A 40-year-old pregnant woman, G4 P3, visits your office at week 30 of gestation. She is very excited about her pregnancy and wants to be the healthiest she can be in preparation for labor and for her baby. What vaccination should she receive at this visit?
Q2
Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following:
Hemoglobin 13.1 g/dL
Hematocrit 42%
Leukocyte count 15,700/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 20%
Monocytes 3%
Eosinophils 1%
Basophils 0.5%
AST 40 U/L
ALT 100 U/L
Alkaline phosphatase 85 U/L
Total bilirubin 1.5 mg/dL
Direct 0.9 mg/dL
Amylase 90 U/L
Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?
Q3
Following a motor vehicle accident, a 63-year-old man is scheduled for surgery. The emergency physician notes a posture abnormality in the distal left lower limb and a fracture-dislocation of the right hip and acetabulum based on the radiology report. The senior orthopedic resident mistakenly notes a fracture dislocation of the left hip. The surgeon's examination of the patient in the operating room shows an externally rotated and shortened left lower limb. The surgeon reduces the left hip and inserts a pin in the left tibia. A review of postoperative imaging leads to a second surgery on the fracture-dislocation of the right hip. Which of the following strategies is most likely to prevent the recurrence of this type of error?
Q4
A 32-year-old woman comes to the office for a regular follow-up. She was diagnosed with type 2 diabetes mellitus 4 years ago. Her last blood test showed a fasting blood glucose level of 6.6 mmol/L (118.9 mg/dL) and HbA1c of 5.1%. No other significant past medical history. Current medications are metformin and a daily multivitamin. No significant family history. The physician wants to take her blood pressure measurements, but the patient states that she measures it every day in the morning and in the evening and even shows him a blood pressure diary with all the measurements being within normal limits. Which of the following statements is correct?
Q5
A 24-year-old man comes to the physician for a routine health maintenance examination. He feels well. He has type 1 diabetes mellitus. His only medication is insulin. He immigrated from Nepal 2 weeks ago . He lives in a shelter. He has smoked one pack of cigarettes daily for the past 5 years. He has not received any routine childhood vaccinations. The patient appears healthy and well nourished. He is 172 cm (5 ft 8 in) tall and weighs 68 kg (150 lb); BMI is 23 kg/m2. His temperature is 36.8°C (98.2°F), pulse is 72/min, and blood pressure is 123/82 mm Hg. Examination shows a healed scar over his right femur. The remainder of the examination shows no abnormalities. A purified protein derivative (PPD) skin test is performed. Three days later, an induration of 13 mm is noted. Which of the following is the most appropriate initial step in the management of this patient?
Q6
A 14-month-old boy is brought to the physician by his mother because of an abdominal bulge that has become more noticeable as he began to walk 2 weeks ago. The bulge increases on crying and disappears when he is lying down. He was born at 39 weeks' gestation by lower segment transverse cesarean section. He has met all developmental milestones. He has been breast-fed since birth. He appears healthy and active. Vital signs are within normal limits. Examination shows a nontender, 1-cm midabdominal mass that is easily reducible. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
Q7
A 26-year-old primigravida woman presents to her obstetrician for her first prenatal visit. Her last menstrual cycle was 12 weeks ago. She denies tobacco, alcohol, illicit drug use, or history of sexually transmitted infections. She denies recent travel outside the country but is planning on visiting her family in Canada for Thanksgiving in 3 days. Her past medical and family history is unremarkable. Her temperature is 97.5°F (36.3°C), blood pressure is 119/76 mmHg, pulse is 90/min, and respirations are 20/min. BMI is 22 kg/m^2. Fetal pulse is 136/min. The patient's blood type is B-negative. Mumps and rubella titers are non-reactive. Which of the following is the most appropriate recommendation at this visit?
Q8
A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?
