A 62-year-old man comes to his primary care physician with a 3-month history of insomnia and severe work anxiety. He says that he is unable to retire because he has no financial resources; however, the stress level at his work has been causing him to have worsening performance and he is afraid of being fired. He thinks that he would be able to resume work normally if he was able to decrease his level of anxiety. His physician prescribes him a trial 1-month regimen of benzodiazepine therapy and schedules a follow-up appointment to see whether this treatment has been effective. Three weeks later, the patient's wife calls and says "My husband was fired from work and it's your fault for prescribing that medication! I know he must have been taking too much of that drug. Don't you know that he had a horrible problem with drug abuse in his 30s?" Which of the following is the most appropriate first action for the physician to take?

Contact the patient directly to discuss the situation

Discharge the patient for inappropriate use of medication

Contact the physician's medical practice insurance company regarding a potential claim

Refer the patient to a substance abuse program

Inform the patient's wife that patient information cannot be disclosed to her due to HIPAA

A 66-year-old man is brought into the emergency department by his daughter for a change in behavior. Yesterday the patient seemed more confused than usual and was asking the same questions repetitively. His symptoms have not improved over the past 24 hours, thus the decision to bring him in today. Last year, the patient was almost completely independent but he then suffered a "series of falls," after which his ability to care for himself declined. After this episode he was no longer able to cook for himself or pay his bills but otherwise had been fine up until this episode. The patient has a past medical history of myocardial infarction, hypertension, depression, diabetes mellitus type II, constipation, diverticulitis, and peripheral neuropathy. His current medications include metformin, insulin, lisinopril, hydrochlorothiazide, sodium docusate, atorvastatin, metoprolol, fluoxetine, and gabapentin. On exam you note a confused man who is poorly kept. He has bruises over his legs and his gait seems unstable. He is alert to person and place, and answers some questions inappropriately. The patient's pulse is 90/minute and his blood pressure is 170/100 mmHg. Which of the following is the most likely diagnosis?

Pseudodementia (depression-related cognitive impairment)

An investigator conducts a case-control study to evaluate the relationship between benzodiazepine use among the elderly population (older than 65 years of age) that resides in assisted-living facilities and the risk of developing Alzheimer dementia. Three hundred patients with Alzheimer dementia are recruited from assisted-living facilities throughout the New York City metropolitan area, and their rates of benzodiazepine use are compared to 300 controls. Which of the following describes a patient who would be appropriate for the study's control group?

An 86-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an assisted-living facility

A 73-year-old woman with coronary artery disease who was recently discharged to an assisted-living facility from the hospital after a middle cerebral artery stroke

A 64-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an assisted-living facility

An 80-year-old man with well-controlled hypertension and mild benign prostate hyperplasia who lives in an independent-living community

A 68-year-old man with hypercholesterolemia, mild benign prostate hyperplasia, and poorly-controlled diabetes who is hospitalized for pneumonia

A 77-year-old Caucasian woman presents to her primary care provider for a general checkup. The patient is with her daughter who brought her to this appointment. The patient states that she is doing well and has some minor joint pain in both hips. She states that sometimes she is sad because her husband recently died. She lives alone and follows a vegan diet. The patient's daughter states that she has noticed her mother struggling with day to day life. It started 2 years ago with her forgetting simple instructions or having difficulty running errands. Now the patient has gotten to the point where she can no longer pay her bills. Sometimes the patient forgets how to get home. The patient has a past medical history of obesity, hypertension, gastroesophageal reflux disease (GERD) controlled with pantoprazole, and diabetes mellitus. Her temperature is 99.5°F (37.5°C), blood pressure is 158/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Which of the following will most likely help with this patient's presentation?

Vitamin B12 and discontinue pantoprazole

Fluoxetine and cognitive behavioral therapy

A 26-year-old primigravida woman comes to her primary care physician for the second prenatal visit. She is 10 weeks pregnant. She has no current complaint except for occasional nausea. She does not have any chronic health problems. She denies smoking or alcohol intake. Her family history is positive for paternal colon cancer at the age of 55. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 120/60 mm Hg, and pulse of 90/min. Physical examination discloses no abnormalities. According to the United States Preventive Services Task Force (USPSTF), which of the following screening tests is recommended for this patient?

Urine culture for asymptomatic bacteriuria

Colonoscopy for colorectal cancer at the age of 40

HbA1C for type 2 diabetes mellitus

Colonoscopy for colorectal cancer at the age of 50

Glucose tolerance test for gestational diabetes mellitus

A 27-year-old woman presents for her routine annual examination. She has no complaints. She has a 3-year-old child who was born via normal vaginal delivery with no complications. She had a Pap smear during her last pregnancy and the findings were normal. Her remaining past medical history is not significant, and her family history is also not significant. Recently, one of her close friends was diagnosed with breast cancer at the age of 36, and, after reading some online research, she wants to be checked for all types of cancer. Which of the following statements would be the best advice regarding the most appropriate screening tests for this patient?

