1. Stephanie Overmars, D.O. IOA 117 th Annual Convention May 4, 2014

2.  Health maintenance examination is an opportunity to focus on disease prevention  No consensus on the optimal frequency  Chance for physicians to strengthen their relationship with patients

3.  Recommendations for this presentation come primarily from the United States Preventive Services Task Force (USPSTF) and are supported by the American Academy of Family Physicians (AAFP).

4.  “Today we will be addressing issues that are important for preventative care. I am proud that you are taking the step to be on top of health promotion. Unfortunately, this may not include all of your chronic illness concerns. If we run out of time today, we may need to schedule a follow up appointment.”

5.  Medical  Allergies  Medications  Surgeries  Specialists  Social  Family History

6.  18.1% of US adults over 18 years of age smoke cigarettes.  Cigarette smoking is the leading cause of preventable death in the US.  More than 16 million Americans suffer from a disease caused by smoking.  Assess readiness to quit.

7.  C – Have you ever felt like you should cut down on your drinking?  A – Have people annoyed you by criticizing your drinking?  G – Have you ever felt bad or guilty about your drinking?  E – Have you ever had a drink first thing in the morning (eye opener) to steady your nerves or to get rid of a hangover?

8.  If you drink alcohol, drink no more than one drink per day. One drink is counted as:

9.  The USPTF has provisionally recommended that women of childbearing age be screened for potential partner violence.  Women who screen positive should be referred to intervention services.

10.  PHQ2 (Patient Health Questionnaire 2): Inquires about the frequency of depressed mood over the past 2 weeks  Over the past 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things  2. Feeling down, depressed, or hopeless  Individuals rate “not at all” (0) to “nearly every day: (3). Score of > 2, recommend filling out PHQ9.  A PHQ 9 score of > 10 has increased probability of being diagnosed as depressed.

11.  Premenopausal women should be screened about reproductive plans.  In those patients not wishing to get pregnant – discuss contraception.  In those patients wishing to get pregnant – discuss supplementation with folic acid, prenatal vitamins, and other appropriate counseling measures.

12.  USPSTF recommends high risk women be screened at least annually for chlamydia, gonorrhea, and syphilis.  USPSTF recommends sexually active women age 24 years and younger be screened annually for chlamydia.  USPSTF and CDC recommend screening all adolescents and adults through 65 years of age for HIV.

13.  Heart disease is the #1 cause of death in women in the US.  Routinely screen  Blood pressure  Weight  Cholesterol  Glucose

14. Systolic (mmHg) Diastolic (mmHg) Normal< 120< 80 Pre-HTN120-13980-89 HTN> 140> 90 *In the general population younger than age 60

15.  Elevated body mass index (BMI) is a marker of unhealthy weight. BMI is measured by taking into account a patient’s weight and height; BMI is measured in kg/m 2.  Underweight: BMI < 18.5  Normal weight: BMI 18.5- 24.9  Overweight: BMI 25-29.9  Obesity: BMI > 30

16.  Measured with a nondistensible tape measure placed around the abdomen at the umbilicus parallel to the floor with the patient standing.  Goal  Women < 35 inches

17.  Cholesterol  Women 20 years and older if increased risk  Screen every 1-5 years  Glucose  All women beginning at age 45  All overweight women with risk factors  Asymptomatic adults with elevated blood pressure  Other

18.  USPSTF recommends that women 55 to 79 years of age take at least 75mg of aspirin per day when the benefit of stroke prevention outweighs the risk of GI hemorrhage.

19.  Most women older than 18 years of age need 7-9 hours of sleep a night.

20.  AHA recommends at least 30 minutes of moderate intensity aerobic activity at least 5 days a week.  AHA recommends at least 25 minutes of vigorous aerobic activity 3 days per week and moderate to high intensity muscle strengthening activity 2 days per week.

21.  Nearly ½ of adults age 30 and older have a form of chronic inflammatory gum disease that can ultimately lead to tooth loss.  Prevention of gum inflammation reduces tooth loss, but there is little evidence to support a twice yearly visit to the dentist for everyone.

22.  USPSTF concludes that that current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults.  AAO Recommends*:  Age < 40 – every 5-10 yrs  Age 40-54 – every 2-4 yrs  Age 55-64 – every 1-3 yrs  Age > 65 – every 1-2 yrs *Adults with No Risk Factors

23.  The USPSTF and AAFP recommend routine biennial screening beginning at 50 years of age with discontinuation at 75 years of age.  The ACOG and ACS recommend annual screening beginning at age 40 without a specific discontinuation age.

24.  Adults 50 to 75 years of age should undergo screening  FOBT (annually)  Sigmoidoscopy (every 5 years) plus FOBT (every 3 years)  Colonoscopy (every 10 years)

25.  DEXA is routinely recommended for women 65 years of age and older.  Screening women younger than 65 years of age should be based on risk assessment.

