cancer risk, and is usually an incidental finding. Overall, lobular neoplasia carries a 4 to 12-fold increase in cancer risk in either breast. Mastectomy is not an appropriate therapeutic choice, as it would be vast overtreatment for this diagnosis. A diagnosis of lobular neoplasia is not an indicator for BRCA testing.

What is the significance of lobular neoplasia of the breast? Select one: a. Increases cancer risk in both breasts b. Prompts consideration of mastectomy c. Warrants testing for BRCA1/2 mutations

You may have been surprised by the variety of options that exist for older adults. Many students are surprised by the costs that are associated with some models of care, especially RCFEs. Students often compare the cost of a month at an RCFE to how much they pay for rent in San Francisco. Some additional reflection questions: - Do you think most older adults plan for where they are going to spend the last few years of their life? - How do you think older adults budget for these potential expenses?

What surprised you the most about these models of care?

Julie's stress can be assessed using the "Caregiver Strain Index," a validated questionnaire that assesses caregiver stress and burden. A score of >7 should prompt intervention to assist the caregiver

What tool could you use to assess Julie's stress and how would you interpret the results?

Reflect on themes from peer presentations. Site-related challenges might include lack of guidance from local, state, and federal governments; new procedures quickly needed for COVID positive residents (whether keeping them in the facility or accepting them back from the hospital); infection control training needed; staffing shortages; staff becoming ill, etc. Resident-related challenges might include family/friends not allowed to visit; lack of socialization due to requirements to stay in room/apt; delay in seeking care because of fear of leaving home and "catching COVID" in a clinic or hospital.

What were the greatest challenges to the models of care and their residents/patients due to COVID 19 and sheltering in place?

This is an epithelial tumor derived from the endometrium. Endometrial carcinomas are divided into two types. Type I tumors are estrogen-dependent and generally less aggressive, while type II tumors are estrogen-independent and more aggressive

Which compartment of the uterus generates this tumor type? Endometrioid Adenocarcinoma

d. Lack of basal cells "Lack of basal cells," a features that defines a malignant gland of prostatic adenocarcinoma, as it has lost its basal or myoepithelial layer, and is now invasive into the surrounding stroma. Malignant glands of prostate cancer contain only a single cell layer, whereas benign glands have both a luminal layer and a basal layer. The luminal layer tends to have lighter pink cytoplasm. Neutrophils in the gland epithelium indicate acute prostatitis, an inflammatory condition, not a neoplastic condition. Prominent nucleoli are seen in many prostate cancer cells, but are not as clear-cut a feature for diagnosis as lack of basal cells.

Which of the following is the most clear-cut feature for diagnosis of prostatic adenocarcinoma in a tissue specimen? Select one: a. Prominent nucleoli b. Light pink cytoplasm c. Neutrophils in gland epithelium d. Lack of basal cells

b. The basement membrane separates the duct from the surrounding intra- and interlobular stroma. the basement membrane lines the outside of the ducts and acini, separating it from the surrounding stroma. The intralobular stroma is composed of loose, myxoid fibrous tissue while the interlobular stroma is composed of dense connective tissue. Loose connective tissue surrounds the acini in a TDLU.

Which of the following statements is true about breast stroma? Select one: a. Interlobular stroma is composed of loose, myxoid fibrous tissue. b. The basement membrane separates the duct from the surrounding intra- and interlobular stroma. c. Dense fibroconnective tissue surrounds each acinus in a TDLU.

It is important for physicians to know the types of settings in which their patients live in order to provide realistic treatment plans and make appropriate referrals to interprofessional team members as needed. This is particularly important when physicians are preparing discharge plans. To ensure a safe transition of care and reduce avoidable hospital readmissions, they must know how to choose appropriate discharge settings and to write discharge recommendations and orders that are feasible in that setting.

Why is it important for you, as a physician, to know options for residential and health care?

d. Provide frequent orientation and facilitate a daily routine and bedtime. Provide frequent orientation and facilitate a daily routine and bedtime. Frequent orientation and facilitating a daily routine and normal sleep wake cycle are nonpharmacologic approaches to treat delirium. Providing familiar objects, daytime activities and a normal routine (including meals), uninterrupted night time sleep, and avoiding high risk medications and "tethers" are additional approaches. Other interventions include early ambulation, and providing hearing aids or eyeglasses if the patient typically uses them. Nonpharmacologic approaches should be tried first before pharmacologic intervention. Ordering a bed alarm will alert the staff if he is trying to get out of bed but it will not help with delirium. In fact, constant triggering of the bed alarm may keep him awake all night which would worsen his delirium (and the sleep/wake cycle of his neighbors!). Hydroxyzine is an antihistamine with anticholinergic properties known to both cause and worsen delirium in older adults, and is a medication that should be avoided in this population. Studies have shown that physical restraints can worsen delirium and lead to physical harm as the patient tries to undo or fight the restraints.

You admit an 84-year-old man (he/him) to the hospital with fever, productive cough, and malaise. His past medical history is notable for dementia and benign prostatic hyperplasia. He is diagnosed with pneumonia and started on IV antibiotics. In the morning of hospital day 2, you find out he was awake and agitated all night, and tried to pull out his IV. He is unable to answer your questions and is distracted, which is markedly different from the time of admission two days prior, when he was attentive and calm. What would be the MOST effective next step in his management? Select one: a. Order an overnight bed alarm so that nurses will be alerted if he gets out of bed. b. Order Hydroxyzine (a sleep aid and anxiolytic) before bed to assure normal sleep-wake cycles. c. Order hand restraints at night so that he can not pull out his IV. d. Provide frequent orientation and facilitate a daily routine and bedtime.

c. Lower your tone and speak into the patient's preferred ear Mr. T is exhibiting signs that indicate he may not understand what you are saying. It is possible that health literacy is a contributing component and it is important to maintain awareness of how aging may affect health literacy. Because his cognitive assessment continues to be within normal limits, consider other possibilities that may be affecting his ability to understand the situation. In this case, he may be hearing impaired, thus lowering your tone and speaking in the patient's preferred ear would be a first step in optimizing communication and his comprehension. Directing the rest of the conversation to his son would be inappropriate since Mr. T's cognitive status is intact and he can likely participate fully in the visit if his hearing/vision needs are met. Increasing the volume of your speech would be unhelpful even if you suspected hearing impairment. Typing your message and asking the patient to read off your computer screen would be an option of last resort.

You are the PCP of Mr. T, an 89-year-old man (he/him) with a history of hypertension, congestive heart failure, and hyperlipidemia who is presenting with new swelling in his legs. He is accompanied by his son. You are concerned the swelling may be due to inadequate diuresis and ask Mr. T which medications he takes and the doses of each. Mr. T turns to his son who lists his father's medications. Throughout the visit, you notice that Mr. T simply nods to many of your questions and often turns to his son for answers. You note that this is a change from prior visits and that Mr. T's cognitive screening continues to be within normal limits. What should you do to improve communication with Mr. T? Select one: a. Direct the rest of the conversation to his son b. Increase the volume of your speech c. Lower your tone and speak into the patient's preferred ear d. Type your message and ask the patient to read off your computer screen

d. Ask if there are any barriers to accessing appointments and medications Ask if there are any barrier to accessing appointment and medications. There are many social determinants of health that impact access to care for older adults, including limited health literacy, social isolation, loneliness, and ageism. It is vital to understand barriers to care and to approach situations such as Mx. G's without making assumptions regarding underlying causes of their med adherence.

Mx. G is a 75-year-old non-binary person (they/them) with a history of hypertension and remote CVA who is here for routine follow up. You notice they have cancelled their previous 3 appointments with you. Upon review of today's vital signs, you note their blood pressure to be 168/92. Previously, Mx. G's BP had been well controlled on HCTZ and Lisinopril with systolics less than 130. When asked if they are taking their BP medications, Mx. G says they have not taken any medications for 2 months. What is the best next step in discussing Mx. G's health with them? Select one: a. Use the teach back method to reinforce the importance of taking their BP medications b. Discuss increasing the dosage of their BP medications c. Discuss the importance of keeping appointments to maximize their health and care coordination d. Ask if there are any barriers to accessing appointments and medications

"Nursing home" or "Skilled Nursing Facility" are both terms for sites that provide short-term or long-term health-related care and services for residents. In this session we focus on long-term residential care, not short-term rehab care. Residents typically have significant difficulty performing ADLs without assistance, and most require assistance with at least 3 ADLs. Residents can be in nursing homes for a variety of reasons including physical dependency/frailty, cognitive impairment/dementia, and baseline psychiatric disorders that all prevent the resident from caring for themselves in the community. Nursing aides and skilled nurses are available 24 hours a day for medication management, vital sign checks, wound care, bathing/toileting/grooming, and behavioral management; nurses can also provide basic medical assessment of residents. Physicians or nurse practitioners may or may not be available on site but are required to see residents on site at regular intervals. Long-term care in NHs is primarily paid for by Medicaid benefits or out of pocket costs (about $90,000/year for a semi-private room). Bottom line: If you are dependent in at least 3 ADLs, NHs can be a good option Nursing Home/Convalescent Home/Skilled Nursing Facility (NH/SNF):

Nursing Home/Convalescent Home/Skilled Nursing Facility (NH/SNF):

b.45-year-old man with testes, no exogenous hormone exposure, recently diagnosed with high-grade invasive ductal carcinoma The correct answer is "45-year-old man with testes, no exogenous hormone therapy, with high-grade invasive ductal carcinoma." Breast cancer in a man with testes, no exogenous hormone exposure, is a suggestive history for possible BRCA mutation. (Our understanding of breast cancer risk is evolving for trans women who have taken gender-affirming hormone therapy.) Routine screening for BRCA1 and BRCA2 mutation is not considered to be beneficial. Testing of children with a suggestive family history is not recommended because there are no risk-reduction strategies in children, and there is a very low risk of children developing one of the cancers associated with BRCA mutation. As these children become adults, they may wish to seek genetic counseling for possible testing.

