ProblemDemand and Supply ProblemSaxum Vineyard, in Paso Robles, CA

ProblemDemand and Supply ProblemSaxum Vineyard, in Paso
Robles, CA, is one of the more than 8,000 wineries in the
United States. While Saxum produces a number of different
kinds of wine, they focus their production on Syrah (also known
as Shiraz). Saxum sells their wines all over the United States.
Suppose you manage a vineyard like Saxum and want to
determine how much you should charge for your Syrah. Suppose
the market demand function for Syrah is as follows.
QD = 200 - 38.18PO + 8.35PS - 2Pc + 10Inc + .8TS + .5M21
Where QD is monthly demand for bottle of Syrah (in millions),
PO is the price of Syrah in the market, PS is the average price
of substitute bottles of wine (other varieties), Pc is the average
price of a pound of cheese and is used to gauge the price of
complimentary goods, Inc is average US per capita income (in
thousands), TS is the number of wine trade shows and
competitions each year which firms can attend to market their
wines, and M21 is the number (in millions) of millennials in the
US over the age of 21. This last variable is included to capture a
change in consumer preferences; millennials are drinking wine
at a much higher rate than previous generations.
The market for Syrah also has supply, produced by wineries
similar to Saxum Vineyard and your winery, which can be
stated as follows.
QS = -100 + 22.93PO - 5PPI - 10PS + 8Temp + 1Sup
Where QS is monthly supply of bottles of Syrah (in millions),
PO is the price of Syrah in the market, PPI is the Producer Price
Index (an index used to gauge changes in the costs of
production in the US), PS is the price of substitute wines which
could easily be produced instead of Syrah, Temp is the expected

temperature during the harvest season for grapes, and Sup is the
number of wineries that supply Syrah in the market (in
thousands).Using the market supply and demand functions for
Syrah given, fill in the template provided with the coefficients
for each function. Using the information below, fill in the
values for each of the variables except Price of Syrah.
Demand:
-Price of Substitutes: $18
-Price of Cheese: $15
-Income: $53,000
-Trade Shows/Competitions: 3
-Millennials = 45 million
Supply
-PPI: 111
-Price of Substitutes: $18
-Temperature: 60
-Number of Suppliers: 8,000
MARKET DEMANDMARKET
SUPPLYCoefficientsValuesCoefficientsValuesInterceptIntercep
tPrice of SyrahPrice of SyrahPrice of SubstitutesPPIPrice of
CheesePrice of SubstitutesIncomeTemperatureTrade
ShowsSuppliersMillennialsa)When the price of Syrah increases
by $1, do supply and demand increase or decrease?b)By how
much? What is the effect on quantity demanded and quantity
supplied? a)b)Quantity demanded by million bottles.Quantity
supplied by million bottles.c)Does a $1 decrease in the price of
substitute bottles of wine shift the demand and supply curves to
the left or right?
d)By how much?
c)d)Demand curve is shifted to the by million bottles.Supply
curve is shifted to the by million bottles.e)Suppose the price of
Syrah is currently $22 per bottle. How many bottles will be
demanded and supplied monthly?

Price of Syrah =$22.00Bottles demanded = millionBottles
supplied = millionf)Is there a shortage or a surplus?
g)How much is the shortage or surplus?
f)g)There is a equal to million bottles.h)If the market price of
Syrah falls to $16 per bottle, how many bottles will be
demanded and supplied monthly?
Price of Syrah =$16.00Bottles demanded = millionBottles
supplied = millioni)Is there a shortage or a surplus?
j)How much is the shortage or surplus?i)j)There is a equal to
million bottles.k)Trying prices in $1 increments between $16
and $22, at what price and quantity does the market equilibrium
occur?
PriceQuantity demanded (in millions)Quantity supplied
(in
millions)$16.00$17.00$18.00$19.00$20.00$21.00$22.00Equilibr
ium price =Equilibrium quantity = million bottlesl)Suppose the
costs of production increase to 123.222. If the price of wine
stays at the point determined in part k, what will be supplied in
the market?
PPI =123.222QS = million bottlesm)Will this create a shortage?
If the costs of production increase to 123.222 and the price of
wine stays at the point determined in part k thiscreate a
shortage.n)With the increase in production costs to 123.222, at
what price will the market be in equilibrium again?
PriceQuantity demanded (in millions)Quantity supplied
(in millions)$18.00$19.00$20.00$21.00$22.00Equilibrium price
=o)What will be demanded and supplied at the price determined
in part n?Equilibrium quantity = million bottles
InstructionsProject Description:
In this problem, you will calculate the quantity demanded,

quantity supplied, and equilibrium price. Then you will
determine the effects of changes in the market conditions on
equilibrium.
For the purpose of grading the project you are required to
perform the following tasks: StepInstructionsPoints
Possible1Start Excel.02In cells D8-D14, E10-E14, H8-H13, and
I10-I13, enter the coefficients and values for the market demand
and market supply functions.
Note: Do not use the equal sign when entering a numeric value.
The values for income and number of suppliers should be
entered in thousands and the value for millennials should be
entered in millions.13In cell H18, determine whether the
quantity demanded increases or decreases when the price of
Syrah increases by $1.
In cell J18, by using a cell reference, calculate the change in the
quantity demanded. Refer to an appropriate cell among D8-D14.
Note: The change in the quantity demanded must be a positive
number.14In cell H19, determine whether the quantity supplied
increases or decreases when the price of Syrah increases by $1.
quantity supplied. Refer to an appropriate cell among H8-H13.
Note: The change in the quantity supplied must be a positive
number.15In cell H23, determine the direction in which the
demand curve shifts when the price of substitute bottles of wine
decreases by $1.
In cell J23, by using a cell reference, calculate the amount of
the shift in the demand curve. Refer to an appropriate cell
among D8-D14.
Note: The amount of the shift in the demand curve must be a

