DISCLOSURES THE ADULT PERIODIC HEALTH EXAM: Screening … · 17-11-09 1 THE ADULT PERIODIC HEALTH EXAM: Screening and Preven@on Dr. Susan R. Goldstein Assistant Professor Department

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THEADULTPERIODICHEALTHEXAM:

ScreeningandPreven@on

Dr.SusanR.GoldsteinAssistantProfessor

DepartmentofFamily&CommunityMedicineUniversityofToronto

FMFNovember9,2017

[email protected]

DISCLOSURES

•  Norelevantdisclosures•  Allrecommenda@onsareCTFPHCunlessotherwisespecified

•  Allrecommenda@onsrefertolowriskADULTS

Objec@ves

•  Provideaevidence-basedPHEtoouradultpa@ents

•  Orderappropriatescreeningtestsbasedonrelevantpa@entdemographics

•  Useresourcesefficientlytopromotepa@enthealth

Awordaboutguidelines

•  Clinicalprac*ceguidelines(CPGs)–  "systema@callydevelopedstatementstoassistprac@@onersandpa@entdecisionsaboutappropriatehealthcareforspecificcircumstances.“ Field&Lohr(1990)

•  Informedbysystema@creviewofevidence•  Op@mizecare,improvehealthoutcomes•  Minimizeharm•  Costeffec@ve

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GuidelinesCanadianTaskForceonPreven*veHealthCare(CTFPHC)•  Recommenda@ons

–  “strong”:benefitsoutweighharms–  “weak”:benefit“probably“outweighsharms

•  Opportunityforcollabora@vediscussion•  Levelsofevidence:GRADEprocess

–  “extenttowhichourconfidenceinanes@mateoftheeffectisadequatetosupportapar@cularrecommenda@on”•  high,moderate,low,noevidence

hbps://canadiantaskforce.ca/

ThePeriodicHealthExamAPeriodicHealthVisit-  topreventdiseaseand

promotehealth-  Ptpresentswithnoapparent

physicalormentalillness-  Mustincludeintermediateor

par@alassessmentfocusingonageandgenderappropriate-  history-  physicalexamina@on-  healthscreening-  relevantcounselling.

hbp://www.health.gov.on.ca/en/pro/programs/ohip/bulle@ns/4000/bul4585.pdf

!Screening!

“Examina@onofagroupofusuallyasymptoma@cpeopletodetectthosewithahighprobabilityofhavingagivendisease,typicallybymeansofaninexpensivediagnos@ctest.”

REMEMBER!

•  Screening,

Whathappenedtotheannualphysical?”

Okenanotherwisehealthypa@entreques@ngayearly“completereview”“Ageneralassessment(A003)isafamilyprac9ceserviceprovidedsomewhereotherthanthepa9ent’shomeandincludesafullhistory(includingmedical,familyandsocialhistoryandfunc/onalenquiry)andexceptforbreast,genitalorrectalexamina9onwherenotwheremedicallyindicatedorrefused,anexamina/onofallbodyparts”

hbp://www.health.gov.on.ca/english/providers/pub/ohip/physmanual/

download/sec@on_2.pdf

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TheAnnualPhysicalisNOTrecommended.

•  November1979:TaskForceonthePeriodicHealthExamrecommendednoannualphysical

•  Thosewhoseekitdon’tneedit•  Toowideanet,riskofharm

AnnualCPX

CochraneReviewGeneralhealthchecksinadultsforreducingmorbidity

andmortalityfromdisease2012•  IncludedRCTsforhealthchecksvsnoneforspecificdiseasesorriskfactors

–  182,880par@cipants•  Outcomesweremorbidityandmortality•  16trials(datafor14):

–  9Totalmortality–  8CVSmortality–  8CAmortality

•  Nodecreasein–  morbidity,–  hospitaliza@on,–  disability,–  worry,–  addi@onalphysicianvisits,or–  absencefromwork