Appropriate follow-up intervals US Medical PG Practice Questions and MCQs
Question 1: A 40-year-old pregnant woman, G4 P3, visits your office at week 30 of gestation. She is very excited about her pregnancy and wants to be the healthiest she can be in preparation for labor and for her baby. What vaccination should she receive at this visit?
A. Measles, mumps, and rubella (MMR)
B. Varicella vaccine
C. Herpes zoster vaccine
D. Live attenuated influenza vaccine
E. Tetanus, diphtheria, and acellular pertussis (Tdap) (Correct Answer)
Explanation: ***Tetanus, diphtheria, and acellular pertussis (Tdap)***
- The Tdap vaccine is recommended during each pregnancy, preferably between **27 and 36 weeks of gestation**, to maximize maternal antibody response and passive antibody transfer to the fetus.
- This provides critical protection against **pertussis (whooping cough)** for the newborn, who is too young to be vaccinated.
*Measles, mumps, and rubella (MMR)*
- The **MMR vaccine is a live vaccine** and is **contraindicated during pregnancy** due to the theoretical risk of congenital rubella syndrome, although no cases have been reported.
- It should be administered **postpartum** if the mother is not immune to rubella.
*Varicella vaccine*
- The **varicella vaccine is a live vaccine** and is **contraindicated during pregnancy** due to the theoretical risk of congenital varicella syndrome.
- Like MMR, it should be offered in the **postpartum period** if the woman is not immune.
*Herpes zoster vaccine*
- The herpes zoster vaccine is typically recommended for **older adults** (50 years and older) for shingles prevention.
- It is **not routinely recommended during pregnancy**, and its safety and efficacy in this population have not been sufficiently established.
*Live attenuated influenza vaccine*
- The **live attenuated influenza vaccine (LAIV)** is **contraindicated during pregnancy** due to its live virus content.
- Pregnant women should receive the **inactivated influenza vaccine (IIV)**, which is safe and recommended during any trimester.
Question 2: Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following:
Hemoglobin 13.1 g/dL
Hematocrit 42%
Leukocyte count 15,700/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 20%
Monocytes 3%
Eosinophils 1%
Basophils 0.5%
AST 40 U/L
ALT 100 U/L
Alkaline phosphatase 85 U/L
Total bilirubin 1.5 mg/dL
Direct 0.9 mg/dL
Amylase 90 U/L
Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?
A. Intravenous heparin therapy followed by embolectomy
B. Careful observation with serial abdominal examinations
C. Endoscopic retrograde cholangiopancreatography with papillotomy
D. Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy (Correct Answer)
E. Immediate cholecystectomy
Explanation: ***Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy***
- The patient presents with **acalculous cholecystitis**, characterized by severe RUQ pain, fever, leukocytosis, elevated transaminases, and ultrasonographic findings of a distended gallbladder with a thickened wall and pericholecystic fluid, but no stones.
- Given his comorbid conditions (diabetes, PVD, recent CABG) and the severity of his illness, empirical **broad-spectrum antibiotics** (like piperacillin-tazobactam) along with image-guided **percutaneous cholecystostomy** for gallbladder decompression are the most appropriate management, avoiding the high risks of immediate surgery.
*Intravenous heparin therapy followed by embolectomy*
- This approach is indicated for **acute mesenteric ischemia with embolism**, which can present with severe abdominal pain and signs of hypoperfusion.
- While the patient has chronic mesenteric ischemia, his current symptoms and imaging findings are more consistent with cholecystitis, and there is no clear evidence of acute embolic event requiring embolectomy.
*Careful observation with serial abdominal examinations*
- This patient exhibits signs of a severe inflammatory process (fever, leukocytosis, RUQ tenderness, elevated LFTs, and sonographic findings of severe inflammation) and systemic illness, making **conservative observation insufficient** and potentially dangerous.
- **Acalculous cholecystitis** is a serious condition with a high risk of complications like perforation and sepsis, especially in critically ill patients, and requires prompt intervention.
