1. PREVENTIVE CARE- MORE THAN JUST A PAP SMEAR 2009 ANN HONEBRINK MD UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF OB GYN

2. WHAT MAKES A GOOD PREVENTIVE INTERVENTION? DEALS WITH A COMMON PROBLEM DEALS WITH A COMMON PROBLEM ACCEPTABLE TO PATIENTS ACCEPTABLE TO PATIENTS LOW FALSE POSITIVE AND FALSE NEGATIVE LOW FALSE POSITIVE AND FALSE NEGATIVE COST EFFECTIVE COST EFFECTIVE LOW RISK ”BACK UP TEST” LOW RISK ”BACK UP TEST” INTERVENTION BASED ON TEST RESULTS HAS POSITIVE IMPACT ON OUTCOME INTERVENTION BASED ON TEST RESULTS HAS POSITIVE IMPACT ON OUTCOME

3. ORGANIZE BY AGE 13-18 13-18 19-39 19-39 40-64 40-64 65+ 65+

4. ORGANIZE BY ASSESSMENT/INTERVENTION SCREENING HISTORY/EXAM/LABS SCREENING HISTORY/EXAM/LABS EVALUATION AND COUNSELING EVALUATION AND COUNSELING IMMUNIZATIONS IMMUNIZATIONS LEADING CAUSES OF MORBIDITY AND MORTALITY-TRY TO ADDRESS THESE WITH ABOVE TOOLS LEADING CAUSES OF MORBIDITY AND MORTALITY-TRY TO ADDRESS THESE WITH ABOVE TOOLS

5. 13-18 First, set the ground rules First, set the ground rules History History Sex/Drugs/Etc!!! Sex/Drugs/Etc!!! Exam- Exam- Height/Weight/BP Height/Weight/BP Secondary sexual characteristics Secondary sexual characteristics What about that first pelvic What about that first pelvicLabs Pap- Begin annually 3 years after first sexual contact Pap- Begin annually 3 years after first sexual contact STD screen STD screen HIV-opt out? HIV-opt out?

6. 13-18 Evaluation and Counseling Sexuality Sexuality Contraception-don’t forget Plan B Contraception-don’t forget Plan B STD prevention STD prevention Orientation Orientation Cardiovascular Risk Factors Cardiovascular Risk Factors Fitness and Nutrition Fitness and Nutrition Psychosocial Eval Psychosocial Eval Safe at home? Safe at home? Suicide/Depression Suicide/Depression Health Risk Behaviors Health Risk Behaviors Seat Belts Seat Belts Gun exposure Gun exposure Sun Screen Sun Screen Tobacco/Alcohol/Drug abuse Tobacco/Alcohol/Drug abuse

7. 13-18 Immunizations Immunizations TDP booster Hep B HPV Menignococcal conjugate vaccine Influenza

8. 13-18 – LEADING CAUSES OF DEATH 1. Accidents 2. Cancer 3. Homicide 4. Suicide 5. Congenital Anomalies 6. Diseases of the heart 7. Chronic lower respiratory diseases 8. Influenza and pneumonia 9. Septicemia 10. Pregnancy, childbirth, postpartum complications

9. 19-39 History History Exam Exam Labs Labs Pap- what about lower risk women? Pap- what about lower risk women? STD screen-when to stop? STD screen-when to stop? HIV-opt out? HIV-opt out?

10. 19-39 Evaluation and Counseling  Sexuality  Fitness and Nutrition-remember folic acid and calcium  Psychosocial Eval  Cardiovascular Risk Factors  Health Risk Behaviors

11. 19-39 Immunizations Immunizations TDP booster Hep B HPV??

12. 19-39 – LEADING CAUSES OF DEATH Cancer Cancer Accidents Accidents Diseases of the heart Diseases of the heart Suicide Suicide HIV HIV Homicide Homicide Cerebrovascular disease Cerebrovascular disease Diabetes Diabetes

13. 40-64 History History Start asking about incontinence Start asking about incontinence Exam Exam Don’t forget to look in the mouth! Don’t forget to look in the mouth! Labs-it gets a little more complicated! Labs-it gets a little more complicated! Pap- what about lower risk women? Pap- what about lower risk women? STD screen-when to stop? STD screen-when to stop? HIV-opt out? HIV-opt out? Mammogram Mammogram Lipids at 45 and q 5 yr Lipids at 45 and q 5 yr FBS at 45 and q 3 yr FBS at 45 and q 3 yr Colon Cancer at 50 Colon Cancer at 50 Dexa- when? Dexa- when?