•  Nooverallreduc@onindiseasespecificoroverallmortality•  Conclusion:generalhealthchecksareunlikelytobebeneficial

hbp://www.bmj.com/content/345/bmj.e7191

ChoosingWiselyPeriodicPxexamhasbenefitsReplaceAnnualPxwithintermibent“preven@vehealthchecks”

hbps://choosingwiselycanada.org/family-medicine/

Periodicpreven*vehealthvisits:amoreappropriateapproachtodeliveringpreven*veservices

FromtheCanadianTaskForceonPreven9veHealthCare

Publica9onpending:Nov.14,2017

“Annualphysicalexamina9onsmightincreasethelikelihoodoffindingcondi9onsofuncertainclinicalimportance.Althoughinves9ga9onandtreatmentofincidentallydiscoveredabnormali9escanbebeneficial,thismustbeweighedagainstthepoten9alharmsoflabeling,false-posi9veendings,andcomplica9onsfromfollow-uptes9ngandunnecessarytreatment.”

CanadianFamilyPhysician,Vol63:November2017

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PeriodicHealthExam/VisitPreven@veHealthCheck

PHE-  history-  physicalexamina@on-  healthscreening-  relevantcounselling.

Howfrequentisperiodic?Annual?Q3y?5y?...1.  Demographics2.  Healthhistory3.  Presenceofchronicmedicalcondi@ons

(monitoringvsscreening)

ThePHE---HISTORY

1.   Pa*entconcerns2.  UpdateCPPinclMedreview3.  Habits/Lifestyle

1.  Smoking,ETOH2.  Diet,vitamins3.  Exercise,weight4.  Safety

1.  Seatbelt2.  BikeHelmet3.  Sunprotec@on4.  Noiseprotec@on

5.  Other4.  Screening:

1.  Cancerscreening2.  Cardiovascular:

1.  DM2.  Lipids3.  AAA?

3.  Osteoporosis4.  STIScreening?

5.  Immuniza@ons

History:Lifestyle•  Lifestyle

–  Smoke:quit!•  aids,nico@nereplacement,

Buproprion–  ETOH:

•  Women10/week(max2/day)•  Men15/wk(max3/day)•  Specialoccasionsmaxis+1•  Don’tdrinkeveryday

–  Exercise•  150min/weekmoderateac@vity•  Minimum10minbursts(CCS)•  +2daysweekmuscle/bone

strengthening

hbp://www.ccsa.ca/Resource%20Library/2012-Canada-Low-Risk-Alcohol-Drinking-Guidelines-Brochure-en.pdf

Diet,vitamins

•  HealthyDiet–  Canada’sfoodguide–  Counselifdietaryrestric@ons

•  AssessCalciumintake–  Under50:1000mg–  Age50+:1200mg–  Dietaryispreferable!!!–  Useonlinecalculatortodetermineintake

•  E.g.OCwww.osteoporosis.ca•  IOFhbps://www.iosonehealth.org/calcium-calculator

•  AssessVitaminD3supplementa@on:–  LowriskofVitDdeficiency:400-1000IU/day–  Mod.RiskofVitDdeficiencyorover50yrs:800-1000IU/day–  max2000IU

hbp://www.cmaj.ca/content/182/17/1864.full

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Obesity&Overweight(2015)•  AssessBMIandWC

•  Target5-10%loss0.5-1kg/week•  Obese(BMI30-40)andhighriskof

DM:offerorrefertostructuredbehavioralprogramsaimedatweightloss(strong/mod)

•  Overweight/obese:offerorrefertostructuredprogramsasabove(weak/mod)

•  Overweight/obese:donotofferwtlossmedica@ons(eg.orlistat/metormin)(weak/mod)

Safety:

