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EXAMINE LESS

Health Maintenance for Adults

Making Each Visit Count

Careful history
Identify risk factors in Hx to focus the exam Select screening (exam and tests) based on age, gender and other risks such as:
low socioeconomic status, coronary risks, unsafe sex practices, tobacco exposure, ETOH, substance/ drug abuse, post-menopause status, personal or Fm Hx of cancer, diabetes mellitus or gestational DM
N501 Wendy Smith

Leading Causes of Death

20-40 years
STDs, HIV, Suicide, Homicide/Violence, MVAs, unintentional injuries

40-65 years
Malignant neoplasms Cardio-Vascular Disease Pulmonary Disease
N501 Wendy Smith

20-40 Age Group

Contributing causes
STDs and HIV: unsafe sexual practices, multiple partners, substance use/abuse especially ETOH, emotional issues Homicide, Suicide, Violence: access to weapons, substance use/abuse-drugs and ETOH, illegal behaviors, emotional issues MVA, Accidents: access to weapons, substance use/abuse, inattention/distraction
N501 Wendy Smith

40 to 65 Age Group
Contributing Causes
Maligant Neoplasms: smoking/tobacco use, diet/nutrition, exposure to toxic/noxious agents, genetics Cardio-Vascular Disease: smoking/tobacco use, diet/nutrition/hyperlipidemia, genetics Pulmonary Disease: smoking, exposure to toxic/noxious agents
N501 Wendy Smith

Maligant Neoplasms: Women

Women (in order)
Incidence: Breast, Lung, Colorectal, Uterus, Ovaries Death: Lung, Breast, Colorecatal, Ovary, Pancreas

Cancer eventually develops in 30% of Americans. 3 of 4 families affected

N501 Wendy Smith

Maligant Neoplasms: Male

Men (in order)
Incidence: Prostate, Lung, Colorectal, Bladder, Lymphoma, Melanoma,Oral Death: Lung, Prostate, Colorectal, Pancreas, Lymphoma, Leukemia

Cancer eventually develops in 30% of Americans. 3 of 4 families affected

N501 Wendy Smith

Screening Exams and Test

Height
once in early 20s then in women at 40 begin q 2-3 yr, if risks for Osteoporosis begin at 35 or when risk assumed.

Weight
not nec q visit unless other risk factors establish a baseline observe for fluctuations, BMI each decade. Wt (kg)/Ht (m sq).
N501 Wendy Smith

Screening Exams and Tests

Obesity major public health concern 1/3 of all Americans over-weight Def of Obesity - excess body fat Def of Overweight - excess body weight to height Most Authorities state periodic as the recommendation for Wt screening.
N501 Wendy Smith

Screening Exams and Tests

Blood Pressure
q 1-2 x each year if within normal range then prn depending on results and risk factors if diastolic BP 85-89mmhg then each visit
African American descent, moderate obesity, first degree relative with HTN, personal Hx of HTN

Most Authorities state periodic in their recommendations for screening

N501 Wendy Smith

Screening Exams and Tests

Cholesterol
Total in early 20s then q 5 yr depending on results and on risk factors. Men begin being more vigilant at 35 yr. Women at 45 yr. Several Authorities do not recommend screening before 35 or 45 yr in Men and Women respectively and do not recommend screening after age 65 in both.
N501 Wendy Smith

Screening Exams and Tests

Eye/Vision Exams
Authorities vary depending on constituent members. USPFT recommends routine vision screening in elderly (>65 yr). Depends on risk factors ie DM, Glaucoma
Patients at high risk for glaucoma: African Americans > 40 yr; Caucasian > 65 yr, Pts with DM, severe myopia, or Fm Hx of glaucoma. Yrly Ophthalmolgy referral for person with DM
N501 Wendy Smith

Screening Exams and Tests

Skin
Authorities vary- USPSTF +/- for routine screening. ACS q 3 yr age 20-39 and yrly 40+ Dont pass up opportunity to observe skin when clients seen for other reasons
Risk factors: Melonocytic percursors, or maker moles, large numbers of common moles, immuno-suppression, Fm or Personal Hx of skin cancer, Hx of sun exposure, fair skin, hair, eyes
N501 Wendy Smith

