**Preventative care Screening Flashcards
Colorectal cancer
The American Academy of Family Physicians recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age (45) to 50 and continuing until age 75.
When there is a family history of colon cancer, it is generally recommended to start screening 10 years before the cancer was found in the family member, or at age 4️⃣0️⃣, whichever is sooner [repeat every 5 years]
Other tests:
FIT
FIT/DNA
FOBT
Increased risk:
❗High Risk
Adenomatous polyps OR CRC: Screening colonoscopy interval of 5 years is appropriate for patients without inflammatory bowel disease who are found to have 1 or 2 small polyps. Five years is also an appropriate interval for patients with a first-degree family history of CRC or adenomatous polyps.
UC: CRC screening with colonoscopy and mucosal sampling should be offered to patients with ulcerative colitis, beginning 8 -10 years after the initial diagnosis (patients with disease limited to the rectum and left colon may begin 12-15 years post diagnosis). Repeat colonoscopy should be performed every 👆🏿-✌🏿[1-2] years thereafter.
HNPCC: every 1-2 years starting at age 20-25
FAP: Yearly starting at age 10-12
Breast Cancer
There is a stronger recommendation that women between the age of 50 and 74 should get screening mammograms every 2 years.
In non-Ashkenazi Jewish women, high-risk criteria are:
- Two first-degree relatives with breast cancer, one of whom was diagnosed when younger than the age of 50.
- A combination of three or more first- or second-degree relatives with breast cancer regardless of the age at diagnosis.
- A combination of breast and ovarian cancer among first- and second-degree relatives.
- A first-degree relative with bilateral breast cancer.
- A combination of two or more first- or second-degree relatives with ovarian cancer, regardless of age at diagnosis.
- A first- or second-degree relative with both breast and ovarian cancer at any age.
- A male relative with breast cancer.
The American College of Physicians states that the potential harms of screening mammography outweigh the benefits in average-risk patients aged 40 to 49 years and suggests that screening occur only if an informed woman requests it.
Prostate cancer
There is evidence supporting DRE and PSA testing as a prostate cancer screen, but concerns exist regarding false-positive tests and any actual reduction in mortality that is gained from doing the tests. Therefore, AAFP feels the evidence is insufficient to recommend for or against routine prostate cancer screening in men younger than 75 years.
Cervical Cancer
21y q3
The American Cancer Society recommends discontinuing Pap screening at age 70, but also notes that a woman who has had three or more documented normal, technically satisfactory Pap tests, and has had no abnormal Pap tests in the last 10 years can safely stop screening.
These societies also recommend that physicians may consider obtaining cervical cytology and HPV DNA testing every 5 years in women ages 30 through 65 years.
Screening can be discontinued in women 65 years and older if there have been no recent abnormal test results.
Normal Pap tests exclude persistent HPV infection, and patients with adequate screening by age 65 are at low risk of developing cervical cancer. In such patients, Pap tests may be stopped. If a patient has a history of cervical intraepithelial neoplasia 2 or higher on histology, screening continues for another 20 years after detection, past age 65 if indicated. Terminating Pap tests at age 65 may not be appropriate for women with risk factors for cervical cancer (eg, immunosuppression, high-risk sexual activity, tobacco use, diethylstilbestrol exposure).
Lung Cancer
55-80y
AND
30+ pack year smoking hx
AND
quit <15 y ago
Low dose CT q1 until 80y
[screening CT’s are low resolution]
AAA
U.S. Preventive Services Task Force (USPSTF) therefore recommends one-time ultrasonographic screening for AAA in men ages 65 to 75 years who have ever smoked. However, there is inadequate data of benefit to recommend screening for AAA in men who have never smoked or women under any circumstances.
Dx: Abdominal ultrasound
Alcohol use and abuse
The USPSTF recommends screening and counseling for all adults for alcohol use and abuse, identifying the quantity and frequency of drinking, adverse consequences, and patterns of use.
Alcohol Use Disorders Identification Test (AUDIT) is the most studied screening tool for detecting alcohol-related problems in primary care settings. It consists of 10 questions and is easy to administer; a three-question version (the AUDIT-C) is more sensitive but less specific than the 10-question AUDIT. The four-item CAGE questionnaire may also be used.
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover [eye opener]?
With a cutoff of two positive answers, the CAGE questionnaire is 77% to 95% sensitive and 79% to 97% specific for detecting alcohol abuse or dependence in primary care settings and indicates that further assessment is warranted. The AUDIT is more sensitive than the CAGE questionnaire in identifying hazardous drinking and alcohol dependence, but the CAGE is easier to deliver in a primary care setting. The TWEAK test, designed specifically for pregnant women, identifies a lower level of alcohol use because any amount of alcohol may be considered hazardous to fetuses. Clinicians should choose a screening test appropriate to their practice and provide counseling and intervention when patients screen positive.