1. Seatbelt2. BikeHelmet3. Sunprotec@on4. Noiseprotec@on

hbp://www.cfpc.ca/projectassets/templates/resource.aspx?id=1184&langType=4105

History-Eyes,Dental•  Dental-oralhygeine

–  ReltoCVSdx,oralCa

•  Vision/Eyeeval(Consensus)•  Highriskincludes

–  DM–  Cataract–  Macdegen–  Glaucoma–  FHxoftheabove

Age Normalscreen

AgeifHighrisk

Highriskscreen

<40 Q10years

Over40 Q3years

41-55 Q5years

Over50 Q2years

56-64 Q3years

Over60 Annual

65+ Q2years

CanadianOpthalmologicalSocietyCanJOpthalmolvol42Nov1,2007

COSVisionScreeningCPGEng_Feb07.odfn

History:SpecificScreening

1.Cancer–  Colorectalcancer–  Lungcancer–  BreastCancer–  CervicalCancer–  ProstateCancer

2.CardiovascularRisk:–  AAA–  DM–  Lipids

3.Bonehealth/Osteoporosis4.STIs&Communicabledisease

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ColorectalCancer(2016)

•  NOcolonoscopyforscreening(weak/low)•  AbnormalFOBT;Cscopewithin8weeks(CCO)

Age FOBT/FIT

Flexsig Evidence

50-59 Q2Y Q10Y Weak/mod

60-74 Q2Y Q10Y Strong/mod

75+ NO NO Weak/low


LungCancer(2016)ScreeningwithLowDoseCT

Forhigh-riskpopula@onsdefinedas:(weak/low)-  persons55to74yearsofage-  ≥30pack-years-  currentlysmokeorhavequit

withinthepast15years-  arediseasefreeatthe@meof

screening.-  ANNUALx3-  Onlyscreenwheretreatmentis

availableCXR+/-sputumcytologyNOTrecommended(strong/low)


BreastCancerScreening

TenyearriskofBreastCancerforwomenintheir:

40s 13/100050s 23/100060s 29/100070s 31/1000

Breastcancer(2011):anopportunityfordiscussion?

Age Mammo Evidence NNS FPs BxRate Mortalitybenefit

40-49 NO Weak/mod

2100 1/3 1/28 15%

50-69 Q2-3yr Weak/mod

720 1/4 1/28 21%

70-74 Q2-3y Weak/low

450 1/5 1/38 32%

75+ Individualchoice

BSE NO Weak/mod

CBE NO Weak/low

MRI NO Weak/noevidencehbps://canadiantaskforce.ca/

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MammographyAdverseOutcomes:

Basedonmedian11yearsscreeningatq2yrs40-49 50-69 70-74

Topreventonedeath:

NNS 2100 720 450

MammoFalsePos 1/3 1/4 1/5

UnnecessaryBiopsy 1/28 1/28 1/38

UnnecessarySurgery 1/200 1/200 1/200

Riskofdyingbaseline

1/313(0.32%) 1/155(0.64%) 1/146(0.68%)

Riskofdyingifscreened

1/370(0.27%) 1/196(0.51%) 1/217(0.46%)

Screeningbenefit 15% 21% 32%

CervicalCancer(2013)Screeningsexuallyac9vewomen

Annualvs.q3yscreen:+3/100,000cervicalCA*CCO:startage21ifsexac@ve,asdefined

Age Screen Evidence

25-29 Q3years Weak/mod

30-69 Q3years Strong/high

70+ Stopif3successivein60s

Weak/low

LowImmunity Annual

Rxfordysplasia* Annual


Prostatecancer:PSAscreening? Prostatecancer(2014)PSAscreening?

•  NOPSA•  <55:(strong/low)•  55-69:(weak/mod)•  70+(strong/low)•  USTFPH2012:NO(D)

BUT•  Melbourneconsensusstatement

–  50-69:PSAreducesincidenceandCa-specificmortalityrates

–  BaselinePSAin40sispredic@veoffuturedisease–  Don’tdenyoldermenwith>10yrlifeexpectancy–  Consideraspartofmul@variateapproach

•  ProstateCancerCanada–  “knowyournumber” hbps://canadiantaskforce.ca/

hbps://www.ncbi.nlm.nih.gov/pubmed/24206066

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CMAJ2014recommenda@onsrePSAtes@ngBenefit?

