Assignment 6

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Test Questions

Learning Objective: Understand normal breast development and common breast problems.

6-1. The breast contains mostly fat tissue, connective tissue, and glands that following pregnancy, will produce milk.

1. True

2. False

6-2. During the menstrual cycle, the breast is smallest on days 4-7, and then begins to enlarge, under the influence of estrogen and later progesterone and prolactin.

1. True.

2. False

In answering questions 6-3 through 6-7, select from column B the category which most closely matches the description in column A. Some responses may be used once, more than once, or not at all.

A. Description	B. Category
6-3. Firm, irregular, unilateral mass in the breast of recent onset.	1. Normal Finding
6-4. One drop of clear nipple discharge found while stripping the ducts.	2. Abnormal Finding
6-5. A dimple in the skin of one breast, most prominent when she raises her arms over her head.
6-6. One breast is slightly larger than the other.
6-7. During pregnancy, the nipples are noticed to have increased in size and darkened in color.

6-8. The usual recommendation for self-breast examination is for a woman to examine her own breasts:

1. Every day.

2. Every week.

3. Every month, right after completing a menstrual flow.

4. Every year, whether she needs it or not.

In answering questions 6-9 through 6-12, select from column B the Test which most closely matches the description in column A. Some responses may be used once, more than once, or not at all.

A. Description	B. Test
6-9. Is 100% reliable at detecting breast cancer.	1. Mammography
6-10. Good at distinguishing cystic from solid masses.	2. Breast Ultrasound
6-11. Detects radio-opaque densities, microcalcifications, and disruption of the normal breast architecture .	3. Both
6-12. Most often used as a screening technique for breast cancer.	4. Neither

6-13. The most common method of biopsy for suspicious dominant breast masses is:

1. Fine needle aspiration.

2. Open biopsy.

3. Excisional biopsy.

4. Radical mastectomy.

6-14. Supernumerary nipples:

1. Should usually be removed because they are very dangerous.

2. Are usually found along the "Tibial Line," extending from the mid-patella down the front of the lower leg and ending at the tip of the middle toe.

3. Are frequently first noticed during pregnancy.

4. Are usually about the same size as normal nipples, but are more trapezoidal in shape.

6-15. Which of the following is NOT true of inverted nipples?

1. They disallow normal breast-feeding.

2. They may be either unilateral or bilateral.

3. They frequently will evert (become outwardly erect) with nipple stimulation.

4. Other than cosmetic issues, they are usually not a problem.

6-16. Breast surgery (excisional biopsy or fine needle aspiration) is almost never warranted on adolescent breasts because breast masses in these young women are essentially 100% benign.

1. True

2. False

6-17. All of the following are true regarding breast infections among nursing mothers, EXCEPT:

1. Breast infections are common.

2. They are characterized by unilateral breast tenderness, redness, fever, and sometimes a thickening or mass.

3. They can be very aggressive with high fevers.

4. Usually they present with very gradual onset of symptoms over several days to a week.

6-18. Cyclic breast pain is a relative contraindication to the use of birth control pills.

1. True

2. False

6-19. If the nipples spontaneously leak discharge, staining the clothing, that is NOT normal.

1. True

2. False

6-20. If a dominant mass is found in the breast which persists through the menstrual cycle, it is usually biopsied.

1. True

2. False

6-21. Most breast cancer occurs among women with two or more high risk factors.

1. True

2. False

6-22. LCDR Nancy Rochefort, your ship's Engineering Officer is standing behind you in the line at the salad bar in the Ward Room at lunch. She whispers, "Doc, can I meet you in the Medical Department after lunch? I've got a problem I need to talk to you about." You agree.