Of the following individuals, who is most likely to gain useful information from genetic testing for BRCA1 and BRCA2 mutations? Select one: a.60-year-old woman with breasts and ovaries, no exogenous hormone exposure, undergoing screening physical for a new job b.45-year-old man with testes, no exogenous hormone exposure, recently diagnosed with high-grade invasive ductal carcinoma c.7-year-old child, gender and internal organs not known, no exogenous hormone exposure, whose mother has ovarian cancer and two aunts have breast cancer

created to advocate for the rights of older adults residing in SNF/NHs, Assisted Living Facilities and Board & Care facilities (RCFEs). It is a federal and state regulated program that receives, responds to and investigates complaints made by residents, family members and anybody else concerned about the well-being of a resident (including elder abuse). In addition, the Ombudsman Program provides consultation and education to the residents and the public regarding resident rights and good care practices. Services are free for residents and families

Ombudsman Program:

SETTING prepare by reviewing notes and inviting patient to involve people most important to them. Prepare environment, ensure time and privacy. Take note of body language, be seated, not standing PERCEPTION find out patient's perception of their illness INVITATION find out how much information they would like and what level of detail KNOWLEDGE give the bad news clearly and simply, avoiding jargon, with frequence pauses to check for understanding. Using warning shot statement first so that patients are prepared bad news is coming EMOTIONS allow patient to express their emotions, using empathetic responses to awknloedge feelings and show suppoer STRATEGY and SUMMARY make a plan with the patient for the future and summarise the discussion checking the patient's understaning

SPIKES protocol for bad news

b.An estimated GFR calculated using the Cockcroft-Gault, MDRD or CKD-Epi equations An estimated GFR calculated using the Cockcroft-Gault, MDRD or CKD-Epi equations. Mr. Terry's serum creatinine, while nearly within normal range, is a misleading marker of his renal function. Muscle mass, the source of serum creatinine, declines with age, especially in frail older adults. Therefore, kidney function can be profoundly impaired despite having a serum creatinine that remains near or even within the normal range in a person with low muscle mass. GFR estimating formulas have been developed to account for some of the key variables known to be related to muscle mass and thus serum creatinine (age, sex, race). These include the Cockcroft-Gault formula, the MDRD equation, and the CKD-Epi equation. Although a 24 hour urine collection could provide a good estimate of GFR, it's not advisable to wait 24 hours to initiate antibiotics while gathering this data. A vancomycin serum concentration after the first dose has no relation to renal function.

Select one: a.Serum creatinine level on admission b.An estimated GFR calculated using the Cockcroft-Gault, MDRD or CKD-Epi equations c.A vancomycin serum concentration checked after the first vancomycin dose d.A 24 hour urine collection to calculate creatinine clearance

Senior housing apartments are quite variable in their mission, structure, and funding sources. These units are specifically designed for older adults and are age restricted (often >62 yo). They serve residents with senior-friendly features, amenities, activities, classes and more. Medical and personal care usually are not included with senior apartments. In some cases, however, housekeeping, meals and other services may be purchased at an additional cost. There are no medical professionals on site although some have a social worker/resident services coordinator. Some units are specifically lower-cost for low or very-low income seniors in the community; some are supplemented by Section 8 and other federal Housing and Urban Development housing programs. Bottom line: If you can live independently and care for your home and self, but just need housing that is both senior-friendly in its makeup and community, as well as at a lower cost, senior housing apartments can be a good option. Senior Housing Apartments

Senior housing apartments

Unlike IADLs, ADLs are self-care tasks that are necessary for daily life as well as independence. ADLs include: • Bathing/showering • Eating/feeding self • Toileting • Dressing • Grooming • Transferring/Ambulating (including with assistive device)

Activities of Daily Living (ADLs):

b. Fine needle aspiration FNA biopsy is a powerful technique for palpable breast masses, as it is an inexpensive and rapid way to obtain diagnostic tissue and triage patient care. Stereotactic core biopsy is performed under mammographic guidance for non-palpable abnormalities, such as calcifications identified on screening mammogram. Seeds are magnetic beads placed by a radiologist around an area of calcifications in the breast. This is followed by surgical location of the seeds using a magnetometer, then removal of tissue in that area. This is a useful technique for removal of an area with calcifications.

A 32-year-old woman (she/her), G0P0, is evaluated for a 2-cm palpable breast mass located in the right upper outer quadrant. Of the following choices, what is the most appropriate next step in management? Select one: a. Stereotactic core biopsy b. Fine needle aspiration c. Placement of seeds

b. Increased Sympathetic Tone This patient has numerous potential causes of psychosocial stress (loss of partner, absence of a current regular sexual partner, stress from career change, heavy academic expectations). Psychological stress is very common with ED as either an inciting or exacerbating factor; ultimately, any form of psychological stress will manifest physically as enhanced sympathetic tone, which will tend to oppose erection responses. This is a young and healthy patient with no risk factors or evidence for vascular disease or low serum testosterone. Normal libido and presence of nocturnal and morning erections suggests (but does not conclusively prove) that his serum testosterone is normal. Chronic benzodiazepine may be associated with sexual problems but this patient's use is minimal and not temporally correlated to ED symptoms. Medical school certainly is busy but it is important to maintain other important aspects of one's life, even during that busy time.

A 35-year-old man (he/him) with a penis presents to your office and reports erectile dysfunction. He denies decreased libido and endorses nocturnal, early-morning erections. Two years ago he left a lucrative job as a consultant to follow his dreams and attend medical school at UCSF. He is newly single as his partner of many years left, citing his career change as a cause. He does not have a regular partner but is dating casually. He has substantial stress; he uses a benzodiazepine about once a week when he is particularly anxious. He is not taking other medications. He denies alcohol use or illicit drug use. His past-medical history is negative. His physical exam is normal. What is the most likely etiology for this patient's ED? Select one: a. Occult Vascular Disease b. Increased Sympathetic Tone c. Low Serum Testosterone d. Benzodiazepine Use e. No time for sex...he is in medical school!

b. Invasive ductal carcinoma The clinical presentation is highly suspicious for cancer. About 75% of breast cancers are invasive ductal carcinoma. The second most common type is invasive lobular carcinoma, accounting for about 10% of cases. Inflammatory breast carcinoma is a clinical diagnosis that refers to rapidly growing advanced invasive ductal carcinoma, in which the tumor spreads to and blocks the lymphatic vessels in the skin. This results in erythema, swelling, and thickening of the skin, with a characteristic "peau d'orange" appearance, not seen in this patient. DCIS typically presents as microcalcifications that are identified on a screening mammogram, and not as a palpable mass.

A 52-year-old woman (she/her) undergoes lumpectomy with sentinel lymph node biopsy for a palpable 4-cm mass of the right central breast. The mass shows irregular borders on mammogram. There is no skin dimpling or thickening over either breast. Of the following choices, what is the most likely diagnosis in the absence of any other information? Select one: a. Invasive lobular carcinoma b. Invasive ductal carcinoma c. Inflammatory breast carcinoma d.Ductal carcinoma in situ

d. Reducing fluids and coffee The scenario describes fits benign prostatic hyperplasia (BPH), a common condition in individuals with prostates as they age. Treatment depends on severity of symptoms, with reduction of fluid intake, including alcohol and caffeine consumption, as a way to try reducing symptoms. TURP is a surgical approach that is performed to remove the hyperplastic tissue impinging on the urethra in cases where dietary changes and medical treatments (such as alpha-blockers and 5-alpha-reductase inhibitors) don't work. Biopsy is a consideration if obtaining diagnostic tissue is important, but it is not the best next step given this clinical picture.

A 55-year-old man (he/hm) is experiencing intermittent urinary frequency, pain on urination, and has had two courses of antibiotics for cystitis in the last few months. Of the following choices, what is the most appropriate next step? Select one: a. Prostatectomy b. Prostate needle core biopsy c. Transurethral resection of the prostate d. Reducing fluids and coffee

b. Endometrial biopsy Any person with postmenopausal bleeding needs to be evaluated for endometrial cancer. The diagnosis of endometrial cancer is most commonly and easily made by endometrial biopsy in the office, but dilatation and curettage remains the gold standard. Endometrial ablation is used for patients with dysfunctional uterine bleeding to reduce menstrual bleeding. It is not an appropriate therapy in this post-menopausal patient. Instead, you should attempt to discover why they are having post-menopausal bleeding. Before performing a hysterectomy, the cause of this patient's postmenopausal bleeding should be evaluated. In particular, they should be evaluated for endometrial cancer. If cancer is found, then a total abdominal hysterectomy with bilateral salpingo-oophorectomy should be performed, with staging surgery as determined by intraoperative findings. However, this is inappropriate before establishing the diagnosis. Intermittent progestin therapy is used in anovulatory patients to reduce the risk of endometrial hyperplasia and endometrial cancer. In this postmenopausal person, this therapy would be inappropriate without first attempting to discover why they are having postmenopausal bleeding.

A 57-year-old non-binary person (they/them), G3P3, presents to your office complaining of vaginal bleeding. Their last menstrual period was 5 years ago; they are not currently on hormone replacement therapy. Which of the following is the most appropriate next step in the management of this patient? Select one: a. Endometrial ablation b. Endometrial biopsy c. Hysterectomy d. Intermittent progestin therapy

b. Depth of myometrial invasion Up to 48% of individuals with a uterus who have atypical hyperplasia on biopsy have concomitant adenocarcinoma at hysterectomy. Endometrial cancer staging involves surgical staging, and is based on how deeply the invasive tumor extends into the myometrium, with invasion into the outer half of the myometrium resulting in a higher stage. Staging therefore requires careful assessment of the hysterectomy gross specimen at the time of surgery, with close communication between the surgical pathologist and surgical oncologist as to the clinical findings intraoperatively. Volume of endometrial tumor does not dictate the decision to proceed with staging. Length of the uterus from cervix to fundus is not a consideration in the decision either. Thickness of the endometrial stripe may have helped trigger her original workup, but during her surgical resection, it is not the determinant for whether to proceed with staging.

A 60-year-old woman (she/her) presents with postmenopausal vaginal bleeding and is found to have atypical hyperplasia on endometrial biopsy. She undergoes hysterectomy with bilateral salpingo-oophorectomy. What is the key intraoperative finding dictating whether a staging procedure is performed? Select one: a. Volume of endometrial tumor b. Depth of myometrial invasion c. Length of the uterus from cervix to fundus d. Thickness of endometrial stripe

Lack of mobility aids Lack of access to technology (internet, devices) Lack of needed environmental modifications

Examples of extrinsic threats to a person's ability to live independently

d. Urodynamics The correct answer is "Urodynamics," a general term for the study of the storage and voiding functions of the urinary bladder. In urodynamics, a catheter with a pressure transducer is passed into the bladder and electrodes (similar to ECG electrodes) are placed on the perineum to assess pelvic floor muscle activity. The electrodes and catheter are monitored as the bladder is slowly filled with fluid passed through the Foley; serial measurements are taken of bladder and urethral pressure and pelvic floor muscle activity. At the conclusion of the test the patient is asked to void and post-void residual urine is assessed. This test assesses bladder filling and emptying and is the most definitive means to accurately assess lower urinary tract function. Urinalysis should be performed to rule out infection but will not provide information on lower urinary tract function. Cystoscopy may be performed but in the absence of hematuria or concerns about obstructive conditions of the urethra and bladder neck (which are rare in women) it is not indicated for this patient. Pelvic MRI will provide detailed images of the pelvis but will not provide any information on lower urinary tract function. Serum creatinine may be helpful to assess baseline renal function, but is not helpful in assessing lower urinary tract function. Please note, if this patient had presented without a history of recent neurological trauma initial management with a voiding diary, elimination of bladder irritants, and empiric trial of pharmacotherapy might be reasonable.