positive number.16In cell H24, determine the direction in which
the supply curve shifts when the price of substitute bottles of
wine decreases by $1.
the shift in the supply curve. Refer to an appropriate cell among
H8-H13.
Note: The amount of the shift in the supply curve must be a
positive number.17In cells H27 and H28, by using cell
references, calculate the bottles demanded and bottles supplied,
respectively, corresponding to Price of Syrah in cell H26. Use
the Excel SUMPRODUCT function as a part of the formula. Use
cell H26 and the appropriate cells among D8-D14, E10-E14,
H8-H13, and I10-I13. 18In cell H32, determine whether there is
a shortage or surplus corresponding to Price of Syrah in cell
H26.
In cell J32, by using cell references, calculate the amount of
shortage/surplus. Use cells H27 and H28.
Note: The amount of shortage/surplus must be a positive
number.19In cells H35 and H36, by using cell references,
calculate the bottles demanded and bottles supplied,
respectively, corresponding to Price of Syrah in cell H34. Use
the Excel SUMPRODUCT function as a part of the formula. Use
cell H34 and the appropriate cells among D8-D14, E10-E14,
H8-H13, and I10-I13. 110In cell H40, determine whether there
is a shortage or surplus corresponding to Price of Syrah in cell
H34.
number.111In cells E43-F49, do the following:

In cell E43, by using relative and absolute cell references,
calculate the quantity demanded corresponding to Price of Syrah
in cell D43. Use the Excel SUMPRODUCT function as a part of
the formula. Use cells D43, D8-D14, E10-E14. Copy the
formula from cell E43 down the column to cell E49.
In cell F43, by using relative and absolute cell references,
calculate the quantity supplied corresponding to Price of Syrah
in cell D43. Use the Excel SUMPRODUCT function as a part of
the formula. Use cells D43, H8-H13, and I10-I13. Copy the
formula from cell F43 down the column to cell F49.212In cell
H50, by using a cell reference, determine the equilibrium price.
Refer to an appropriate cell among D43-D49.
In cell H51, by using a cell reference, determine the equilibrium
quantity. Refer to an appropriate cell among E43-F49.113In cell
H54, by using cell references, calculate the quantity supplied
corresponding to Price of Syrah in cell H50 and Costs of
production in cell H53. Use the Excel SUMPRODUCT function
as a part of the formula. Use cells H50, H53, H8-H13, I11-I13.
114In cell K56, determine whether the change in the costs
creates a shortage.115In cells E59-F63, do the following:
calculate the quantity demanded corresponding to Price in cell
D59. Use the Excel SUMPRODUCT function as a part of the
formula. Use cells D59, D8-D14, and E10-E14. Copy the
calculate the quantity supplied corresponding to Price in cell
D59. Use the Excel SUMPRODUCT function as a part of the
formula. Use cells D59, H53, H8-H13, and I11-I13. Copy the
formula from cell F59 down the column to cell F63.216In cell
H64, by using a cell reference, determine the equilibrium price.

Refer to an appropriate cell among D59-D63.117In cell H66, by
using a cell reference, determine the equilibrium quantity. Refer
to an appropriate cell among E59-F63.118Save the workbook.
Close the workbook and then exit Excel. Submit the workbook
as directed.0
CASE STUDY
You are working with Dr. Stephanie Lee at her family medicine
clinic. Dr. Lee tells you, "The next patient, Mrs. Payne, is a 45-
year-old cisgender female who is here for a health maintenance
exam. It looks like she hasn't had a visit for over five years.
When you're talking with Mrs. Payne, I'd like you to find out if
she has any current concerns, update her past medical history,
and do a brief review of systems. Then, come on out and tell me
what you've discovered and we'll both go in to do the physical
exam together."
You introduce yourself to Mrs. Payne and begin obtaining her
history:
Medical History:
"Do you mind if I ask you a few questions to find out how you
are doing?"
Mrs. Payne says, "That sounds fine."
"What brought you in today?"
"I feel fine, but I know I should get checked out since it's been
a while and I need to have a Pap test and mammogram."
"I would like to update your medical history. Do you have any
chronic medical problems?"
"Well, I don't really have any medical problems."
"Have you had any operations?"
"I had my tubes tied shortly after the birth of my last child."
"Are you on any medications, or are you allergic to any
medications?"
"I take an occasional Tylenol or ibuprofen for pain or headache
and a multivitamin. I'm not allergic to any medicine as far as I
know."

