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TALK MORE EXAMINE LESS

TALK MORE 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:

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TALK MORE EXAMINE LESS

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  1. TALK MOREEXAMINE LESS Health Maintenance for Adults

  2. 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

  3. Leading Causes of Death • 20-40 years • Unintentional injuries, MVAs, Homicide/Violence, Suicide, HIV/AIDS, STDs • 40-65 years • Cardio-Vascular Disease • Malignant Neoplasm • Pulmonary Disease

  4. 20-40 Age Group • Contributing causes • Homicide, Suicide, Violence: access to weapons, substance use/abuse-drugs and ETOH, illegal behaviors, emotional issues • MVA, Accidents:substance use/abuse, inattention/distraction • STDs and HIV: unsafe sexual practices, multiple partners, substance use/abuse especially ETOH, emotional issues

  5. 40 to 65 Age Group • Contributing Causes • Cardio-Vascular Disease: smoking/tobacco use, diet/nutrition/hyperlipidemia, genetics • Malignant Neoplasm’s: smoking/tobacco use, diet/nutrition, exposure to toxic/noxious agents, genetics • Pulmonary Disease: smoking, exposure to toxic/noxious agents in environment/occ

  6. Malignant Neoplasm’s: Women • Women (in order) • Incidence: Breast, Lung, Colorectal, Uterus, Ovaries • Death: Lung, Breast, Colorectal, Ovary, Pancreas • Cancer eventually develops in 30% of Americans. 3 of 4 families affected

  7. Malignant Neoplasm’s: 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

  8. Screening Exams and Tests • Height • once in early 20’s then in women at 40 begin q 2-3 yr, if risks for Osteoporosis begin at 35 or when risk assumed. • Weight • Dependent on risk factors establish a baseline observe for fluctuations, BMI (body mass index) each yr. Wt (kg)/Ht (m sq), “adult growth charts”

  9. 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 or per risks and body habitus (what they look like).

  10. 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 85-89 mmhg then each visit • Risk Factors that affect frequency of screening. African American descent, moderate obesity, first degree relative with HTN, personal Hx of HTN • Most Authorities state “periodic” in their recommendations for screening depends on risk factors

  11. Screening Exams and Tests • Cholesterol • Total in early 20’s then q 5 yr depending on results and on risk factors. Men begin greater vigilance at 35 yr. Women at 45 yr. Rx abn lipids in those with > risk CAD • Lipid screening includes: total cholesterol (TC), and high density (HDL-C). Some clinicians will do total panel including trigylcerides esp if risk Factors : CAD risks, family hx, early menopause, first degree relative with HTN/CAD/CVD, DM, Smoker.

  12. Screening Exams and Tests • Eye/Vision Exams • “Authorities” vary depending on constituent members. USPSTF recommends routine vision screening in elderly (>65 yr). • May do earlier and more frequently it 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

  13. Screening Exams and Tests • Skin • “Authorities” vary- USPSTF +/- for routine screening. ACS q 3 yr age 20-39 and yrly 40+ • Don’t pass up opportunity to observe skin when clients seen for other reasons. Always Educate! • 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

  14. 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. ACS -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

  15. 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 yearly or as approp depending on risk factors. • Risk Factors: Fm Hx of 1st degree relative before age 50, prior hx of Breast Ca, or atyp hyperplasia = CBE q yr

  16. Screening Exams and Tests • Clinical Breast Exam • ACS, ACOG, ACP recommend yearly clinical breast exam on women 40 yr or > • Standard of practice, do CBE with periodic exam in > 40 yr • USPSTF – Clinicians who advise BSE or who do routine CBE … should understand currently insuff evidence that practice affects breast ca mortality, likely to > incidence clinical assessment and biopsy.

  17. Screening Exams and Tests • Mammography: with Informed Consent • Most effective approach to early detection of breast cancer, sensitivity of 70-90% and specificity of 90-95%. When done by accredited screening centers Controversy: When to begin & how often to do? • USPSTF recommends screening mammography, with/without CBE every 1 –2 yrs for women aged 40 – 70 yrs. (B rating).Some major studies have questioned if mammography screening reduces mortality in women younger than 50 yrs, more recently in all women! –In studies frequency varied from 12 – 33 months.HIGH RISK DO ANNUALLY~!

  18. Screening Exams and Tests • Mammography More! • Should refer pts to mammography screening centers with proper accreditation and quality assurance standards. http://www.fda.gov/cdrh/mammography/certified.html • You must have office/clinic system in place to ensure timely and adequate follow-up for abn results – often issue of liability cases.