A 62-year-old woman (she/her) is evaluated for inability to control urination. She was in a car crash two months ago and sustained a spinal cord injury. Since that time, she has experienced urgency and frequency with frequent incontinence of small amounts of urine. Which of the following laboratory or imaging studies will be the MOST helpful to assess the cause of her incontinence? Select one: a. Urinalysis b. Cystoscopy c. Pelvic MRI d. Urodynamics e. Serum creatinine

e. Vascular Disease The correct answer is vascular disease. Absence of morning erections suggests (albeit not conclusively) a neurologic, vascular, or hormonal etiology over a psychogenic etiology. This patient has several risk factors for vascular disease, including HTN, smoking, and an elevated BMI. He has not sought medical care in several years, so a metabolic work up including fasting blood glucose/Hgb A1c, cholesterol, and triglycerides would be appropriate. Current AUA guidelines recommend assessment of serum testosterone; while there may be a hormonal issues that contributes to this patient's ED the most likely cause in this case is vascular disease. While many medications contribute to ED proton pump inhibitors are not a major cause of medication-induced ED. ED is associated with aging but this relates in many cases to comorbid vascular conditions.

A 63-year-old man (he/him) with a penis comes to your clinic with the chief complaint of erectile dysfunction. He says he started having difficulty achieving an erection one year ago. This issue is causing problems in his relationship with his partner. He has not had morning erections for the past year. His past medical history is notable for GERD, for which he takes omeprazole. He states he last saw a doctor about 10 years ago, as "life got in the way." He has a stressful job as a line cook, and smokes one half pack of cigarettes per day during breaks. His vitals are T 98.8F, P 78, BP 154/86, RR 12, and his BMI is 31. His exam is otherwise unremarkable. Which of the following is the most likely etiology of this patient's erectile dysfunction? Select one: a. Performance anxiety b. Low Testosterone c. Omeprazole d. Aging e. Vascular Disease

c. Oral contraceptive pill use Maximum benefits are seen with 5 years of use, and the protective effect appears to remain for up to 10 years after use is stopped. For endometrial cancer, it is hypothesized that OCPs minimize exposure to unopposed estrogen during the follicular phase of the menstrual cycle, thereby inhibiting estrogen-induced cell proliferation. People who are postmenopausal who receive exogenous estrogenic agents alone (i.e., without concomitant exogenous progesterone) have an increased risk of endometrial adenocarcinomas. Individuals who are obese have increased risk of endometrial cancer. Obesity is a risk factor for anovulation with continued production of estrogen. This results in a state of "unopposed estrogen" because, without ovulation, the ovary produces little or no progesterone. Additionally, fat cells contain the enzymes that convert androgens to estrogen, contributing even more circulating estrogen.

A 63-year-old woman with a uterus (she/her), G2P2, presents with 3 months of intermittent vaginal bleeding. She experienced menopause 10 years ago and had no bleeding until her current symptoms. Before menopause she used oral contraceptives for birth control, and since stopping her periods has been on estrogen replacement therapy for symptom management. She has been obese her entire adult life. In addition to her parity, which of the following components protects against the development of endometrial cancer? Select one: a. Estrogen replacement therapy b. Obesity c. Oral contraceptive pill use

a. The patient's postoperative PSA will be non-zero. The prostate gland is surrounded by pink fibromuscular stroma. The presence of benign glands at the periphery of the prostatectomy specimen indicates that glandular tissue was transected during the procedure, and that additional glandular tissue potentially remains in the patient. This limits the utility of using postoperative PSA levels to evaluate recurrence of disease, though a spike in PSA would still be concerning and merit further workup. Prostatitis is an inflammatory condition of the prostate that is distinct from the presence of benign glands at the margin of a surgical specimen. TURP (transurethral resection of the prostate) is not the appropriate treatment for biopsy-proven adenocarcinoma, as the TURP procedure results in multiple separate tissue fragments that can't be reconstructed to assess margin status and other important information. TURP is used to treat BPH (benign prostatic hyperplasia). In about 5% of cases in the UCSF experience, prostatic adenocarcinoma is diagnosed as an incidental finding when reviewing the TURP specimen, underscoring the value of microscopic analysis of TURP tissue fragments

A 65-year-old man (he/him) recently underwent prostatectomy for biopsy-proven prostatic adenocarcinoma. The pathology report confirms the presence of adenocarcinoma in the prostatectomy specimen, and indicates that benign glands are present at the cauterized surgical margin. What is the significance of this finding? Select one: a. The patient's postoperative PSA will be non-zero. b. The patient may have prostatitis. c. The patient could have opted for TURP over prostatectomy.

:c. Hospital-associated functional decline Hospital-associated functional decline. Hospital-associated disability, or functional decline, is the most common complication of older adults admitted to the hospital, occurring in 30-50% of hospitalized older adults, and often results in the need for rehabilitation prior to returning home. In addition, his history of requiring a cane at baseline indicates he is at even higher risk for developing mobility disability from insufficient exercise/ambulation while in the hospital. This disability can be prevented by writing specific activity orders for ambulation during the hospital stay, and checking in with the patient daily to make sure he/she is ambulating. Nosocomial infections occur in 10% of patients; of these, CAUTI (Catheter Associated Urinary Tract Infection, is the most prevalent (40% of nosocomial infections—if the patient has a catheter), and hospital acquired pneumonia is less frequent. Nosocomial pneumonia in particular can be exacerbated by lying in bed, which causes increased lung residual volumes and can be ameliorated by mobilization. DVT occurs in 10-25% of hospitalized patients depending on baseline risk factors.

A 77-year-old man (he/him) presents to the emergency room with fever, nausea, vomiting, anorexia, and right upper quadrant pain. He is diagnosed with acute cholecystitis. Although initially very ill, he rapidly responds to IV fluids and IV antibiotics, and undergoes an elective cholecystectomy during the same admission. He receives a foley catheter intraoperatively that is discontinued one day post-op. At baseline, he lives alone, is independent in ADLs, uses a cane, and rides public transportation. His past medical history includes hypertension, COPD, and BPH, all of which are well controlled on medications. Which of the following hospital complications is he MOST likely to develop during his hospital stay? Select one: a. Catheter-associated urinary tract infection b. Deep vein thrombosis c. Hospital-associated functional decline d. Nosocomial (healthcare-associated) pneumonia

d. Glandular atrophy and increased fibrous connective tissue. Androgen hormone therapy results in atrophy of breast glandular tissue and an increase in dense fibrous stroma. The description "Hyperproliferation of lobules and acini with compression of surrounding stroma" refers to some of the breast tissue changes seen in pregnancy, when the hormonal milieu includes estrogen, progesterone, and prolactin. "Increased numbers of acini with compression of surrounding myoepithelial cells and stroma, and accumulation of clear, lipid-rich cytoplasmic vacuoles in secretory cells" describes lactational/secretory change seen in lactating breast tissue. "Multiple terminal ductal-lobular units with collagenous interlobular stroma and more vascular intralobular stroma" describes breast tissue in a post-pubertal environment influenced predominantly by estrogen and progesterone.

A transgender man (he/him) was on testosterone for more than a year prior to undergoing bilateral mastectomy (top surgery) as part of gender-affirming care. He is not pregnant or lactating. Predict what was seen histologically in the breast tissue specimen. a.Hyperproliferation of lobules and acini with compression of surrounding stroma. b. Increased numbers of acini with compression of surrounding myoepithelial cells and stroma, and accumulation of clear, lipid-rich cytoplasmic vacuoles in secretory cells. c. Multiple terminal ductal-lobular units with collagenous interlobular stroma and more vascular interlobular stroma. d. Glandular atrophy and increased fibrous connective tissue.

Ageism is a process of systematic stereotyping or discrimination against people because they are old. SDOH as "the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies, development agendas, cultural and social norms, social policies, and political systems." In sum, ageism exists in healthcare and the effects of ageist communication and care are important to older adults, impact how they engage in care, and have major effects on their health and healthcare expenditures. ageism affects rapport with older adult patients and may lead to less disclosure of symptoms or other problems affecting health, such as important social, functional and medical issues. Unfortunately, studies show that providers communicate differently in medical encounters involving older versus younger adults.

Ageism Social Determinants of Health

Cognitive impairment Sensory impairments (hearing, vision) Impaired mobility Multimorbidity Polypharmacy Health behaviors (smoking, excessive alcohol use, sedentary lifestyle)

Examples of intrinsic threats to a person's ability to live independently

d. Compression of the S2-4 parasympathetic fibers of the pelvic nerve The question stem describes a patient with acute atonic (or hyporeflexive) bladder that is most likely due to his spinal stenosis causing cauda equina syndrome. The S2-4 parasympathetic fibers of the pelvic nerves, which mediate bladder contraction, are the most likely affected in this scenario. There is no reason for this patient to have an abnormality of the pontine micturition center, which mediates the awareness and control of voiding. While this patient likely has decreased bladder sensation, this is not the CAUSE of his current difficulty urinating. The most common cause of urinary obstruction in older patients with prostates overall is prostatic obstruction, this clinical scenario and imaging suggests a neurologic cause. Compression of the pudendal nerve, which normally facilitates micturition by MAINTAINING external sphincter tone, would cause incontinence rather than obstruction. Urethral stricture (scar inside the urethra) may present with difficulty urinating but in the absence of a history of urethral trauma and with presence of neurologic findings this is less likely.

An 80-year-old man (he/him) with a prostate and history of low back pain complains of difficulty urinating for the last 2 days and numbness of his buttocks and perineum. He has difficulty initiating a urine stream and reports that his urine stream is weak. Lumbar spine CT images reveal spinal stenosis compressing the nerves of the cauda equina (L4-L5). Which of the following is the most likely explanation for his new onset difficulty voiding? Select one: a. Decreased awareness of the need to void b. Benign prostatic hyperplasia c. Compression of the pudendal nerve d. Compression of the S2-4 parasympathetic fibers of the pelvic nerve e. Urethral stricture disease

c. Diphenhydramine r: Diphenhydramine. The patient is experiencing an adverse drug reaction of acute urinary retention from one of the medications he was given during his hospitalization. The most likely culprit would be Diphenhydramine AKA Benadryl, given for the rash and pruritus he experienced from the IV antibiotic. Diphenhydramine is an anticholinergic medication and in addition to urinary retention, can also cause dry mouth, constipation, drowsiness, confusion, and delirium. Older adults are particularly susceptible to anticholinergic side effects and medications with these side effects should generally be avoided in this population. It would be unlikely for Albuterol, Aspirin, Doxycycline, or atorvastatin to cause urinary retention.