Social History:
"Have you ever smoked?"
"Yes, I'm afraid I do smoke a pack of cigarettes a week. I keep
trying to quit, but I just never seem to be able to do it."
"Do you drink alcohol?"
"No, I don't drink any alcohol at all."
"Have you ever used any recreational drugs?"
"I never tried any illegal drugs. My friends have smoked
marijuana but I was always too afraid to try."
"How much do you exercise?"
"I used to try to walk at lunchtime, but I don't do that anymore.
It just seems like I've been too busy to have time to exercise."
"Have you been hit, kicked, punched, or otherwise hurt by
someone in the past year? If so, by whom?"
"No, I feel safe."
Family History:
"How is the health of your family members?"
"My father has high blood pressure and my mother has mild
arthritis, but both are in good health. My two sisters are
healthy."
"What about your extended family?"
"I don't know how my grandparents died, but I think one of
them had diabetes. My mom's sister has breast cancer but is
doing well after surgery and chemotherapy."
Mrs. Payne asks you, "Does having an aunt with breast cancer
increase my risk of developing breast cancer? My aunt was
diagnosed with breast cancer when she was about 70 years old."
You were able to reassure Mrs. Payne that the risk is increased
only if there is a history in a first-degree relative, such as a
parent or sibling.
OB/GYN:
"How old were you when your periods began?"
"Around 13 or 14."
"Are your periods usually regular?"
"They have always been regular until the last year, when my

menstrual flow has decreased."
"Can you describe what you mean?"
"My cycles have lengthened and the flow has decreased. I think
I might be having hot flashes once in while, too. I'm wondering
if I might be going through menopause."
You tell Mrs. Payne you would like to address this issue i n
more detail when you return later with Dr. Lee.
"Have you ever had an abnormal Pap test?"
"I had one abnormal Pap test seven or eight years ago. Dr. Lee
did a test and took some samples but everything turned out
normal. I had another Pap test one year later that was normal. I
then had another normal one a few years ago, right?"
"Right. You mentioned having a child. How many times have
you been pregnant?"
"I have been pregnant three times, and I have three children."
When you ask Mrs. Payne about health maintenance, she says
she has never had a mammogram. She tells you, "One of the big
reasons I've been putting off coming to see Dr. Lee is because I
know she will recommend a mammogram. I think I should have
one since my aunt had breast cancer and all, even though we
just discussed how that shouldn't increase my risk. But a friend
of mine told me her mammogram was very painful. I have done
breast self-exams, but not very often. I did notice some
tenderness the last time I did my exam."
You respond, "Let's talk more about mammograms with Dr. Lee
when she comes in. Are there any other issues you'd like to
cover today?"
Mrs. Payne indicates that she's discussed all her concerns with
you already. You excuse yourself while Mrs. Payne changes
into a gown for her physical exam.
After presenting Mrs. Payne's history and vital signs to Dr. Lee,
the two of you knock on the door and reenter the room. After
greeting Mrs. Payne, Dr. Lee asks if she minds if you perform
the physical examination with Dr. Lee observing. Mrs. Payne

assents.
Physical Exam
Vital signs:
· Temperature is 37 °C (98.6 °F)
· Pulse is 81 beats/minute
· Respiratory rate is 12 breaths/minute
· Blood pressure is 128/72 mmHg
· Weight is 81.6 kg (180 lbs)
· Height is 168 cm (66 in)
· BMI is 29 kg/m2
General: Mrs. Payne is a well-appearing 45-year-old female.
Head, eyes, ears, nose, and throat (HEENT): All unremarkable.
Teeth are in good repair with several fillings and some tobacco
staining noted.
Neck: Normal-sized thyroid with no nodules. Trachea is in the
midline.
Cardiovascular: Normal S1 and S2 with no murmurs, gallops, or
rubs. Pulses are palpable and equal throughout.
Respiratory: Clear with good respiratory excursions. No
palpable lymph nodes are noted in the cervical or inguinal
regions.
Musculoskeletal: Good muscle development and normal range
of motion of all joints.
Neurologic: Cranial nerves are intact; normal strength and
sensation; reflexes are equal and symmetrical; normal gait.
Performing a Breast Exam
Although breast exam is not a recommended screening test, it is
important to know how to perform it in a patient with
symptoms.
A good breast exam consists of both visual
inspection and palpation.
Visual inspection:
With patient sitting upright on the exam table, have her lower
her gown to her waist so the breasts can be fully visualized.
· Look for symmetry in shape and assess skin changes,

including any erythema, retractions, dimpling, or nipple
changes.
· Ask the patient to lift her hands overhead to accentuate any
retraction or dimpling.
Palpation:
For the palpation portion of the exam, ask patient to lie back on
the exam table and place her hands over her head, thus
flattening the breast tissue on the chest wall.
· Carefully examine each breast using a vertical strip pattern.
After you have finished the breast exam, you examine Mrs.
Payne's abdomen.
Abdomen:
No hepatosplenomegaly, tenderness, or masses.
Dr. Lee then explains to you the correct technique for a pelvic
exam, as Mrs. Payne is due for her Pap test.
Dr. Lee next inspects the cervix and vaginal walls for lesions or
discharge before obtaining cytology. "Now I'm going to obtain a
sample," she tells Mrs. Payne.
TEACHING POINTObtaining a Pap Test
One common method for collecting the Pap test is to use a
spatula and cytobrush, though there are single-collection
products available for this purpose as well.
Using the combination involves two steps: First, the spatula is
rotated several times to obtain a sample from the ectocervix.
The cytobrush is then inserted into the os and rotated 180
degrees.
Care is taken to make sure that the squamo-columnar junction
(the area of the endocervix where there is rapid cell division
and where dysplastic cells originate) is adequately sampled.
The sample is then placed into a liquid medium.
Using the liquid-based system over the conventional Pap test
technology allows for later testing of the sample for the
presence of human papillomavirus (HPV) if the Pap comes back
abnormal.