  19. Screening Exams and Tests • Mammography in Women >70 yr • Routine mammograms for All! Trends of women life-span longer more healthy – live > 90’s • USPSTF recommends frequency of 1-2 yrsbut based on only two randomized trials of women > 69 yr. no trials enrolled women> 70yr –Need for studies! • Increased risk of breast ca in older women but greater chance of dying form comorbid illness.

  20. Screening Exams and Test • Pap Smear (and Pelvic Exam) • All women who are/have been sexually active should have regular Pelvic exams and Pap Smear. • Exams & all testing (including for STIs) begin when the woman first engages in sexual intercourse. • If onset is not reliable assume 18 yrs. • Def of regular depends on “authority”

  21. 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: Hx STDs, especially HPV, early age first intercourse, multiple sexual partners, long term use of OCs (>5yr), low socioecon status, cig smokers.

  22. Screening Exams and Tests • Paps (and Pelvics) Continued. • CTFPHE & USPSTF • Routine pelvic exam is not recommended for the detection of ovarian cancer. (not sens or specific) • insufficient evidence +/- for screening of asymptomatic women who are not 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”

  23. Screening Exams and Tests • Paps (and Pelvics) recommendationsMay begin to do Pap screen q 3yrs at 30ys if meet all the criteria. • Criteria = reg screened, has had two previously norm paps and has had no abn smears & no new sex partners. (continue to screen in immigrants with hx. lack of reg screening prog).ACS = PAP screening stopped at 70 if has been reg screened • Hysterectomy no cervix, no Pap. If had hysterectomy for cancer, continue with Pap

  24. Screening Exams and Tests • 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

  25. 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 IBDz (Inflammatory bowel), polyps, endometrial, ovarian or breast cancer

  26. Screening Exams and Tests • DRE of NO value as a screening test for colo (rectal) cancer, fewer than 10% of colorectal cancers can be palpated. Probably a better exam for detecting rectal ca/masses. Can do FOBT at same time but neither adequatefor CR Ca screening. • 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 if no risk > 50 yr either by home FOBT annually, Sigmoidoscopy q 5 yr, BE q 5yrs? or Colonoscopy q 10yr. If has risks screen when detected!

  27. Screening Exams and Tests • Examination using a Flex Sig is very specific but sensitivity depends on skill of examiner and length of instrument – (if no sedation ?? get to 35cm few to 60 cm, if need to use sedation then Colonoscopy better) • 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. High variable sens 26-92% but good specificity 90-99%. Many false pos second to diet, meds, other GI conditions – then must do follow-up.

  28. Screening Exams and Tests • Colonoscopy detects 80-95% of CR cancers the Most Sensitive and Specific: but comes with > risk, expense, discomfort? • CTFPHE does not recommend FOBT for routine screening, also does not recommend for “at risk”. “Patients with true cancer family syndrome should be screened with colonoscopy, not FOBT or sigmoidoscopy” • USPSTF sigmo & FOBT is preferable combining both results in superior results.

  29. 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. • ?Ethics should you screen in those who predicted life expectancy is < 10 yrs!

  30. 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. • Do in 50-70yr age group. • ACS annual exam 50 > yr, Am Uro for 40 > yr if high risk, 45 yr AA.

  31. Screening Exam and Tests • Prostate Specific Antigen Blood Test – Must include informed consent! • 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 - (i.e. if you have cancer it will show it!) for lab values > than 4 ng/ml range 20-30%. • However a sig % of early cancers 10 – 20% will be missed with PSA testing alone.

  32. Screening Exams and Tests • Controversy! No data indicating PSA screening decreases mortality from cancer. Address on indiv basis. Pts who seek screening fully informed before testing of risks and lack of est benefit of DRE & PSA. Elevated PSA unreliable for dx of cancer. Only 20-30% of time. As PSA rises the proportion of pts with ca rises. However, 20% of pts with sig ca have N PSA. • USPSTF insufficient evidence for routine screening by PSA, DRE or Utrasound. • ACS, A Uro Assoc, Annual test > 50 yr

  33. Screening Exams and Tests • Testicular Exam • 1% of all cancers most common in white men aged 20-34 yr. Prognosis very good. 100% curable with early detection. Rate controversy 1/10,000 vs 3/10,000? • 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. Screening not been studied but if 100,000 age 15-35 were screened at most 10-30 cases detected.

  34. 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 counseling, and TSE. • Even though most lesions detected by Pt/Partner- no evidence for promotion of TSE per USPSTF – but we do it! Be on alert if pt presents with hydrocele, epididymitis or testicular trauma. • ACS: exam q 3 yrs from 20-39 yrs.