An 85-year-old man (he/him) with history of COPD, coronary artery disease, and hypertension was hospitalized for 4 days with community-acquired pneumonia. His sputum cultures were negative. He was treated initially with IV antibiotics and has now been changed to oral doxycycline for the past day, and he is responding well. His course was complicated by a diffuse skin rash and pruritus from his initial IV antibiotic, for which he was given diphenhydramine. His other medications are albuterol, aspirin, and atorvastatin. You had planned to discharge him to home today on oral antibiotics, but the nurse now says that he has been unable to void for the past 10 hours. Which of the following medications he received is the MOST likely culprit? Select one: a. Albuterol b. Aspirin c. Diphenhydramine d. Doxycycline e. Atorvastatin

b. She has delirium based on the Confusion Assessment Method (CAM) She has delirium based on the Confusion Assessment Method (CAM). Besides a UTI, this patient has symptoms of delirium. Using the CAM screening tool, the patient screens positive for delirium as she demonstrates inattention, disorganized thinking, and altered level of consciousness; per her spouse this is an acute onset of mental status changes. The case suggests that the patient does not have dementia at baseline (she is independent in her ADLs and IADLs) and even if she did, this would still not be considered normal behavior. Being older does not automatically imply that the patient will have altered mental status during a hospitalization; all patients have the potential to develop delirium. The patient's history is not consistent with depression, which would be more of a chronic presentation of symptoms rather than an acute change in mental status.

An 87-year-old woman (she/her) is admitted to the hospital for a left hip fracture. At admission, she is noted to be confused and inattentive as you attempt to take a medical history. She knows her name, is aware that she is at Zuckerberg San Francisco General, and recognizes her spouse, but cannot tell you the details of her symptoms leading up to this admission. In addition, she keeps losing her train of thought and must be redirected back to your line of questioning, repeatedly telling you about "the cats and the luggage" when you query her about how she's feeling. She falls asleep repeatedly in the middle of your interview. Her spouse reports that "this is not like her at all." Usually, she is independent in ADLs, does all the grocery shopping and housekeeping without needing assistance, and loves the Chronicle's daily crossword puzzle. How would you best characterize the patient's mental status? Select one: a. She has dementia and this behavior is expected during a hospitalization b. She has delirium based on the Confusion Assessment Method (CAM) c. She is manifesting normal behavior for any older adult in the hospital d. She is depressed and requires a Psychiatry consult

c. Detection of ovarian cancer recurrence CA-125 is not useful for screening in the general population because elevations are associated with benign gynecologic conditions such as menstruation, pregnancy, and endometriosis; with inflammatory conditions such as diverticulitis or pancreatitis; and with other types of metastatic cancers. It is, however, useful for monitoring disease recurrence in patients with known ovarian cancer. Home pregnancy kits test for hCG, not CA-125.

An ideal screening test is inexpensive, convenient, and has a high sensitivity and specificity for detecting its target. In which setting could CA-125 be considered a useful screening tool? Select one: a. Detection of ovarian cancer in the general population b. Detection of pregnancy in a kit for home use c. Detection of ovarian cancer recurrence

Home-based care programs are for older adults for whom routine clinic-based care is not feasible given significant difficulties with mobility, complex comorbidities, and/or psychosocial needs. Most patients in these programs have live-in or hired caregivers to assist them with IADLs and ADLs. In San Francisco, individual PCPs may choose to provide home-based visits, or "housecalls," but there are also organized homebased care programs/practices. The San Francisco VA Home Based Primary Care and UCSF Care at Home programs are two examples of such programs. Typically, patients are seen by a provider in their home or RCFE for both regular check-ups as well as urgent care issues. Most home-based care providers draw labs, give vaccinations, and do basic procedures within the home; patients can also have some imaging services performed in the home. Providers connect patients to a wide array of social support services, other specialists who also make home visits, and homebased rehabilitation services. Home-based care programs/practices are comprised of healthcare professionals, including but not limited to: physicians, nurse practitioners, RNs, and social workers. Care is paid for in a similar fashion to a regular clinic visit. Bottom line: If you are still able to live at home or in an RCFE but need medical care and resource coordination provided to you where you reside, consider a referral to a home-based care program Home-based Care

Home-Based Care

· Angiotensin receptor blocker (Valsartan) is lowering blood pressure—chronic effect is blocking angiotensin II and blocking renal chemoreceptor responses for volume expansion/vasoconstriction/sympathetic stimulation · Alpha blocker (Tamsulosin) taken at night/bedtime is vasodilating, preventing constriction. Timing of falls (patient fell at night time) suggests this is a factor. Other antihypertensive medications that have been associated with postural hypotension are diuretics (by decreasing intravascular volume), beta-blockers (by further blunting heart rate responses), and dihydropyridine calcium channel blockers/nitrates (by vasodilation). Falls may be most common in the first few weeks of initiation of an antihypertensive medication or after an increase in the medication.

How might a patient's medications affect the necessary reflexes and responses to maintain blood pressure in the standing position?

• Endothelial dysfunction (arterial: decreased vasoconstriction and vasodilation)-> less ability to constrict when volume decreased or in response to cold, standing, etc.; less ability to increase flow during ischemia • Ventricle that is less compliant (needs full volumes/pressures to eject enough to maintain stroke volume so cardiac output may fall with standing (remember: cardiac output = stroke volume X heart rate). Ventricle has impaired relaxation such that it cannot fill as well and fills slower so increases the importance of atrial contraction to late diastolic filling (explains impact of atrial fibrillation) • Blunted barorcepter reflex responses: baroreceptor-sensing pressure changes-> diminished beta-adrenergic (chronotropic and inotropic) and parasympathetic responses manifested by o Less increase in cardiac ventricular contractility—limits maximum cardiac output. Cardiac output is often normal at rest but reduced with exercise compared to younger individuals o Less increase in heart rate with standing • dAlterations in renal perfusion responses, RAS system blunts responses to hypovolemia, and decreased perfusion upon standing

How might cardiovascular changes with aging physiologic responses necessary to maintain blood pressure in the standing position?

The "triple test" for breast cancer consists of physical exam, breast imaging (such as mammography or ultrasound), and pathologic analysis of tissue. In this case, since the mass was palpable, fine needle aspiration (FNA) biopsy was a good next step in workup, though at some institutions without a dedicated FNA service, or in older patients, mammography might be obtained after physical exam. The FNA shows branching antler-horn cell clusters as the main arrangement of lesional epithelial cells. Breast imaging in this case was by mammogram; the BI-RADS score of 2 falls in the lower range for risk of malignancy. Taken together, the physical exam findings show a palpable, smooth, mobile, and clinically stable mass; FNA biopsy shows findings consistent with fibroadenoma, and the mammogram result is compatible with fibroadenoma as well. Since the mass is bothersome to the patient, she opts to have it removed. The gross photo shows a well-circumscribed firm-appearing mass that is distinct from background fatty tissue. Though the microscopic findings are not shown from the resection specimen, all the evidence points to excision of a fibroadenoma in this young and previously healthy patient. Fibroadenoma is a benign entity that is cured by surgical removal. Sometimes patients opt not to remove the lesion if it doesn't bother them or interfere with their daily life. The patient's prognosis is excellent, as fibroadenoma has no impact on future cancer risk.

In 1-2 paragraphs, (a) explain how the triple test for breast cancer was applied in this situation, ultimately resulting in surgical excision of this mass, (b) summarize the clinical findings using appropriate diagnostic terminology, and (c) state the patient's prognosis.

Description: Single family homes/townhomes/ apartments that offer the security and social activities of a community living environment. Admission Criteria: In general, age-restricted (age >62) and must be independent in most IADLs and all ADLs Healthcare services: None Typical Services: -Social activities Usually at additional cost: -Laundry / linen service -Meals -Transportation Regulation: not regulated Also known as: -Retirement Communities-Retirement Homes-Senior Apartments-Senior Housing Payment: -Out of pocket. Not covered by Medicare or MediCal -For low income seniors, some are supplemented by Section 8 and other federal Housing and Urban Development housing programs.

Independent Living Description Admission Criteria Healthcare services Typical Services Regulation Also known as Payment

a. Homeostenosis Homeostenosis refers to a lower physiologic reserve in each organ system compared with younger adults. The cardiovascular, renal, and central nervous systems are usually the most vulnerable in older adults. With aging, there are less physiologic reserves available to respond to stressors; in this case, NSAID use is the stressor that precipitates AKI. There is no evidence provided that Mr. B has underlying stage 4 CKD. Homeostasis refers to the dynamic physiologic processes through which the body maintains internal 'equilibrium' in the face of stressors. While we do not have enough information to presume whether most of Mr. B's glomeruli are hyperfiltrating, that in itself would not make him more vulnerable to nephrotoxic medications; at any rate, hyperfiltrating glomeruli are likely compensating for the loss of glomeruli over time.

Mr. B is an 85-year-old man (he/him) with no known medical problems who sprained his ankle while throwing a football back and forth with his 25-year-old grandchild. His grandchild recommended that he take Advil, an over the counter non-steroidal anti-inflammatory drug (NSAID). Mr. B took 800 mg three times daily for the next 7 days. Shortly thereafter, he went to his primary care doctor for a routine checkup, who drew bloodwork that revealed an elevated creatinine and reduced eGFR consistent with acute kidney injury (AKI). What makes Mr. B more vulnerable to AKI than his grandchild? Select one: a. Homeostenosis b. He likely has underlying stage 4 chronic kidney disease, which in turn places him at greater risk for AKI c. Homeostasis d. At his age, most of his glomeruli are hyperfiltrating which make him more vulnerable to potentially nephrotoxic medications such as NSAIDs.

c. Senior housing apartment Senior housing apartment. Mr. E is endorsing challenges in his current living situation related to isolation and a lack of community. A senior housing apartment could provide both the scale of accommodations he might be used to in his apartment with the built-in peer community and scheduled community activities that senior housing provides; most senior housing apartments even come with a van that will transport the patient to activities or shopping. He does not require any assistance with ADLs, thus a skilled nursing facility would be inappropriate. Likewise, he is managing his IADLs (with the exception of driving), thus an RCFE is likely too high of a care level for him. He doesn't require assistance with housekeeping and daily care tasks, and chore help wouldn't address social isolation, so remaining at home with additional services would not be ideal.