Currently two liquid-based systems are approved by the FDA.
You should check with your lab to find out which system is
preferred.
Once the sample is obtained, let the patient know the speculum
is about to be withdrawn.
Then, withdraw the speculum slightly to clear the cervix, loosen
the speculum and allow the "bills" to fall together, and continue
to withdraw while rotating the speculum to 45 degrees.
Performing a Bimanual Exam
Screening for ovarian cancer with a bimanual exam is not
recommended, but it is the technique you would use should you
need to do the exam for a symptomatic patient.
First, explain to your patient what you are going to do.
Next, apply lubricant (e.g., K-Y jelly) to the index and middle
fingers of your nondominant gloved hand and insert them into
the patient's vagina.
Move cervix side to side (laterally) to ensure that it is
nontender and mobile.
Place your non-gloved hand on the abdomen just superior to the
symphysis pubis, feeling for the uterus between your two hands.
This gives you an idea of its size and position.
Then, moving your pelvic hand to each lateral fornix, try to
capture each ovary between your abdominal and pelvic hands.
The ovaries are usually palpable in slender, relaxed patients, but
are difficult or impossible to feel in obese patients.
Mrs. Payne's cervix is freely moveable and nontender, and her
uterus is normal in size and position. Her ovaries are not
palpable.
"Everything is fine," Dr. Lee tells Mrs. Payne. "We're going to
leave the room for a minute and give you a chance to get
dressed, and then we can talk some more when we come back."
When you have left the room, you tell Dr. Lee that you are a
little confused about when Pap tests are recommended, so she
reviews the guidelines with you.
Cervical Cancer Screening Guidelines
In 2012, the ACS, the USPSTF, the American College of

Obstetrics and Gynecology (ACOG), and the American Society
for Colposcopy and Cervical Pathology (ASCCP) came to a
consensus on cervical cancer screening.
Since that time, many organizations have updated their
recommendations to include the use of high-risk HPV (hrHPV)
testing alone. The frequency of testing and age of first use
varies.
In 2018, the USPSTF updated their guidelines to recommend
that:
· At age 21: cervical cancer screening should begin.
· Between ages 21 and 29: screening should be performed every
three years with cytology alone.
· Between ages 30 and 65: screening can be done every five
years with high risk HPV (hrHPV) testing alone, every five
years with cotesting (hrHPV and cytology), or every three years
with cytology alone.
Since that time, many organizations have updated their
recommendations to include the use of high risk HPV (hrHPV)
testing alone. The frequency of testing and age of first use
varies.
Importantly, it should be noted that the new guidelines stipulate
that certain risk groups need to have more frequent screening.
They include patients who have compromised immunity, are
HIV positive, have a history of cervical intraepithelial neoplasia
grade 2, 3, or cancer, or have been exposed to diethylstilbestrol
(DES) in utero. (DES is a nonsteroidal estrogen that was given
to pregnant females to prevent miscarriages. However, it was
linked to clear cell adenocarcinoma of the vagina and its use
was discontinued in 1971.)
Patients older than 65 years who have had adequate screening
within the last 10 years may choose to stop cervical cancer
screening. Adequate screening is three consecutive normal Pap
tests with cytology alone or two normal Pap tests if combined
with HPV testing.
Patients who have undergone a total hysterectomy for benign
reasons do not require cervical cancer screening.

While you are in the hallway waiting for Mrs. Payne to get
dressed, you and Dr. Lee discuss breast and cervical cancer
screening. She asks you, "What constitutes a good screening
test?"
Characteristics of a Good Screening Test
1. Accuracy (high sensitivity and specificity)
Sensitivity
· Measures proportion of actual positives that are correctly
identified as such (e.g., percentage of sick people identified as
having the condition)
· The more sensitive the test, the fewer false negative results.
Specificity
· Measures the proportion of negatives that are correctly
identified as such (e.g., percentage of well people identified as
not having the condition)
· The more specific the test, the fewer false positives.
2. Able to detect disease in an asymptomatic phase
3. Minimal associated risk
4. Reasonable cost
5. Acceptable to patient
6. There is an available treatment for the disease
The Pap test fits into the definition of a good screening test
because the test is relatively inexpensive, easy to perform, and
acceptable to patients.
Cervical cancer has a long asymptomatic preinvasive state
(often a decade or more), and there are effective treatments for
preinvasive disease.
Although the Pap test has a sensitivity of only betw een 30% and
80% and a specificity of 86% to 100%, cancer deaths from
cervical cancer decreased markedly in the U.S. after the Pap test
was introduced.
Based on Mrs. Payne's history, you and Dr. Lee have
determined that she is at average risk for breast cancer. Dr. Lee