  35. Screening Exams and Tests • Asymp DM :Fasting Plasma Glucose, best choice in asymp pts. GHbg (Ha1c) unreliable as screening tool as is RBS, and OGTT (inconvenient). • DM affects 6.2% of US pop (14 mill), the prevalence of DM sig high among, Hispanics, African Americans, and American Indians. Leads to enormous amt of morbid and mortality, synergistic with other Dzs. • Screening for Dm in asymptomatic non-pregnant adults is not recommended. Selected case finding for adults who are: • RISKS: obese, older age >40, HTN, Hyperlipids, Fm Hx, high risk ethnic group.

  36. Screening Exam and Tests • Thyroid Screening; rare cancer 4/100,000 • Female 77% cases 2x more than males • Risk factors: exposed to head & neck x-rays in childhood, fm hx, or other endocrine neoplasms, post partum. • Sens of thyroid palp = 15% LOW • Rx for thyroid ca is very effective overall 5 yr survival is 95% even in absence of formal screening. High false pos rate for palpation. TSH excllnt for screening for Dz if suspected per Hx and PE. • USPSTF insuff evidence +/- thyroid palp.

  37. Screening Exams and Tests • Asymptomatic Anemia: Hgb, Hct • Anemia: most common cause Fe def in young and those <65y in > 65 yr blood loss (GI bleed) • Most prevalent in young women (4.5%) and elderly men (4.8%), more common in individuals of low socio-economic status, in African Americans. Hemaglobinopathies: found in individuals of Mediterranean descent, Caribbean, Latin American, Asian and African American. • No routine screening recommended

  38. Screening Exams and Tests • STIs • Syphilis, Gonorrhea, Chlamydia, HIV • High risk sexually active persons, 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. Rediscovered sexuality. Abused persons. Pregnant women. • Offer STI screening, even if asymptomatic, especially Chlamydia, to all sexually active women 25 yrs and younger. Offer STI screening to those whose hx reveals risk factors or if one STI is present. In all age groups!

  39. Screening Exams and Tests • Osteoporosis • More than 25 million Americans have Osteoprosis. Each year 1.3 million #. High morbidity and mortality assoc. • After age 65 most common #’s are hip and arm • 70% of #’s in people > 45 yrs related to osteoporosis. • common sites are lower thoracic & lumber vertebrae • Risk factors: female, low dietary intake of Ca++, during adolescence, early menopause, Caucasian or Asian ancestry, Fm Hx of osteoporosis, demineralizing states: cancer, menopause, pregnancy, eating disorders, low estrogen states.

  40. Screening Exams and Tests • USPSTF recommends that women 65 > yr be screened routinely for Osteoporosis risk, begin at 60 yr in women at risk using the Osteoporosis Risk Assessment Instrument (ORAI). • IF at risk- densitometry = DXA • Local standard of practice: intital screen women > 50 yrs, if not 2 SD below N for age ok screen in 10 yrs, encourage Ca++ intake & exercise. If 1 SD screen in 5 yrs, Ca++, exercise, consider meds based on other risks. If 2 SD then all above and meds and follow up in 1 yr.

  41. Screening Tests and Exams • Depression: Screen those at high risk: prior suicide attempt, recent life event (neg > pos), worsening health self or sig other, unexplained fatigue, sleep disorder or unexplained somatic problems, female gender, post partum, lack of social support, hx of sex abuse, current subs abuse, hx of dom violence. • USPSTF insuff evidence +/- routine screening. Practitioner should maintain a high index of suspicion. • Use one of formal screening tools. • Have sys/protocol in place for pos screen- full work-up, treatment and close follow-up

  42. Screening Exams and Tests • Cognitive & Functional Impairment • Will cover screening test specifics in more depth in Age > 65yrs group. • USPSTF insufficient evidence +/- for routine screening in asymptomatic persons. • Screening requires multiple aspects of mental function: orientation, short term memory, receptive & express language ability, attention and visual/spatial ability = Mini Mental Status Exam (MMSE).

  43. Screening Exams and Tests • Domestic Violence, Partner Violence USPSTF insufficient evidence +/- use of specific screening instruments for family violence. Judicious for Examiner to include a few direct questions about abuse (physical or sexual) as part of routine hx. • Risk: presentation of multiple injuries and implausible explanation. Elderly in care of another at increased risk. Non-emancipated individuals- dev disabled, those with barriers of language or self-expression. Pregnant Women, young maternal age, substance abuse, single parent.

  44. 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 but do • sero test and if neg vaccinate esp if high risk • Health care workers, families with immunocomp members, workers in day care centers

  45. 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 especially in high risk folks who were vaccinated > 5 yrs previous

  46. 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

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