Mr. E is an 80-year-old man (he/him) presenting to clinic for routine follow-up with a history of osteoarthritis of the knees and hypertension. He lives alone in an apartment in Daly City. He is recently widowed and is finding the time alone at home challenging, and he and his spouse used to go to the symphony, museums, and local music festivals. Mr. E doesn't drive, and though he can take the Silver Ride taxi service to appointments, finds it challenging to get out and "just see people and do things." He is independent in housekeeping, cooking, and laundry. He shops by walking to the grocery store 2 blocks away. He has no difficulties with activities of daily living. He attended a local senior center for a while, and although he enjoyed the company and activities, found it challenging to develop friendships given the inconsistent attendance of others. Where would be the most appropriate residential model for this patient? Select one: a. Skilled nursing facility b. Residential care facility (eg., Assisted Living or Board and Care) c. Senior housing apartment d. Remain at home with support from housekeepers and paid caregivers

c. Muscle wasting Muscle wasting. On bed rest, muscle strength decreases approximately 1-1.5%/day, 10%/week. The effect is greater in the lower extremities than the upper. Inactivity also rapidly causes muscle shortening which in turn can lead quickly to decreased flexibility and contractures. Although he has risk factors (older age, immobilization), it is less likely that Mr. F has developed a deep vein thrombosis as those generally do not present with bilateral weakness, but with swelling, pain, and/or warmth of the affected extremity. Cerebral infarct could cause weakness but that would typically be unilateral and present with additional symptoms and signs suggesting a stroke. It is unlikely, given that he has shown overall improvement on antibiotics, that there is a new occult infection causing acute weakness.

Mr. F is an 80-year-old man (he/him) admitted to the inpatient medicine service with lethargy and fever. He has a history of hypertension, COPD, and BPH. He lives independently in the community. He is diagnosed with urosepsis and started on IV antibiotics. He improves overall, as evidenced by resolution of fever, normal WBC, and is now alert and attentive. On hospital day 3, you begin to prepare for his discharge, and ask a physical therapist to evaluate his mobility since he hadn't gotten out of bed since admission to the hospital. Mr. F complains of being "so weak in my legs" and states that he cannot walk more than the distance to his commode. An examination of his legs reveals diffuse weakness upon strength testing but no other abnormalities. What is the most likely cause of Mr. F's current inability to ambulate? Select one: a. Lower-extremity deep vein thrombosis b.Cerebral infarct c. Muscle wasting d. Occult infection

b. Nephrolithiasis Renal and ureteral stones are the most common cause of acute upper urinary tract obstruction (hydronephrosis). Impacted stones can block urinary flow and cause severe pain. Ultrasound is very sensitive for hydronephroris but detects only about 70% of urinary stones; even though a stone is not visualized in this case urolithiasis is the most likely cause of obstruction. Both Benign Prostate Hypertrophy and Prostate Cancer may cause hydronephrosis but the onset is typically slow and painless and the hydronephrosis usually affects both kidneys. Renal Cell Carcinoma is typically apparent on renal ultrasound although dedicated CT scan with contrast is usually required to completely evaluate for this. Pyelonephritis is associated with flank pain but typically also includes other signs/symptoms of infection (eg fever, white blood cells and nitrates on urinalysis)

Mr. Gallagher is a 60-year-old man (he/him) with a prostate who comes to see you, his PCP, for a complaint of severe 10/10 lower right-sided back pain, radiating to his groin, that began two days ago. He has not had any weight loss. He denies fever. He does not drink alcohol or smoke cigarettes. When asked about family history, Mr. Gallagher mentions that his father once complained of similar pain. Urinalysis is revealing of red blood cells. Renal ultrasound is obtained and shows hydronephrosis of the right kidney. The left kidney and bladder are normal. Which of the following is the MOST likely diagnosis on your differential? Select one: a. Benign prostatic hypertrophy b. Nephrolithiasis c. Prostate cancer d. Renal Cell Carcinoma e. Pyelonephritis

a. Paraphimosis Paraphimosis is the condition in which the penile foreskin is left proximal to the glans penis for a prolonged period of time; constriction from this retracted foreskin restricts venous outflow from the glans penis and can lead to painful glanular edema. Paraphimosis may occur when a health care provider fails to pull the foreskin over the glans after Foley catheter insertion. Phimosis is the condition in which the penile foreskin cannot be retracted proximal to the glans; in phimosis the glans is not visible. This patient has an indwelling Foley which is draining appropriately so he is not in urinary retention. Balanoposthitis is superficial infection of the glans penis; it may occur in patients who have severe phimosis and/or poor hygiene habits but is less likely as a cause of this patient's symptoms given nature of onset and absence of discharge. Priapism is prolonged, painful erection of the penis and is associated with penile erection (flaccidity).

Mr. Smith is a 68-year-old man (he/him) with a penis who underwent surgery this morning for a hip fracture. He is reporting penile pain and has a foley catheter in place which was inserted in the operating room. He denies having been circumcised. He had no penile pain prior to surgery. On physical exam the penile shaft is flaccid. The glans penis is visible; it is erythematous, swollen, and tender but there is no discharge. A foley catheter is in place draining clear yellow urine. What is the cause of Mr Patel's penile pain? Select one: a. Paraphimosis b. Phimosis c. Urinary Retention d. Balanoposthitis e. Priapism

d.Mrs. H has multiple diseases that compound each other, resulting in collectively adverse effects on health, function, and quality of life. Mrs. H has multiple diseases that compound each other, resulting in collectively adverse effects on health, function, and quality of life. Mrs. H demonstrates multimorbidity, which is the compound effect of multiple diseases on an individual patient, leading to medication-related problems, functional impairment, and decreased quality of life. Multimorbidity therefore requires complex healthcare management, decision making, and coordination. Mrs. H's multiple chronic conditions do have a compounding nature with each other; for instance, her atrial fibrillation and anticoagulation coupled with her osteoporosis and frequent falling puts her at an increased risk of functional impairment and serious injury. Multimorbidity implies multiple chronic diseases that interact and require complex decision making and coordination; a patient can have more than three diseases that do not interact and therefore would not meet the definition of having multimorbidity. Also, the number of diseases a patient has does not necessarily correlate with prognosis. Simultaneously applying multiple disease-specific clinical practice guidelines in patients with more than two diseases may lead to care that is impractical, irrelevant, or even harmful. While Mrs. H's atrial fibrillation certainly adds to her complex medical picture, it would likely not be the sole factor contributing to her worse overall function.

Mrs. H is an 87 year old woman (she/her) with a history of atrial fibrillation (on anticoagulation), osteoarthritis, osteoporosis, hypothyroidism, hypertension, and mild dementia, who had three falls this past year. She and her son (he/him) present to your clinic for a routine check-up. Her son reflects upon how differently his mother is aging compared to his father (Mr. H), who is also 87 years old, has only hypertension and osteoarthritis, and seems overall much healthier. How does Mrs. H's situation differ from that of Mr. H? Select one: a.Mrs. H has more than 3 diseases, which means she has a prognosis of two years or less, which is worse than Mr. H's prognosis. b.Mrs. H requires an approach to care which involves simultaneously applying multiple disease-specific clinical practice guidelines, such as those for hypertension and atrial fibrillation. c.Mrs. H's atrial fibrillation and anticoagulation cause her to have worse overall function. d.Mrs. H has multiple diseases that compound each other, resulting in collectively adverse effects on health, function, and quality of life.

a. Sacrum Pressure injuries (e.g. ulcers) are a common but preventable complication of hospitalization for older adults. They appear on high-pressure surfaces of the body, such as the sacrum, heels, and any bony protuberance that is making contact with a bed or chair for prolonged periods of time. Although it is possible that Mrs. M had this sacral pressure ulcer prior to arriving at the hospital, it is also highly possible that she developed it while lying in the ED for 16 hours. It only takes 2 hours to develop a pressure ulcer over an immobile bony protuberance. They are less likely to appear on the dorsalis of the foot and anterior chest given that these areas do not typically make contact with the bed. The posterior knee, although touching the bed when the patient lies on his/her back, does not have a bony protuberance which traps and applies pressure to the skin between bone and bed.

Mrs. M is an 88-year-old woman (she/her) with dementia who presented to the emergency department with lethargy and a fever. She is found to have urosepsis and the plan is to admit her to the inpatient medicine service. However, there is no immediate bed availability in the hospital, so Mrs. M remained in the ED for 16 hours. Upon admission to the medicine ward, a nurse pages you to the bedside, asking you to "please come and evaluate a skin lesion." On examination, the lesion is a 2 cm partial thickness loss of skin with an erythematous wound bed. Where is the most likely location of this lesion? Select one: a. Sacrum b. Dorsalis of foot c. Anterior chest d. Posterior knee

A Ask where she stores her medications. Brightly colored medications can be easily mistaken for candy by 3-year-olds. Review with Mrs. R that medications should be stored in areas out of sight and out of her grandchild's reach. If medications are kept in a bag or purse, then those items should also be stored in a closet or other high area that is not easily accessible. Given Mrs. R's medical history, she is taking hypoglycemic, antihypertensive, antihyperlipidemic medications, in addition to pain medications - all of which pose a danger if ingested by her grandchild. The other answer options are not reliable ways to prevent her grandchild from getting and ingesting her medications. Furthermore, 'childproof' bottles may be impractical for patients with arthritis.

Mrs. R is a 70 year-old-woman (she/her) with a history of diabetes, hypertension, hyperlipidemia, osteoarthritis, and chronic back and knee pain. She is the primary caregiver for her 3-year-old grandchild, with whom she lives. She is in your clinic for a routine check up, feels that she is doing well, and wishes to "check" with you on how well her diseases are currently controlled. In addition to discussing her comorbidities, you wish to discuss health maintenance, including administering a flu vaccine since flu season is approaching. Which of the following is also important to ask Mrs. R regarding medication safety and her grandchild? Select one: a. Ask where she stores her medications b. Ask if she tells her grandchild not to take her medications c. Ask if she keeps her medications in childproof bottles d. Ask if she avoids taking her medications in her grandchild's presence

c. Cystoscopy The standard components of a hematuria work up include cystoscopy and upper tract imaging (eg CT with contrast, renal bladder ultrasound, MRI). Of the available options, cystoscopy is the one that is most appropriate to rule out bladder processes. The most concerning possibility is a malignancy of the bladder; tobacco use is a major risk factor for this. In a patient with significant concern for malignancy renal bladder ultrasound would not be sufficiently informative; a contrast enhanced study of the kidneys with delayed phase imaging of the ureters is also appropriate but is not a listed option here. In the absence of patient-reported dysuria and concomitant absence of white blood cells or nitrates on urinalysis the likelihood of infection is low, empiric antibiotics are not indicated. Urodynamics is useful for assessment of bladder function but is not informative regarding causes of hematuria

Ms Jones is a 65-year-old woman (she/her) who is a retired kindergarten teacher presenting to her primary care provider for an increase in urinary frequency and intermittent red urine over the past three weeks. She denies any dysuria or abdominal pain. She has no medical problems and takes no medications. She has been smoking two packs of cigarettes a day since she was 18 years old. She lives at home and attends pottery classes at her senior center weekly. Her dipstick urinalysis is positive for blood but negative for nitrates and leukocyte esterase. 10 RBC/hpf are seen on microscopy. What is the most appropriate next step? Select one: a. Urine culture and empiric treatment with ciprofloxacin b. Renal and bladder ultrasound c. Cystoscopy d. Urodynamics

c.Loneliness Loneliness is defined as the subjective feeling of being alone (perceived isolation). It also relates to the distress that results from discrepancies between ideal and perceived social relationships. In contrast, social isolation refers to a complete or near-complete lack of contact with society, and it relates to a quantifiable number of relationships (actual isolation). Given that she lives with multiple relatives, she is not socially isolated and her symptoms best support loneliness, not high social connectedness or anxiety. A brief screener for loneliness that is available in the UCSF Health EMR is the UCLA three-item loneliness scale Loneliness is a significant risk factor for premature mortality and is comparable with the effects of smoking. It has been shown to have a greater impact on health than obesity, physical inactivity, and air pollution.· Together and independently, loneliness and social isolation have been shown to have a negative association with function, independence with ADLs, specific health outcomes such as cardiovascular disease and dementia, and mortality.