*Endoscopic retrograde cholangiopancreatography with papillotomy*
- **ERCP with papillotomy** is indicated for conditions like **choledocholithiasis** (common bile duct stones) or **cholangitis**, which cause biliary obstruction.
- The ultrasound shows **no stones** and features specific to cholecystitis rather than common bile duct obstruction, making ERCP inappropriate as an initial step.
*Immediate cholecystectomy*
- While cholecystectomy is the definitive treatment for cholecystitis, immediate open or laparoscopic cholecystectomy in a critically ill patient with **acalculous cholecystitis** after recent CABG carries a **very high morbidity and mortality risk**.
- **Percutaneous cholecystostomy** offers a safer, less invasive alternative for source control and stabilizes the patient before potential delayed definitive surgery if needed, once the patient's condition improves.
Question 3: Following a motor vehicle accident, a 63-year-old man is scheduled for surgery. The emergency physician notes a posture abnormality in the distal left lower limb and a fracture-dislocation of the right hip and acetabulum based on the radiology report. The senior orthopedic resident mistakenly notes a fracture dislocation of the left hip. The surgeon's examination of the patient in the operating room shows an externally rotated and shortened left lower limb. The surgeon reduces the left hip and inserts a pin in the left tibia. A review of postoperative imaging leads to a second surgery on the fracture-dislocation of the right hip. Which of the following strategies is most likely to prevent the recurrence of this type of error?
A. Marking the surgical site
B. Implementing a checklist
C. Conducting a preoperative time-out (Correct Answer)
D. Verifying the patient’s identity
E. Performing screening X-rays
Explanation: ***Conducting a preoperative time-out***
- A **preoperative time-out** is a crucial step in the Universal Protocol, ensuring that the entire surgical team confirms the correct patient, correct site, and correct procedure immediately before incision. This would have caught the discrepancy between the planned surgery and the surgeon's actions.
- The surgical time-out provides a final opportunity for all team members to voice concerns or identify errors, preventing wrong-site surgery as occurred here.
*Marking the surgical site*
- While **surgical site marking** is part of the Universal Protocol, it primarily prevents wrong-side or wrong-level surgery when multiple potential sites exist or when laterality is critical.
- In this scenario, the issue was a misidentification of the *injured* hip at the point of action, not necessarily an ambiguity on which limb *to mark*. The surgeon operated on the palpably injured hip, but it was the wrong one according to the actual diagnosis.
*Implementing a checklist*
- Implementing a comprehensive **surgical safety checklist** can reduce errors across many domains, but its effectiveness depends on strict adherence and a culture of safety.
- While valuable, a checklist alone might not have prevented this specific error if the initial misinterpretation of the radiology report by the resident wasn't explicitly cross-checked at a critical "stop" point.
*Verifying the patient’s identity*
- **Verifying patient identity** is a fundamental safety measure at multiple points, including admission, consent, and before surgery, but it prevents operating on the wrong patient.
- In this case, the correct patient was identified; the error was related to the specific surgical site on that patient.
*Performing screening X-rays*
- **Screening X-rays** are typically performed to assess the extent of injury and confirm the diagnosis before surgery. This was done, and the radiology report correctly identified the right hip injury.
- The error arose from the *interpretation* and *communication* of these findings, not the absence of imaging itself. The existing radiology report, if properly reviewed and confirmed, would have prevented the error.
Question 4: A 32-year-old woman comes to the office for a regular follow-up. She was diagnosed with type 2 diabetes mellitus 4 years ago. Her last blood test showed a fasting blood glucose level of 6.6 mmol/L (118.9 mg/dL) and HbA1c of 5.1%. No other significant past medical history. Current medications are metformin and a daily multivitamin. No significant family history. The physician wants to take her blood pressure measurements, but the patient states that she measures it every day in the morning and in the evening and even shows him a blood pressure diary with all the measurements being within normal limits. Which of the following statements is correct?
