Chapter 004. Screening and Prevention of Disease (Kỳ 5) doc

Chapter 004. Screening and
Prevention of Disease
(Kỳ 5)

A number of techniques can assist the physician with the growing number
of recommended screening tests. An appropriately configured electronic health
record can provide reminder systems that make it easier for physicians to track and
meet guidelines. Some systems provide patients with secure access to their
medical records, providing an additional means to enhance adherence to routine
screening. Systems that provide nurses and other staff with standing orders are
effective for smoking prevention and immunizations. The Agency for Healthcare
Research and Quality and the Centers for Disease Control and Prevention have
developed flow sheets as part of their "Put Prevention into Practice" program
( Age-specific recommendations for
screening and counseling are summarized in Table 4-5.
Table 4-5 Age-Specific
Causes of Mortality and Corresponding
Preventative Options

Age
Group
Leading
Causes of Age-
Specific Mortality

Screening Prevention Interventions to
Consider for Each Specific Population
15–
24
1. Accident
2. Homicide

3. Suicide
4.
Malignancy
5. Heart
disease

Counseling on routine seat
belt use, bicycle/motorcycle/ATV helmets
(1)

Counseling on diet and
exercise (5)

Discuss dangers of alcohol
use while driving, swimming, boating (1)

Ask about vaccination status
(tetanus, diphtheria, hepatitis B, MMR,
rubella, varicella, meningitis, HPV)

Ask about gun use and/or
gun possession (2,3)

Assess for substance abuse
history including alcohol (2,3)

Screen for domestic violence
(2,3)


Screen for depression and/or
suicidal/homicidal ideation (2,3)
 Pap smear for
cervical cancer
screening, discuss STD prevention (4)

Recommend skin, breast, and
testicular self-exams (4)

Recommend UV light
avoidance and regular sun screen use (4)

Measurement of blood
pressure, height, weight and body mass
index (5)
 Discuss healt
h risks of
tobacco use, consider emphasis of cosmetic
and economic issues to improve quit rates
for younger smokers (4,5)
 Chlamydia
screening and
contraceptive counseling for sexually
active females

HIV, hepatitis B, and syphilis
testing if there is high-
risk sexual
behavior(s) or any prior history of sexually
transmitted disease

25–
44
1. Accident
2.
Malignancy
3. Heart
disease
4. Suicide
5. Homicide

As above plus consider the following:

Readdress smoking status,
encourage cessation at every visit (2,3)

Obtain detailed family
history of malignancies and begin early
screening/prevention program if patient is
at significant increased risk (2)

Assess all cardiac risk factors
6. HIV
(including screening for diabetes and
hyperlipidemia) and consider primary

prevention with aspirin for patients at >3%
5-year risk of a vascular event (3)

Assess for chronic alcohol
abuse, risk factors for viral hepatitis, or

other risks for development of chronic liver
disease

Begin breast cancer
screening with mammography at age 40 (2)

45–
64
1.
Malignancy
2. Heart
disease
3. Accident
4. Diabetes
mellitus

Consider prostate cancer
screen with annual PSA and digita
l rectal
exam at age 50 (or possibly earlier in
African Americans or patients with family
history) (1)

Begin colorectal cancer
screening at age 50 with either fecal occult
blood testing, flexible sigmoidoscopy, or
5.
Cerebrovascular
disease
6. Chronic

lower respiratory
disease
7. Chronic
liver disease and
cirrhosis
8. Suicide
colonoscopy (1)
 Reassess vaccination sta
tus
at age 50 and give special consideration to
vaccines against
Streptococcus
pneumoniae
, influenza, tetanus, and viral
hepatitis

Consider screening for
coronary disease in higher risk patients
(2,5)
65
1. Heart
disease
2.
Malignancy
3.
Cerebrovascular
disease
As above plus consider the following:

Readdress smoking status,

encourage cessation at every visit (1,2,3)
 One-
time ultrasound for
AAA in men 65–
75 who have ever smoked

