Transcript B2B_Periodic_Health_Exam_2011

Back to Basics, 2011
POPULATION HEALTH:
Periodic Health Exam,
Immunization, & Special
Populations
Epidemiology & Community
Medicine
Based on slides prepared by Dr. R. Spasoff
April 2011
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MCC Objectives: Periodic Health Exam
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Objectives
Through efficient, focused, data gathering:
In an infant, toddler, or child elicit information about risk factors at conception, pregnancy,
and birth, familial factors, and existing signs of illness or environmental risk factors (missed
immunization, diet, passive smoke inhalation, skin protection). Determine height, weight,
head circumference, medical status, and developmental milestones.
For a youth, elicit information about nutrition, physical activity, drug use, sexual/social/peer
activities, emotional concerns, and communication with parents.
In adults, elicit information about lifestyle patterns, psychological, social, and physical
functioning, symptoms of any illness, and situational factors affecting mood.
In seniors, elicit information about past illness, lifestyle factors, mental function, drug use,
physical and social activity, emotional concerns, social relations, and support systems.
List and interpret critical clinical and laboratory findings which were key in the processes of
exclusion, differentiation, and diagnosis:
Select investigation specific to age and gender concerns (e.g., VDRL for youth, chlamydia
screen for high-risk youths, cholesterol for>35 year, fecal occult blood for middle age,
tuberculin testing, HIV serology for high-risk group, mammography for>50 year, pap smear
for adult women, rubella serology for young women).
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MCC Objectives: Periodic Health Exam
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Conduct an effective plan of management for a patient who is well and without disease, well
and with disease, not well and with disease, not well and without disease:
Communicate and make recommendations regarding disease prevention (e.g., healthy diet,
calcium supplements for women, folic acid for women planning pregnancy, exercise, breast
self-exam, avoidance of high-risk sexual behavior, barrier contraceptives, flossing, fluoride
toothpaste, balance training and home-based prevention program for elderly).
Communicate and make recommendations regarding accident prevention (e.g., recommend
helmet use for bicycle injury, smoke detector use, avoid drinking/drugs and driving, seatbelt/air bag use).
Encourage patient control over health (e.g., hepatitis immunization for high-risk travel,
influenza and pneumococcal immunization for elderly or chronic disease patients,
measles/mumps/rubella for youth).
Outline intervention(s) that would reduce risk for an existing condition detected (e.g.,
Amantadine/Rimantadine if high-risk for influenza, sun avoidance/protective clothing,
smoking cessation, reduce alcohol, regular condom use for STD).
For a frequently encountered risk factor (e.g., colon cancer), outline one intervention that
would reduce the risk for the condition.
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077 PERIODIC HEALTH
EXAMINATION (1)
• “Determine patient’s risks for common gender/age specific
conditions”
• This would involve knowing something about prevalence
of condition, as well as patient’s risk factors for it.
• Objectives identify certain common conditions for each
age group
• Use periodic health exam for health promotion/disease
prevention interventions.
• Case-finding and screening for disease & risky behaviours
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Key conditions (1)
• Infant/Toddler <3 years
– Delayed growth & development
– Abuse/neglect
• Child 3-12 years
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Vision/hearing defect
“Accidents”
Delayed development
Abuse/neglect
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Key conditions (2)
• Youth 13-24 years
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MVA
Substance abuse
STDs
Contraception
Sedentary lifestyle
Female: rubella/HPV immunization
Eating disorders (don’t know why not included)
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Key conditions (3)
• Adult 25-44 years
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Substance abuse
Eating disorders
Family violence
Hypertension
Female: cervical cancer
Male: elevated cholesterol, MVA
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Key conditions (4)
• Middle age 45-64 years
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Lung cancer
Colon cancer
Skin cancer
Obesity
Female: osteoporosis, breast cancer
Male: IHD, prostate cancer (55 and up)
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Key conditions (5)
• Seniors >64 yrs
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Elder abuse
Falls
Drug-related morbidity
Nutrition
Cancer
Dementia (Should be on MCC list)
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077 PERIODIC HEALTH
EXAMINATION (2)
• “Elicit information about ethnic, family,
socio-economic, occupational, and
lifestyle characteristics that are known
to be at high risk for a particular
condition.”
• Presumably means “…known to convey
a high risk…”
• MCC provides a list for each age group
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Key Age-specific Risk factors (1)
• Infant, Toddler, Child:
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Risk factors at conception, pregnancy, birth
Familial factors
Existing signs of illness
Environment (missed immunization, diet,
passive smoke inhalation, skin protection)
– Height, weight, head circumference, medical
status, developmental milestones
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Key Age-specific Risk factors (2)
• Youth
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Nutrition
Physical activity
Drug use
Sexual/social/peer activities
Emotional concerns
Communication with parents
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Key Age-specific Risk factors (3)
• Adults:
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Lifestyle patterns
Psychological, social and physical functioning
Symptoms of any illness
Situational factors affecting mood
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Key Age-specific Risk factors (4)
• Seniors:
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Past illness
Lifestyle factors
Mental function
Drug use
Physical and social activity
Emotional concerns
Social relations and support systems
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Periodic Health Exam (2A)
• General:
– Use lab tests only for specific to age and sex
concerns. Do not use the same battery of tests
in all patients.
