1. Preventive Medicine Internal Medicine Lecture Series Danielle M Hansen, DO November 1, 2006

2. Levels of Prevention Primary: Prevents disease by removing its causes Primary: Prevents disease by removing its causes Secondary: Detects asymptomatic disease and stops progression Secondary: Detects asymptomatic disease and stops progression Tertiary: Prevent disease progression or complications Tertiary: Prevent disease progression or complications

3. Types of Clinical Prevention Immunizations Immunizations Screening Screening Behavioral Counseling Behavioral Counseling Chemoprevention Chemoprevention

4. Types of Clinical Prevention Immunizations Immunizations Screening Screening Behavioral Counseling Behavioral Counseling Chemoprevention Chemoprevention

5. Influenza Epidemiology: Over 60yo >90% of Influenza related deaths Epidemiology: Over 60yo >90% of Influenza related deaths Vaccination Vaccination Indications: Indications: –Men and Women over 50 –Residents of ECF –Health Care Providers –Chronic Illnesses (Heart Disease, Pulmonary Disease, Diabetes, Renal Insufficiency, Hemoglobinopathy, Immunodeficiency) Frequency: Annually Frequency: Annually

6. Pneumococcal Infections Epidemiology: 40,000 deaths from pneumococcal infections annually in US Epidemiology: 40,000 deaths from pneumococcal infections annually in US Vaccination Vaccination Indications: Indications: –Men and Women over 65 –Chronic Illness (Heart Disease, Pulmonary Disease, Diabetes, Renal Insufficiency, Hemoglobinopathy, Immunodeficiency) Frequency: Frequency: –One time if received after 65 –Revaccinate one time after 65 if received before 65 –Revaccinate every 5 years for asplenia, chronic renal disease, or immunocompromised

7. Types of Clinical Prevention Immunizations Immunizations Screening Screening Behavioral Counseling Behavioral Counseling Chemoprevention Chemoprevention

8. Breast Cancer Epidemiology: Epidemiology: –212,920 invasive; 61,980 in situ –Age > 50 –Estrogen Exposure Screening Test: Mammography Screening Test: Mammography Indications: Indications: –Women age 40 until life expectancy <10y Frequency: Annually Frequency: Annually

9. Breast Cancer

10. Cervical Cancer

11. Epidemiology: >10,000 diagnosis; >3,500 deaths Epidemiology: >10,000 diagnosis; >3,500 deaths Screening Test: Pap Smear Screening Test: Pap Smear Indications: Indications: –Women beginning 3 years after onset of sexual intercourse, or age 21 until age 70. Frequency: Frequency: –Annually until age 30 –Every 3 years after age 30 for patients with 3 negative smears

12. Colorectal Cancer Epidemiology: Epidemiology: –3 rd most common CA, 1 in 3 deaths –Blacks > Whites –Men > Women –Age > 50 Screening Test: Screening Test: –FOBT –Double Contrast Barium Enema –Sigmoidoscopy –Colonoscopy Indications: Men and Women over 50 until life expectancy < 5 years Indications: Men and Women over 50 until life expectancy < 5 years Frequency: Frequency: –FOBT annually –Double Contrast Barium Enema q 5 years –Sigmoidoscopy q 5 years –Colonoscopy q 10 years

13. Prostate Cancer Epidemiology: 234,460 diagnosis, 27,350 deaths Epidemiology: 234,460 diagnosis, 27,350 deaths Screening Test: PSA and DRE Screening Test: PSA and DRE Indications: Indications: –Men over 50 –African Americans or Patients with positive family history over 40 Frequency: Annually until life expectancy <10 years Frequency: Annually until life expectancy <10 years

14. Osteoporosis Epidemiology: 1.3 million osteoporotic fractures annually in US Epidemiology: 1.3 million osteoporotic fractures annually in US Screening Test: Bone Mineral Density Screening Test: Bone Mineral Density Indications: Indications: –Women over 65 –Women 60-64 with risk factors Frequency: Biannually Frequency: Biannually

15. Cholesterol Epidemiology: CHD leading cause of death in Men and Women, all races Epidemiology: CHD leading cause of death in Men and Women, all races Screening Test: Screening Test: –Fasting Lipid Profile Indications: All over 20 Indications: All over 20 Frequency: Frequency: –Patients without CHD and goal LDL q 5y –Patients with borderline high and <2 risk factors q 1-2y

16. Diabetes Epidemiology: 8% of US Epidemiology: 8% of US Screening Test: Fasting Blood Glucose Screening Test: Fasting Blood Glucose Indications: All over age 45 Indications: All over age 45 Frequency: Every 3 years Frequency: Every 3 years

