Transcript Preventative Medicine - Georgetown University: Web hosting

Preventative Medicine
Michele Ritter, M.D.
Argy Resident – February, 2007
Preventative Medicine
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Routine care of the healthy patient
includes screening for asymptomatic
disease and assessing the potential
risk factors that contribute to disease
or other health problems.
History
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Lifestyle Screening
– Seat Belt Use
– Sun Exposure
– Diet
– Exercise
– Domestic Violence
History – Sexual History
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Sexual History
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In young adults, adolescents
Check for STD risk factors
– Promiscuity
– Unprotected sexual intercourse and history of venereal
infection
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Individuals should receive screening about safe sex
practices and benefits of barrier-protection
contraception
? MSM
Women < 25 years should undergo screening
for chlamydial infection
Periodic HIV testing and syphilis screening should be
offered to those at risk
History -Depression
Screening
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SIG E CAPS
– Sleep, Interest, Guilt, Energy,
Concentration, Appetite, Affect,
Psychomotor agitation, Suicide
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Two questions:
"Over the past two weeks, have you felt
down, depressed, or hopeless?"
 "Over the past two weeks, have you felt little
interest or pleasure in doing things?"
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History – Alcohol/Drug
Use
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CAGE Questions
– Have you every felt you ought to Cut down on
your drinking?
– Have people Annoyed you by criticizing your
drinking
– Have you ever felt Guilty or bad about your
drinking?
– Have you ever had a drink first thing in the
morning to stead your nerves or get rid of a
hangover? (Eyeopener?)
History – Tobacco Use
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In the year 2000, smoking was attributed to
5 million premature deaths worldwide
In the U.S., smoking is attributed to 400,000
deaths a year
– Most deaths due to CAD, COPD, Lung cancer
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The incidence of cigarette smoking is
increasing worldwide – estimated > 5 trillion
cigarettes smoked annually
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However, prevalence in US is DECREASING
Annual cost of smoking in US is >90 billion
dollars a year
Smoking Cessation
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The 5 “A’s” for smoking cessation
1. Ask: Systematically identify all tobacco users
at every visit
2. Advise: Strongly urge all tobacco users to
quit
3. Assess: Determine a patient’s willingness to
attempt to quit
4. Assist: Aid the patient in quitting.
1.
Includes counseling, pharmacotherapy, social
support
5. Arrange: Schedule follow-up contact.
Smoking Cessation
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Pharmacotherapy
– Nicotine Replacement
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Design to ameliorate symptoms of nicotine withdrawal:
anxiety, dysphoria or depressive symptoms, insomnia,
increased appetite/weight gain,
Includes:
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Polacrilax (gum) – increases quiting 2-fold
Transdermal (patches) – delivers 40-50% of what a
smoker at 1 ½ packs a day receives
Nasal Spray – has increased tendency for prolonged
nicotine dependence
Inhaler – caution: may cause bronchospasm
Smoking Cessation
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Pharmacotherapy (cont.)
– Bupropion (Zyban)
– Enhance noradrenergic, dopaminergic function
– Also used as an anti-depressant (Wellbutrin)
– Has been shown to significantly increase rate of smoking
cessation (especially when used in combination with
nicotine replacement).
– Caution in anorexic/bulemics (increased rate of seizures)
– Varenicline
– Is a partial agonist of nicotine acetylcholine receptor
– Has been shown to increase rate of quitting (may even
be better than bupropion)
Smoking Cessation
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Every tobacco user should be offered counseling
and nicotine replacement or other pharmacotherapy
at every visit.
Counseling should focus on:
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Establishing a quit date
Emphasizing abstinence
Using other family members
Avoiding alcohol and other drugs.
Only possible exceptions…
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Ulcerative Colitis – quitting smoking associated with UC
exacerbations.
Schizophrenia – those who smoke have better attention and
memory
Routine Physical
Examination
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Blood Pressure
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Monitor every 2 years
Goal Blood pressure:
– 140/90 in most patients
– 130/80 in patients with Diabetes or Renal Disease
Should be measured on 3 separate occassions before diagnosing
hypertension.
