Preventative Medicine Michele Ritter, M.D. Argy Resident – February, 2007.

Preventative Preventative MedicineMedicine

Michele Ritter, M.D.Michele Ritter, M.D.

Argy Resident – February, Argy Resident – February, 20072007

Preventative MedicinePreventative Medicine

Routine care of the healthy Routine care of the healthy patient includes screening for patient includes screening for asymptomatic disease and asymptomatic disease and assessing the potential risk assessing the potential risk factors that contribute to disease factors that contribute to disease or other health problems. or other health problems.

HistoryHistory

Lifestyle ScreeningLifestyle Screening– Seat Belt UseSeat Belt Use– Sun ExposureSun Exposure– DietDiet– ExerciseExercise– Domestic ViolenceDomestic Violence

History – Sexual History – Sexual HistoryHistory Sexual HistorySexual History

In young adults, adolescentsIn young adults, adolescents Check for STD risk factorsCheck for STD risk factors

– PromiscuityPromiscuity– Unprotected sexual intercourse and history of Unprotected sexual intercourse and history of

venereal infectionvenereal infection Individuals should receive screening about safe Individuals should receive screening about safe

sex practices and benefits of barrier-protection sex practices and benefits of barrier-protection contraceptioncontraception

? MSM? MSM Women < 25 years should undergo

screening for chlamydial infection Periodic HIV testing and syphilis screening Periodic HIV testing and syphilis screening

should be offered to those at risk should be offered to those at risk

History -Depression History -Depression ScreeningScreening SIG E CAPSSIG E CAPS

– Sleep,leep, Interest, , Guilt, uilt, Energy, nergy, Concentration, oncentration, Appetite, ppetite, Affect, ffect, Psychomotor agitation, sychomotor agitation, Suicideuicide

Two questions:Two questions: "Over the past two weeks, have you felt "Over the past two weeks, have you felt

down, depressed, or hopeless?" down, depressed, or hopeless?" "Over the past two weeks, have you felt "Over the past two weeks, have you felt

little interest or pleasure in doing little interest or pleasure in doing things?"things?"

History – Alcohol/Drug History – Alcohol/Drug UseUse CAGE QuestionsCAGE Questions

– Have you every felt you ought to Have you every felt you ought to Cut down ut down on your drinking?on your drinking?

– Have people Have people Annoyed you by criticizing nnoyed you by criticizing your drinkingyour drinking

– Have you ever felt Have you ever felt Guilty or bad about uilty or bad about your drinking?your drinking?

– Have you ever had a drink first thing in the Have you ever had a drink first thing in the morning to stead your nerves or get rid of morning to stead your nerves or get rid of a hangover? (a hangover? (Eyeopener?)yeopener?)

History – Tobacco UseHistory – Tobacco Use

In the year 2000, smoking was In the year 2000, smoking was attributed to 5 million premature deaths attributed to 5 million premature deaths worldwideworldwide

In the U.S., smoking is attributed to In the U.S., smoking is attributed to 400,000 deaths a year400,000 deaths a year– Most deaths due to CAD, COPD, Lung cancerMost deaths due to CAD, COPD, Lung cancer

The incidence of cigarette smoking is The incidence of cigarette smoking is increasing worldwide – estimated > 5 increasing worldwide – estimated > 5 trillion cigarettes smoked annuallytrillion cigarettes smoked annually

However, prevalence in US is DECREASINGHowever, prevalence in US is DECREASING Annual cost of smoking in US is >90 Annual cost of smoking in US is >90

billion dollars a yearbillion dollars a year

Smoking CessationSmoking Cessation

The 5 “A’s” for smoking cessationThe 5 “A’s” for smoking cessation1. Ask: Systematically identify all tobacco : Systematically identify all tobacco

users at every visitusers at every visit2. Advise: Strongly urge all tobacco users : Strongly urge all tobacco users

to quitto quit3. Assess: Determine a patient’s : Determine a patient’s

willingness to attempt to quitwillingness to attempt to quit4. Assist: Aid the patient in quitting.: Aid the patient in quitting.