Ms. C is an 87-year-old woman (she/her) who lives with her son, her daughter, son-in-law, and four grandchildren. At her check-up, she reports thinking a lot lately about her mortality, and feeling distressed that her family doesn't spend as much time with her as she'd like them to. She also often feels "left out" of family activities although she lives with her family and several additional family members often visit. What best fits Ms. C's description? Select one: a. Social isolation b. High social connectedness c.Loneliness d. Anxiety

c. Mobilize (get her moving) out of bed as early as safely possible post-hip fracture repair Mobilize (get her moving) out of bed as early as safely possible post-hip fracture repair. Prevention of post-op delirium entails a number of proven strategies, including early mobilization as soon as possible to improve sleep/wake cycles (getting up and out of bed helps!) and prevent deconditioning. Unless indicated in order to monitor a specific issue, q4 hr vital checks interfere with overnight sleep which in turn places a patient at risk of delirium (option a). Prevention of falling is not an indication for a foley catheter (option b). Ms. M also does not have an indication for continuous telemetry. Elimination of "tethers" (foley catheters, telemetry wires, etc), also helps with early mobilization.

Ms. M is an 86-year-old woman (she/her) with moderate dementia who is admitted to the hospital with a right hip fracture due to a fall. She lives in a skilled nursing facility and is dependent in all ADLs except feeding. She can ambulate with a walker. After discussing the risks and benefits of undergoing surgical repair, her daughter (who Ms. M previously designated as her healthcare decision maker) decided to proceed with surgery. Which of the following should be done post-operatively to prevent a likely and common post-op complication for this patient? Select one: a. Check her vital signs every 4 hours for close monitoring of her condition b. Insert a foley catheter to prevent her from falling out of bed and re-injuring her hip when trying to use the commode c. Mobilize (get her moving) out of bed as early as safely possible post-hip fracture repair d. Maintain her on telemetry for 72 hours post-op to monitor her heart rate

d. Stress urinary incontinence; Kegel exercises; urethral sling surgery Stress Urinary Incontinence (SUI) is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. It can be seen with or can be distinct from Urge Urinary Incontinence (UUI), which is the complaint of involuntary leakage accompanied or immediately preceded by sudden, compelling need to urinate. If both types of incontinence are present the most appropriate diagnosis is Mixed Urinary Incontinence (MUI); in many cases of MUI one sub-type is predominant in terms of bother. Lifestyle modifications may be of benefit for voiding symptoms of any type but the most direct and effective therapy for SUI is pelvic floor muscle training (ie Kegel exercises); if this fails surgical placement of a urethral sling is highly effective

Ms. Thompson, a 40 year-old G2P2 woman (she/her) with a vagina, uterus and ovaries presents to you, her gynecologist, with a chief complaint of urinary leakage. She leaks urine every time she laughs, sneezes, or jumps up and down. She denies sudden sensations of need to urinate. This problem has been present since the birth of her youngest daughter two years ago. The leakage has worsened to the point where she has had to wear 3 incontinence garments a day over the last six months. Her urinalysis and post-void residual are within normal limits. What is the diagnosis? What are the most appropriate first and second line therapies for Ms. Thompson? Select one: a. Urge urinary incontinence; lifestyle modification; anticholinergic medication b. Urge urinary incontinence; Kegel exercises; urethral sling surgery c. Stress urinary incontinence; lifestyle modification; anticholinergic medication d. Stress urinary incontinence; Kegel exercises; urethral sling surgery e. Mixed urinary incontinence; Kegel exercises; anticholinergic medication

a.She has a blunted sympathetic and parasympathetic response to baroreceptor activation, leading to an inability to compensate for a drop in blood pressure upon standing. There is a blunted sympathetic and parasympathetic response to baroreceptor activation in older adults upon standing. In younger persons, baroreceptors sense a fall in central pressure, which leads to parasympathetic withdrawal at the sinus node, which in turn leads to an increase in heart rate to compensate for the initial drop in blood pressure. This is followed by beta-adrenergic stimulation, which leads to norepinephrine release, which in turn leads to an increase in heart rate and vasoconstriction in the periphery. A decrease in these responses with aging predisposes to postural hypotension.The arteries and ventricles are typically more stiff and the left ventricle is typically less compliant with age, requiring full volumes/pressures to eject enough blood to maintain stroke volume. There is nothing else in the history/exam provided to suggest a myocardial infarction. Our maximum heart rate decreases with age which again predisposes for a blunted response to a drop in blood pressure.

Ms. Z is a 75-year-old woman (she/her) with a history of coronary artery disease and osteoporosis who presents to the urgent care center after sustaining a ground level fall. She reports she became dizzy upon standing up at home, lost her balance, and fell onto her right hip. You check her vital signs and note that she has a >25 mm Hg drop in her systolic blood pressure with standing. Her right hip is tender and shows bruising, but an x-ray does not show a fracture. What is the most likely mechanism of Ms. Z's dizziness that led to her fall? Select one: a.She has a blunted sympathetic and parasympathetic response to baroreceptor activation, leading to an inability to compensate for a drop in blood pressure upon standing. b. Her arteries and ventricles are less stiff, leading to lower baseline diastolic and systolic blood pressures that are lowered further by standing. c. She had an acute myocardial infarction, which caused her left ventricle to become more compliant, baggy, and unable to eject a sufficient stroke volume. d. Her maximum heart rate is higher than it might have been 20 years ago, leading to inefficient ventricular "squeeze" during each contraction when her heart is "stressed" by standing up.

BENIGN Name: serous cystadenoma, serous adenofibroma, or serous cystadenofibroma Behavior: completely benign is surgery curative? yes is intraoperative staging performed? no BORDERLINE Name: serous borderline tumor Behavior: uncertain/low malignant potential, may grow and spread over many years is surgery curative? maybe - patients need close monitoring especially if contralateral ovary isn't remove is intraoperative staging performed? yes MALIGNANT Name: serous carcinoma Behavior: grows excessively and spreads widely is surgery curative? no is intraoperative staging performed? yes

Ovarian Benign, Borderline, and Malignant Name Behavior is surgery curative? is intraoperative staging performed?

•Epithelial tumors are the most common type of ovarian tumors, and within that group, serous epithelial tumors are the most common type of malignancy, accounting for about 40% of all ovarian cancers. serous cystadenomas are derived from the ovarian surface epithelium. High-grade serous carcinoma of the ovary originates in the fallopian tube fimbriae or from serous inclusion cysts in the ovary and is associated with p53 mutations.

Ovarian Tumors - Which compartment generates this tumor type? Serous Cystadenomas High-grade serous carcinomas

No, the benign-borderline-malignant progression for epithelial tumors of the ovary is unlikely to apply here. Ovarian epithelial tumors are divided into two categories: type I tumors, which go through a benign-borderline-malignant sequence to result in low-grade carcinoma (including serous and other histological types), and type II tumors, which typically present as high-grade serous carcinoma without any lower-grade precursor lesion. The patient's imaging findings of bilateral tumors, mainly solid (supported by the gross image) and microscopic findings of epithelial complexity with prominent papillary growth, in the context of clinically advanced disease (omental caking and peritoneal involvement by the same tumor) all strongly suggest a diagnosis of high-grade serous carcinoma. Therefore, this is most likely a type II tumor, for which the benign-borderline-malignant progression would not apply. Additional information: the negative serum hCG effectively rules out pregnancy, and the serum CA-125 is a nonspecific marker that can be elevated in a variety of conditions, including benign entities (pregnancy and endometriosis, among others), inflammatory conditions (diverticulitis, pancreatitis), or malignancy (epithelial ovarian tumors, metastatic disease). Serum CA-125 is useful in monitoring disease recurrence for patients with epithelial ovarian tumors.

PA is a 43-year-old woman (she/her), G2P2, who presents to her gynecologist with several weeks of abdominal fullness. She reports unintentional weight loss of 10 lbs over the past two months, but still feels bloated. She wonders if she might be pregnant again, but she does not have nausea or breast tenderness, both symptoms she experienced early in her prior pregnancies. Abdominal exam confirms bilateral abdominal fullness. Labs drawn after her clinic visit show: serum hCG is negative and serum CA-125 is 102 U/mL (normal CA-125 is <36 U/mL in adults with ovaries). CT scan shows bilateral adnexal masses that are mixed solid and cystic, mainly solid. Omental caking and peritoneal nodules are present. She undergoes surgical resection. The following images show representative gross and microscopic findings seen for both the right and left ovary. One of the peritoneal nodules sampled intraoperatively by frozen section also shows similar microscopic findings to what is shown below In 1-2 concise paragraphs, address whether the benign-borderline-malignant progression is likely to apply for this patient's tumor. Justify your answer with evidence from the clinical and pathologic findings.