Screening Exams and Tests

Oral Exam
In US 90% of oral and pharyngeal cancer attributable to tobacco and the synergistic effect of ETOH USPSTF +/- routine screening. Q yearly in persons who do/did chew, or smoke tobacco, and in those especially >50 who combine/d it with ETOH. All clients Yrly Dental exam esp>65yr
N501 Wendy Smith

Screening Exams and Tests

Clinical Breast Exams
Women < 40 yr : For Breast Cancer USPSTF no direct evidence of superior effectiveness of CBE alone compared with no other screening. Sensitivity 45% overall. Standard of Practice - follows ACOG: Women over 18 should have CBE during the periodic exam (not nec for ca detect) yearly or as approp depending on risk factors.
N501 Wendy Smith

Screening Exams and Tests

Clinical Breast Exam Women >40
ACS, ACOG, ACP recommend yearly clinical breast exam on women 40 yr or > Standard of practice, if no risk do CBE with periodic exam in > 40 yr USPSTF only begin at 50, age range 50-69yr - confusing, +/- to recommend for CBE alone in this age group
N501 Wendy Smith

Screening Exams and Test

USPSTF and CBE in Women under 50 and over 70 yr
no evidence to support practice in non-high risk women under 50. No evidence that specifically evaluates CBE alone in screening high risk women < 50yr;
high burden of suffering and higher pos predicitve value - could go ahead and do it. Over 70, those who have reasonable life expect not just CBE, + Mammo
N501 Wendy Smith

Screening Exams and Tests

Mammography
Most effective approach to early detection of breast cancer sensitivity of 70-90% and specificity of 90-95%

Controversy
Some major studies questioned if mammography screening reduces mortality in women younger than 50 yrs -- Morbidity!!
N501 Wendy Smith

Screening Exams and Tests

Mammography in Women 49 yr or <
Controversy varies from should not screen ACP and CTFPHE to ACS begin screening at 40 yr. USPSTF & Am College of Prevent Med. Admitt +/- screening in this age group, but recommend screening high risk younger women.
How predictive are the risk factors?!!!!
N501 Wendy Smith

Screening Exams and Tests

Mammography in Women 50 yr +
Little controversy. Routine mammograms Yrly by CTFPHE and many others. USPSTF recommends frequency of 1-2 yrs

Women 65 yrs +
USPSTF & CTFPHE screen as above until 70, Again controversy, Am Geri Society recommends >65 q 2-3 yrs until 85 yr.
N501 Wendy Smith

Screening Exams and Test

Pelvic Exam and Pap Smear
All women who are/have been sexually active should have regular Pelvic exams and Pap Smear. Exams and testing should begin when the woman first engages in sexual intercourse.
If onset is not reliable assume 18 yrs. Def of regular depends on authority
N501 Wendy Smith

Screening Exams and Tests

A little more consensus here than with Breast issues
All women who are non-high risk. Should have two annual pap smears and pelvic exam and if pap WNL then may offer q 3 yrs.
Risk factors: STDs, especially HPV, early age first intercourse, multiple sexual partners, long term use of Ocs (>5yr), low socioecon status, cig smokers
N501 Wendy Smith

Screening Exams and Tests

Paps and Pelvics Continued.
CTFPHE & USPSTF
Routine pelvic exam is not recommended for the detection of ovarian cancer insufficient evidence +/- for screening of asymptomatic women at increased risk. However the CTFPHE gets off the hook if you are doing a pelvic for another reason, then it is reasonable to do bimanual/adnexa
N501 Wendy Smith

Screening Exams and Tests

Paps and Pelvics recommendations
ACP screening stopped at 65 if has been reg screened, has had two previously norm paps and has had no abn smears! USPSTF +/- if reg screened, Norm results stop at 65 yr. CTFPHE q 3 yrs up to 69 yr Hysterectomy no cervix, no Pap. If had hysterectomy for cancer, continue with Pap
N501 Wendy Smith