1.1. Includes counseling, pharmacotherapy, social Includes counseling, pharmacotherapy, social supportsupport

5. Arrange: Schedule follow-up contact.: Schedule follow-up contact.


PharmacotherapyPharmacotherapy– Nicotine ReplacementNicotine Replacement

Design to ameliorate symptoms of nicotine Design to ameliorate symptoms of nicotine withdrawal: anxiety, dysphoria or depressive withdrawal: anxiety, dysphoria or depressive symptoms, insomnia, increased appetite/weight symptoms, insomnia, increased appetite/weight gain, gain,

Includes: Includes: Polacrilax (gum)Polacrilax (gum) – increases quiting 2-fold – increases quiting 2-fold Transdermal (patches) Transdermal (patches) – delivers 40-50% of – delivers 40-50% of

what a smoker at 1 ½ packs a day receiveswhat a smoker at 1 ½ packs a day receives Nasal Spray Nasal Spray – has increased tendency for – has increased tendency for

prolonged nicotine dependenceprolonged nicotine dependence Inhaler Inhaler – caution: may cause bronchospasm– caution: may cause bronchospasm


Pharmacotherapy (cont.)Pharmacotherapy (cont.)– Bupropion (Zyban)Bupropion (Zyban)

– Enhance noradrenergic, dopaminergic functionEnhance noradrenergic, dopaminergic function– Also used as an anti-depressant (Wellbutrin)Also used as an anti-depressant (Wellbutrin)– Has been shown to significantly increase rate of Has been shown to significantly increase rate of

smoking cessation (especially when used in smoking cessation (especially when used in combination with nicotine replacement).combination with nicotine replacement).

– Caution in anorexic/bulemics (increased rate of Caution in anorexic/bulemics (increased rate of seizures)seizures)

– VareniclineVarenicline– Is a partial agonist of nicotine acetylcholine Is a partial agonist of nicotine acetylcholine

receptorreceptor– Has been shown to increase rate of quitting (may Has been shown to increase rate of quitting (may

even be better than bupropion)even be better than bupropion)


Every tobacco user should be offered Every tobacco user should be offered counseling and nicotine replacement or other counseling and nicotine replacement or other pharmacotherapy at every visit.pharmacotherapy at every visit.

Counseling should focus on:Counseling should focus on:– Establishing a quit dateEstablishing a quit date– Emphasizing abstinenceEmphasizing abstinence– Using other family membersUsing other family members– Avoiding alcohol and other drugs.Avoiding alcohol and other drugs.

Only possible exceptions…Only possible exceptions… Ulcerative ColitisUlcerative Colitis – quitting smoking associated with – quitting smoking associated with

UC exacerbations.UC exacerbations. SchizophreniaSchizophrenia – those who smoke have better – those who smoke have better

attention and memoryattention and memory

Routine Physical Routine Physical ExaminationExamination Blood PressureBlood Pressure

Monitor every 2 yearsMonitor every 2 years Goal Blood pressure: 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 Should be measured on 3 separate occassions before diagnosing hypertension.diagnosing hypertension.

JNC 7 Guidelines:JNC 7 Guidelines:

CategoryCategory Systolic Blood Systolic Blood Pressure (mmHg)Pressure (mmHg)

Diastolic Blood Diastolic Blood Pressure mmHGPressure mmHG

NormalNormal <120<120 < 80< 80

PrehypertensionPrehypertension 120-139120-139 80-8980-89

Stage 1 Stage 1 HypertensionHypertension

140-159140-159 90-9990-99

Stage 2 Stage 2 HypertensionHypertension

≥≥160160 ≥≥100100

Routine Physical Routine Physical ExaminationExamination Height/WeightHeight/Weight

PeriodicallyPeriodically Body Mass IndexBody Mass Index

– BMI = body weight (in kg) ÷ stature BMI = body weight (in kg) ÷ stature (height, in meters) squared (height, in meters) squared

– If > 30, should receive obesity If > 30, should receive obesity counselingcounseling

– Healthy diet, with emphasis on limited Healthy diet, with emphasis on limited intake of saturated fat and adequate intake intake of saturated fat and adequate intake of fruits, vegetables and whole grainsof fruits, vegetables and whole grains

– Regular physical activityRegular physical activity

Routine LabsRoutine Labs

Lipid profileLipid profile– Check Fasting lipid profile in patients 20 Check Fasting lipid profile in patients 20

years or older.years or older.– If normal, check every 5 years.If normal, check every 5 years.