tells you that the recommendation regarding when to perform
screening mammography varies.
"We all struggle to keep up with the constantly changing
recommendations," Dr. Lee tells you. "I follow the USPSTF
guidelines. They review cancer screening as well as health
maintenance issues in general. The USPSTF guidelines are
strictly evidence-based and probably eliminate some of the bias
brought to the table by specialists. A nice feature of the
USPSTF guidelines is that they also review the guidelines from
other organizations."
Dr. Lee further observes that, in Mrs. Payne's age group, even
though the most common cancers are breast, lung, and
colorectal cancers, screening for them is not necessarily
suggested.
TEACHING POINTRecommendations for Breast Cancer
Screening Mammography
U.S. Preventive Services Task Force
Biennial screening mammography for females aged 50 to 74
years
(Grade B recommendation)
The decision to start regular, biennial screening mammography
before age 50 should be an individual one and take patient
context into account, including the patient's values regarding
specific benefits and harms.
(Grade C recommendation)
American Cancer Society
Females aged 45 to 54 should get mammograms every year.
Females aged 55 and older should switch to mammograms every
two years, or have the choice to continue yearly screening.
Females aged 40 to 44 should have the choice to start annual
breast cancer screening with mammograms if they wish to do
so. The risks of screening, as well as the potential benefits,
should be considered.
American College of Radiology
For females at average risk, < 15% lifetime risk of breast
cancer, annual screening with mammography or digital breast

tomosynthesis is recommended starting at age 40.
*As of 2018, The American College of Radiology (ACR) has
classified African American females as high risk.
(ACR Appropriateness Category: Usually Appropriate)
Most guidelines do not recommend routine mammography for
females younger than 40 unless they fall into a high-risk
category, such as females with a known BRCA mutation.
TEACHING POINTShared Decision-Making in the Setting of
Conflicting Guidelines
Part of a clinician's job is to help patients make informed
decisions that incorporate their personal and family history/risk
factors and personal health beliefs. Clinicians need to be aware
of the different guidelines. It is important to present the pros
and cons of different recommendations and guide patients in a
shared decision-making process. In situations where there are
differences in recommendations, it is important to get the
patient's input.
Dr. Lee tells you that breast-related concerns like lumps and
discharge are common in primary care practice.
TEACHING POINT
Evaluating a Breast Lump
First, take a good history from the patient, including:
· Precise location of the lump
· How it was first noticed (accidentally, by breast self-
examination, clinical breast examination, or mammogram)
· How long it has been present
· Presence of nipple discharge
· Any change in size of the lump (especially ask whether the
lump changes in size according to phase of the menstrual cycle)
The next step is a thorough breast exam: Certain characteristics
on physical exam increase the suspicion of malignancy.
· For example, the presence of a single, hard, immobile lesion
of approximately 2 cm or larger with irregular borders increases
the likelihood of malignancy.
Diagnostic tests:

· If it feels cystic, aspiration can be attempted and the fluid sent
for cytology. Fine needle aspiration is a procedure family
physicians can do in the office.
· If it feels solid, mammography is the next step.
· Ultrasound can be helpful in distinguishing a solid mass from
a cystic lesion.
Follow-up:
If the workup suggests that the lesion is benign (which the vast
majority are), close follow-up with regular breast exams and
mammography is indicated.
Next, you and Dr. Lee review breast cancer screening. The most
commonly used screening tool is mammography. Physician
breast exam has not been shown in studies to meet the screening
criteria.
TEACHING POINTBreast Cancer Screening Studies
Mammography
Benefits
Mammography is a good screening test that can detect
asymptomatic early stage disease, and there is good evidence
that mammography decreases breast cancer mortality.
Risks
As with any other screening test, there is a potential for false-
positive results (leading to unnecessary procedures) or false-
negative results (giving patients a false sense of security). The
sensitivity of mammography is between 60% and 90%. Low
sensitivity means more false negative results. False-negative
results are more common in younger females, as denser breast
tissue makes it harder to find abnormalities on x-rays.
Mammography is a radiograph, which involves some radiation
exposure. However, modern mammography systems use
extremely low levels of radiation, usually about 0.1 to 0.2 rad
per x-ray, which is minimal and provides negligible risk.
Also, mammograms can be uncomfortable for patients.
Breast MRI
Not recommended for screening the general population of

asymptomatic, average-risk females.
May be indicated in the surveillance of females with more than
a 20% lifetime risk of breast cancer (for example, individuals
with genetic predisposition to breast cancer by either gene
testing or family pedigree, or individuals with a history of
mantle radiation for Hodgkin disease).
May be used as a diagnostic tool to identify more completely
the extent of disease in patients with a recent breast cancer
diagnosis.
Contrast-enhanced breast MRI may be indicated in the
evaluation of patients with breast augmentation in whom
mammography is difficult.
Breast Ultrasound
USPSTF guidelines says there is insufficient evidence to use
this for screening in females with dense breasts. The American
College of Radiology (ACR) notes that it increases breast
cancer detection in females with dense breasts but also
increases the risk of false positives. This tool is generally used
for evaluation of suspected abnormalities.
Dr. Lee asks, "What other important health maintenance issues
do we need to address?"
You suggest checking Mrs. Payne's immunization status. You
both review Mrs. Payne's chart and then visit the CDC
immunization information website (PDF). Seeing that Mrs.
Payne's last tetanus shot was over 10 years ago, you recommend
she get a Tdap now. Also, since she is a smoker, you
recommend she receive the pneumovax vaccine today. She
should receive a flu vaccine every fall.
"Okay. Is there anything else we should talk with Mrs. Payne
about when we go back?" You feel you should address Mrs.
Payne's smoking, her excessive weight, her lack of exercise, and
osteoporosis prevention. Dr. Lee agrees.
TEACHING POINTImmunization: Tdap
Tetanus, diptheria, and acellular pertussis (Tdap) should replace
a single dose of Td for adults age 19 through 64 who have not