26.  Start screening at age 21  Low risk: Screen every 3 years  Co-testing for HPV is an option at age 30  Discontinue screening at age 65, or after hysterectomy due to benign pathology

27.  Influenza – 1 dose annually (ages 19+)  Adults aged 65 years or older can receive the standard dose or the high dose (Fluzone)  Tdap – substitute 1 time dose of Tdap for Td booster; then boost with Td every 10 years (ages 19+)  Varicella – 2 doses (ages 19+)  All adults without evidence of immunity to varicella.  Doses must be at least 4 weeks apart.  Do not give during pregnancy.  HPV – 3 doses (ages 19-26)  Second dose given 4-8 weeks after the first dose  Third dose given 24 weeks after the first dose and at least 16 weeks after the second dose (minimum interval of 12 weeks).  Do not given during pregnancy

28.  Zoster – 1 dose (ages 60+)  May given immunization whether there is a prior episode of herpes zoster or not  Pneumonia – 1 dose (ages 65+)  May give dose for < 64 years of age if chronic condition criteria is met.  One time revaccination 5 years after the first dose is recommended for 19-64 years of age with chronic renal failure, function or anatomic asplenia, or immunocompromising conditions  Persons who received 1 or 2 doses before age 65 years for any indication should receive another dose of the vaccine at age 65 if at least 5 years have passed since their previous dose  No further doses are needed for persons vaccinated after age 65 years

29.  Consider other immunizations if criteria are met:  Meningococcal – 1 or more doses (ages 19+)  Hepatitis A – 2 doses  Hepatitis B – 3 doses

30.  Was there anything at your visit today that we did not discuss that you feel is important?

32.  “Ages 40-64 Years: Exams and Screening Tests.” ACOG. http://www.acog.org. Accessed April 7, 2014.  “Ages 65 years and older: Exams and Screening Tests.” ACOG. http:/www.acog.org. Accessed April 7, 2014.  American Academy of Family Physicians. Obesity – Clinical Recommendations. June 2013. http://s.aafp.org/?q=obesity+clinical+recommendations&q1=&x1=&first_serach=0&search=Entire+ Site. Accessed April 15, 2014.  American Heart Association. Recommendation for Physical Activity in Adults. http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/American-Heart-Association- Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.jsp. Accessed April 15, 2014.  American Psychological Association. Patient Health Questionnaires (PHQ-9 & PHQ-2). http://www.apa.org. Accessed April 14, 2014.

33.  Borgmeyer C. “2014 Hypertension Guidelines Stands to Simplify Treatment, Says Expert.” AAFP News. Dec 18, 2013.  Center for Disease Control. Adult Cigarette Smoking in the United States: Current Estimates. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/. Accessed April 14, 2014.  Comprehensive Adult Medical Eye Examination. 2010. http://oneaao.org/preferred-practice- pattern/comprehensive-adult-medical-eye-evaluation--octobe. Accessed April 22, 2014.  Deen, D. Metabolic Syndrome: Time for Action. Amer Fam Phys. 2004; 69(12):2875-2882.  National Cholesterol Education Program. Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. www.nhlbi.nih.gov/guidelines/cholestrol/atp3. Accessed April 15, 2014.

34.  National Institute on Alcohol Abuse and Alcoholism. CAGE Questionnaire. February 2002. http://pubs.niaaa.nih.gov/publications/inscage.htm  National Sleep Foundation. How Much Sleep Do We Really Need? http://sleepfoundation.org/how- sleep-works/how-much-sleep-do-we-really-need. Accessed April 15, 2014.  Recommended Adult Immunization Schedule- United States 2014. Center for Disease Control and Prevention.  Riley M, et al. Health Maintenance in Women. Amer Fam Phys 2013; 87(1):30-37.  Saint Louis, C. Rethinking the Twice-Yearly Dentist Visit. New York Times. June 10, 2013.  Screening for cervical cancer. Obstet Gnecol. 2012; 120(5): 1222-1238.

35.  U.S. Preventive Services Task Force. Aspirin for the Prevention of Cardiovascular Disease. October 2013. http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm. Accessed April 15, 2014.  U.S. Preventive Services Task Force. Screening Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse. May 2013. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm. Accessed April 15, 2014.  U.S. Preventive Services Task Force. Screening for Breast Cancer. December 2013. http://www.uspreventiveservicestaskforce.org/breastcancer.htm. Accessed April 15, 2014.  U.S. Preventive Services Task Force. Screening for Chlamydial Infection. June 2013. http://www.uspreventiveservicestaskforce.org/uspstf/uspschlm.htm. Accessed April 15, 2014.  U.S. Preventive Services Task Force. Screening for Colorectal Cancer. April 2014. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm. Accessed April 20, 2014.

36.  U.S. Preventive Services Task Force. Screening for Gonorrhea. June 2013. http://www.uspreventiveservicestaskforce.org/uspstf/uspsgono.htm. Accessed April 15, 2014.  U.S. Preventive Services Task Force. Screening for HIV. April 2013. http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm. Accessed April 15, 2014.  U.S. Preventive Services Task Force. Screening for Impaired Visual Acuity in Older Adults. April 2014. http://www.uspreventiveservicestaskforce.org/uspstf/uspsviseld.htm. Accessed April 22, 2014.  U.S. Preventive Services Task Force. Screening for Osteoporosis. March 2011. http://www.uspreventiveservicestaskforce.org/uspstf/uspstf.htm. Accessed April 20, 2014.  U.S. Preventive Services Task Force. Screening for Syphilis Infection. July 2004. http://www.uspreventiveservicestaskforce.org/uspstf/uspssyph.htm. Accessed April 15, 2014.  Women’s Health. A Lifetime of Good Health: Your Guide to Staying Healthy. February 2011. https://www.womenshealth.gov/publications/our-publications/a-z-list.html#a. Accessed April 13, 2014.