GlucoseGlucose– Begin at age 45 years (or earlier if cardiac Begin at age 45 years (or earlier if cardiac

risk factors, hyperplipidemia, family history)risk factors, hyperplipidemia, family history)– Diabetes Mellitus Definition:Diabetes Mellitus Definition:

– Fasting glucose ≥ 126 on two separate occasions on two separate occasions– Random glucose ≥ 200 on two occasions (with on two occasions (with

symptoms of diabetessymptoms of diabetes

Routine Labs (cont.)Routine Labs (cont.)

TSHTSH Controversial whether or not to check Controversial whether or not to check

regularlyregularly Some guidelines recommend periodic Some guidelines recommend periodic

checking in :checking in :– Postmenopausal womenPostmenopausal women– Postpartum womenPostpartum women– DiabetesDiabetes– Down’s SyndromeDown’s Syndrome– ElderlyElderly

Additional Screening Additional Screening ExamsExams OsteoporosisOsteoporosis

– Bone mineral density exam (DEXA scan)Bone mineral density exam (DEXA scan) Women age Women age ≥ 65 years≥ 65 years At-risk women ages 60-64/ At-risk menAt-risk women ages 60-64/ At-risk men

– Risk factors include: prolonged hyperthyroidism, Risk factors include: prolonged hyperthyroidism, celiac sprue, anorexia nervosa, hypogonadism, celiac sprue, anorexia nervosa, hypogonadism, early menopause, history of androgen-early menopause, history of androgen-deprivation, long-term corticosteroid therapy, a deprivation, long-term corticosteroid therapy, a family history of osteoporosis, low body weight, family history of osteoporosis, low body weight, personal history of fracture.personal history of fracture.

– Calcium/Vitamin D supplementation Calcium/Vitamin D supplementation – Start calcium at age 30Start calcium at age 30

Additional Screening Additional Screening ExamsExams Abdominal Aortic AneurysmAbdominal Aortic Aneurysm

Men aged 65-75 years of age who have Men aged 65-75 years of age who have ever smokedever smoked

One time screening for abdominal aortic One time screening for abdominal aortic aneurysm by ultrasoundaneurysm by ultrasound

Special Pregnancy Special Pregnancy RecommendationsRecommendations Folic acid supplementationFolic acid supplementation

– In all women beginning at In all women beginning at preconception and continuing until preconception and continuing until pregnancypregnancy

HIV testingHIV testing– Recommended in all pregnant Recommended in all pregnant

womenwomen

Cancer ScreeningCancer Screening

Cervical Cancer– Pap SmearPap Smear

Beginning when patient becomes sexually Beginning when patient becomes sexually active until age 65 (or until total hysterectomy)active until age 65 (or until total hysterectomy)

At least every 3 years.At least every 3 years. Insufficient evidence to screen routinely for Insufficient evidence to screen routinely for

human papillomavirus (HPV)human papillomavirus (HPV)– HPV-DNA testing as follow-up if low-grade atypia HPV-DNA testing as follow-up if low-grade atypia

or other abnormalities found..or other abnormalities found..


Breast Cancer– MammogramMammogram

Once every 1 to 2 years age 40-49 Once every 1 to 2 years age 40-49 yearsyears

Annual mammogram for age Annual mammogram for age ≥ 50≥ 50

– Breast examBreast exam Either performed by patient or provider, Either performed by patient or provider,

has not been found to have any effect has not been found to have any effect on outcome.on outcome.


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.

Cancer Screening – not Cancer Screening – not yet routinely yet routinely recommendedrecommended Prostate Cancer

– USPSTF has not found evidence supporting the USPSTF has not found evidence supporting the routine use of PSA.routine use of PSA.

