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TALK MORETALK MOREEXAMINE LESSEXAMINE LESS

Health Maintenance for Adults

N501 Wendy Smith

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 Unintentional injuries, MVAs,

Homicide/Violence, Suicide, HIV/AIDS, STDs

40-65 years Cardio-Vascular Disease Malignant Neoplasm Pulmonary Disease

N501 Wendy Smith

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

N501 Wendy Smith

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

N501 Wendy Smith

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

N501 Wendy Smith

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

N501 Wendy Smith

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”

N501 Wendy Smith


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).

N501 Wendy Smith


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

N501 Wendy Smith


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.

N501 Wendy Smith


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

N501 Wendy Smith


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

N501 Wendy Smith


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

Oral Exam In US 90% of oral and pharyngeal cancer attributable

to tobacco and the synergistic effect of ETOH

N501 Wendy Smith


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

N501 Wendy Smith


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.

N501 Wendy Smith


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~!

N501 Wendy Smith


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.

N501 Wendy Smith

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 yrs but 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.


N501 Wendy Smith

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”

N501 Wendy Smith


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.

N501 Wendy Smith


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”

N501 Wendy Smith


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

N501 Wendy Smith


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


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

N501 Wendy Smith


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 adequate for 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!

N501 Wendy Smith


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.

N501 Wendy Smith


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.

N501 Wendy Smith


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!

N501 Wendy Smith


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.

N501 Wendy Smith

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.

N501 Wendy Smith


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

N501 Wendy Smith


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.

N501 Wendy Smith


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.

N501 Wendy Smith


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.

N501 Wendy Smith

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.

N501 Wendy Smith


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

N501 Wendy Smith


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!

N501 Wendy Smith


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.

N501 Wendy Smith


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.

N501 Wendy Smith

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

N501 Wendy Smith


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).

N501 Wendy Smith


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.

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 but do 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 especially 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, immigrant& refugees

N501 Wendy Smith

Pharmaceuticals

ASA: Strong Recommend in Adults who are at increased risk for CHD. Discuss harms and benefits. AAFP (initially only men then added

women) aged 40 to 84 yrs with risk factors for CHD informed of the risk/benefit of prophylaxis

N501 Wendy Smith

Pharmaceuticals

Estrogen, Progestin (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. USPSTF recommends against routine use of combined Estrogen/Progestin for prevention of chronic conditions of in postmeno women.

Recommends against unopposed Estrogen in women who have had hysterectomy.

N501 Wendy Smith

Pharmaceuticals

HRT for menopausal symptoms:USPSTF did not consider the use of HRT for the management of menopausal symptoms, which is the subject of recommendations by other expert groups. Women and clinicians should discuss the balance of risks and benefits.

Stay tuned.

N501 Wendy Smith

Young Adult Advice

Rejoice, O young man, in thy youth; and let thy heart cheer thee in the days of thy youth, and walk in the ways of thine heart, and in the sight of thine eyes: but know thou, that for all these things God will bring thee into judgment. Therefore remove sorrow from thy heart, and put away evil from thy flesh: for childhood and youth are vanity.

Old Testament Ecclesiastes 11:9-10

N501 Wendy Smith

Young Adult Advice

What old people tell you you cannot do, you try and find you can…. I am convinced that to maintain ourself on this earth is not a hardship, but a pastime, if we may

live simply and wisely. Henry David Thoreau

Life is a big canvas; throw all the paint on it you canDanny Kaye

N501 Wendy Smith

Counseling: Young Adult 20-40

Smoking: tobacco issues: q visit Safe Sex: q visit Contraception: if appropriate q visit esp

on annual 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, don’t 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

or more recent combination rec of time and frequency: any opportunity

Sun Protection: sunscreen, hat, clothing: any opportunity

N501 Wendy Smith


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. More to encourage personal investment in healthy body.

N501 Wendy Smith


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


Anticipatory guidance 35-45 yr PRN 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

Middle Age thoughts

Forty is the old age of youth

Fifty is the youth of old age

(Victor Hugo)

N501 Wendy Smith

Middle Aged Opinions

The Younger generation complains about what we are and do!

They say they’ll do better. They should! They’re standing on our

shoulders. (unknown)

N501 Wendy Smith

Mid-life Advice

The most important words in midlife are – Let Go. Let it happen to you. Let it happen to your partner. Let the feelings. Let the changes… You are moving out of roles and into the self…. It would be surprising if we didn’t experience some pain as we leave the familiarity of one adult stage for the uncertainty of the next. But the willingness to move through each passage is equivalent to the willingness to live abundantly. If we don’t change, we don’t grow. If we don’t grow, we are not really living. Gail Sheehy

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, don’t get in car with others,weapons/ ammunition.

N501 Wendy Smith


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


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/colonoscopy, Pap,

Mammo, Osteoporosis.

N501 Wendy Smith


Pharmaceuticals: q visit Vts, Calcium, ASA.

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

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