A. The physician has to measure the patient’s blood pressure because it is a standard of care for any person with diabetes mellitus who presents for a check-up. (Correct Answer)
B. Assessment of blood pressure only needs to be done at the initial visit; it is not necessary to measure blood pressure in this patient at any follow-up appointments.
C. The physician should not measure the blood pressure in this patient and should simply make a note in a record showing the results from the patient’s diary.
D. The physician should not measure the blood pressure in this patient because she does not have hypertension or risk factors for hypertension.
E. The physician should not measure the blood pressure in this patient because the local standards of care in the physician's office differ from the national standards of care so measurements of this patient's blood pressure cannot be compared to diabetes care guidelines.
Explanation: **The physician has to measure the patient’s blood pressure because it is a standard of care for any person with diabetes mellitus who presents for a check-up.**
- For individuals with **diabetes mellitus**, regular **blood pressure monitoring** by a healthcare professional is a fundamental component of their routine care, regardless of home measurements.
- This practice ensures accuracy, identifies **white coat hypertension**, and allows for early detection and management of **cardiovascular risks** inherent to diabetes.
*Assessment of blood pressure only needs to be done at the initial visit; it is not necessary to measure blood pressure in this patient at any follow-up appointments.*
- This statement is incorrect as **regular blood pressure monitoring** is essential for all follow-up visits in diabetic patients due to their elevated risk of developing **hypertension** and associated complications.
- Even if initial measurements are normal, blood pressure can change over time, necessitating continuous assessment to maintain optimal **cardiovascular health**.
*The physician should not measure the blood pressure in this patient and should simply make a note in a record showing the results from the patient’s diary.*
- Relying solely on **patient-recorded blood pressure** measurements, while valuable, does not replace the need for an **in-office measurement** by a healthcare provider.
- This is crucial for verifying the accuracy of home devices, assessing for **masked hypertension**, and ensuring compliance with **clinical guidelines**.
*The physician should not measure the blood pressure in this patient because she does not have hypertension or risk factors for hypertension.*
- This is incorrect; the patient's diagnosis of **Type 2 Diabetes Mellitus** itself is a significant **risk factor for hypertension** and cardiovascular disease.
- All individuals with diabetes require ongoing **blood pressure monitoring**, irrespective of their current blood pressure status or other obvious risk factors.
*The physician should not measure the blood pressure in this patient because the local standards of care in the physician's office differ from the national standards of care so measurements of this patient's blood pressure cannot be compared to diabetes care guidelines.*
- This statement is generally incorrect and illogical; **national guidelines** for diabetes care, including blood pressure monitoring, are established to ensure consistent and high-quality care across different settings.
- Healthcare providers are expected to adhere to these **national standards of care** or explain any deviations, making the measurement of blood pressure a critical part of a diabetic patient's visit.
Question 5: A 24-year-old man comes to the physician for a routine health maintenance examination. He feels well. He has type 1 diabetes mellitus. His only medication is insulin. He immigrated from Nepal 2 weeks ago . He lives in a shelter. He has smoked one pack of cigarettes daily for the past 5 years. He has not received any routine childhood vaccinations. The patient appears healthy and well nourished. He is 172 cm (5 ft 8 in) tall and weighs 68 kg (150 lb); BMI is 23 kg/m2. His temperature is 36.8°C (98.2°F), pulse is 72/min, and blood pressure is 123/82 mm Hg. Examination shows a healed scar over his right femur. The remainder of the examination shows no abnormalities. A purified protein derivative (PPD) skin test is performed. Three days later, an induration of 13 mm is noted. Which of the following is the most appropriate initial step in the management of this patient?
A. Administer isoniazid for 9 months
B. Collect sputum sample for culture
C. Perform interferon-γ release assay
D. Obtain a chest x-ray (Correct Answer)
E. Perform PCR of the sputum
Explanation: ***Obtain a chest x-ray***
- A **positive PPD test** (13 mm induration in a patient with risk factors) indicates possible **latent tuberculosis infection (LTBI)**, but before initiating treatment, it's crucial to rule out **active tuberculosis (TB)**.