Skin Cancer– Routine screening for skin cancer using a total Routine screening for skin cancer using a total

body skin exam not recommended.body skin exam not recommended. Ovarian Cancer

– Does not recommend vaginal ultrasound or CA-125 Does not recommend vaginal ultrasound or CA-125 measurementmeasurement

Lung Cancer– No established guidelines yet for the use of No established guidelines yet for the use of

screening CT of the chestscreening CT of the chest

ImmunizationsImmunizations

Influenza Vaccine– Yearly for all adults Yearly for all adults ≥ 65 years≥ 65 years– Younger adults with risk factorsYounger adults with risk factors

CHD, COPD, asthma, Diabetes, renal CHD, COPD, asthma, Diabetes, renal dysfunction, hemoglobinopathies, dysfunction, hemoglobinopathies, immunosuppressionimmunosuppression

PregnancyPregnancy Occupational risk (health care workers, Occupational risk (health care workers,

employees of long-term care facilities)employees of long-term care facilities)


Pneumococcal– All adults All adults ≥ 65 years≥ 65 years– Younger adults with risk factors:Younger adults with risk factors:

CHD, COPD, Diabetes, liver disease, renal CHD, COPD, Diabetes, liver disease, renal failure, nephritic syndrome, splenectomy, failure, nephritic syndrome, splenectomy, immunosuppressive conditions, immunosuppressive conditions, chemotherapychemotherapy

Alaskan natives and certain Native Alaskan natives and certain Native American populationsAmerican populations

– Give second dose after 5 years if Give second dose after 5 years if ≥ 65≥ 65


Hepatitis B– Consists of three doses, initial dose, dose 1 month Consists of three doses, initial dose, dose 1 month

later, dose 6 months laterlater, dose 6 months later– Check serologic immunity at 10-year intervals, with Check serologic immunity at 10-year intervals, with

a single booster for those with undetectable levels a single booster for those with undetectable levels of HepBsAbof HepBsAb

– Recommended for:Recommended for: Adolescents and young adults who have not Adolescents and young adults who have not

previously been immunized.previously been immunized. Anyone with a history of STDsAnyone with a history of STDs Immunocompromised hostsImmunocompromised hosts PrisonersPrisoners Patients born outside U.S.Patients born outside U.S. Health care providersHealth care providers ESRD on chronic hemodialysisESRD on chronic hemodialysis


Hepatitis A– Both vaccine and immunoglobulin availableBoth vaccine and immunoglobulin available

Immunoglobulin only given when more Immunoglobulin only given when more immediate immunity neededimmediate immunity needed

– Two doses administered 6 months apartTwo doses administered 6 months apart– Recommended in:Recommended in:

Persons traveling to developing countriesPersons traveling to developing countries Food handlersFood handlers Men who have sex with menMen who have sex with men Injection drug usersInjection drug users Chronic Liver diseaseChronic Liver disease


Tetanus– All adolescents and adults should receive All adolescents and adults should receive

tetanus/diphtheria (Td) vaccine.tetanus/diphtheria (Td) vaccine.– Booster every 10 years or at time of Booster every 10 years or at time of

laceration/puncture woundlaceration/puncture wound Measles

– Recommended for adults born after 1956 without Recommended for adults born after 1956 without evidence of immunity or prior infectionevidence of immunity or prior infection

– Booster should be given to adolescents and young Booster should be given to adolescents and young adults (recent outbreaks in colleges)adults (recent outbreaks in colleges)

– Immigrants who have not received primary series Immigrants who have not received primary series should receive a single MMR.should receive a single MMR.

