1. Preventative Medicine
Michele Ritter, M.D.
Argy Resident – February, 2007

2. Preventative Medicine
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.

3. History Lifestyle Screening Seat Belt Use Sun Exposure Diet Exercise
Domestic Violence

4. History – Sexual History
In young adults, adolescents
Check for STD risk factors
Promiscuity
Unprotected sexual intercourse and history of venereal infection
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

5. History -Depression Screening
SIG E CAPS
Sleep, Interest, Guilt, Energy, Concentration, Appetite, Affect, Psychomotor agitation, Suicide
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?"

6. History – Alcohol/Drug Use
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?)

7. History – Tobacco Use
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
The incidence of cigarette smoking is increasing worldwide – estimated > 5 trillion cigarettes smoked annually
However, prevalence in US is DECREASING
Annual cost of smoking in US is >90 billion dollars a year

8. Smoking Cessation The 5 “A’s” for smoking cessation
Ask: Systematically identify all tobacco users at every visit
Advise: Strongly urge all tobacco users to quit
Assess: Determine a patient’s willingness to attempt to quit
Assist: Aid the patient in quitting.
Includes counseling, pharmacotherapy, social support
Arrange: Schedule follow-up contact.

9. Smoking Cessation Pharmacotherapy Nicotine Replacement
Design to ameliorate symptoms of nicotine withdrawal: anxiety, dysphoria or depressive symptoms, insomnia, increased appetite/weight gain,
Includes:
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

10. Smoking Cessation 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)

11. Smoking Cessation
Every tobacco user should be offered counseling and nicotine replacement or other pharmacotherapy at every visit.
Counseling should focus on:
Establishing a quit date
Emphasizing abstinence
Using other family members
Avoiding alcohol and other drugs.
Only possible exceptions…
Ulcerative Colitis – quitting smoking associated with UC exacerbations.
Schizophrenia – those who smoke have better attention and memory

12. Routine Physical Examination
Blood Pressure
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
80-89
Stage 1 Hypertension
90-99
Stage 2 Hypertension
≥160
≥100

13. Routine Physical Examination
Height/Weight
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

14. Routine Labs Lipid profile Glucose
Check Fasting lipid profile in patients 20 years or older.
If normal, check every 5 years.
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

15. Routine Labs (cont.) TSH
Controversial whether or not to check regularly
Some guidelines recommend periodic checking in :
Postmenopausal women
Postpartum women
Diabetes
Down’s Syndrome
Elderly

16. Additional Screening Exams
Osteoporosis
Bone mineral density exam (DEXA scan)
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

17. Additional Screening Exams
Abdominal Aortic Aneurysm
Men aged years of age who have ever smoked
One time screening for abdominal aortic aneurysm by ultrasound

18. Special Pregnancy Recommendations
Folic acid supplementation
In all women beginning at preconception and continuing until pregnancy
HIV testing
Recommended in all pregnant women

19. Cancer Screening Cervical Cancer Pap Smear
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..

20. Cancer Screening Breast Cancer Mammogram Breast exam
Once every 1 to 2 years age years
Annual mammogram for age ≥ 50
Breast exam
Either performed by patient or provider, has not been found to have any effect on outcome.

21. Cancer Screening 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.

22. Cancer Screening – not yet routinely recommended
Prostate Cancer
USPSTF has not found evidence supporting the routine use of PSA.
Skin Cancer
Routine screening for skin cancer using a total body skin exam not recommended.
Ovarian Cancer
Does not recommend vaginal ultrasound or CA-125 measurement
Lung Cancer
No established guidelines yet for the use of screening CT of the chest

23. Immunizations 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)

24. Immunizations 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
Give second dose after 5 years if ≥ 65

25. Immunizations 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:
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

26. Immunizations Hepatitis A Both vaccine and immunoglobulin available
Immunoglobulin only given when more immediate immunity needed
Two doses administered 6 months apart
Recommended in:
Persons traveling to developing countries
Food handlers
Men who have sex with men
Injection drug users
Chronic Liver disease

27. Immunizations Tetanus Measles
All adolescents and adults should receive tetanus/diphtheria (Td) vaccine.
Booster every 10 years or at time of laceration/puncture wound
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

28. Immunizations Varicella Meningococcal
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.
Meningococcal
College students living in dormitories
Travelers to the “meningitis belt” in sub-Saharan Africa

29. Let’s try a few cases…
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.

30. Case #1 Physical Exam: 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.

31. Case # 1
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?

32. Case #2
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.

33. Case #2
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?

34. Case # 3
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.

35. Case # 3 What testing do you want to perform in this patient?
What medications should she be taking?
What immunizations should she receive?