Screening Exams and Tests

Problem with these recommendations
Large proportion, particularly elderly African-American, women of lower socioecon status do not have regular Paps. In some geographic areas, 75% of women >65 yr report no pap within previous 5 yr. >25% of invasive cervical cancers occur in women > 65 yr. 40-50% of all women who die of cervical cancer are > 65 yr
N501 Wendy Smith

Screening Exams and Tests

DRE, FOBT & Sigmoidoscopy
Risk factors for colorectal cancer include: hx of one of the familial polyposis syndromes, Fm cancer syndromes colorectal ca in first degree relative, personal hx of IBS, polyps, endometrial, ovarian or breast cancer

N501 Wendy Smith

Screening Exams and Tests

DRE of limited value as a screening test for colorectal cancer, fewer than 10% of colorectal cancers can be palpated. USPSTF no recommendation made regarding use of DRE for colorectal screening. CTFPHE if do exam for men 50-70 yr, no need to discontinue practice. Women????? USPSTF screening for all individuals > 50 yr either by FOBT and/or Sigmoidoscopy.
N501 Wendy Smith

Screening Exams and Tests

Examination using a Flex Sig is most specific (100%) and sensitive (skill of examiner and length of instrument)
30% of cancers within reach of 25 cm rigid 40-50% within reach of 35 cm flex 50-60% within reach of 60 cm flex

No risk begin at 50 yrs repeat q 5-10 yrs FOBT q yr

N501 Wendy Smith

Screening Exams and Tests

CTFPHE does not recommend FOBT for routine screening, also does not recommend for at risk. Patients with true cancer family syndrome should be screening with colonoscopy, not FOBT USPSTF insuff evidence to determine if sigmo or FOBT is preferable or if combining both results in superior results.
N501 Wendy Smith

Screening Exams and Tests

Prostate Cancer
most freq dx cancer in men, second leading cause of death in men.
Risk factors: increasing age, 80% of it dx in men over 65 yr. African American, FM Hx, ?+/increase fat intake. Autopsy studies show that 30% of men over age 50 have histologic evidence of prostate cancer, yet carry only a 3% lifetime risk for death from it.
N501 Wendy Smith

Screening Exams and Tests

DRE/Prostate Exam
exam affords opportunity for limited palp of the prostate. Sensitivity 33-69% and the specificity 49-97%. Scant evidence that exam decreases mortality from prostate ca. ACS annual exam 50> yr, Am Uro for 40> yr if high risk. USPSTF & CTFPHE +/- insuff evidence
N501 Wendy Smith

Screening Exam and Tests

Prostate Specific Antigen
Gylcoprotein specific to the prostate NOT prostate cancer, produced by all types of prostate tissue. Sensitivity and Specificity a problem due to this. Pos predictive Value (ie if you have cancer it will show it!) for lab values > than 4 ng/dL range of 20-30%
N501 Wendy Smith

Screening Exams and Tests

Controversy! No data indicating PSA screening
decreases mortality from cancer

Definitive evidence is lacking that treatments

such as radical prostatectomy are superior to watchful waiting for localized prostate cancer

USPSTF routine screening by PSA, DRE or Utrasound not recommended ACS, A Uro Assoc, Annual test > 50 yr
N501 Wendy Smith

Screening Exams and Tests

Testicular Exam
1% of all cancers most common in white men aged 20-34 yr. Prognosis very good.
Risk factors: cryptorchidism, Previous testicular ca, gonadal dysgenesis, Klinefelters syndrome, in utero DES No info on sensitivity or specificity of CTE or TSE exam. Published evidence re TSE detection, in asymp individ in small number of case reports.
N501 Wendy Smith