– Contraindicated in pregnant womenContraindicated in pregnant women


Varicella– Since 1995, is routinely administered to children.Since 1995, is routinely administered to children.– Indicated in all susceptible adults and adolescentsIndicated in all susceptible adults and adolescents– Contraindicated in pregnant women and Contraindicated in pregnant women and

immunosuppresed people.immunosuppresed people.– Avoid close contact with immunosuppresed Avoid close contact with immunosuppresed

patients within 4 weeks of administration.patients within 4 weeks of administration. Meningococcal

– College students living in dormitoriesCollege students living in dormitories– Travelers to the “meningitis belt” in sub-Saharan Travelers to the “meningitis belt” in sub-Saharan

AfricaAfrica

Let’s try a few cases…Let’s try a few cases…

A 46-year old female comes to your office for A 46-year old female comes to your office for a physical examination. She has no history of a physical examination. She has no history of medical problems, but has not been to a medical problems, but has not been to a doctor in 5 years. She stopped having periods doctor in 5 years. She stopped having periods 2 years ago. She also admits to a broken 2 years ago. She also admits to a broken wrist 9 months ago, for which she wore a cast wrist 9 months ago, for which she wore a cast for 8 weeks. She has a family history of for 8 weeks. She has a family history of hypertension in her mother, and colon cancer hypertension in her mother, and colon cancer in her father at age 55. She denies any in her father at age 55. She denies any tobacco, alcohol use. States her moods been tobacco, alcohol use. States her moods been “great” and she and her husband have been “great” and she and her husband have been taking a yoga class together. taking a yoga class together.

Case #1Case #1

Physical Exam:Physical Exam:– 142/85, 72, Ht: 4’ 11” Wt: 209#142/85, 72, Ht: 4’ 11” Wt: 209#– Gen: Alert, oriented, in NADGen: Alert, oriented, in NAD– CV: RRRCV: RRR– Resp: LCTA bilaterallyResp: LCTA bilaterally– Abd: soft, nontender, NABSAbd: soft, nontender, NABS– Ext.: No lower extremity edemaExt.: No lower extremity edema– Skin: multiple ecchymoses on proximal Skin: multiple ecchymoses on proximal

arms and back in various stages of healing.arms and back in various stages of healing.

Case # 1Case # 1

What additional lifestyle screening do What additional lifestyle screening do you want to perform in this patient?you want to perform in this patient?

What labs would you order?What labs would you order? What screening studies might you What screening studies might you

perform?perform? What immunizations, if any, might you What immunizations, if any, might you

give?give? Would you automatically recommend Would you automatically recommend

any medications in this patient?any medications in this patient?

Case #2Case #2

A 69-year old male with a history of A 69-year old male with a history of hypertension presents for follow-up. He hypertension presents for follow-up. He states that he’s been very good about states that he’s been very good about his preventative care – he had a his preventative care – he had a colonoscopy last year, and got his colonoscopy last year, and got his pneumonia shot and flu shots this year. pneumonia shot and flu shots this year. He does continue to smoke 2 packs a He does continue to smoke 2 packs a day, and his wife whispers that the day, and his wife whispers that the number of tequila shots he takes at number of tequila shots he takes at night seem a bit excessive.night seem a bit excessive.

Case #2Case #2

What additional lifestyle What additional lifestyle screening questions do you want screening questions do you want to ask?to ask?

What labs do you want to make What labs do you want to make sure are up to date in this sure are up to date in this patient?patient?

What other screening studies, if What other screening studies, if any, do you want to perform?any, do you want to perform?

Case # 3Case # 3

A 24-year old female comes to your A 24-year old female comes to your clinic for a physical exam. She hasn’t clinic for a physical exam. She hasn’t seen a doctor in 4 years. She states seen a doctor in 4 years. She states that she think she may want to get that she think she may want to get pregnant soon, but isn’t sure which of pregnant soon, but isn’t sure which of her boyfriends is going to be the lucky her boyfriends is going to be the lucky man. She admits to smoking a couple man. She admits to smoking a couple of cigarettes a day, and has a few beers of cigarettes a day, and has a few beers during the week. She states that her during the week. She states that her mother didn’t believe in shots growing mother didn’t believe in shots growing up, so she’s never gotten any.up, so she’s never gotten any.

Case # 3Case # 3

What testing do you want to What testing do you want to perform in this patient?perform in this patient?

What medications should she be What medications should she be taking?taking?

What immunizations should she What immunizations should she receive?receive?

Preventative Medicine Michele Ritter, M.D. Argy Resident – February, 2007.

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