Transcript PHE Dr Ponka

LMCC review: the
PHE
Dr. David Ponka
Assistant Professor
Department of Family Medicine
Practice
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PHE stands for
1) plasma heat exchange
2) public health emergency
3) public health engineering
4) preventative health examination
5) all of the above
Practice
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PHE stands for
1) plasma heat exchange
2) public health emergency
3) public health engineering
4) preventative health examination
5) all of the above, but especially 4
PHE
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The ‘check up’
Quite common in Canada
Feasibility and efficiency data controversial e.g. to
apply the US Preventive Health recommendations,
estimated 10.6 hrs a day required
 (Pimlott N Who has time for family medicine? CFP 2008
(54): 14-15)
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But several proven manoeuvers, based on
likely morbidity in a particular age group
What is…
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Primary prevention
Secondary prevention
Tertiary prevention
PHE
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An opportunity for:
 Primary prevention (screen for risky behaviour, health
promotion, disease prevention), case finding, screen for
undetected disease (secondary prevention)
Also in practice an opportunity to:
 Update clinical data, consolidate a patient’s cumulative
medical profile, review medications, review social context,
allergies, immunization history
 Enhance patient-physician relationship
 “non-measurable” factors
What four characteristics makes a
screening intervention compelling?
What four characteristics makes a
screening intervention compelling?
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Burden of condition (that’s why we don’t
screen for mesothelioma…)
Quality of screening intervention (that’s why
prostate screening is this controversial…)
Effectiveness of the intervention (another
reason for prostate screening…)
Price (though inborn errors of metabolism
recently added in Ontario…)
CTFPHC
Grades of Recommendations
CMAJ 2003;169:207-208
Copyright ©2003 Canadian Medical Association or its licensors
Let’s focus on 6 age categories:
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Infants and toddlers (<1)
Toddlers and Children (1-12)
Youth (13-20)
Adults (21-49)
Middle age (50-69)
Elderly (>70)
What are the highest health risks for
an infant (<1)?
What are the highest health risks for
an infant (<1)?
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Congenital
Infectious
SIDS/suffocation
Growth and development/nutrition
Abuse
So, what routine interventions are
most indicated in infants?
So, what routine interventions are
most indicated in infants?
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Accessing risk of congenital abnormalities
based on pregnancy history, ethnic history,
family history and environment (e.g. FAS)
Immunizations
Advice on sleep
Advice on diet
Screening physical examination
What are the highest health risks for
toddlers and children (1-12)?
What are the highest health risks for
toddlers and children (1-12)?
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ACCIDENTS!
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Trauma
Fire
Drowning
Heart defects
Abuse/neglect
So, what routine interventions are
most indicated for toddlers/children?
So, what routine interventions are
most indicated for toddlers/children?
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Counselling re accident prevention:
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helmets
smoke alarms
water temperature
swimming lessons
Heart exam
Psychosocial history taking
So according to CPS, CTF for infants,
toddlers, and children:
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Home visits for high risk families (A)
Developmental milestones (B)
Dental hygiene (A)
Injury prevention (bike helmets, smoke
detectors) (B)
Car seats (A)
Sleeping position (A)
Infant, Toddlers, Children PHE:
Physical Exam
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Ht, wt, head circumference (B)
hearing, hips, eyes (Red reflex,
cover/uncover) (A)
visual acuity testing (B)
Infants, Toddlers, Children PHE Tests
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Blood lead (high risk infants) (B)
Hb for High risk infants (B)
Infants, Toddlers, Children PHE
Therapies
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Routine Immunizations (A)
Hep B vaccination (A)
What are the highest health risks for
youth (13-24)?
What are the highest health risks for
youth (13-24)?
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ACCIDENTS
Mental health
Habits including drugs
Suicide
STDs
HEADS interview:
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H (Home)
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"Do you have many friends?”
"What do you do with your free time?
D (Drugs)
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"Where do you go to school?”.
"What do you do with your free time?”
A (Activities)
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.Don't assume what is "normal" (for example, don't assume an adolescent lives with both
parents).Get an idea of the dynamics of the home situation.
E (Education)
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"Whom do you live with?”)
"Do any of your friends smoke?" (less intimidating)
S (Sexuality)
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emphasize that you ask everyone the same questions
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Start with less threatening topics (eg, menstrual cycle in females).