received a dose of Tdap previously.
When you reenter the room, Dr. Lee reassures Mrs. Payne,
"Your physical exam was normal. However, I have several
suggestions and recommendations I would like to discuss with
you. But first let's talk a bit about menopause, since I'm told
you have some concerns."
TEACHING POINTMenopause
Timing
On average, patients with ovaries reach menopause at age 51,
but menopause can start earlier or later. A few patients start
menopause as young as 40, and a very few as late as 60. Those
who smoke tend to go through menopause a few years earlier
than nonsmokers. The timing of an individual's menopause
cannot be predicted. Only after a patient has not menstruated for
12 straight months can menopause be confirmed.
Perimenopause
The gradual transition to menopause is called perimenopause.
The ovaries don't abruptly stop; they slow down. During
perimenopause it is still possible to get pregnant. The ovaries
are still functional, and ovulation may occur, although not
necessarily on a monthly basis. Perimenopause can last from
two to eight years.
Symptoms
Menopause affects each person differently. Some reach
menopause with little to no trouble; others experience severe
symptoms that drastically hamper their lives. Menstrual
irregularity is the hallmark of perimenopause. Patients should
be advised to call their clinician if their menses come very close
together, if the bleeding is heavy, or if the bleeding lasts more
than a week.
Other perimenopausal symptoms due to estrogen deficiency
include:
Hot flashes: Hot flashes are brief feelings of heat that may make
the face and neck flushed and cause temporary red blotches to
appear on the chest, back, and arms. Sweating and chills may
follow. Hot flashes vary in intensity and typically last between

30 seconds and 10 minutes. Dressing in light layers, using a fan,
getting regular exercise, avoiding spicy foods and heat, and
managing stress may help.
Vaginal dryness: This can make intercourse uncomfortable. A
water-soluble lubricant may be recommended. A patient's libido
may also change.
Mood swings: Mood swings, especially depression, are common
during perimenopause and menopause. Patients should let their
clinician know if they are experiencing this, so that resources
and support may be found.
Dr. Lee asks you if Mrs. Payne has any risk factors for
osteoporosis. "Yes," you reply. "She is a smoker."
TEACHING POINT
Recommendations for Osteoporosis Prevention
Before menopause, estrogen offers some protection against
heart disease and osteoporosis. This protection is lost when
estrogen levels ebb with menopause.
Calcium Intake
Calcium supplementation for osteoporotic fracture prevention
has raised concerns that it may increase the risk of
atherosclerotic vascular disease and kidney stones. However, it
is unclear from the present data whether intake of dietary
calcium versus calcium supplementation increases
cardiovascular risk or the risk for kidney stones. A USPSTF
2018 recommendation statement concluded that current
evidence is insufficient to assess the risks and benefits of
calcium and vitamin D supplementation for the prevention of
fractures in premenopausal and noninstitutionalized
postmenopausal patients. Therefore the USPSTF is currently
recommending against 1,000 mg or less of calcium and 400 IU
or less vitamin D supplementation in community-dwelling
postmenopausal patients.
At this time the most prudent recommendation would be to try
to increase intake of dairy and try to include weight-bearing
exercises such as walking into a daily routine.

TEACHING POINT
Recommendations for Osteoporosis Screening
· For females 65 and older, screening with dual energy x-ray
absorptiometry (DEXA) is recommended.
· For females under 65, the USPSTF recommends using the
World Health Organization's Fracture Risk Assessment Tool to
risk-stratify. Screening with DEXA is recommended if the risk
of fracture is greater than or equal to that of a 65-year-old
White female without additional risk factors (9.3 percent over
10 years). These recommendations are being reviewed by the
USPSTF.
· Dr. Lee moves on to the next topic. "I'd like to talk next about
your weight," she tells Mrs. Payne. "By losing 5 to 10 percent
of your body weight, you can significantly reduce your risk of
diabetes, hypertension, and cardiovascular disease."· "How do
you feel about your weight at this point?"
· "I weigh too much. I would feel better physically and
emotionally if I could only lose about 10 or 20 pounds. But I
don't know where to start."· "Well, we are here to help you with
that," offers Dr. Lee. Can you tell me what you would eat in a
typical day?"
· Mrs. Payne lists her daily diet for you: "Well, I usually skip
breakfast because mornings are so chaotic, plus I know I don't
really need to eat more than I do. For lunch, I eat a sandwich or
leftover pasta, an apple or orange, and I drink water. I also have
a weakness for a couple of cookies after lunch to keep me going
through the day. For dinner, I try to cook lean meats, and we
usually have rice with it. Again, I drink water. My family likes
strawberries and blackberries. We try to eat something like that
when it's available. And, we have cake or ice cream for dessert.
At night, while I'm watching TV is my weakness—I'll often eat
some chips or have another helping of dessert."
· "Alright, you are making some excellent choices by eating two
fruits a day, choosing lean meats, and drinking water. I would
like to continue to see you doing these things."
· You tell Mrs. Payne about some additional nutritional