“We should do a Pap smear now. Blood tests are not recommended for screening purposes.”

“Your last Pap smear 3 years ago was normal. We can repeat it after 2 more years.”

“Remember that information on the internet is vague and unreliable. You don't need any screening tests at this time.”

“Yes, you are right to be concerned. Let us do a mammogram and a blood test for CA-125.”

“You need HPV (human papillomavirus) co-testing only.”

A 28-year-old asymptomatic pregnant woman at 12 weeks gestation presents for prenatal care. She has no personal or family history of diabetes. Her BMI is 32 kg/m². She had a random glucose of 118 mg/dL at her first visit. She asks about gestational diabetes screening. Considering her risk factors and current pregnancy, what is the most appropriate screening approach?

Perform fasting glucose and hemoglobin A1c now to assess for preexisting diabetes

Perform 3-hour oral glucose tolerance test at 16 weeks

Diagnose gestational diabetes based on random glucose and begin treatment

Perform 1-hour glucose challenge test now

Defer screening until 24-28 weeks gestation per routine protocol

Geriatric screening protocols for USMLE Step 1: High-Yield Diagnosis Lessons

Geriatric Screening - The 5Ms Framework

Mind: Assess cognition (dementia), mood (depression), and delirium.
- Tools: MMSE, MoCA, PHQ-9, CAM.
Mobility: Screen for fall risk, gait, and balance.
- Test: Timed Up and Go (TUG) test; risk if >12 seconds.
Medications: Review polypharmacy and high-risk drugs.
- Guidelines: Beers Criteria, STOPP/START.
Multi-complexity: Manage multiple chronic conditions and functional decline.
- Assess: ADLs & IADLs.
Matters Most: Clarify patient values, care preferences, and goals.
- Action: Discuss advance directives.

⭐ Functional status is a stronger predictor of mortality in the elderly than the number of comorbidities.

Mind & Mobility - Brains & Balance

Cognitive Assessment
- No universal mandate; screen if concern for impairment.
- Tools: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Mini-Cog.
- Screen for depression (PHQ-2/PHQ-9) as it can mimic/worsen cognitive decline.
Mobility & Falls Risk
- Screen all adults ≥65 years annually for falls.
- Timed Up and Go (TUG) Test: Patient stands, walks 10ft (3m), turns, returns, and sits.
  - >12 seconds indicates ↑ fall risk.

⭐ The "Timed Up and Go" (TUG) test is a key predictor of functional mobility and future fall risk. It assesses gait, balance, and transitional movements.

Timed Up and Go (TUG) Test Procedure Diagram

Meds & More - Pills & Problems

Beers Criteria for Medications in Older Adults

Polypharmacy: Concurrent use of ≥5 medications, increasing risk of adverse drug events (ADEs), falls, and non-adherence.
Beers Criteria: Key guidelines for identifying potentially inappropriate medications (PIMs) in adults ≥65 years to reduce harm.
- Strong Anticholinergics (e.g., diphenhydramine): Risk of confusion, dry mouth, constipation.
- Benzodiazepines / Z-drugs: ↑ risk of cognitive impairment, delirium, falls, fractures.
- Chronic NSAIDs: Can exacerbate heart failure, renal injury, and GI bleeds.
- Opioids: High risk for sedation, respiratory depression, and falls.

⭐ Prescribing Cascade: An adverse drug event is misinterpreted as a new medical condition, leading to a new, potentially unnecessary prescription. E.g., prescribing a laxative for constipation caused by an opioid.

USPSTF Tweaks - Old Rules, New Game

Lung Cancer: Annual low-dose CT for adults 50-80 with a 20-pack-year history, who currently smoke or quit within 15 years.
Colorectal Cancer: Start screening at age 45 (down from 50) and continue until 75.
Aspirin (Primary Prevention):
- NOT recommended for primary prevention in adults ≥60.
- Individual decision for ages 40-59 with ≥10% 10-year CVD risk.
AAA: One-time ultrasound for men 65-75 who have ever smoked.

⭐ The biggest change for lung cancer screening was lowering the smoking history from 30 to 20 pack-years and the starting age from 55 to 50, significantly expanding the eligible population.

High‑Yield Points - ⚡ Biggest Takeaways

AAA screening: One-time ultrasound for men aged 65-75 who have ever smoked.

Osteoporosis: Screen women ≥65 with a DEXA scan.

Fall risk: Assess all older adults, often with the "Get Up and Go" test.

Sensory screening: Routinely check for vision and hearing impairment.

Mental health: Screen for depression and assess for cognitive impairment when concerned.

Key immunizations: Ensure influenza, pneumococcal, and zoster vaccines are current.

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