Open the door to disc of sexual orientation, kind of sexual activity (eg anal sex, oral sex,
masturbation), protection used
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Adults
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Thorough ROS, and targeted exam (+skin)
FBS and cholesterol q3 years
Cervical cancer screening in women
STD screening if at risk
Osteoporosis screening at 50 if at risk
Consider cancer screening if family history
Immunization boosters
Middle age (50-69)
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Thorough ROS, and targeted exam (+skin)
Colon cancer screening (FOBT qyear or
colonoscopy q5-10years for average risk
adults)
Mammography/paps
Continue cardiovascular risk factor
screening
Old age (>69)
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Stop cancer screening unless requested by
patient or life expectancy deemed
>10years
Focus on ROS and cardiovascular
screening, Framingham optimization
Skin screening
Adult/Senior disease prevention:
Discussion/Counseling
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Noise control and hearing protection (A)
Smoking cessation counseling, nicotine repl therapy (B)
Seat belt counseling (B)
Dietary advice on leafy greens and veggies (B)
Calcium supplements for women
Folic acid for women child bearing age (A)
Exercise/Mod physical activity (B)
Avoid sun exposure and protective clothing (B)
EtOH screening and counseling (B)
Adult/Senior disease prevention:
Discussion/Counselling cont
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Caregiver concern of cognitive impairment
(A)
Multidisciplinary fall assessment (post fall)
(A)
Breast self examination (D)
Adult/Senior PHE Tests:
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TB high risk groups: Mantoux skin tests (A)
Colon cancer screen: FOB adults (>50 yrs) (A) or
sigmoidoscopy (Adults >50) (B); colonoscopy if HNPCC
(B)
BMD: if at risk
Fasting lipids: Women >50 or post-menopausal, or
men>40 or earlier if RFs
Fasting glucose: >40 if at risk
STD testing (see youth)
Syphilis testing if at risk
Pap tests (women 18-69) (B)
Mammogram (women 50-69) (A)
Adult/Senior PHE Therapies:
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TB Therapy (INH prophylaxis for skin test converters) (B)
Influenza high risk groups: Outreach strategies (A),
amantadine prophylaxis (eg nursing homes) (A), Annual
immunization (B)
Immunocompetent institutionalized >55: pneumococcal
vaccination (B)
Varicella vaccination susceptible adolescents and adults
(A)
Rubella vaccination for non-pregnant susc women of child
bearing age
BP management (A), Osteoporosis counseling and HRT
pros/cons (B)
Ethics (caveats)
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Informed consent
Risks
Labelling
Which of the following screening interventions
are indicated in an apparently healthy 50 year
old woman?
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Mammogram
Pap test
Vitamin B12 level
FOBT
BMD
CXR
Which of the following screening interventions
are indicated in an apparently healthy 50 year
old woman?
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Mammogram
Pap test
Vitamin B12 level
FOBT
BMD
CXR
Which of the following screening interventions
are indicated in an apparently healthy 72 year
old man?
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CXR
Fall assesment
Vitamin B12 level
FOBT
BMD
PSA
Which of the following screening interventions
are indicated in an apparently healthy 72 year
old man?
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CXR
Fall assesment
Vitamin B12 level
FOBT
BMD
PSA
Quiz:
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Should the following counseling points/physical
exam maneuvers/tests/therapies be included in
an evidence-based PHE? (Yes/No)
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Weight and height measurement of a 6 mo old baby girl
Varicella vaccination of 9 mo boy who has not yet had
chicken pox
Counselling on sexual activity and contraception for
well teenage boy
Teaching 50 yo woman breast self-exam
B12 and TSH tests for asymptomatic 40 yo woman
Quiz continued…
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Should the following counseling points/physical
exam maneuvers/tests/therapies be included in
an evidence-based PHE? (Yes/No)
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Fecal occult blood testing of 65 yo man with no
complaints
Urinalysis for 18 yo woman
BP check for 46 yo man
BMI measurement in 60 yo man
Blood lead screen for 1 yo child eating painting 1950’s
house
Quiz continued…
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List 5 examples of evidence based
recommendations for accident prevention
Accident Prevention answers:
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Helmet use for bicycles
Smoke detector use
Avoid drinking and driving
Seat-belt/air bag use
Hot water regulators