- A chest x-ray is the initial step to screen for signs of active disease, such as **infiltrates, cavitations**, or **lymphadenopathy**, which would necessitate a different treatment regimen than LTBI.
*Administer isoniazid for 9 months*
- This is a standard treatment for **LTBI**, but it should only be initiated after **active TB has been ruled out**.
- Treating active TB with LTBI monotherapy would be inadequate and could lead to **drug resistance**.
*Collect sputum sample for culture*
- **Sputum culture** is essential for diagnosing active pulmonary TB and for **drug susceptibility testing**, but it's typically performed *after* a chest x-ray suggests active disease.
- In a patient with a positive PPD and no symptoms, starting with sputum cultures without imaging is not the most appropriate first step.
*Perform interferon-γ release assay*
- **Interferon-γ release assays (IGRAs)**, such as QuantiFERON-TB Gold or T-Spot.TB, are alternative tests for detecting **M. tuberculosis infection**.
- While IGRAs can be used in place of or in conjunction with PPD, they also do not differentiate between latent and active infection, so a chest x-ray would still be required.
*Perform PCR of the sputum*
- **PCR (nucleic acid amplification test)** of sputum rapidly detects *M. tuberculosis* DNA and is a valuable tool for diagnosing **active TB**, especially in cases where rapid results are needed.
- However, like sputum culture, it is usually reserved for situations where there is a strong suspicion of active disease based on clinical symptoms or imaging findings.
Question 6: A 14-month-old boy is brought to the physician by his mother because of an abdominal bulge that has become more noticeable as he began to walk 2 weeks ago. The bulge increases on crying and disappears when he is lying down. He was born at 39 weeks' gestation by lower segment transverse cesarean section. He has met all developmental milestones. He has been breast-fed since birth. He appears healthy and active. Vital signs are within normal limits. Examination shows a nontender, 1-cm midabdominal mass that is easily reducible. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
A. CT scan of the abdomen
B. Emergent open repair
C. Elective open repair
D. Abdominal ultrasound
E. Reassurance and observation (Correct Answer)
Explanation: ***Reassurance and observation***
- This presentation is classic for an **umbilical hernia** in an infant, characterized by an abdominal bulge that increases with crying and reduces when lying down. Most umbilical hernias in children under **5 years of age** close spontaneously.
- Given the patient's age (14 months), small size of the hernia (1 cm), and reducibility, the most appropriate management is **observation**, as surgical correction is typically reserved for larger hernias, symptomatic hernias, or those persisting beyond 4-5 years of age.
*CT scan of the abdomen*
- A CT scan uses **ionizing radiation** and is generally not indicated for the diagnosis or routine management of uncomplicated umbilical hernias in children.
- The diagnosis of an uncomplicated umbilical hernia is primarily **clinical**, based on history and physical examination.
*Emergent open repair*
- **Emergent repair** is only indicated for complicated hernias, such as those that are **incarcerated** (cannot be reduced) or **strangulated** (compromised blood supply), which present with features like pain, erythema, tenderness, or signs of bowel obstruction.
- The patient's hernia is described as **nontender** and **easily reducible**, indicating it is uncomplicated and does not require immediate surgical intervention.
*Elective open repair*
- **Elective surgical repair** for umbilical hernias is usually considered for children over **4-5 years of age** if the hernia has not resolved spontaneously, or for smaller hernias that are causing symptoms or are cosmetically concerning.
- At 14 months, spontaneous closure is still very likely, so surgical intervention is premature.
*Abdominal ultrasound*
- While ultrasound can visualize an umbilical hernia, it is generally **not necessary** for diagnosis as it is a clinical diagnosis.
- It might be used in ambiguous cases or to assess for complications, but it does not change the management in this clear-cut case of an uncomplicated, reducible umbilical hernia.