The National Institute on Alcohol Abuse and Alcoholism defines at-risk drinking as more than 14 drinks per week or 4 drinks per occasion in men and more than 7 drinks per week or 3 drinks per occasion in women. However, harmful drinking is defined by consequences and not by the quantity consumed.
For patients older than age 65, it is recommended that they ingest no more than 1 drink per day.
Ethyl glucuronide (EtG) urine test detects recent alcohol consumption, but says nothing about the level of consumption or abuse.
An elevated MCV is 96% specific for alcohol abuse with a 63% predictive value. The GGT is 76% specific with a predictive value of 61%.
Tx: Naltrexone is known to be helpful for both opiate addiction and alcohol addiction. Naltrexone saturates opiate receptor sites and leaves them unavailable for opiate attachment. For alcohol abuse, naltrexone works differently, reducing the reinforcing effect of alcohol (not allowing patients to become “drunk”).
Naltrexone has been shown to decrease alcohol craving, reduce heavy drinking days (defined as >5 drinks for men and >4 for women), and increase days of abstinence. It can be initiated while the patient is still drinking. It is contraindicated in patients taking opioids as it can precipitate withdrawal, and in those with acute hepatitis or liver failure.
Disulfiram - The reaction to alcohol that occurs is manifested by flushing, nausea, and vomiting. The aldehyde dehydrogenase inhibitor disulfiram is an aversive agent that causes an unpleasant physiologic reaction (tachycardia, flushed skin, headache, nausea, vomiting) when alcohol is consumed. It can be used only in abstinent patients and would not be preferred in patients who are actively drinking. Candidates for disulfiram must be highly motivated or take the medication in a supervised setting as a patient may skip a dose to avoid the medication’s aversive reaction when alcohol is desired. It is considered a second-line agent that is used when naltrexone and acamprosate are either ineffective or contraindicated.
Acamprosate - Affects both γ-aminobutyric acid (GABA) and glutamine neurotransmission, both of which are important in alcohol’s effect on the brain. Acamprosate, which is primarily used to maintain abstinence, should be avoided in patients with significant renal impairment.
Cx:
Withdrawl
Hx: Symptoms include anxiety and tremulousness.
Px: Physical examination may show tachycardia, elevated blood pressure, and tremors. Other findings of chronic alcohol use such as spider angioma, hepatosplenomegaly, or peripheral neuropathy may be present.
Delirium tremens, a severe complication of withdrawal characterized by fever, profound confusion, and hallucinations, and associated with a high level of morbidity and mortality, usually does not occur before the second to third day of abstinence. Clinicians should identify the severity of withdrawal and factors that may predict the onset of serious complications.
Tx: Benzodiazepines are first-line therapy for patients who require alcohol withdrawal treatment or prophylaxis. Patients with a history of seizures should receive a prophylactic long-acting benzodiazepine on a fixed schedule even if they are asymptomatic during the acute alcohol withdrawal period. β-Blockers and clonidine can control tachycardia and hypertension, and haloperidol can treat agitation and hallucinosis.
The CIWA scale can help determine the need for medically supervised withdrawal management. Patients with an alcohol use disorder who have not had a drink for five days or more and have a CIWA score of less than 10 will in most cases not need management.
Osteporosis
Many expert groups, including the United USPSTF recommends one-time DEXA screening for osteoporosis in all women age >65, as well as for women age <65 who have an equivalent risk of osteoporotic fracture.
The risk can be estimated using the FRAX fracture risk assessment tool.
Dx: Osteoporosis is diagnosed by a DEXA T-score of less than –2.5 (>2.5 standard deviations below the mean for a young adult at peak bone density) (ie, T score <-2.5) OR the presence of fragility fractures. The term osteopenia is used when the T score is between -1 and -2.4.
A fragility fracture (fracture sustained in a fall from a standing height) defines osteoporosis regardless of bone mineral density results.
Fracture Risk Assessment Tool (FRAX)
Bone demineralization is the hallmark of osteoporosis. This disease predisposes patients to pathologic fractures, particularly of the hip and vertebrae. However, it does not cause joint destruction. The most common clinical manifestation of osteoporosis is a vertebral compression fracture; other presentations include hip fractures and distal radius (Colles) fractures and shortened stature.