17. Thyroid Disease Epidemiology: 10% abnormal TSH; 5% disease Epidemiology: 10% abnormal TSH; 5% disease Screening Test: TSH Screening Test: TSH Indications: All over 35 Indications: All over 35 Frequency: Every 5 years Frequency: Every 5 years

18. Abdominal Aortic Aneurysm

19. Epidemiology: 9,000 Deaths per year Epidemiology: 9,000 Deaths per year –Men 4-6x Women –75% Tobacco Users –Age > 60 Screening Test: Abdominal Ultrasound Screening Test: Abdominal Ultrasound Indications: Indications: –Men ages 65-75 who have ever smoked. –Men ages 65-75 with first-degree relative who had AAA repair or death from AAA Frequency: One Time Frequency: One Time

20. Sexually Transmitted Diseases Epidemiology: Epidemiology: –2.8 million Chlamydia infections annually –330,132 Gonorrhea infections annually Screening Test: Nucleic acid amplification test Screening Test: Nucleic acid amplification test Indications for Chlamydia: Indications for Chlamydia: –Sexually active women ages 15-25 –Older women with behavioral risk factors Frequency: Annually Frequency: Annually Indications for Gonorrhea: Indications for Gonorrhea: –Sexually active women ages 15-29 in high risk areas

21. HIV Epidemiology: 1 million; 25% undiagnosed Epidemiology: 1 million; 25% undiagnosed Screening Test: Rapid HIV Test Screening Test: Rapid HIV Test Indications: All ages 13-64 Indications: All ages 13-64 Frequency: Annually for at risk Frequency: Annually for at risk

22. Vision Epidemiology: Epidemiology: –Glaucoma 2.5 million in US; 130,000 become blind; 50% undiagnosed Screening Test: Screening Test: –Snellen Chart for visual acuity –Glaucoma screening Indications: Men and Women over 65 Indications: Men and Women over 65 Frequency: Annually or Biannually Frequency: Annually or Biannually

23. Hearing Epidemiology: Epidemiology: Screening Test: Screening Test: –Audiometer –Whisper Voice Test Indications: Men and Women over 65 Indications: Men and Women over 65 Frequency: Physician’s Discretion Frequency: Physician’s Discretion

24. Types of Clinical Prevention Immunizations Immunizations Screening Screening Behavioral Counseling Behavioral Counseling Chemoprevention Chemoprevention

25. Behavioral Counseling High Risk Behavior High Risk Behavior Depression Depression Domestic Violence Domestic Violence Diet and Exercise Diet and Exercise Tobacco Tobacco Alcohol Alcohol Advance Directives Advance Directives

26. Types of Clinical Prevention Immunizations Immunizations Screening Screening Behavioral Counseling Behavioral Counseling Chemoprevention Chemoprevention

27. Asthma Controller RX Controller RX Inhaled Corticosteroid Inhaled Corticosteroid

28. Coronary Artery Disease

29. AceI/ARB AceI/ARB Lipids Monitored Lipids Monitored Lipid RX Lipid RX B Blocker B Blocker

30. Diabetes HgbA1C (annually) HgbA1C (annually) Dilated Retinal Exam (annually) Dilated Retinal Exam (annually) Microalbuminuria (annually) Microalbuminuria (annually) Lipid check (biannually) Lipid check (biannually) AceI/ARB if HTN AceI/ARB if HTN

31. Heart Failure AceI/ARB AceI/ARB B Blocker B Blocker

32. Questions???

33. Competency Exam 1. A 48 year old female presents as a new patient to your office with complaints of L knee pain. She reports a remote history of minor trauma to the knee. She has not seen a doctor in >15 years when her last child was born. She denies any medical problems and has only been taking Ibuprofen for her knee pain. What is the most important thing to do for this patient? A. Obtain L knee x-ray B. Prescribe Mobic 15mg/day C. Inject the knee with steroids. D. Schedule B/L screening mammogram.

34. Competency Exam 2. A 27 year old male with PMHx of Asthma presents to your office for a follow up. He reports that his father was recently diagnosed with colon cancer at the age of 49. Your patient denies any change in bowel habits, hematochezia, or melena. When should your patient undergo his first colonoscopy? A. Age 27 B. Age 39 C. Age 40 D. Age 50

35. Competency Exam 3. A 54 year old male presents to your office for follow up of his chronic medical problems. He has a history of splenectomy S/P MVA 5 years ago. He received the pneumoccocal vaccine at the time of his accident. When is he due for another immunization? A. Now B. Age 59 C. Age 65 D. Never