CMAJ2014recommenda@onsrePSAtes@ng:Harm?

USPreven@veServicesTaskForce(USPSTF)DRAFT2017

Menages55–69:Crecommenda*onMenage70+:D•  TheUSPSTFrecommendsthatcliniciansinformmenages55to69years

aboutthepoten@albenefitsandharmsofprostate-specifican@gen(PSA)–basedscreeningforprostatecancer.

•  Thedecisionaboutwhethertobescreenedforprostatecancershouldbeanindividualone.Screeningoffersasmallpoten@albenefitofreducingthechanceofdyingofprostatecancer.However,manymenwillexperiencepoten@alharmsofscreening,includingfalse-posi@veresultsthatrequireaddi@onaltes@ngandpossibleprostatebiopsy;overdiagnosisandovertreatment;andtreatmentcomplica@ons,suchasincon@nenceandimpotence.TheUSPSTFrecommendsindividualizeddecisionmakingaboutscreeningforprostatecancerakerdiscussionwithaclinician,sothateachmanhasanopportunitytounderstandthepoten@albenefitsandharmsofscreeningandtoincorporatehisvaluesandpreferencesintohisdecision.

•  PleaserefertotheClinicalConsidera@onssec@onsonscreeninginAfricanAmericanmenandmenwithafamilyhistoryofprostatecancerformoreinforma@ononthesehigher-riskpopula@on

USPreven@veServicesTaskForce

PSAHarmsofScreeningCounselingTool:1000menx13yrs


VIDEOhbps://canadiantaskforce.ca/tools-resources/videos/

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hbps://www.youtube.com/watch?v=bTgS0DuhaUU 2.CardiovascularRisks:Screening

•  AAA•  Diabetes•  Lipids

Cardiovascular:AbdominalAor@cAneurysm(2017)

•  ONE@meabdominalultrasoundfor

MEN•  YES:ages65to80(weak/mod)•  NO:over80(weak/low)

WOMEN:•  No(strong/verylow)

•  CanadianSocietyforVascularSurgeryStatement–  ALLmen65-75–  Considermenunder65withFhx–  Considerwomenover65withhxofCerebrovascdx,smokers,orFHx

hbps://canadiantaskforce.ca/hbp://www.cmaj.ca/content/189/36/E1137.full.pdf+html

DiabetesScreening

CTFPHC2012

CanadianDiabetesAssn2013/2016update

RISKassessmentusingDiabe*cRiskCalculator

Q3-5years

ANNUAL

Whenisbloodtestrequired?

IfHiorVeryHirisk Age40thenq3yrsIfHiorVeryHiriskRiskfactors*

Frequencyofscreen Hiriskq3-5yrVeryhirisk:annual

Q3-5yrIfVeryhiorotherriskfactors,morefrequently

Preferredbloodtest HbA1C-cutoff6.5%FBSorOGTTacceptablealterna@ves

FBSorHbA1C

Whattodoifborderline IFHbA1C6.0.-6.4%ORFBS6.1-6.9SHOULDdoOGTTIfHbA1C5.5-5.9%ORFBS5.6-6.0MAYdoOGTT

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RiskCalculators:CANRISK(CanadianDiabetesRiskAssessmentQues*onnaire)hgp://www.diabetes.ca/documents/for-professionals/NBI-CANRISK.pdf

Highrisk33+

RiskCalculators:FINDRISC(FinnishDiabetesRiskScore)

AgeBMIWC

ExerciseDiet

BPmedsHxGLUFHx

HI:15-20

VeryHI21+

Diabetes:

CTFPHC2012


Whenisbloodtestrequired?