JNC 7 Guidelines:
Category
Systolic Blood
Pressure (mmHg)
Diastolic Blood
Pressure mmHG
Normal
<120
< 80
Prehypertension
120-139
80-89
Stage 1 Hypertension
140-159
90-99
Stage 2 Hypertension
≥160
≥100
Routine Physical
Examination
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Height/Weight
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Periodically
Body Mass Index
– BMI = body weight (in kg) ÷ stature (height,
in meters) squared
– If > 30, should receive obesity counseling
– Healthy diet, with emphasis on limited intake of
saturated fat and adequate intake of fruits,
vegetables and whole grains
– Regular physical activity
Routine Labs
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Lipid profile
– Check Fasting lipid profile in patients 20 years or
older.
– If normal, check every 5 years.
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Glucose
– Begin at age 45 years (or earlier if cardiac risk
factors, hyperplipidemia, family history)
– Diabetes Mellitus Definition:
– Fasting glucose ≥ 126 on two separate occasions
– Random glucose ≥ 200 on two occasions (with
symptoms of diabetes
Routine Labs (cont.)
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TSH
Controversial whether or not to check
regularly
 Some guidelines recommend periodic
checking in :
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Postmenopausal women
Postpartum women
Diabetes
Down’s Syndrome
Elderly
Additional Screening
Exams
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Osteoporosis
– Bone mineral density exam (DEXA scan)
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Women age ≥ 65 years
At-risk women ages 60-64/ At-risk men
– Risk factors include: prolonged hyperthyroidism, celiac
sprue, anorexia nervosa, hypogonadism, early
menopause, history of androgen-deprivation, long-term
corticosteroid therapy, a family history of osteoporosis,
low body weight, personal history of fracture.
– Calcium/Vitamin D supplementation
– Start calcium at age 30
Additional Screening
Exams
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Abdominal Aortic Aneurysm
Men aged 65-75 years of age who have ever
smoked
 One time screening for abdominal aortic
aneurysm by ultrasound
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Special Pregnancy
Recommendations
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Folic acid supplementation
– In all women beginning at preconception
and continuing until pregnancy
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HIV testing
– Recommended in all pregnant women
Cancer Screening
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Cervical Cancer
– Pap Smear
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Beginning when patient becomes sexually active until
age 65 (or until total hysterectomy)
At least every 3 years.
Insufficient evidence to screen routinely for human
papillomavirus (HPV)
– HPV-DNA testing as follow-up if low-grade atypia or
other abnormalities found..
Cancer Screening
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Breast Cancer
– Mammogram
Once every 1 to 2 years age 40-49 years
 Annual mammogram for age ≥ 50
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– Breast exam
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Either performed by patient or provider, has
not been found to have any effect on
outcome.
Cancer Screening
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Colon Cancer
– Beginning at age ≥ 50
– Colonoscopy, flexible sigmoidoscopy, fecal
occult blood testing, barium enema used
alone or in combination are equally
effective.
– If family history of colon cancer in first
degree relative, first colonoscopy 10
years prior to his/her age at diagnosis.
Cancer Screening – not yet
routinely recommended
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Prostate Cancer
– USPSTF has not found evidence supporting the routine use
of PSA.
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Skin Cancer
– Routine screening for skin cancer using a total body skin
exam not recommended.