Question 7: A 26-year-old primigravida woman presents to her obstetrician for her first prenatal visit. Her last menstrual cycle was 12 weeks ago. She denies tobacco, alcohol, illicit drug use, or history of sexually transmitted infections. She denies recent travel outside the country but is planning on visiting her family in Canada for Thanksgiving in 3 days. Her past medical and family history is unremarkable. Her temperature is 97.5°F (36.3°C), blood pressure is 119/76 mmHg, pulse is 90/min, and respirations are 20/min. BMI is 22 kg/m^2. Fetal pulse is 136/min. The patient's blood type is B-negative. Mumps and rubella titers are non-reactive. Which of the following is the most appropriate recommendation at this visit?
A. Measles-mumps-rubella vaccination
B. Rh-D immunoglobulin
C. One hour glucose challenge
D. PCV23 vaccination
E. Influenza vaccination (Correct Answer)
Explanation: ***Influenza vaccination***
- The patient is in her **first trimester** and should receive an **inactivated influenza vaccine (IIV)** because she will be traveling during the flu season.
- The **Centers for Disease Control and Prevention (CDC)** recommends that all pregnant women receive the influenza vaccine, regardless of the trimester of pregnancy.
*Measles-mumps-rubella vaccination*
- The **MMR vaccine** is a **live attenuated vaccine** and is **contraindicated in pregnancy** due to the theoretical risk of congenital rubella syndrome.
- Since the patient's **rubella titers are non-reactive**, she should defer vaccination until **after delivery**.
*Rh-D immunoglobulin*
- **Rh-D immunoglobulin** is administered to Rh-negative mothers to prevent alloimmunization, but it is typically given at **28 weeks' gestation** and again postpartum if the baby is Rh-positive.
- This patient is only **12 weeks pregnant**, making prophylaxis unnecessary at this time.
*One hour glucose challenge*
- The **one-hour glucose challenge test** for **gestational diabetes mellitus** is routinely performed between **24 and 28 weeks' gestation**.
- Performing this test at **12 weeks' gestation** would be premature and not provide accurate results.
*PCV23 vaccination*
- The **pneumococcal polysaccharide vaccine (PPSV23)** is generally recommended for pregnant women only if they have risk factors like chronic medical conditions (e.g., asthma, diabetes, heart disease) or are immunocompromised.
- This patient has **no risk factors** indicating a need for **PCV23 vaccination** at this time.
Question 8: A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?
A. Colorectal screening (Correct Answer)
B. Blood glucose and/or HbA1c screening
C. Blood pressure at least once every 3 years
D. Yearly Pap smear
E. Bone mineral density screening
Explanation: ***Colorectal screening***
- **Colorectal cancer screening** is generally recommended to start at age **45 years** for individuals at average risk.
- This patient is 46 years old, making immediate colorectal screening appropriate based on current guidelines.
*Blood glucose and/or HbA1c screening*
- **Blood glucose or HbA1c screening** for diabetes is recommended starting at age **35 for all adults** or earlier if there are risk factors such as obesity or a family history of diabetes.
- While this patient is 46, this screening should have already been initiated, and it is not the *most* uniquely recommended screening for this specific age that might have been overlooked.
*Blood pressure at least once every 3 years*
- **Blood pressure screening** should be performed **at least annually** for adults aged 40 and older, or more frequently if there are risk factors.
- Screening only every 3 years is insufficient for a 46-year-old patient.
*Yearly Pap smear*
- **Pap smear frequency** has changed; for women aged 30-65 with normal results, screening is recommended every **3 years** with cytology alone, or every 5 years with high-risk HPV testing alone or co-testing.
- A yearly Pap smear is no longer typical practice for a woman with normal prior results and no specific risk factors.
*Bone mineral density screening*
- **Bone mineral density (BMD) screening** for osteoporosis is typically recommended for women starting at age **65 years** or earlier if they have significant risk factors.
- This patient is 46 years old and has no mentioned risk factors, so BMD screening is not routinely indicated at this age.
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