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PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR 2009

PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR 2009. ANN HONEBRINK MD UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF OB GYN. WHAT MAKES A GOOD PREVENTIVE INTERVENTION?. DEALS WITH A COMMON PROBLEM ACCEPTABLE TO PATIENTS LOW FALSE POSITIVE AND FALSE NEGATIVE COST EFFECTIVE LOW RISK ”BACK UP TEST”

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PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR 2009

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  1. PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR2009 ANN HONEBRINK MD UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF OB GYN

  2. WHAT MAKES A GOOD PREVENTIVE INTERVENTION? • DEALS WITH A COMMON PROBLEM • ACCEPTABLE TO PATIENTS • LOW FALSE POSITIVE AND FALSE NEGATIVE • COST EFFECTIVE • LOW RISK ”BACK UP TEST” • INTERVENTION BASED ON TEST RESULTS HAS POSITIVE IMPACT ON OUTCOME

  3. ORGANIZE BY AGE • 13-18 • 19-39 • 40-64 • 65+

  4. ORGANIZE BY ASSESSMENT/INTERVENTION • SCREENING HISTORY/EXAM/LABS • EVALUATION AND COUNSELING • IMMUNIZATIONS • LEADING CAUSES OF MORBIDITY AND MORTALITY-TRY TO ADDRESS THESE WITH ABOVE TOOLS

  5. 13-18 • First, set the ground rules • History • Sex/Drugs/Etc!!! • Exam- • Height/Weight/BP • Secondary sexual characteristics • What about that first pelvic Labs • Pap- Begin annually 3 years after first sexual contact • STD screen • HIV-opt out?

  6. 13-18 Evaluation and Counseling • Sexuality • Contraception-don’t forget Plan B • STD prevention • Orientation • Cardiovascular Risk Factors • Fitness and Nutrition • Psychosocial Eval • Safe at home? • Suicide/Depression • Health Risk Behaviors • Seat Belts • Gun exposure • Sun Screen • Tobacco/Alcohol/Drug abuse

  7. 13-18 • Immunizations TDP booster Hep B HPV Menignococcal conjugate vaccine Influenza

  8. 13-18 – LEADING CAUSES OF DEATH • Accidents • Cancer • Homicide • Suicide • Congenital Anomalies • Diseases of the heart • Chronic lower respiratory diseases • Influenza and pneumonia • Septicemia • Pregnancy, childbirth, postpartum complications

  9. 19-39 • History • Exam • Labs • Pap- what about lower risk women? • STD screen-when to stop? • HIV-opt out?

  10. 19-39 Evaluation and Counseling • Sexuality • Fitness and Nutrition-remember folic acid and calcium • Psychosocial Eval • Cardiovascular Risk Factors • Health Risk Behaviors

  11. 19-39 • Immunizations TDP booster Hep B HPV??

  12. 19-39 – LEADING CAUSES OF DEATH • Cancer • Accidents • Diseases of the heart • Suicide • HIV • Homicide • Cerebrovascular disease • Diabetes

  13. 40-64 • History • Start asking about incontinence • Exam • Don’t forget to look in the mouth! • Labs-it gets a little more complicated! • Pap- what about lower risk women? • STD screen-when to stop? • HIV-opt out? • Mammogram • Lipids at 45 and q 5 yr • FBS at 45 and q 3 yr • Colon Cancer at 50 • Dexa- when?

  14. 40-64 EVALUATION AND COUNSELLING • Sexuality- ask about postmenopausal atrophy symptoms, don’t forget contraception/std prevention • Fitness and Nutrition-remember folic acid and calcium • Psychosocial Eval- • Sleep hygiene • Cardiovascular Risk Factors • Health Risk Behaviors-Menopausal symptoms????

  15. 40-64 • Immunizations TDP booster Flu Vaccine at 50

  16. 40-64 – LEADING CAUSES OF DEATH • Cancer • Diseases of the heart • Cerebrovascular disease • COPD • Accidents • Diabetes • Chronic Liver Disease • Septicemia • Suicide • HIV

  17. Over 65 • History • Keep asking about incontinence/atrophy • Exam • Don’t forget to look in the mouth! • Labs-it gets a little more complicated! • Pap- what about lower risk women? • Mammogram yearly • Lipids- q 5 yr • FBS at 45 and q 3 yr • Colon cancer screen- FOBT/Sigmoidoscopy/Colonoscopy • Urinalysis • Bone Density??? • When to stop????

  18. Over 65 Evaluation and Counseling • Sexuality- ask about postmenopausal atrophy symptoms, reinforce “safer” sex • Fitness and Nutrition-remember calcium and Vitamin D • Psychosocial Eval- Sleep hygiene, Fall Prevention • Cardiovascular Risk Factors • Health Risk Behaviors-Menopausal symptoms????

  19. Over 65 • Immunizations TDP booster Flu Vaccine Pneumococcal Vaccine

  20. Over 65 – LEADING CAUSES OF DEATH • Diseases of the heart • Cancer • Cerebrovascular disease • COPD • Alzheimer’s Disease • Pneumonia and Influenza • Diabetes • Renal disease • Accidents

  21. Special Issues- Cancer Screening/Prophylaxis • Ovarian cancer screening issues • BRCA1- 45% lifetime risk ovarian cancer • BRCA2 – 25% lifetime risk ovarian cancer • Lynch Type II- consider prophylactic oophorectomy

  22. Special Issues- Cancer Screening/Prophylaxis • Chemoprophylaxis for Breast Cancer in High Risk Groups • RR>4-genes, 2+ 1st degree relatives with breast cancer, personal hx br ca, Age>65 • RR 2.1-4-One 1st degree relative with br ca, nodular densities on mamm, Atypical Hyperplasia, Hi dose chest radiation • GAIL Model- age at menarche, age first child, current age, number first degree relavies with breast cancer, prior breast biopsy, prior atypical hyperplasia

  23. PAP SMEAR TRIAGE • Bethesda System- • adequate? • Reading • Normal • Ascus (+ or – HPV) • ASC-H • AGUS • LGSIL • HGSIL • Cancer

  24. As with everything we teach you • This is all subject to change without notice • US Preventive Services Task Force- www.ahrq.gov/clinic/uspstfix/.htm • American College of Obstetricians and Gynecologists-www.acog.org • American Cancer Society-www.cancer.org

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