Nostar@ngageIfHiorVeryHirisk

Age40thenq3yrsIfHiorVeryHiriskRiskfactors*

Preferredbloodtest [email protected]%FBS(7.0)orOGTT(11.1)

FBSorHbA1C


Lo-mod:q5?yHiriskq3yrVeryhiorotherriskfactors,morefrequently

Whattodoifborderline IFHbA1C6.0.-6.4%ORFBS6.1-6.9SHOULDdoOGTTIfHbA1C5.5-5.9%ORFBS5.6-6.0MAYdoOGTTbutshouldtestOGTTifalsoariskfactor

RiskfactorsforDM

hbp://guidelines.diabetes.ca/app_themes/cdacpg/resources/cpg_2013_full_en.pdf

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Diabetes:

CTFPHC2012


Preferredbloodtest [email protected]%FBS(7.0)orOGTT(11.1)

HbA1CFBS


Over40:q3yHiriskq3yrVeryhiorotherriskfactors,morefrequently

Whattodoifborderline IFHbA1C6.0.-6.4%ORFBS6.1-6.9SHOULDdoOGTTIfHbA1C5.5-5.9%ORFBS5.6-6.0MAYdoOGTTbutshouldtestOGTTifalsoariskfactor

CDAscreeningalgorithm

hbp://guidelines.diabetes.ca/app_themes/cdacpg/resources/cpg_2013_full_en.pdf

Guidelines.diabetes.caLipidguidelines

SimplifiedLipid2015 CCS2016

ScreenMen 40-75 40-75

ScreenWomen 50-75 40-75

Useriskcalculator YesCKDuseQRISK2

Mod-FRS*orCLEM*(www.chiprehab.com}

Screenearlierifriskfactors Yes Yes,alsoifSouthAsianFirstNa@ons

hbp://www.cfp.ca/content/61/10/857hbp://ccs.ca/images/Guidelines/PocketGuides_EN/Pocket_Guides/Lipids%20Pocket%20Guide_2016.pdf

*notvalidatedforSouthAsian,Firstna@ons,otherimmigrantpopula@ons,considerQRISK2

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CCS:LipidGuidelinesScreenregardlessofagewithriskfactors:

–  Evidenceofatherosclerosis–  AAA–  DM–  BP–  CKD–  Obese–  Currentsmoker–  Lipiddeposits(arcus,xanthalasma)–  HIV–  Inflammatoryboweldisease–  COPD–  Erec@ledysfn–  FHX:prematurecvd(55/65)ordyslipidemia–  BPInpregnancy(new!)-medianageof1stcvseventage38!!

hbp://www.onlinecjc.ca/ar@cle/S0828-282X(16)30732-2/pdf

Lipidguidelines


LoriskScreenfrequency 5years 5years*

Nonfas@nglipids Yes YesifTG<4.5

Otherscreeningtests LimiteduseforCACscoreorLp(a)

1’preven@on,whototreat FRS10-19%moddosesta@nFRS20+%highdosesta@n

Sta@nindicatedgroupFRS10-19&LDL>3.5*FRS20+YES

Non-HDLcholorApoBareop@ons:notaffectedbyameal!!Withfood:LDLdown10%TGup20%

CCS:Sta@nindicatedcondi@onsTreatregardlessofLDL

1.  Clinicalatherosclerosis-MI,ACS,CVA,TIA,Caro@ddx,PVD

2.AAA->3cmorpriorsurgery

3.DM:age40+-or15yrdura@on,or-age30+withmicrovasccomp

4.CKD:3mo+and-uACR>3.0OReGFR<60

5.LDL>=5.0mmol,familialhyperChol


Lipidguidelines


Monitoring:targetlipidsifRxd

NONoALT,CKrou@ne

LDL50%[email protected](nonHDL2.6)

Over75 Discourage,individualize FRSnotvalidated

Lifestyle Counselreexercise,healthydietEsp.MedDiet(strong)NOOmega3PUFAsuppsOtherdiets:seeguidelines

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3.Bonehealth&osteoporosis(2013)

•  CTFPHCreferences2010guidelines–  CMAJ:2010Clinicalprac@ceguidelinesofthediagnosisandmanagementofosteoporosisinCanada