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Ovarian Cancer
– Does not recommend vaginal ultrasound or CA-125
measurement
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Lung Cancer
– No established guidelines yet for the use of screening CT
of the chest
Immunizations
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Influenza Vaccine
– Yearly for all adults ≥ 65 years
– Younger adults with risk factors
CHD, COPD, asthma, Diabetes, renal
dysfunction, hemoglobinopathies,
immunosuppression
 Pregnancy
 Occupational risk (health care workers,
employees of long-term care facilities)
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Immunizations
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Pneumococcal
– All adults ≥ 65 years
– Younger adults with risk factors:
CHD, COPD, Diabetes, liver disease, renal
failure, nephritic syndrome, splenectomy,
immunosuppressive conditions, chemotherapy
 Alaskan natives and certain Native American
populations
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– Give second dose after 5 years if ≥ 65
Immunizations
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Hepatitis B
– Consists of three doses, initial dose, dose 1 month later,
dose 6 months later
– Check serologic immunity at 10-year intervals, with a
single booster for those with undetectable levels of
HepBsAb
– Recommended for:
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Adolescents and young adults who have not previously been
immunized.
Anyone with a history of STDs
Immunocompromised hosts
Prisoners
Patients born outside U.S.
Health care providers
ESRD on chronic hemodialysis
Immunizations
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Hepatitis A
– Both vaccine and immunoglobulin available
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Immunoglobulin only given when more immediate
immunity needed
– Two doses administered 6 months apart
– Recommended in:
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Persons traveling to developing countries
Food handlers
Men who have sex with men
Injection drug users
Chronic Liver disease
Immunizations
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Tetanus
– All adolescents and adults should receive
tetanus/diphtheria (Td) vaccine.
– Booster every 10 years or at time of laceration/puncture
wound
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Measles
– Recommended for adults born after 1956 without evidence
of immunity or prior infection
– Booster should be given to adolescents and young adults
(recent outbreaks in colleges)
– Immigrants who have not received primary series should
receive a single MMR.
– Contraindicated in pregnant women
Immunizations
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Varicella
– Since 1995, is routinely administered to children.
– Indicated in all susceptible adults and adolescents
– Contraindicated in pregnant women and
immunosuppresed people.
– Avoid close contact with immunosuppresed patients within
4 weeks of administration.
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Meningococcal
– College students living in dormitories
– Travelers to the “meningitis belt” in sub-Saharan Africa
Let’s try a few cases…
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A 46-year old female comes to your office for a
physical examination. She has no history of
medical problems, but has not been to a doctor in 5
years. She stopped having periods 2 years ago.
She also admits to a broken wrist 9 months ago, for
which she wore a cast for 8 weeks. She has a
family history of hypertension in her mother, and
colon cancer in her father at age 55. She denies
any tobacco, alcohol use. States her moods been
“great” and she and her husband have been taking
a yoga class together.
Case #1
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Physical Exam:
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142/85, 72, Ht: 4’ 11” Wt: 209#
Gen: Alert, oriented, in NAD
CV: RRR
Resp: LCTA bilaterally
Abd: soft, nontender, NABS
Ext.: No lower extremity edema
Skin: multiple ecchymoses on proximal arms
and back in various stages of healing.
Case # 1
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What additional lifestyle screening do you
want to perform in this patient?
What labs would you order?
What screening studies might you perform?
What immunizations, if any, might you give?
Would you automatically recommend any
medications in this patient?
Case #2
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A 69-year old male with a history of
hypertension presents for follow-up. He
states that he’s been very good about his
preventative care – he had a colonoscopy
last year, and got his pneumonia shot and
flu shots this year. He does continue to
smoke 2 packs a day, and his wife whispers
that the number of tequila shots he takes at
night seem a bit excessive.
Case #2
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What additional lifestyle screening
questions do you want to ask?
What labs do you want to make sure
are up to date in this patient?
What other screening studies, if any,
do you want to perform?
Case # 3
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A 24-year old female comes to your clinic
for a physical exam. She hasn’t seen a
doctor in 4 years. She states that she think
she may want to get pregnant soon, but
isn’t sure which of her boyfriends is going to
be the lucky man. She admits to smoking a
couple of cigarettes a day, and has a few
beers during the week. She states that her
mother didn’t believe in shots growing up,
so she’s never gotten any.
Case # 3
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What testing do you want to perform
in this patient?
What medications should she be
taking?
What immunizations should she
receive?