approaches to a healthier diet.· "Do you think you could try any
of these changes?"
· Mrs. Payne says, "I could start eating breakfast, buy whole
wheat stuff, and decrease my desserts to three servings weekly."
· "That would be excellent," Dr. Lee concludes. "Let's follow up
on these goals at our next visit."
·
Dr. Lee reminds Mrs. Payne that increasing her physical activity
would also assist weight loss.· "What type of activity do you
enjoy?"
· "I used to walk during my lunch hour, but I've gotten away
from it. I could start doing that again."
"Now I'd like to talk about smoking," continues Dr. Lee."Have
you thought about quitting?"
"I've tried to quit smoking a few times but was never able to
make it stick. I'd like to quit for good."
Turning to you, Dr. Lee says, "It sounds like Mrs. Payne is at
the 'preparation stage' according to the transtheoretical model
for change."
Mrs. Payne declines assistance with medication to help her stop
smoking.
When discussing smoking cessation, it is a good idea to start
with the five "A's": ask, advise, assess, assist, arrange. With
Mrs. Payne, you have asked and assessed. Fortunately, Mrs.
Payne is interested in quitting, but typically you would want to
advise as well. Since Dr. Lee has noted the patient is in the
preparation stage but does not want to use medication, you can
provide her with some of the other smoking cessation strategies
below. Make sure to arrange for follow up!
"Now, I've just got a few more loose ends we need to tackle at
this appointment. Since your last tetanus shot was over 10 years
ago, I'd like you get a Tdap shot today. In 10 years, you will
need a Td."

Dr. Lee turns to you and asks,"Is there any blood work we
should order on Mrs. Payne today?"
"I think a lipid profile and fasting glucose would be indicated."
Dr. Lee agrees.
"I'd like you to schedule a follow-up appointment so we can go
over your lab results and your progress with your lifestyle
goals," She tells Mrs. Payne.Dr. Lee asks her, "Do you have any
questions about our recommendations?"
"No, you both have answered all my questions. I am going to try
to start eating breakfast regularly, increasing my exercise, and
try getting out and walking daily. I'll work on cutting back
smoking as well. Thanks for all your help," Mrs. Payne says as
she shakes hands with both of you and heads out the door.
On your last day with Dr. Lee, you see Mrs. Payne is on the
schedule to follow up on her lab results. Before going into the
room, you review her results with Dr. Lee:
Fasting glucose: 86 mg/dl
Lipids:
· Total cholesterol 183 mg/dl
· HDL 52 mg/dl
· LDL 121 mg/dl
· Triglycerides 137 mg/dl
Using her blood pressure from her initial visit and current
cholesterol results, the atheroslerotic cardiovascular disease
(ASCVD) risk calculator shows that Mrs. Payne's 10-year risk is
2.6 percent. For more required information about risk factors
for ASCVD, read the Aquifer Cholesterol Guidelines Module.
Pap test results: Satisfactory; with evidence of ASC-US; HPV
negative on co-testing.
Dr. Lee reviews with you the current way cervical cytology is
reported via the Bethesda System. Since you know that infection
with specific types of HPV is required for the development of
cervical cancer and high-grade cervical lesions, you are
reassured by the fact that Mrs. Payne's Pap is negative for HPV.
You and Dr. Lee also take a look at the recommendations to

follow-up on Mrs. Payne's Pap test results. Because of her ASC-
US and HPV negative findings, the current recommendation is
to retest in 3 rather than 5 years. (See guidelines below).
The Bethesda System for Reporting Cervical Cytology
Using this system of reporting, cervical cytology pathology
results are given in three categories:
1. Specimen adequacy
In order to be "adequate," the Pap test must contain over 5,000
squamous cells and have sufficient endocervical cells.
(Endocervical cells are columnar epithelial cells found just
proximal to the squamo-columnar junction, the site of beginning
dysplastic changes.) If they are present, it shows that you have
sampled the transformation zone, and therefore the specimen is
"adequate."
2. General categorization of results
Is there any evidence of intraepithelial lesion or malignancy?
3. Interpretation of results
Either the Pap is negative for intraepithelial lesion or
malignancy, or there is evidence of epithelial abnormalities.
Epithelial abnormalities are further divided into four categories.
· Atypical squamous cells (ASC): Some abnormal cells are seen.
These cells may be caused by an infection or irritation or may
be precancerous.
· Low-grade squamous intraepithelial lesion (LSIL). LSIL may
progress to a high-grade lesion but most regress.
· High-grade squamous intraepithelial lesion (HSIL). This is
considered a significant precancerous lesion.
· Squamous cell carcinoma.
You and Dr. Lee enter the room and greet Mrs. Payne. She says
she had already received the report that her mammogram was
normal. Dr. Lee also tells her that her blood sugar was normal
and that her cholesterol was at the recommended level. She tells
her that her Pap test had only a mild abnormality but that there
is little risk of cancer and recommends a repeat co-testing in