Screening Exams and Tests

Testicular clinical exam
USPSTF & CTPHE no routine screening, but if being seen for other issues, ie STDs, Contraception, Sports PE, etc. then a good opportunity to examine 20-35 yr male and discuss issue, in high risk counselling, and TSE. ACS: exam q 3 yrs from 20-39 yrs.
N501 Wendy Smith

Screening Exams and Tests

Asymp DM :Fasting Blood Glucose
DM affects 6.2% of US pop, the prevalence of DM sig high among, Hispanics, African Americans, and American Indians Screening for Dm in asymptomatic nonpregnant adults is not recommended. Selected case finding for adults who are:
obese, older age >40, Fm Hx, high risk ethnic group
N501 Wendy Smith

Screening Exams and Tests

Asymptomatic Anemia: Hgb, Hct
Most prevalent in young women (4.5%) and elderly men (4.8%), more common in individuals of low socio-economic status, in African Americans. Hemoglobinopathies: found in individuals of Mediterranean descent, Caribbean, Latin American, Asian and African American. No routine screening recommended
N501 Wendy Smith

Screening Exams and Tests

STDs
Syphilis, Gonorrhea, Chlamydia, HIV
High risk sexually active persons younger than 25 yr, those who have had multiple sex partners, prior hx of STD, practice anal intercourse, prostitutes and persons who exchange sex for other goods, users of illicit drugs, inmates of detention centers.

Offer STD screening, even if asymptomatic, if hx is reveals risk factors. In all age groups! N501 Wendy Smith

Screening Exams and Tests

Osteoporosis
More than 25 million Americans have Osteoprosis. Each year 1.3 million #
70% of #s in people > 45 yrs related to osteoporosis common sites are lower thoracic & lumber vertebrae After age 65 most common #s are hip and arm Risk factors: female, low dietary intake of Ca++, during adolescence, early menopause, N501 Wendy Smith Caucasian or Asian ancestry, Fm Hx of

Screening Exams and Tests

USPSTF insufficient evidence to recommend for or against screening with bone densitometry in post-meno women Possible only in case of high risk where one would only consider HRT to prevent osteoporosis
N501 Wendy Smith

Immunizations
Tetanus-Diptheria (Td) q 10 yr,
ACP single booster at 50 yrs if received initial series

Varicella high prob of Immunity even with negative hx

sero test and if neg vaccinate esp if high risk
Health care workers, families with immunocomp members, workers in day care centers
N501 Wendy Smith

Immunizations
Pneumoccocal
CTFPHE all persons 55 yr or > USPSTF all persons 65 yr or >, or if younger and have any of the following risks
Cardiac, Pulmonary, Renal disease, DM, Sickle Cell Disease, post chemo, living conditions that place at risk ie. Poverty, homelessness etc.

USPSTF revaccinate in high risk folks who were vaccinated > 5 yrs previous
N501 Wendy Smith

Immunization
Influenza, offer annually to all individuals 65 yrs of age or older. Also offer to adults who are at increased risk for influenza related complications
Chronic Pulmonary and Cardiac disorders or those who may transmit influenza to individuals at risk i.e. health care worker and household members of immunocompromised
N501 Wendy Smith

Other
PPD skin test with Mantoux all individuals at high risk.
Close contact with persons known or suspected to have TB, HIV+, inject illicit drugs or other high risk substance abusers (crack cocaine), immunocompromised, residents and employees of high-risk congregate setting (correctional, nursing home, mental institutions, homeless/residential facilities, health care workers, immigrants/refugees
N501 Wendy Smith

Pharmaceuticals
ASA
AAFP men aged 40 to 84 yrs with risk factors for CAD informed of the risk/benefit of prophylaxis CTFPHE does not support routine ASA therapy for primary prevention in asymptomatic men or women USPSTF insufficient evidence for or against use for primary prevention in asymptomatic
N501 Wendy Smith

Pharmaceuticals
Estrogen, Progestin (HRT)
AAFP all perimenopausal women should be counseled about the benefits and risks of postmenopausal HRT ACOG, ACP, USPSTF, CTFPHE All peri and post Meno women should be counseled regarding the probable risks and benefits of HRT so they can make informed choice
N501 Wendy Smith