– Interpret results taking into account age/gender,
etc.
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077 PERIODIC HEALTH
EXAMINATION (3)
• “Conduct an effective plan of management”
• All patients:
– Encourage patient control over health
– Follow recommendations of CTFPHC
(http://www.ctfphc.org/ )
• Patient with risk factors:
– Counsel about risk factor reduction, using
health belief model, stages of change model,
etc.
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078-3 PERIODIC HEALTH
EXAMINATION (1)
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Clinical Guidelines for primary and preventive care
Targeted and Evidence based
Objectives target common conditions for each age group
Use periodic health exam for health promotion/disease
prevention interventions.
• Case-finding and screening for disease & risky behaviours
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Classification of
Recommendations
• A Good evidence to recommend
• B Fair evidence to recommend
• C Existing evidence is conflicting and
does not allow to make a
recommendation for or against
• D Fair evidence to recommend against
• E Good evidence to recommend against
• I insufficient evidence to recommend
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Elements
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Discussion
Physical exam
Tests
Therapy
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Gen Pop- Discussion
• Dental Hygiene (community fluoridation,
brushing , flossing) (A)
• Noise control, hearing protection (A)
• Seatbelt use (B)
• Injury prevention (bicycle helmets, smoke
detectors) (B)
• Moderate physical activity (B)
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Gen Pop- Discussion
• Avoid sun exposure and wear protective
clothing (B)
• Problem drinking screening, counselling (B)
• Counselling to protect against STI’s (B)
• Nutritional counselling on fat and
cholesterol (B)
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Gen Pop- Physical Exam
• Clinical breast exam women age 50-69 (A)
• Blood pressure measurement (B)
• BMI measurement in obese adults (B)
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Gen Pop- Tests
• Mutiphase screening with FOB test
adults>50 q1-2 yrs (A)
• Sigmoidoscopy adults > 50 freq not
established (B)
• Bone Mineral Density (1 major or 2
minor criteria)
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The Canadian Task Force on Preventive Health Care concludes
that there is fair evidence to recommend screening
postmenopausal women to prevent fragility fractures (no or
low trauma fractures) (grade B recommendation). Although
there is no direct evidence that screening reduces fractures,
there is good evidence that screening is effective in identifying
postmenopausal women with low bone mineral density and
that treating osteoporosis can reduce the risk of fractures in
this population (grade A recommendation).
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Gen Pop- Tests
• Fasting lipid profile Controversial
• Fasting glucose- hypertension and
hyperlipidemia (B)
• Mammography women 50-69 q1-2 yrs (A)
• Sexually active women Pap Smear q1y x2,
then q3y if both normal
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Gen Pop- Tests not
Recommended
• PSA still has insufficient evidence to justify
screening
• Syphilis tests should not be done routinely
• Breast self exam (D)- fair evidence of no
benefit and good evidence of harm
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Gen Pop- Therapy
• Folic Acid supplementation women of child
bearing age (A)
• Pharmacologic treatment of hypertension
with diastolic BP>90 mm Hg
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Special Pops- Smokers
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Counsel on smoking cessation
Nicotine replacement therapy (A)
Referral to smoking cessation program (B)
Dietary advice on leafy green vegetables
and fruits (B)
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Special Pops- Pediatric
• Discussion
– Home visits to high risk families (A)
– Inquiry into developmental milestones (B)
• Physical
– Repeated examination of hips hearing and eyes (A)
– Serial heights weights and head circumference (B)
– Visual acuity testing (>2 yrs) (B)
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Special Pops- Pediatric
• Tests
– Routine hemoglobin fir high risk populations
(sickle cell and thalassemia) (B)
– Blood lead screening for high risk infants (B)
• Therapy
– Immunization
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Special Pops- Adolescents
• Counsel on sexual activity and
contraceptive methods (B)
• Counsel to prevent smoking initiation (B)
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Perimenopausal Women
• Counsel on osteoporosis
• Counsel on risks and benefits of hormone
replacement therapy (B)
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Special Pops- adults>65
• Follow up on caregiver concern of cognitive
impairment (A)
• Multidisciplinary post-fall assessment (B)
• Visual acuity (Snellen) (B)
• Hearing impairment (B)
Special Pops- Familial
• First degree relative with melanoma
– Full body skin exam (B)
• Familial Adenomatous Polyposis
– Sigmoidoscopy and genetic testing (B)
• Hereditary non-polyposis colorectal cancer
– Colonoscopy (B)
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Special Pops- Other
• Tb high risk
– Mantoux testing (A)
– INH chemoprophylaxis for close contacts and
recent convertors (B)
• STI high risk
– Voluntary HIV antibody screening (A)
– Gonorrhea screening (A)
– Chlamydia screening (B)
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