•  Purpose:topreventfragilityfractures(vsdiagnosingosteoporosis)

•  Riskassessment-–  Assessmenandwomenage50+forriskfactorsfor#

•  1.Lowbonedensity

WhentomeasureBMD?

hbp://www.osteoporosis.ca/health-care-professionals/guidelines/

3.Bonehealth&osteoporosis(2013)•  Riskassessment-

–  Assessmenandwomenage50+forriskfactorsfor#•  1.Lowbonedensity

–  10yrrisk:CAROCrecommendedasisCdndata

•  2.Fallsandfractures-askaboutFALLSinelderly–  Ifyes:getupandgotest

•  Annualheight:–  Ifsuspectvertebralfracture:lateralxrayT/Lspine

• WhentomeasureVitDlevel:– Ifrecurrent#,pretreatmentorbonelossdespitetreatment

– ONLYaker3mosoftreatment&don’trepeatif>75nmol/L

Recommenda@ons:FracturePreven@on

•  Exercise-– aerobic–  resistance– balance– corestabilityifvert#

•  FallPreven@on•  CalciumandVitD

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4.STIs:WhototestCanadianSTIGuidelines(2013)

•  Screenhighrisk–  Sexac*veyouth,25y/o–  Newpartnersormorethan2partnersinthepastyear–  Serialmonogamy-seriesofrela@onshipsover@me–  Nocontracep@onornonbarriermethods–  ContactsofpeoplewithSTIs–  Sexworkers/partners–  Ivdrugusers/partners–  Unsafesexualprac@ces–  Homeless–  Assault/abuse–  HxofSTI–  Anonymoussexualpartneringor“survivalsex”

hbps://www.canada.ca/en/public-health/services/infec@ous-diseases/sexual-health-sexually-transmibed-infec@ons/canadian-guidelines/sexually-transmibed-infec@ons/canadian-guidelines-

[email protected]

STItes@ng•  Whattotest:–  *Chlamydia:swaborurine(M:novoidx2hrs)–  *Gonorrhea:cervicalswab/urine–  Syphilis:VDRLserology– HepBsag– HIV?

•  Unprotectedanal/vagintercourse•  Immune-compromised•  Symptoma@c•  Reques@ngit

–  ZIKAvirustes@ng

*allsexac@veannuallyuptoage25hbp://healthycanadians.gc.ca/publica@ons/diseases-condi@ons-maladies-affec@ons/commibee-statement-

treatment-preven@on-zika-declara@on-comite-traitement-preven@on/index-eng.php?&_ga=2.142326650.977125862.1509904030-1094833840.1502453926#a9

STItes@ngZIKAvirustes@ng:

•  Ifss3-dayspostarriveto14dayspostdeparturefromendemicarea

•  Ifacutelyunwell>10dayssstestjustserology•  <10dayssstestbothRT-PCRandserology•  Malesposttravelwithillness-atleast2weekspostexposure

•  Assympmaleswithtravelhistoryifpartnerconsideringpregnancyinnext6mos

•  Recommenda@onforboth:abstain/condomsfor2mosposttravel

•  Pregnantwomen:iftravelhx,shouldassess,considerscreen

hbp://healthycanadians.gc.ca/publica@ons/diseases-condi@ons-maladies-affec@ons/commibee-statement-treatment-preven@on-zika-declara@on-comite-traitement-preven@on/index-eng.php?