Lieutenant Commander Rochefort has a newly-discovered breast lump in the upper outer quadrant of the right breast. It is about 2 cm in diameter, is firm, mobile, non-tender and not fixed to the the chest wall. She is 32 years old, with no pregnancies and no family history of breast cancer. Your ship is on patrol in the Arabian Gulf, due to return to Bahrain in 2 weeks, but within helo distance of Bahrain now. Your plan for Lieutenant Commander Rochefort is:

1. Immediate helo MEDEVAC to Bahrain for further medical evaluation of the breast lump.

2. Wait until you return to Bahrain and then arrange for medical evaluation of the lump at the clinic.

3. You have read about fine needle aspiration biopsy and it doesn't sound too difficult. Go ahead and give it a try.

4. Reassure her that it feels like a benign fibroadenoma and with no family history of breast cancer, it can be safely ignored.

Learning Objective: Understand menopause, the associated medical issues, and various alternatives for management.

In answering questions 6-23 through 6-32, select from column B the risk category which most closely matches the clinical conditions in column A. Some responses may be used once, more than once, or not at all.

A. Clinical Condition	B. Risk
6-23. Hot flashes.	1. Risk of menopause
6-24. Vaginal dryness.	2. Risk of estrogen therapy
6-25. Loss of bone mass.	3. Neither
6-26. Increased risk of cardiovascular disease.
6-27. Gall bladder disease.
6-28. Night sweats.
6-29. Memory loss.
6-30. Endometrial hyperplasia, in the absence of progesterone
6-31. Sleeplessness
6-32. Lung cancer

6-33. Laboratory tests for menopause (an elevated LH and FSH with a low estradiol level) are usually inconsistent during episodes of hot flashes.

1. True

2. False

6-34. Typical recommendations for calcium intake during menopause are:

1. 325 mg/day

2. 1200-1500 mg/day

3. 2000-3000 gm/day

4. None. It is not necessary to augment dietary calcium.

6-35. Treatment of menopause often involves:

1. Continuous estrogen and prednisone therapy.

2. Cyclic estrogen and progesterone therapy.

3. Cyclic Rocephin and Doxycycline therapy.

4. Continuous NaCl and KOH therapy.

6-36. Birth control pills during menopause are:

1. Contraindicated.

2. Essential for preventing unwanted pregnancy.

3. Are associated with irregular periods.

4. Particularly useful in women who are experiencing several months of ovarian dysfunction (menopausal symptoms), followed by resumption of normal function.

6-37. Decreased libido associated with menopause:

1. Should always be treated.

2. May be caused by a variety of factors.

3. Is usually improved by taking testosterone-reducing drugs.

4. All of the above.

6-38. Chief Jones had surgery 6 months ago for chronic PID, with removal of her uterus, fallopian tubes and ovaries. Following surgery, she was placed on continuous conjugated estrogens, 0.625 mg each day. She is a 30 year old non-smoker. She has generally done well, but complains during your deployment that she continues to have severe night sweats and hot flashes. These are particularly annoying since she works in the engine room where the ambient temperature is high. A good clinical approach to the Chief's problem would be to:

1. Increase her dose of estrogen from 0.625 to 1.25 mg per day (double the dose).

2. Decrease her dose of estrogen from 0.625 mg/day to 0.3 mg (half the dose)

3. Add progesterone to protect her against developing endometrial hyperplasia.

4. Give her a course of Rocephin and Doxycycline to cover the possibility of any lingering PID.

Learning Objective: Understand the medical support of women in military environments.

6-39. Planning for the medical support of women in operational environments is important for a successful operation.

1. True.

2. False

6-40. The following are true statements about pregnancy, EXCEPT::

1. Ectopic pregnancy occurs about once in every 100 pregnancies.

2. About one in five pregnancies ends as a miscarriage.

3. General Medical Officers typically possess the training and skills to confidently manage early pregnancy problems.

4. Emergency MEDEVAC of unstable obstetric patients is dangerous. .

6-41. Predeployment screening should include checking each female crewmembers' medical record for:

1. Pap status.

2. Number of previous pregnancies.

3. Prior history of domestic physical abuse.

4. Cooperativeness during physical exams.

6-42. For women in field environments, urination is:

1. Usually simple and fast.

2. Safe.

3. Often avoided as long as possible.

4. Unnecessary.

6-43. Intentional dehydration is associated with:

1. Degradation in physical and mental health.

2. Decreased physical performance.

3. Increased risk of urinary tract infection.

4. All of the above.

6-44. Birth control use in field environments is associated with:

1. Lighter periods.

2. More cramps.

3. Excessive nausea.

4. All of the above.

In answering questions 6-45 through 6-52, select from column B the type of feminine hygiene product which most closely matches the description in column A. Some responses may be used once, more than once, or not at all.