Risk factors: Smoking, fractures, menopause, alcohol, asian race, RA, corticosteroids.
Tx:
Best way to prevent is via exercise. Calcium and vitamin D can help keep bones strong. 1,000 mg and 600 IU of vitamin D daily is recommended (if not in the sun at least 20 minutes a day).
The National Osteoporosis Foundation (NOF) recommends antiosteoporotic therapy for persons whose risk of major osteoporotic fracture over the next 10 years is 20% or greater or whose risk of hip fracture over the next 10 years is 3% or greater.
Bisphosphonates: Alendronate is approved for both osteoporosis prevention and treatment by the Food and Drug Administration (FDA).
Zoledronic acid (IV bisphosphonate) is preferred for women with postmenopausal osteoporosis who are unable to take oral bisphosphonates (gastroesophageal reflux disease) or who desire the convenience of less frequent dosing.
Raloxifene, a selective estrogen receptor modulator, is also approved for osteoporosis prevention by the FDA. However, vasomotor symptoms are highly associated with its use.
Teriparatide, or recombinant human parathyroid hormone, is an anabolic agent that increases bone density and decreases fracture risk. However, it is considered second-line therapy to bisphosphonates, is expensive, and has been associated with an increased risk of osteosarcoma.
Hep C
Baby boomers (1945-1965)
HIV
ELISA
HTN
2 consecutive measurements
Ambulatory BP monitoring
DM
The US Preventive Services Task Force recommends screening for T2DM in asymptomatic adults with sustained blood pressure (BP; treated or untreated) >135/80 mm Hg. In contrast, the American Diabetes Association (ADA) recommends screening patients who are: overweight or obese (body mass index >25 kg/m2) AND who have risk factors (eg, BP >140/90 mm Hg, dyslipidemia [high-density lipoprotein levels <35 mg/dL and/or triglyceride levels >250 mg/dL], first degree relative with diabetes OR member of a high-risk ethnic group, or polycystic ovary syndrome).
Asymptomatic patients without risk factors should consider screening at age 45 years.
The National Kidney Foundation and the American Diabetes Association recommend:
- Screen annually for diabetic nephropathy with annual testing with a spot urine test (urine albumin–creatinine ratio) for moderately increased albuminuria (microalbuminuria). [In patients with type 1 diabetes of 5 years’ duration and in all patients with type 2 diabetes starting at the time of diagnosis]
- Glycemic control should be monitored with HbA1c measurements every 3 to 6 months.
- Obtain an annual fasting ⚪lipid profile, including LDL-C, triglyceride, high-density lipoprotein cholesterol, and total cholesterol levels, and adjust treatment to meet goals.
- Perform a foot examination at each visit.
- Obtain an annual dilated funduscopic examination from a specialist, unless otherwise dictated by the specialist.
In the absence of unequivocal symptomatic hyperglycemia, the diagnosis of diabetes must be confirmed on a subsequent day by repeating the same test suggestive of diabetes (the hemoglobin A1c measurement). If results of two different diagnostic tests are available and both are diagnostic for diabetes, additional testing is not needed.
HLD
Guidelines for statin therapy:
Clinically significant ASCVD
- Acute coronary syndrome
- Stable angina
- Arterial revascularization (eg, CABG)
- Stroke, TIA, PAD
- Low-density lipoprotein (LDL) cholesterol level >190 mg/dL
- Age 40-75 with diabetes
- 10-year ASCVD risk ≥7.5%: High-intensity statin
- 10-year ASCVD risk <7.5%: Moderate-intensity statin
Lipid Values:
Total cholesterol >200 mg/dL
low-density lipoprotein (LDL) cholesterol >130 mg/dL 😈
High-density lipoprotein (HDL) cholesterol <40 mg/dL
AND fasting triglycerides ≥150 mg/dL
Elevated triglyceride levels (>150 mg/dL) are associated with increased risk of cardiovascular events, and extremely elevated levels (>1,000 mg/dL) can cause pancreatitis.
Of all the lipid values, low HDL is the single best predictor of an adverse outcome.
Smoking cessation increases HDL by 5 to 10 mg/dL
Tx:
In patients with mild-moderate hypertriglyceridemia (150-500 mg/dL) who have known or are at high risk for coronary artery disease (CAD), initiation of a high-intensity statin (eg, rosuvastatin, atorvastatin) is the recommended first-line pharmacologic therapy.
In addition, lifestyle modifications targeting secondary causes of hypertriglyceridemia should be pursued. Although moderate alcohol intake is associated with reduced cardiovascular mortality, heavy intake can significantly raise triglyceride levels; therefore, alcohol intake to no more than 2 drinks a day (1 drink a day for women). Increased exercise and weight loss are also beneficial.