14. 40-64 EVALUATION AND COUNSELLING  Sexuality- ask about postmenopausal atrophy symptoms, don’t forget contraception/std prevention  Fitness and Nutrition-remember folic acid and calcium  Psychosocial Eval-  Sleep hygiene  Cardiovascular Risk Factors  Health Risk Behaviors-Menopausal symptoms????

15. 40-64 Immunizations Immunizations TDP booster Flu Vaccine at 50

16. 40-64 – LEADING CAUSES OF DEATH Cancer Cancer Diseases of the heart Diseases of the heart Cerebrovascular disease Cerebrovascular disease COPD COPD Accidents Accidents Diabetes Diabetes Chronic Liver Disease Chronic Liver Disease Septicemia Septicemia Suicide Suicide HIV HIV

17. Over 65 History History Keep asking about incontinence/atrophy Keep asking about incontinence/atrophy Exam Exam Don’t forget to look in the mouth! Don’t forget to look in the mouth! Labs-it gets a little more complicated! Labs-it gets a little more complicated! Pap- what about lower risk women? Pap- what about lower risk women? Mammogram yearly Mammogram yearly Lipids- q 5 yr Lipids- q 5 yr FBS at 45 and q 3 yr FBS at 45 and q 3 yr Colon cancer screen- FOBT/Sigmoidoscopy/Colonoscopy Colon cancer screen- FOBT/Sigmoidoscopy/Colonoscopy Urinalysis Urinalysis Bone Density??? Bone Density??? When to stop???? When to stop????

18. Over 65 Evaluation and Counseling  Sexuality- ask about postmenopausal atrophy symptoms, reinforce “safer” sex  Fitness and Nutrition-remember calcium and Vitamin D  Psychosocial Eval- Sleep hygiene, Fall Prevention  Cardiovascular Risk Factors  Health Risk Behaviors-Menopausal symptoms????

19. Over 65 Immunizations Immunizations TDP booster Flu Vaccine Pneumococcal Vaccine

20. Over 65 – LEADING CAUSES OF DEATH Diseases of the heart Diseases of the heart Cancer Cancer Cerebrovascular disease Cerebrovascular disease COPD COPD Alzheimer’s Disease Alzheimer’s Disease Pneumonia and Influenza Pneumonia and Influenza Diabetes Diabetes Renal disease Renal disease Accidents Accidents

21. Special Issues- Cancer Screening/Prophylaxis Ovarian cancer screening issues Ovarian cancer screening issues BRCA1- 45% lifetime risk ovarian cancer BRCA1- 45% lifetime risk ovarian cancer BRCA2 – 25% lifetime risk ovarian cancer BRCA2 – 25% lifetime risk ovarian cancer Lynch Type II- consider prophylactic oophorectomy Lynch Type II- consider prophylactic oophorectomy

22. Special Issues- Cancer Screening/Prophylaxis Chemoprophylaxis for Breast Cancer in High Risk Groups Chemoprophylaxis for Breast Cancer in High Risk Groups RR>4-genes, 2+ 1 st degree relatives with breast cancer, personal hx br ca, Age>65 RR>4-genes, 2+ 1 st degree relatives with breast cancer, personal hx br ca, Age>65 RR 2.1-4-One 1 st degree relative with br ca, nodular densities on mamm, Atypical Hyperplasia, Hi dose chest radiation RR 2.1-4-One 1 st degree relative with br ca, nodular densities on mamm, Atypical Hyperplasia, Hi dose chest radiation GAIL Model- age at menarche, age first child, current age, number first degree relavies with breast cancer, prior breast biopsy, prior atypical hyperplasia GAIL Model- age at menarche, age first child, current age, number first degree relavies with breast cancer, prior breast biopsy, prior atypical hyperplasia

23. PAP SMEAR TRIAGE  Bethesda System-  adequate?  Reading Normal Normal Ascus (+ or – HPV) Ascus (+ or – HPV) ASC-H ASC-H AGUS AGUS LGSIL LGSIL HGSIL HGSIL Cancer Cancer

24. As with everything we teach you This is all subject to change without notice This is all subject to change without notice US Preventive Services Task Force- www.ahrq.gov/clinic/uspstfix/.htm US Preventive Services Task Force- www.ahrq.gov/clinic/uspstfix/.htm www.ahrq.gov/clinic/uspstfix/.htm American College of Obstetricians and Gynecologists-www.acog.org American College of Obstetricians and Gynecologists-www.acog.org American Cancer Society-www.cancer.org American Cancer Society-www.cancer.org