First, we address the genetic workup, findings, and clinical recommendations. LA's genetic workup is in keeping with the 2019 recommendation by the US Preventive Services Task Force that patients with relatives with breast, ovarian, fallopian tube, or peritoneal cancer be checked for a family history suggestive of BRCA mutation (her older sister has ovarian cancer). Though we are not provided additional details about the suggestive findings, we are told that a deleterious (adverse) germline BRCA1 mutation is identified. A germline mutation in BRCA1 or BRCA2 results in an estimated lifetime risk of developing breast cancer of 40-85% (this range can vary depending on the reference cited). A germline mutation in BRCA1 or BRCA2 results in a risk of developing ovarian cancer of 20 to 60% by age 70 (again, this range can vary, but the important point is that it is high for both breast cancer and ovarian cancer). Because of this large increase in cancer risk, LA opts to undergo bilateral mastectomy and salpingo-oophorectomy as prophylactic or risk-reducing procedures to minimize her risk of cancer development at these sites. Next, we address the significance of the pathologic findings. Some patients with BRCA1 and BRCA2 germline mutations show significant epithelial atypia in their fallopian tubes in the form of serous tubal intraepithelial carcinoma (STIC). These lesions are thought to be an origin of ovarian high-grade serous carcinoma, which also involves p53 mutations, whereas low-grade serous carcinoma of the ovary likely originates in a borderline ovarian tumor as a precursor, and involve KRAS and BRAF mutations. In risk-reducing salpingo-oophorectomy (RRSO), the entire ovary and fallopian tube on either side is submitted for pathologic analysis to look for areas of epithelial atypia. In some cases, grossly suspicious lesions may be present, but more commonly, microscopic abnormalities are identified without gross lesions, as for this patient. The fimbria is the site of the tube most commonly involved by STIC; the fimbria is the portion of the tube that sweeps over the ovary and potentially may seed it with malignant cells.

PA is a 43-year-old woman (she/her), G2P2, who presents to her gynecologist with several weeks of abdominal fullness... The patient's younger sister, LA (she/her), age 35, undergoes genetic counseling and testing, and is found to have a deleterious germline BRCA1 mutation. She opts to undergo bilateral mastectomy and salpingo-oophorectomy as recommended. At the time of pathologic analysis, no gross abnormalities are identified, but a microscopic focus of epithelial atypia is identified in the fimbria of her left fallopian tube. In 2-3 paragraphs, connect the pieces of information provided about LA's workup to explain their significance as fully as you can, based on the concepts covered this week in Life Stages. Your answer should address genetic workup and findings, clinical recommendations, and pathologic analysis.

Description: PACE works by coordinating a combination of medical and social services at an adult day health center and via in-home services. PACE becomes the patient's health care and social work team; patients transition their primary care services to the doctors at the PACE site. Admission Criteria: Age >55 -Eligible for custodial care (dependent in most ADLs) but want to remain at home and can do so safely -Dual eligible (has both Medicare and MediCal) -Must live within service area Healthcare services:Provided by an interprofessional team, including MD/NP, dentists, optometrists, rehab therapists, social workers, home health aides Typical Services: Social activities ADL/IADL assistance included, e.g.: Regulation: State & Federal Regulations payment: -Covered by Medicare and MediCal together. If the patient does not qualify for MediCal, may pay out of pocket for MediCal's portion.

Program of All-Inclusive Care for the Elderly (PACE) Description Admission Criteria Healthcare services Typical services regulation payment

PACE sites are federally (Medicare) and state (Medicaid) funded programs whose goal is to keep frail older adults living in the community and out of institutionalized long-term care (NHs) for as long as possible. Eligible for older adults >55yo who would otherwise meet a nursing home level of care, PACE works by coordinating an all-inclusive combination of medical and social services through adult day programs and in-home services. PACE becomes the patient's health care and social work team; patients transition their primary care services to the doctors at the PACE site. Most PACE enrollees are transported to the PACE center during the day hours, socialize with peers and staff, and eat meals on site. Enrollees see interprofessional health care providers and receive rehabilitation services at the site as needed. They then return home at the end of the day program; as a result, there must be an in-home caregiving support structure through family members or hired caregivers for the hours the enrollee is not at the PACE site. PACE is paid for jointly by Medicaid and Medicare; some participants have only Medicare and pay out of pocket for the balance. In San Francisco, we are fortunate to interface with the original PACE model site: On Lok in Chinatown as well as several other On Lok sites throughout the city. Bottom line: Think of PACE as the "all-inclusive resort" version of health care with the goal of keeping you in your home and out of a nursing home. If you are eligible for NH level care but want to stay at home, a PACE can be a good optio

Program of All-Inclusive Care for the Elderly (PACE):

a. Improvement with continued work with physical therapy to regain function Improvement with continued work with physical therapy to regain function. Mr. F's new weakness and inability to ambulate as before hospitalization is an example of functional decline, defined as a decrement in physical &/or cognitive functioning. This is the leading complication of hospitalization in older adults and occurs in 34-50% of hospitalized older patients. Functional decline leads to prolonged hospitalization, increased institutionalization/loss of independence, higher health care expenditures, higher readmission rates, and higher mortality. Fortunately, intervening with regular strength and mobility training through physical therapy can help to reverse many effects of hospital incurred functional decline. While it is possible the Mr. F will need a cane to ambulate upon discharge, we cannot know at this point, with the information given, whether he will need it for the rest of his life. There is no reason, given his prior independent status, to assume that he is now condemned to prolonged functional decline as long as his functional impairments are addressed promptly and effectively. There is also no evidence to suggest that muscle wasting increases risk of myositis.

Referring to the same case as above, what is the prognosis for Mr. F's inability to ambulate? Select one: a. Improvement with continued work with physical therapy to regain function b. He will likely need to use a cane for the rest of his life c. He will experience gradual functional decline from this point forward as a result of the hospitalization d. He is at a higher risk of developing myositis

RCFEs can be either "Assisted Living Facilities (ALFs)" (16+ beds) or "Board and Care Homes (B&Cs)" (4 to 6 beds). Both are non-medical facilities that provide a room and meals, as well as housekeeping. Some of these sites can provide storage and distribution of medication for self-administration, and personal care assistance with a few ADLs like hygiene, dressing, eating, bathing and transferring—however these services often cost extra. RCFEs serve persons 60 years of age and older. This level of care and supervision is for people who are unable to safely live by themselves but who do not need 24-hour nursing care. Since they are considered non-medical facilities, RCFEs are not required to have nurses, certified nursing assistants or doctors on staff. RCFEs are NOT paid for by Medicare or Medicaid and are an out of pocket expense. Bottom line: If you are unable to live independently to care for your home and self, and would benefit from structured housing with basic essentials (meals, housekeeping) provided at cost WITHOUT any daily medical or nursing related needs, RCFEs can be a good option.

Residential Care Facility for Elders (RCFE):

Description:This category includes: Board and Care (usually 4-6 beds) Assisted Living Facilities (usually 16+ beds) Both provide 24 hr assistance with activities of daily living such as eating, bathing, and using the bathroom but NOT medical services Admission Criteria: In general, age-restricted (age >60), cannot independently perform some ADLs, but must NOT require 24 hr skilled nursing or medical care Healthcare services: None Typical Services: Social activities ADL/IADL assistance usually at additional cost, Regulation: State Also known as: -Personal care homes-Eldercare facilities -Domiciliary care-Adult Living Facilities -Group Homes payment: Out of pocket. Not covered by Medicare or MediCal

Residential Care for Elders (RCFEs) Description Admission Criteria Healthcare services Typical Services Regulation Also known as Payment

Socioeconomic and Psychiatric Risk Factors Unmarried status Lack of social support Caregiving role Lower SES Lower household income Living alone Negative life events Positive family hx of depression Substance abuse Prior depressive episodes, prior suicide attempts Medical Risk Factors cognitive impairment/dementia cardiovascular disease/stroke cancer parkinson's disese lung disease arthritis sensory impairement diabetes mellitus HIV related illness Age

Risk factors for late-life depression Socioeconomic and Psychiatric Risk Factors Medical Risk Factors

a. Atrophy Decreased levels of sex hormones during menopause result in fewer numbers and sizes of glands. Atrophic breast largely shows the replacement of breast tissue with fibroadipose tissue. Breast tissue in an adult with testes, without exogenous estrogen exposure, does not show ductal complexity and TDLUs. However, large branching ducts would be found embedded within surrounding fibroadipose tissue, and are not seen in this sample, which is of adequate size to identify the ducts if present. Lactational change during pregnancy results in the hyperproliferation of glands with intracytoplasmic vacuoles and a hobnailed appearance (bulging cells like hobnails on a boot).

Select one: a. Atrophy b. Breast tissue in an adult born with testes, without exogenous estrogen exposure c. Lactational change

b. Ciliated cells: passage of oocyte from the fallopian tube to endometrium The cells indicated in the image are ciliated cells, which produce rhythmic beating of their cilia to sweep the ovulated oocyte from the fimbrial end of the tube toward the uterine cavity for implantation in the endometrium. Secretory cells (which are non-ciliated - a few are present in this image) are responsible for producing lubricating secretions, but they are not present in the indicated area.

Select one: a.Ciliated cells: production of lubricating secretions b. Ciliated cells: passage of oocyte from the fallopian tube to endometrium c. Secretory cells: production of lubricating secretions d. Secretory cells: passage of oocyte from the fallopian tube to endometrium

b.Reproductive age The correct answer is "Reproductive age." This image is from the ovary and shows a relatively numerous population of ovarian follicles, though not follicles are not as abundant as in the fetus. In addition, the typical "ovarian-type" stroma is present, consisting of dense spindle cells, another clue as to anatomic site. Fetal ovaries would be densely packed with follicles with little intervening ovarian stroma. The ovaries of post-menopausal individuals are typically devoid of residual ovarian follicles.

Select one: a.Fetal development b.Reproductive age c.Post-menopausal stage

(a) Ageism affects rapport with older adult patients and may lead to less disclosure of symptoms or other problems affecting health, such as important social, functional, and medical issues. Studies show that providers communicate differently in medical encounters involving older versus younger adults. One study found doctors were less patient and less engaged with their older patients (b) Older adults build and maintain relationships with trusted providers and seek to end relationships with providers they do not trust. Many felt that they were not being heard, which led to distrust in the relationship and feeling powerless. It is likely that ageism contributes to these feelings and preferences

The impact of ageism on health can be seen through

· Our ability to navigate our physical environment is critical for getting to/from appointments, picking up medications, accessing community resources to maintain our health etc. · Medicare has very specific criteria for what assistive technologies it will cover. Example of devices excluded from coverage include: hearing aids, bath seats, grab bars, home elevators, wheelchair ramps. Additionally, a critical statutory requirement is that durable medical equipment must involve use in the home. · About 600,000 older adults stop driving each year, according to the National Association of Area Agencies on Aging. This means that older adults must find alternative ways to reach their appointments such as public transportation. However, older adults with access to public transportation often choose not to use it for various reasons, including distance to transit stops and concerns about safety.

The impact of physical environment on access to care for older adults:

Low income older adults are more likely to report barriers to accessing care than higher income adults · Although it was thought that there would be greater equality regarding access to care in older adults because of Medicare, studies have found that this is not true, and that supplemental insurance to Medicare is a determining factor driving access to care. Access to care encompasses the ability to secure timely appointments, preventative services, and overall affordability. o Medicare beneficiaries with private supplemental health insurance are more likely than their counterparts lacking such coverage to make at least one physician visit annually, to receive preventive services such as cancer screening, and to have a usual source of care. o Beneficiaries who lack supplementary coverage are more likely to experience longer waits in doctors' offices, to delay care because of costs, and to receive medical care in a hospital setting rather than a doctor's office. o Private supplementary insurance coverage is associated with better survival outcomes. Apart from those who are more severely disabled in ADLs, the odds of dying within a year are estimated to be between 37% and 53% lower among Medicare beneficiaries with private supplementary insurance relative to those without such coverage.