🥅The most recent American College of Cardiology/American Heart Association (ACC/AHA) cholesterol treatment guidelines discuss four high-risk groups that warrant treatment for hyperlipidemia:
If the ASCVD 10-year risk is less than 10%:
Tx goal: LDL Less than 160 mg/dL
If the ASCVD 10-year risk is between 10% and 20%:
Tx goal: LDL Less than 130 mg/dL.
If the ASCVD 10-year risk is greater than 20%
Tx goal: LDL Less than 100 mg/dL
💗Newly diagnosed atherosclerotic cardiovascular disease (ASCVD) OR patients with diabetes 🍭
Tx goal: LDL Less than 70 mg/dL
Rx:
High-intensity statin therapy: Atorvastatin, 🅰40 mg to 80 mg/day, or rosuvastatin, 20 mg to 40 mg/day.
The 80-mg dose is best tolerated in younger patients and those without multiple medications or multiple comorbidities.
The guidelines recommend high-intensity statin for patients with ASCVD who are younger than age 75 years.
The goal of high-intensity statin therapy is to lower the LDL cholesterol level by ≥50%, although routine follow-up of LDL cholesterol levels to guide therapy is not recommended.
Moderate-intensity statin therapy: Atorvastatin 10 to 20 mg/day.
Fish oil: is high in omega-3 fatty acids and has been shown to be beneficial in lowering cholesterol. Fish oils work by decreasing secretion of triglycerides by the liver.
Gemfibrozil changes the hepatic metabolism of lipoproteins and is a logical choice for the patient with low HDL and elevated triglycerides.
Niacin was the first lipidlowering agent associated with decreased total mortality. It moderately decreases LDL, can increase HDL by 20% to 25%, and moderately decreases triglycerides.
Cx:
Secondary Dyslipidemia
Even high-intensity statin therapy may be ineffective in the setting of untreated hypothyroidism, diabetes mellitus, obstructive liver disease, or nephrotic syndrome.
Metabollic Syndrome
The clinical importance of identifying the metabolic syndrome is the increased risk for cardiovascular disease and type 2 diabetes mellitus. Persons with the metabolic syndrome should receive aggressive intervention focused on lifestyle modification to decrease weight, increase physical activity, and implement a nonatherogenic diet in addition to undergoing treatment for the significant metabolic abnormalities that define the syndrome.
The metabolic syndrome is frequently identified in patients with polycystic ovary syndrome and has also been associated with the development of other disorders, including fatty liver disease, obstructive sleep apnea, hyperuricemia, and gout.
Dx: The diagnosis of metabolic syndrome is made by the presence of three or more of the following five criteria:
Waist circumference: Men, >40 in (102 cm); Women, >35 in (88 cm)
Triglycerides: ≥150 mg/dL
High-density lipoprotein (HDL) cholesterol: Men, <40 mg/dL; Women, <50 mg/dL
Blood pressure: ≥130/85 mm Hg
Fasting glucose: ≥110 mg/dL
Smoking
Five-Step Brief Intervention for Smoking Cessation:
Current recommendations are that all clinicians assess tobacco use at every visit, encourage every patient to make a quit attempt, and counsel patients appropriately.
A recommended strategy for counseling is to follow the 5 A’s:
Ask about tobacco use
Advise to quit
Assess willingness to make a quit attempt
Assist in quit attempt
Arrange follow-up
The 5 R’s: To Motivate Patients Unwilling to Quit
Encourage patient to think of Relevance of quitting smoking to their lives
Assist patient in identifying the Risks of smoking
Assist the patient in identifying the Rewards of smoking cessation
Discuss with the patient Roadblocks or barriers to attempting cessation
Repeat the motivational intervention at all visits
Motivational Interviewing: stages of change
Precontemplation - Education about the health area
Contemplation - Cost-benefit analysis; develop discrepancy between patient goals and current behavior
Preparation - Brainstorm options; assist in developing a concrete action plan
Action - Encourage tracking/monitoring actions; validate patient and provide feedback; discuss and elicit social support
Maintenance - Check progress; troubleshoot slips/concerns of the patient; reinforce successes and build patient confidence
Relapse - Judge choices, not the patient; focus on past success; identify new supports that reinforce healthy behavior
Px:
The use of pharmacotherapy (nicotine replacement, bupropion, or varenicline) doubles the odds of smoking cessation.