&_ga=2.142326650.977125862.1509904030-1094833840.1502453926#a9

Hepa@@sC(2017)•  NOforlowrisk(strong/verylow)•  YESonlyifRiskfactors

–  Bloodtxpriorto1992–  Iv/nasaldruguser–  SexualcontactofHepCorivdruguser

–  Dialysis–  Incarcera@on–  Taboo–  Percutaneousexposure–  MomwithHcv

•  CanadianLiverFounda@on:one@metes@ngifborn1945to1975


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Immuniza@on:AdultVaccines•  TdapONCEakerage18,then

Tdq10yr•  IPV:adulttravellersx1•  MMR:Idoseborn>1970if

suscep@ble•  Varicella:2dosesasadultif

suscep@ble•  Meningococcal:onedose<=24

y/oifnotpreviouslyimmunized•  Flushot-annual•  Pneumonia-preventIPD&CAP

–  Prevnar13@65y/o•  @50ifimmsupp/hiv/HSCT

–  Pneumo23@65:8weekslater•  earlierifatrisk

•  HPV•  HZ

hbps://www.canada.ca/en/public-health/services/[email protected]

Adultpneumococcalvaccines

PREVNAR13

PNEUMO23

hbp://www.health.gov.on.ca/en/public/programs/immuniza@on/docs/pcv_hcp_qa_en.pdf

AdultVaccines:HPV,HZHPV(Cervarix,Gardasil,Gardasil9)

–  Women9to44+;Menuptoage26+–  NACI:NOUPPERAGELIMIT–  CONSIDERFORALLMEN/WOMEN!!–  Only2dosesrequiredunderage15

hbps://www.canada.ca/en/public-health/services/[email protected]

Zostavax Shingrex

Type live adjuvant

Dosing 1dose 2doses:0,2-6mos

PreventnHZages50-70

66-80% 93-97%

>70 32% 91%

PreventPHN

66% 88%

Cangivewithpneumo23

AvailableJan2018

Wait1yearpostHZ

History-Other

•  ReviewofSystems?NO– ButDOaddresspa@entconcerns???

•  Specialconsidera@ons**– Menover45:LUTS,ED– Womenover45:menopausescreen

•  MQ6:Menses,VMS,VVA,Bladder,Sleep,Mood

•  WhatNOTtoask/screenfor:– Depression– Cogni@veimpairment>65ifasymptoma@c

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PHYSICALEXAM PhysicalExam

•  HT•  WT•  BMI•  WC

Men Women

NorthAmerican 102cm(40”) 88cm(35”)

Europe,SubsaharanAfrica,Middleeast,Mediterranean

94cm 80cm

Asia,Japan,South/CentralAmerica

90cm 80cm

PhysicalExam

•  Vision

–  Snellen-elderly(B)•  Hearing?

–  whisperedvoicetest-elderly(B)

•  BloodPressure

BP:CHEPguidelines20162017guidelinespending,nochangestoassessment

•  Office:Electronicpreferredovermanual(C)–  manual:averagereadings2&3

•  Ifhighconfirmbyoutsidereadings:–  ABPMorHBPM–  HBPM:

•  am/pmreadingsx7,averagelast12readings

•  Ifofficehighandhomeislow:doABPM

Method DxofHTn

OfficeOBPM 140/90

AutomatedOfficeAOBP

135/85

HomeHBPM 135/85

AmbulatoryABPM Awake135/85or24hMean130/80

Diabe@cs 130/80

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2017CHEPguidelines

guidelines.hypertension.ca

Breastexam?NO

CanadianTaskForceonPreven@veHealthCare

Pelvicexam?NO(2016)

•  TheCTFPHCrecommendsnotperformingascreeningpelvicexamina@on(ie.asymptoma@cpa@ent)toscreenfor– non-cervicalcancer,– pelvicinflammatorydisease,or– othergynecologicalcondi@onsinasymptoma@cwomen.(strong/mod)


DigitalRectalExam?NO


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GENERALLAB&SCREENINGTESTSJinasymptoma@cpa@ents

CHOOSINGWISELY:•  NO:

–  Hb–  TSH–  PSA–  U/A–  EKG–  CXR–  XST

Timesavers

Pa@entPrep/Handouts

ChoosingWisely

AddresscommonissuesinadvancePromoteacollabora@vediscussion

Makeyourownpa*enthandout?•  Lifestyle

–  Smoke–  Etoh–  Exercise–  Diet–  Ca++,VitD–  Safetyinterven@ons

•  Immuniza@ons–  Tetq10–  AnnualFlushot–  Pneumoniavaccines–  HPV–  HZ

•  Commonteststhatwemayorder–  Bloodwork:DM,lipids

•  NOPSA–  EKG:no–  CXR:no–  BMD65orearlier–  Mammoq2y@50–  Papq3yr–  FOBTq2yr@50