Consider pulmonary function
testing for all long-
term smokers to assess
4. Chronic
lower respiratory
disease
5.
Alzheimer's
disease
6. Influenza
and pneumonia
7. Diabetes
mellitus
8. Kidney
disease
9. Accidents

10.
Septicemia
for development of chronic obstructive
pulmonary disease (3,7)

Vaccinate all smokers
against influenza and S. pneumoniae

at age
50 (6)

Screen all postmenopausal
women (and all men with risk factors) for
osteoporosis

Reassess vaccination status
at age 65, emphasis on influenza and
S.
pneumoniae (3,7)

Screen for dementia and
depression (5)
 Screen for visual
and hearing
problems, home safety issues, and elder
abuse (9)

Note:
The numbers in parentheses refer to areas of risk in the mortality
column affected by the specified intervention.
Abbreviations: MMR, measles-mumps-
rubella; HPV, human papilloma
virus; STD, sexually transmitted disease; UV, ultraviolet; PSA, prostate-
specific
antigen; AAA, abdominal aortic aneurysm.
A routine health care examination should be performed every 1–3 years
before age 50 and every year thereafter. History should include medication use
(prescription and nonprescription), allergies, dietary history, use of alcohol and

tobacco, sexual practices, and a thorough family history, if not obtained
previously. Routine measurements should include assessments of height, weight
(body mass index), and blood pressure, in addition to the relevant physical
examination. The increasing incidence of skin cancer underscores the importance
of screening for suspicious skin lesions. Hearing and vision should be tested after
age 65, or earlier if the patient describes difficulties. Other gender- and age-
specific examinations are listed in Table 4-3. Counseling and instruction about
self-examination (e.g., skin, breast) can be provided during the routine
examination.
Many patients see a physician for ongoing care of chronic illnesses, and
this visit provides an opportunity to include a "measure of prevention" for other
health problems. For example, the patient seen for management of hypertension or
diabetes can have breast cancer screening incorporated into one visit and a
discussion about colon cancer screening at the next visit. Other patients may
respond more favorably to a clearly defined visit that addresses all relevant
screening and prevention interventions. Because of age or comorbidities, it may be
appropriate in some patients to abandon certain screening and prevention
activities, although there are fewer data about when to "sunset" these services. The
risk of certain cancers, like cancer of the cervix, ultimately declines, and it is
reasonable to cease Pap smears after about age 65 if previous recent Pap smears
have been negative. For breast, colon, and prostate cancer, it is reasonable to
reevaluate the need for screening after about age 75. For some older patients with
advanced diseases such as severe chronic obstructive pulmonary disease or
congestive heart failure or who are immobile, the benefit of some screening
procedures is low, and other priorities emerge when life expectancy is <10 years.
This shift in focus needs to be done tactfully and allows greater focus on the
conditions likely to impact quality and length of life.
Acknowledgments
The author is grateful to Dan Evans, MD, for contributions to this topic in
Harrison's Manual of Medicine.

Further Readings
Barrett-Connor E et al: The ri
se and fall of menopausal hormone therapy.
Annu Rev Public Health 26:115, 2005 [PMID: 15760283]
Fenton JJ et al: Delivery of cancer screening: How important is the
preventive health examination? Arch Intern Med 167(6):580, 2007 [PMID:
17389289]
Greenla
nd P et al: Coronary artery calcium score combined with
Framingham score for risk prediction in asymptomatic individuals. JAMA
291:210, 2004 [PMID: 14722147]
Ransohoff DF, Sandler RS: Clinical practice: Screening for colorectal
cancer. N Engl J Med 346:40, 2002 [PMID: 11778002]
U.S. Preventive Services Task Force: Clinical preventive services for
normal-
risk adults. Put prevention into practice. Agency for Healthcare Research
and Quality, Rockville, MD, January 2003. Available at

Wright JC, Weinstein MC: Gains in life expectancy from medical
interventions—
standardizing data on outcomes. N Engl J Med 339:380, 1998
[PMID: 9691106]