Nicotine replacement therapy is considered safe in most patients. Three nicotine replacement products are available over the counter (nicotine gum, lozenge, and patch), and two are available by prescription (inhaler and nasal spray).
Nicotine replacement should be used with caution when working up unstable angina.
Bupropion is contraindicated in patients taking monoamine oxidase inhibitors or with seizure or eating disorders.
The average weight gain associated with smoking cessation is 10 lb (4.5 kg) and is higher in women than it is in men. In both men and women, the benefits of smoking cessation outweigh any risks associated with weight gain.
Varenicline is a selective nicotinic receptor partial agonist. Dose modifications would be needed in people with severe renal disease. Common side effects include nausea, insomnia, and abnormal dreams. Varenicline is taken for 1 week before the quit date, and therefore can be taken while a person is still
smoking.
Varenicline has been demonstrated to be more effective than bupropion, and combinations of varenicline with various nicotine replacement therapies have showed cessation rates higher than nicotine replacement or bupropion alone.
Must be used with caution in patients with kidney impairment or on dialysis and in patients with cardiovascular disorders.
_*Both bupropion and varenicline_ must be used with caution in patients with serious psychiatric illness because they may cause neuropsychiatric symptoms such as personality changes, vivid dreams, or suicidal ideation.
Nortriptyline has demonstrated only modest effectiveness in smoking cessation trials and is considered a second-line agent. Combining either nortriptyline or bupropion with a selective serotonin reuptake inhibitor is relatively contraindicated.
E-cigarettes
Adolescent e-cigarette users had increased rates of chronic bronchitic symptoms. Further investigation is needed to determine the long-term effects of e-cigarettes on respiratory health.
Although e-cigarette vapor may be less hazardous than tobacco smoke, our findings can be used to challenge the idea that e-cigarette vapor is safe, because many of the volatile organic compounds we identified are carcinogenic. Messaging to teenagers should include warnings about the potential risk from toxic exposure to carcinogenic compounds generated by these products.
Addictive
Depression
Using a formal tool for severity assessment (e.g., the Patient Health Questionnaire 9 [PHQ-9]) helps quantify the nature of the response; patients are considered to have at least a partial response if a 50% or greater decrease in symptom score has occurred.
Dx: The characteristics of a major depressive disorder include depressed mood most of the day nearly every day for at least 2 weeks; loss of all interest and pleasure; disturbances of appetite, weight, sleep, or activity; fatigue or loss of energy; self-reproach or inappropriate guilt; poor concentration or indecisiveness; morbid thoughts of death (not just fear of dying) or suicide; or all of these.
Tx: Major depression is ideally treated with a combination of medication and psychotherapy. The goal of treatment is to achieve complete remission within 6 to 12 weeks and continue treatment for 4 to 9 months thereafter. Patients should be assessed 2 and 4 weeks after starting therapy for adherence, adverse drug reactions, and suicide risk and again at 6 to 8 weeks for response to therapy.
Treatment options for partial responders and nonresponders include using a higher dose of the same agent (ineffective in this patient), adding a second agent, switching to a new drug, or adding psychotherapy.
Electroconvulsive therapy (ECT) is indicated in severely depressed patients, such as those with profound suicidal ideation or psychotic features in whom a rapid response to therapy is particularly desirable. ECT should be managed by a psychiatrist, most often as part of comprehensive inpatient treatment.
Hospitalization: Depressed patients who have an intent or plan for suicide are at the highest risk for actually committing suicide and should be hospitalized if they have poor social support, are intoxicated, are actively delusional, or are likely to be noncompliant with medication.
Rx: SSRIs
Sertraline, citalopram, and acetalopram are preferred in geriatrics
Paroxetine (most sedation, anticholinergic) and Fluoxetine (longest half-life, drug interactions) are not preferred in geriatrics.
SNRI (pain?)
Wellbutrin (no sequal side effects and is activating)
TCA (anticholinergic)
Mirtazepine (improves sleep and appetite)
Ddx:
MDD
Bipolar
Among young depressed adults, the presence of prior hypomanic symptoms in a patient with depression is suggestive of the possibility of the presence of bipolar disorder.
Diagnostic criteria for mania include a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week. Typical symptoms include inflated self-esteem or grandiosity, a decreased need for sleep, distractibility, increased goal-directed behavior, and excessive involvement in pleasurable activities that have a high potential for consequences (unrestrained buying sprees, sexual indiscretions).
Dysthymia
A chronic mood disorder characterized by depressed mood or anhedonia at least half the time for at least 2 years accompanied by two or more vegetative or psychological symptoms and functional impairment.