A. Description	B. Type of Product
6-45. Easier to insert and remove in field environments.	1. Tampons
6-46. Provide some protection against dirt in the field.	2. Pads
6-47. Takes up less space in your pack.	3. Both.
6-48. Can "wick" dirty water up into the vagina.
6-49. Personal preference is important.
6-50. Function adequately in field environments.
6-51. Should be changed regularly to prevent infection.
6-52. Should be brought to the field environment in sufficient quantity to meet the woman's needs until resupply can be accomplished.

6-53. Experienced women usually plan on using about 5-6 wet wipes per day during a field deployment when access to washing and bathing facilities are limited or non-existent

1. True

2. False

6-54. Women and men deployed to field environments must never share the same quarters, in accordance with DOD Instruction 98-35B.

1. True.

2. False.

In answering questions 6-55 through 6-58, select from column B the fabric which most closely matches the description in column A. Some responses may be used once, more than once, or not at all.

A. Description	B. Fabric
6-55. Wicks some moisture away from the body to the outer garments.	1. Cotton
6-56. With strenuous physical activity, bunches into a soggy, abrasive mass	2. Synthetic (nylon)
6-57. Not very comfortable in hot climates when at rest.	3. Both
6-58. The ideal fabric for undergarments in all circumstances.	4. Neither

6-59. Dehydration causes loss of G-tolerance in both men and women.

1. True.

2. False.

6-60. Women, because of their higher body fat composition, are more likely to have intravascular nitrogen bubbles, as a group, than men.

1. True

2. False

6-61. You are assigned to accompany a military unit to seize and hold a helicopter landing zone (LZ) for a two-week period. The LZ will be used to evacuate American citizens from a foreign country engaged in a low to medium intensity civil war. Although no organized resistance is expected, you anticipate an occasional mortar round and possible sniper fire. Your job is to establish a small medical facility, treating minor injuries and stabilizing sick and wounded for MEDEVAC transport to ships just over the horizon. Among your medical team are 3 female junior enlisted personnel. The rest of the landing party consists of 85 men.

In reviewing the plans for this evolution, you notice that following successful seizure of the LZ and securing the perimeter, tents for quartering the unit are to be set up along a line of trees, relatively close to medical, supply and the command post. About 150 yards across an open field are two tents and a separate latrine for women.

In your discussions with the commander of the landing team, you:

1. Bring to his attention your concerns about female tentage, based on it being relatively remote from everyone else (danger), the latrine being so far from the worksite (intentional dehydration), requiring traversing 150 yeards of open space in order to urinate (danger), and fragmenting of unit cohesiveness (their tents are better than our tents).

2. Earn bonus points with the commander by complimenting him on his very fine plan.

3. Insist that the women be fully integrated into the unit.

4. Ask for a transfer to another unit.

6-61. Among the first of the American citizens to reach the LZ is Janet McClusky, a 21 year old who is 3 months pregnant and bleeding. Your plan is to:

1. Have her lie still at the medical tent until the next helo out to the ship.(about an hour)

2. Plan to keep her at the LZ until all bleeding stops.

3. Set her up for a pelvic examination so you can learn more details about her condition.

4. Start IV oxytocin at 12 mIU/min.

6-62. Later in the afternoon, a helicopter arrives with several more civilians. Just after touching down, the LZ comes under intense mortar and small arms fire. The helicopter is hit, severely wounding the crewmembers and the civilian passengers who have not yet gotten off the helo. Two of your three female corpsmen were standing next to the helo when it was hit. They both suffered metal fragment wounds to the legs. Despite their wounds and the continuing small arms fire at the helicopter, they each repeatedly entered the burning helicopter, cutting loose the wounded crewmembers and civilians and dragging them to the relative safety of a nearby ditch. The helicopter crew chief was too heavy for either of them to drag, so together, they rolled him onto a poncho liner and dragged him to the ditch. While half-way to the ditch, a mortar round landed close to them, further wounding one of the corpsmen in the buttocks and shoulder. After reaching the ditch, their position was nearly overrun by enemy sappers. Using side-arms from the wounded helicopter crew, they defended their patients against attack. Together, they accounted for 5 enemy dead before the attackers retreated.

