Preventative Medicine

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 • 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:

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 • 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 65-75 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 • Once every 1 to 2 years age 40-49 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 • 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 • 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?