three years. She would not recommend waiting for five years, as
she did with this Pap. Mrs. Payne thanks you both for the good
news.
Aware that Mrs. Payne has a young daughter, you volunteer to
tell her about the HPV vaccine.
The CDC notes that as of 2017, only the 9-valent will be
available in the U.S. Another important change is that the HPV
series is considered complete after two doses in patients who
receive the first dose before age 15 and the second dose at least
five months after the first (ideally six to 12 months apart).
See an overview of the HPV vaccine recommendations for
clinicians.
The vaccines can be expensive, and patients should be advised
to check with their individual insurance carrier about coverage.
Dr. Lee notices Mrs. Payne's weight: "I see that you have lost
two pounds since your last visit."
"Well, I tried. I have taken your advice and started to eat
breakfast and have cut back on sweets and portion size. I have
been able to walk three times a week," replies Mrs. Payne.
"Good job! Keep up the good work," applauds Dr. Lee.
Dr. Lee poses her last question: "And how are you doing with
smoking cessation?"
"Great! I'm down to only one or two cigarettes a day! By the
next time you see me I may have stopped smoking altogether!"
Mrs. Payne exclaims.
Dr. Lee offers encouragement and says she would like to see her
again in three weeks to monitor her progress.
Mrs. Payne thanks you both and says she will really try to
continue to make the changes to her lifestyle.
This is the final page of the case. We value your perspective on
the learning experience. After completing three required
feedback ratings you can finish the case and access the case
summary.

Grader - Instructions Excel 2016 ProjectChapter 2 Demand
and Supply Problem (v2)
Project Description:
In this problem, you will calculate the quantity demanded,
quantity supplied, and equilibrium price. Then you will
determine the effects of changes in the market conditions on
equilibrium.
Steps to Perform:
Step
Instructions
Points Possible
1
Start Excel. Download and open the workbook named:
Chapter_2_Demand_and_Supply_Problem_Start.
0
2
In cells D8-D14, E10-E14, H8-H13, and I10-I13, enter the
coefficients and values for the market demand and market
supply functions.
Note: Do not use the equal sign when entering a numeric value.
The values for income and number of suppliers should be
entered in thousands and the value for millennials should be
entered in millions.
1
3
In cell H18,determine whether the quantity demanded increases
or decreases when the price of Syrah increases by $1.
quantity demanded. Refer to an appropriate cell among D8-D14.
Note: The change in the quantity demanded must be a positive
number.

1
4
In cell H19,determine whether the quantity supplied increases
or decreases when the price of Syrah increases by $1.
In cell J19, by using a cell reference, calculate the val ue of the
shift. Refer to an appropriate cell among H8-H13.
Note: The change in the quantity supplied must be a positive
number.
1
5
In cell H23,determine the direction in which the demand curve
shifts when the price of substitute bottles of wine decreases by
$1.
the shift in the demand curve. Refer to an appropriate cell
among D8-D14.Note: The amount of the shift in the demand
curve must be a positive number.
1
6
In cell H24,determine the direction in which the supply curve
shifts when the price of substitute bottles of wine decreases by
$1.
the shift in the supply curve. Refer to an appropriate cell among
H8-H13.
Note: The amount of the shift in the supply curve must be a
positive number.
1
7
In cells H27 and H28, by using cell references, calculate the
bottles demanded and bottles supplied, respectively,

corresponding to Price of Syrah In cell H26. Use the Excel
SUMPRODUCT function as a part of your formula. Use cell
H26 andthe appropriate cells among D8-D14, E10-E14, H8-H13,
and I10-I13.
1
8
In cell H32,determine whether there is a shortage or surplus
corresponding to Price of Syrah In cell H26.
number.
1
9
In cells H35 and H36, by using cell references, calculate the
bottles demanded and bottles supplied, respectively,
corresponding to Price of Syrah In cell H34. Use the Excel
SUMPRODUCT function as a part of your formula. Use cell
H34 andthe appropriate cells among D8-D14, E10-E14, H8-H13,
and I10-I13.
1
10
In cell H40,determine whether there is a shortage or surpl us
corresponding to Price of Syrah In cell H34.
number.
1
11
In cells E43-F49, do the following:

calculate the quantity demanded corresponding to Price of Syrah
In cell D43. Use the Excel SUMPRODUCT function as a part of
your formula. Use cells D43, D8-D14, E10-E14. Copy the
calculate the quantity supplied corresponding to Price of Syrah
In cell D43. Use the Excel SUMPRODUCT function as a part of
your formula. Use cells D43, H8-H13, and I10-I13. Copy the
formula from cell F43 down the column to cell F49.
2
12
price. Refer to an appropriate cell among D43-D49.
quantity. Refer to an appropriate cell among E43-F49.
1
13
In cell H54, by using cell references, calculate the quantity
supplied corresponding to Price of Syrah In cell H50 andCosts
of production In cell H53. Use the Excel SUMPRODUCT
function as a part of your formula. Use cells H50, H53,H8-H13,
I11-I13.
1
14
In cell K56,determine whether the change in the costs creates a
shortage.
1
15
In cells E59-F63, do the following:
calculate the quantity demanded corresponding to Price In cell
D59. Use the Excel SUMPRODUCT function as a part of your

formula. Use cells D59, D8-D14,and E10-E14. Copy the
calculate the quantity supplied corresponding to Price In cell
D59. Use the Excel SUMPRODUCT function as a part of your
formula. Use cells D59, H53, H8-H13, and I11-I13. Copy the
formula from cell F59 down the column to cell F63.
2
16
price. Refer to an appropriate cell among D59-D63.
1
17
quantity. Refer to an appropriate cell among E59-F63.
1
18
Save the workbook. Close the workbook and then exit Excel.
Submit the workbook as directed.
0
Total Points
18
Created On: 07/05/2019 1 Chapter 2 Demand and Supply
Problem (v2)

ProblemDemand and Supply ProblemSaxum Vineyard, in Paso Robles, CA

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