How Do I Choose the Best Diagnostic Strategy? (Exercise)

Warm Up: Diagnosing Pulmonary Embolism. Read the attached material and be prepared to discuss and answer the questions.

Case # 1
You are a primary care physician returning calls late on Friday afternoon. You reach Ms. Nowicki, a 50 y/o lady you have seen off and on for mild hypertension, at her home and find her quite agitated. She recently underwent screening mammography at a health facility associated with her job and has now received a letter saying her mammogram is 'abnormal' and she 'needs further evaluation.' She further explains that her aunt, whom she had been quite close to, just died over the summer after a long battle with breast cancer. Her question is very direct: "Doctor, does this mean I have breast cancer?" How do you respond?

Case # 2
A 45 year old man in your practice has been complaining over the last year of a tightness and 'uncomfortable feeling' in the chest. You send him for an exercise stress test and the results come back "1.5 mm ST depression in anterior leads at 9 minutes of exercise. Test is abnormal." What do you do now?

Case # 3
You have a business executive for a patient who has had several bouts of esophagitis whom you suspect is a heavy drinker. He is a blustery, assertive individual and you have never confronted him directly on this issue. You decide to use the CAGE screening questionnaire as part of a 'routine physical' to see if you can get a better handle on his drinking problem. He answers "yes" to 2 of the 4 questions in the written form, but as you talk it through with him he grudgingly acknowledges a positive response to a 3rd item. What does this information tell you?

Case # 4
You are on the surgery rotation and follow the resident down to the ER to evaluate a 17 y/o male with abdominal pain. The resident does a quick history and physical and concludes that the patient probably has appendicitis. You ask the resident how reliable these physical findings are, but all you get is a shrug of the shoulder. How else could this problem be addressed?