2: 55-year-old man annual exam Flashcards
metabolic syndrome
characterized by abdominal obesity, dyslipidemia, hypertension, and insulin resistance with or without impaired glucose tolerance.
RISE Mnemonic for Preventive Visits
Risk factors: Identify risk factors for serious medical conditions during history and physical exam. Immunizations: Provide recommended
immunizations/chemoprophylaxis.
Screening tests: Order appropriate screening tests.
Education: Educate patients on ways to live healthier while reducing risks for disease.
Most Frequent Causes of Death for a 55-Year-Old Male in the U.S.
malignant neoplasm heart disease unintentional injury (accident) diabetes mellitus chronic lung disease chronic liver disease cirrhosis
Many risk factors have been independently associated with cardiovascular disease (CVD) including:
sedentary lifestyle stress premature family history excess alcohol use and many more (e.g. obesity, poor diet, low selenium levels, high homocysteine levels, etc.)
Most of a person’s risk for CVD and for stroke (together called atherosclerotic cardiovascular disease, or ASCVD) can be determined by a limited set of major risk factors. Other minor risk factors are only helpful if they adjust a patient’s risk category from that determined by the major risk factors.
American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend assessing major ASCVD risk factors every four to six years in adults age 20 to 79 who are free from ASCVD.
Effects of moderate alcohol intake:
The best-known effect of moderate alcohol intake is a small increase in HDL cholesterol. However, regular physical activity is another effective way to raise HDL cholesterol, and niacin can be prescribed to raise it to a greater degree. Alcohol or some substances such as resveratrol found in alcoholic beverages may prevent platelets in the blood from sticking together. That may reduce clot formation and reduce the risk of heart attack or stroke. (Aspirin may help reduce blood clotting in a similar way.) How alcohol or wine affects cardiovascular risk merits further research, but right now the American Heart Association does not recommend drinking wine or any other form of alcohol to gain these potential benefits.
Effects of red wine:
Over the past several decades, many studies have been published about how drinking alcohol may be associated with reduced mortality due to heart disease in some populations. Some researchers have suggested that the benefit may be due to wine, especially red wine. Others are examining the potential benefits of components in red wine such as flavonoids and other antioxidants in reducing heart disease risk. The linkage reported in many of these studies may be due to other lifestyle factors rather than alcohol. Such factors may include increased physical activity, and a diet high in fruits and vegetables and lower in saturated fats. No direct comparison trials have been done to determine the specific effect of wine or other alcohol on the risk of developing heart disease or stroke.
Effects with certain chronic diseases
Patients with heart failure, cardiomyopathy, diabetes, hypertension, arrhythmia, obesity, hypertriglyceridemia, or who are taking medications may have adverse effects from alcohol ingestion.
Relevant immunization recommendations:
Influenza is recommended annually.
Current recommendations recommend substituting a one-time dose of Tdap for Td booster (tetanus and diphtheria) for ages 11 to 64 to provide additional pertussis protection, then boost with Td every 10 years.
One dose of zoster vaccine is recommended when patients turn 60.
Immunocompromising conditions:
Live vaccines, like zoster (also MMR, OPV, and Varicella), should not be administered to immunocompromised patients, their close contacts, or to pregnant women.
The USPSTF grades each recommendation according to one of five classifications:
A: The USPSTF recommends this service. There is high certainty that the service improves health outcomes; net
benefit is substantial.
B: The USPSTF recommends this service. There is high certainty that the service improves health outcomes; net benefit is fair or fair certainty that the net benefit is moderate - substantial.
C: The USPSTF recommends against routinely providing this service. There is moderate or high certainty that health outcomes are not improved; net benefit is small. However there may be occasions that warrant provision of this service in a patient.
D: The USPSTF recommends against providing this service. There is moderate or high certainty that the service does not have any net benefits, or harms outweigh benefits.
I: There is insufficient evidence to recommend for or against the service.
United States Preventive Services Task Force Screening Recommendations for a 55-Year- Old Asymptomatic Man Who Smokes
“A” or “B” screening recommendations include:
Colorectal cancer
Obesity
Diabetes mellitus
Lipid disorders
Tobacco use
Hypertension
Alcohol misuse
Lung cancer screening: only recommended under certain circumstances. Annual screening for lung cancer with low-dose computed tomography is recommended in adults ages 55 to 80 years who have a 30 pack- year smoking history and currently smoke or have quit within the past 15 years. In this case, Mr. Reynolds has been smoking for 5 years, so lung cancer screening would not be indicated
Hepatitis C virus infection: screen in persons at high risk for infection. Offer one-time screening for HCV infection to adults born between 1945 and 1965.
Depression
Note: One of the USPSTF depression screening recommendations is Grade B, another is Grade C.
Grade B: Screen adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.
Grade C: Do not routinely screening adults for depression when staff-assisted depression care supports are not in
place. There may be considerations that support screening for depression in an individual patient.
Screen for depression with two questions:
- Over the past two weeks, have you ever felt down, depressed, or hopeless?
- Over the past two weeks, have you felt little interest or pleasure in doing things?
“D” (not recommended) screening recommendations include:
Bacteriuria, bladder cancer, pancreatic cancer, testicular cancer, spirometry for COPD, genital herpes, gonorrhea, hemochromatosis, and hepatitis B.
Patients at higher risk for particular disorders may be candidates for some of these screening tests, so it is important to consider other factors, including family history, travel history, sexual history, etc.
“I” screening recommendations include:
Prevention of motor vehicle injuries with seatbelt use and avoiding driving under the influence of alcohol; family and intimate partner violence screening; illicit drug use; and skin cancer screening.
Depending upon the patient population, additional screening receiving an “I” recommendation are: screening for glaucoma; lung cancer screening; oral cancer screening; and thyroid disease screening.
Prostate Cancer Screening Recommendations
The U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer (Grade D). Based on the data reviewed, they concluded that PSA-based screening in average-risk males results in little or no reduction in prostate-cancer-related deaths and is associated with harms related to tests, procedures, and treatment of the condition, some of which may be unnecessary.
Other organizations, such as the American Cancer Society (ACS) and the American Urology Association (AUA) recommended that men ages 55 to 69 thinking about having prostate cancer screening should make informed decisions based on available information, discussion with their doctor, and their own views on the benefits and side effects of prostate cancer screening and treatment.
PSA Screening: Benefits and Harms
The potential benefit of PSA screening is that it may lead to prolonged life from early detection and treatment of prostate cancer. In addition to the potential benefit of early detection of malignant prostate cancer, some men may receive psychological reassurance that they probably do not have prostate cancer or they have probably caught it early so it can be treated.
A potential harm of PSA screening is serious complication (such as erectile dysfunction, urinary incontinence, bowel dysfunction) or even death from treatment of a prostate cancer that would not have caused symptoms if left undetected during his lifetime. Another potential harm is pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results.
Colon Cancer Screening Options
The USPSTF recommends screening for colorectal cancer beginning at age 50 years and continuing until age 75 years using:
fecal occult blood testing
sigmoidoscopy
colonoscopy