Pharmaceuticals
HRT
USPSTF insuff evidence +/- to recommend HRT in all women as primary prevention. ACP All women
regardless of race should consider preventive hormone therapy Hysterectomized women no need to add Progestin Women with CAD, or at increased risk benefit Consider risk/benefit in those at increased risk for Breast Cancer
N501 Wendy Smith

Pharmaceuticals
HRT Secondary prevention or relief of symptoms
Unless contraindicated offer to all for secondary prevention or relief of climacteric symptoms. Advise of risk/benefit
contradindications complete and relative: smoker, family or personal hx of breast cancer, hx of migraines, hx of thromboembolic disease, Liver disease, hx of reproductive cancer: ovary, uterus, gallbladder disease, familial hyperlipidemia, fibroids, endometriosis, seizure disorder, hypertension, unexplained vag bleeding
N501 Wendy Smith

Counseling: Young Adult 20-40

Smoking: tobacco issues: q visit Safe Sex: q visit Contraception: q visit +exams/pap smear Injury and Accident Issues: q visit
Seatbelts, helmets, safety gear/personal protection at work/home/hobbies, smoke and CO detectors, DUI of ETOH or drugs, dont get in car with others,weapons/ ammunition.
N501 Wendy Smith

Counseling Young Adult 20-40

ETOH, substance use vs abuse:q visit Exercise: 30mins q day or at least 3x/wk: any opportunity Sun Protection: sunscreen, hat, clothing: any opportunity

N501 Wendy Smith

Counseling Young Adult 20-40

Nutrition & Cholesterol: any opportunity
Variety of foods, food pyramid, increase fruit, veg, low fat dairy, calcium intake, increase fiber, limit fats & cholesterol, limit salt, adequate water: 6 8oz glasses H20/day

Self care & self exams: any opportunity

Testicular, Breast, Skin, Oral, Immunizations,
N501 Wendy Smith

Counseling Young Adult 20-40

Anticipatory Guidance 20-35 yr: PRN
Independence: own place, college, career, financial Establishing intimacy and relationships Marriage, adjusting life style Buying home, financial management Starting family, time management, changing roles, stressful times/emotional issues
N501 Wendy Smith

Counseling Young Adult 20-45

Anticipatory guidance 35-45 yr
Balancing work/family Dealing with adolescent children, launching, communication issues Expanding family to admit new members Changing body image Stress, emotional issues
N501 Wendy Smith

Counseling Middle Adult 40-65

Smoking, Tobacco use: q visit Blood Pressure
If WNL, monitor at least annually
Discuss prn: Stress, relaxation, salt limit, exercise

Injury and Accident Issues: q visit

Seatbelts, helmets, safety gear/personal protection at work/home/hobbies, smoke and CO detectors, DUI of ETOH or drugs, dont get in car with others,weapons/ ammunition.
N501 Wendy Smith

Counseling Middle Adult 40-65

ETOH, substance use vs abuse: q visit Exercise: 30mins q day or at least 3x/wk: any opportunity Sun Protection: sunscreen, hat, clothing: any opportunity Immunizations: prn
N501 Wendy Smith

Counseling Middle Adult 40-65

Nutrition & Cholesterol: any opportunity
Variety of foods, food pyramid, increase fruit, veg, low fat dairy, calcium intake, increase fiber, limit fats & cholesterol, limit salt, adequate water: 6 8oz glasses H20/day

Self exams and clinical exams: prn

SELF: Skin, breast, oral, FOBT CLINICAL: Sigmoidoscopy, Pap, Mammo
N501 Wendy Smith

Counseling Middle Adult 40-65

Pharmaceuticals: q visit
Vts, Calcium, ASA, HRT

Anticipatory Guidance: PRN

Time of largest earning power, reassess goals New roles: executive, retiree, grandparent. Losses: job, home, spouse Insurance: life, medical (Medicare) Durable power, advanced directives
N501 Wendy Smith