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Resources

•  [email protected]/ctphc-guidelines

•  NACIhbp://www.phac-aspc.gc.ca/naci-ccni/•  ChoosingWiselyh^ps://choosingwiselycanada.org/

•  Others:CDA,CHEP,CCS

Primrose2015Preven@veScreeningGuidelines

Updateonage-appropriatepreven@vemeasuresandscreeningforCanadianprimarycareproviderswww.cfp.ca/content/62/2/131.full

CFPCPreven@veCareChecklistshbp://www.cfpc.ca/projectassets/templates/resource.aspx?

id=1184&langType=4105

STAMPS

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Summary

•  PHEisintendedasapa@ent-centeredpreven@onandscreeninginterven@oninHEALTHYindividuals

•  Frequencyandcontentshouldbeindividualized–  Don’toverlookyourpa@entswithchronicdx

•  Notallguidelinesarecreatedequal•  Thereiss@llan“art”tothescienceofmedicine

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PSAcounseling(2014)Harms&Benefits

•  Resultsofscreening1,000menwiththePSAtestage55–69years,screenedovera13-yearperiod,andwithaPSAscreeningthresholdof3.0ng/ml

•  720menwillhaveanega@vePSAtest.•  178menwithaposi@vePSAinwhomfollow-uptes@ngdoesnotiden@fy

prostatecancer.•  4ofthese178willexperiencebiopsycomplica@onssuchasinfec@onand

bleedingsevereenoughtorequirehospitaliza@on.•  102menwillbediagnosedwithprostatecancer.•  33ofthese102prostatecancerswouldnothavecausedillnessordeath.

Becauseofuncertaintyaboutwhethertheircancerwillprogress,mostmenwillchoosetreatmentandmayexperiencecomplica@onsoftreatment.

•  5menwilldiefromprostatecancerdespiteundergoingPSAscreening.•  1manwillescapedeathfromprostatecancerbecauseheunderwent

PSAscreening

hbps://canadiantaskforce.ca/guidelines/published-guidelines/prostate-cancer/

Figure5


17-11-09

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Pneumo23

HighriskgroupsforPneumonia•  Chroniccerebralspinalfluid(CSF)leak•  Chronicneurologiccondi@onthatmayimpairclearanceoforalsecre@ons•  Cochlearimplants(includingthosechildrenwhoaretoreceiveimplants)•  Chroniccardiacorpulmonarydisease•  Diabetesmellitus•  Asplenia(func@onaloranatomic)•  Sicklecelldiseaseorotherhemoglobinopathies•  Congenitalimmunodeficienciesinvolvinganypartoftheimmunesystem,includingB-lymphocyte

(humoral)immunity,T-lymphocyte(cell)mediatedimmunity,complementsystem(properdin,orfactorDdeficiencies),orphagocy@cfunc@ons

•  Hematopoie@cstemcelltransplant(recipient)•  HIVinfec@on•  Immunosuppressivetherapyincludinguseoflongtermcor@costeroids,chemotherapy,radia@on

therapy,post-organtransplanttherapy,andcertainan@-rheuma@cdrugs•  Chronickidneydisease,includingnephro@csyndrome•  Chronicliverdisease(includinghepa@ccirrhosisduetoanycause)•  Malignantneoplasmsincludingleukemiaandlymphoma•  Solidorganorislettransplant(candidateorrecipient)

Documents

DISCLOSURES THE ADULT PERIODIC HEALTH EXAM: Screening … · 17-11-09 1 THE ADULT PERIODIC HEALTH EXAM: Screening and Preven@on Dr. Susan R. Goldstein Assistant Professor Department