All of the wounded and both hospital corpsmen were later sent by MEDEVAC to the ship. One of the corpsmen is the mother of three small children and the other is single. Following this event, as their immediate supervisor, you:

1. Initiate an investigation to determine why they did not follow the normal procedure of first stabilizing the C-spine before rolling the crewchief onto the poncho liner and dragging him across the ground.

2. Initiate UCMJ proceedings against them for unauthorized use of deadly force.

3. Make a mental note to lecture the mother of 3 not to take chances like she did at the LZ.

4. Nominate both of them to receive the Navy Cross.

In answering questions 6-63 through 6-69, match the stress of captivity in Column A with the type of stress in Column B.

A. Stress of Captivity B. Type of Stress

6-63. Boredom 1. Physical

6-64. Diarrhea 2. Mental

6-65. Wounds.

6-66. Guilt.

6-67. Confinement

6-68. Weather extremes

6-69. Exhaustion

6-70. SFC Renee Sullivan, while on a medical humanitarian mission in a small West African nation, is ambushed by bandits from across the border and taken prisoner, along with 5 other members of her team, and two State Department officials. Repeated efforts to obtain their release through negotiation have failed. Three weeks after their capture, intelligence sources determine the hostages are being held at a small, isolated encampment. The Marine Expeditionary Unit (Special Operations Capable) on station successfully launches an extraction of all the hostages. Aboard the large-deck amphibious assault ship, you are the first medical provider to evaluate SFC Sullivan.

Her main medical concerns are 1) feeling weak and dizzy (which she attributes to the profuse, watery, foul-smelling, diarrhea she's had for the last 5 days), and 2) a bad sunburn on her neck, face and arms. She appears dehydrated, with a dry tongue. Her BP is 100/50 and her pulse is 110 BPM. Your immediate medical response is to:

1. Start an IV with crystalloid.

2. X-ray the C-Spine.

3. Perform a pelvic exam.

4. Send a message to the Brook Army Hospital Burn Unit asking for guidance on management of her burns.

6-71. Several hours later, she is resting comfortably in the ship's hospital and feeling much better. She has showered, changed clothes, and looks much better. Microscopic examination of a fresh stool specimen has revealed the presence of Giardia trophozoites, and you have started treatment with oral metronidazole 250 mg TID for 5 days. She makes two requests: 1) She would like to call her mother in New York, to tell her she's OK, and 2) She would like to see and thank Gunnery Sergeant Jesus Hernandez, USMC, for rescuing her. GySgt Hernandez, led an assault team to the hut where she was held captive. After dropping two flash-bangs through the window, he flattened the door, and neutralized two guards who offered resistance. He then picked up SFC Sullivan, weak from dehydration and stunned by the flash-bangs, and carried her to the waiting helicopter. Your response is:

1. Explain that Navy regulations do not allow for use of official satellite communications for personal use.

2. Explain that it would be a bad idea to meet with GySgt. Hernandez, since she might have a contagious form of dysentery.

3. Get her mother on the satellite phone and get GySgt Hernandez up to the Medical Department to see her.

6-72. While interviewing her about her experience in captivity, she indicates to you that she was not sexually assaulted, except that occasionally a guard would grab her breasts. She adds, "I've gone through worse things on the subway." Your response is:

1. Let her know that if she wants to talk more about any of her experiences at any time, you'll be happy to discuss things further.

2. Try to get more details about her subway experience, and a description of the perpetrator(s), if possible.

3. Prescribe anti-depressent medication to assist her in dealing with this sexual abuse.

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