The impact of socioeconomic factors on access to care for older adults:

a. Leiomyosarcoma and leiomyomas The clinical setting describes a dominant nodule in the uterine wall with a soft (necrotic) and bloody (hemorrhagic) interior and multiple smaller background nodules with a less concerning gross appearance. This description is concerning for leiomyosarcoma as well as leiomyomas (they can co-exist and often do). The patient had abnormal uterine bleeding, which is commonly caused by leiomyomas, with the presence of pelvic pain being an additionally concerning sign for the possibility of leiomyosarcoma. However, the symptoms of leiomyoma and leiomyosarcoma can overlap. Keep in mind that the final diagnosis of leiomyosarcoma requires microscopic evaluation for the presence of cellular atypia, increased mitotic activity, and necrosis. Endometrioid adenocarcinoma is not a strong suggestion in this description, given that the inner lining of the uterine cavity (the endometrium) appears delicate and pink-red. Thickened endometrium would be concerning if described, as it suggests at least hyperplasia. The outer lining (serosa) is described as smooth and slippery, which is normal given that it consists of a smooth layer of peritoneal connective tissue. No serosal process (including serosal adhesions, or bands of fibrous tissue) is suggested by this description.

You are evaluating a hysterectomy specimen from a patient with abnormal uterine bleeding and pelvic pain. The specimen has multiple firm nodules in its wall, distending its normal shape. The largest nodule is 7 cm in size with a soft and bloody interior. The remaining nodules are between 1 and 2 cm in size. The cut surface of these smaller nodules appears whorled and tan-white and feels firm. The inner lining of the uterine cavity appears delicate and pink-red. The outer lining of the uterus feels smooth and slippery. What are the diagnoses you predict in this specimen? Select one: a. Leiomyosarcoma and leiomyomas b. Leiomyomas c. Endometrioid adenocarcinoma and leiomyomas d. Serosal adhesions and leiomyomas

a. Tumor is likely to contain p53 mutations. The description is highly suspicious for high-grade serous carcinoma. Serous ovarian carcinoma is divided into two types: type I, or low-grade (well-differentiated) serous carcinoma, and type II, or high-grade (moderately to poorly differentiated) serous carcinoma. Low-grade serous carcinomas may originate in ovarian serous borderline tumors, whereas high-grade serous carcinomas originate in the fallopian tube fimbriae or from serous inclusion cysts in the ovary. The development of serous cystadenomas, serous borderline tumors, and low-grade serous carcinoma is a continuous pathway due to KRAS and BRAF mutations. In contrast, high-grade serous carcinomas are associated with p53 mutations and do not arise from the low-grade serous tumors. Bilateral largely solid masses do raise consideration of metastasis, but this patient has no prior cancer history, and a primary ovarian or tubal process is more likely. Patients with ovaries who have high-grade serous carcinomas often have widespread metastasis at the time of presentation, resulting in poor prognosis and the need for systemic therapy as well as a surgical approach.

You are evaluating right and left adnexal tumors from a 41-year-old woman (she/her). She has no prior cancer history. The tumors have a largely solid appearance with a few papillary projections grossly. Which of the following is most accurate? Select one: a. Tumor is likely to contain p53 mutations. b. The findings represent progression through a benign-borderline-malignant sequence. c. The masses represent metastases to the ovaries. d. Surgery is curative.

c. 9 The Gleason score is a sum of the two most common Gleason patterns or grades in the tumor. Gleason grading is an architectural grading system that has been in use for decades, which stratifies the tumor into five grades (1 through 5) based on its architectural appearance at low power. Low-grade tumor (grades 1-3) is composed of individual well-formed glands, while higher grade tumor (grades 4 and 5) demonstrates more complex architecture that includes fused glands, cribriform glands, single cells, and solid nests of tumor. While Gleason scores can theoretically range from 2-10, in modern practice, the Gleason scores reported on biopsy range from 6-10 (since Gleason patterns 1 and 2 cannot be reliably identified in small biopsies). The tumor as described consists entirely of higher grade patterns, and therefore the answer choice 9 is the best fit (cribriform glands are grade 4, and single cells are grade 5).

You are reviewing prostate biopsy slides with a pathologist, who diagnoses prostatic adenocarcinoma. You observe that the tumor in the biopsy sample consists entirely of cribriform glands and single cells. Which of the following is the most appropriate Gleason score for this tumor? Select one: a. 3 b. 6 c. 9 d. 12

b. The Women's Health Initiative showed that women on hormone replacement therapy had an increase in the incidence of breast cancer with no cardiovascular protection The Women's Health Initiative was stopped when interim analyses demonstrated an unacceptable risk profile for a drug in a prevention trial. There was an increase in the incidence in breast cancer (an increase of 8 cases per 10,000 women) with no cardiovascular protection (and potentially increased cardiovascular risk). There was, in fact, an increase in blood clots, strokes and coronary heart disease.

You are seeing ML, a 60-year-old woman (she/her) who went through menopause ten years ago. She is not currently experiencing any bothersome menopausal symptoms. A friend encouraged her to consider hormone replacement therapy, and she is wondering if it would protect her against heart disease. Referencing the results of the Women's Health Initiative, what would you tell her? Select one: a. The Women's Health Initiative was stopped early because hormone replacement therapy was shown to have such a dramatically positive effect on cardiovascular outcomes. b. The Women's Health Initiative showed that women on hormone replacement therapy had an increase in the incidence of breast cancer with no cardiovascular protection. c. The Women's Health Initiative showed that women on hormone replacement therapy had a decrease in both cardiovascular events and breast cancer. d. The Women's Health Initiative was inconclusive on the benefits versus risks of using hormone replacement therapy to reduce cardiovascular risk. More studies need to be performed on this question in the future.

b.Residential care facility (eg., Assisted Living or Board and Care) Residential care facility (eg., Assisted Living or Board and Care). The patient has challenges in his home given his new difficulties with mobility post-patellar fracture (he cannot maneuver his stairs). In addition, he's developed a need for assistance in IADLs (housekeeping and laundry). Also importantly, he feels socially isolated and would likely benefit from increased opportunities for engaging with his peers. An RCFE would support all of the above needs of this patient. As he owns his own home, he likely has assets (including his house) that could pay for an RCFE. This patient does not need skilled nursing care (there is no noted impairment in ADLs, no skilled therapy needs). He needs a higher level of care than Senior Housing Apartments given his dependency with certain IADLs. While he could remain at home with increased assistance, that would not address his social isolation nor perhaps his desire to move "someplace more manageable."

You are seeing an 84-year-old man (he/him) in clinic 6 months after a complex right patellar fracture caused by tripping over a tree root. He underwent surgery and has had a very slow but steady recovery in his mobility, but still needs a walker. His spouse passed away 2 years ago and his children live out of state. He lives alone in his own home in the Inner Sunset. Since his surgery, he's found it increasingly challenging to climb to the second floor of his home. He is also feeling isolated and comments that he is considering moving to "someplace more manageable." He hired a housekeeper to help with housekeeping and laundry as it's been hard to do strenuous activities since his surgery. Where would be the most appropriate residential model for this patient? Select one: a.Skilled nursing facility b.Residential care facility (eg., Assisted Living or Board and Care) c. Senior housing apartment d. Remain at home with support from housekeepers and paid caregivers

b. Caregiving role Caregiving role. Mrs. L is manifesting some symptoms of depression (decreased appetite, weight loss, loss of interest in activities). Being a caregiver, for example, comes with a higher risk of depression given the stressors that role places on an individual. While Mrs. L's hypertension could predispose her to additional chronic comorbidities that in total could increase her risk of depression , her hypertension is currently well controlled and she has no other comorbidities. Despite her prior smoking history, she does not have known COPD or other lung diseases, which is another known risk factor. While anxiety may co-exist with depression, there is no report of anxiety-related symptoms to suggest it.

You are the primary care provider for Mrs. L, a woman (she/her) who has a past medical history of well controlled hypertension and is a former smoker. You receive a phone call from her daughter who wanted to report some concerns. Over the past several months, Mrs. L seems more withdrawn, and reported to her daughter a decreased appetite and weight loss. She stopped attending social events at the local senior center, which she used to enjoy. Mrs. L is the primary caregiver for her spouse, who has advanced Parkinson's disease. Her daughter is their only child and lives out of state. Her daughter is also concerned about Mrs. L's increasing social isolation due to Mrs. L's belief that her spouse always needs her to be close by. What is a likely contributing risk factor for Mrs. L's change in behavior? Select one: a. Hypertension b. Caregiving role c. Prior smoking d. Anxiety

c. Finasteride This patient has primarily obstructive symptoms, which are most commonly associated with enlargement of the prostate. Pharmacologic management of enlarged prostate can be accomplished with alpha blockers (eg terazosin, doxazosin, tamsulosin) or 5 alpha reductase inhibitors (5ARI, eg fiansteride, dutasterside). Alpha blockers are effective but carry a risk of orthostasis; in this patient with baseline balance issues and a prior fall it is preferable to avoid alpha blockers (such as terazosin). 5ARI are an effective management strategy for men with BPH and prostate volume of greater than 40 mL; these drugs may cause sexual side effects but are not associated with orthostasis. Oxybutinin is an anti-muscarinic drug useful in patients with primarily irritative symptoms; it is unlikely to benefit this patient and carries substantial risk of altered mental status in older patients. Flutamide is an androgen receptor blocker; it is used in some patients with prostate cancer but is not a standard of care in management of BPH. Transurethral Resection of the Prostate (TURP) is an effective therapy for BPH; it may be a consideration if the patient fails management with 5ARI.

Your first patient of the morning is Mr. Jain, a 76-year-old man (he/him) with a prostate who has been experiencing increasing difficulty initiating urination over the last couple of years. He also notes a weaker urine stream when he voids. He denies any recent fevers, hematuria, dysuria, or changes in bowel habits. He had a stroke 5 years ago and has some residual right side weakness. He is on chronic anti-coagulation. At Mr. Jain's last visit two months ago, he was prescribed tamsulosin 0.4 mg daily. He fell while walking to the bathroom last month and worries that he could really hurt himself if he falls again. Today, on digital rectal exam, his prostate is over 50 mL. Urinalysis is normal. Which of the following therapies is the most appropriate next step for this patient? Select one: a. Oxybutinin b. Terazosin c. Finasteride d. Flutamide e. Transurethral resection of the prostate (TURP)