Rethinking the Checkup Goals of the Checkup Promote

Rethinking the Check-up

Goals of the Check-up Promote health Identify risk factors Detect disease

Where do we get our information?

USPSTF Grades

Lucia 17 years old High school senior

First priority: complete history

Physical exam: which elements are needed?

Does Lucia need a pelvic exam? Does she need a Pap smear?

Does Lucia need STI tests?

What about primary prevention? Birth control Emergency contraception Immunizations

HPV immunization Gardasil Cervarix

Summary: what Lucia needs Complete history Depression screening Body mass index Urine gonorrhea/chlamydia HIV test RPR Immunizations Contraception counselling Folic acid supplement

Elizabeth 36 -year-old bartender Smokes ½ pack per day “Check me for everything!”

Does Elizabeth need a Pap smear?

How often do women need a Pap smear? ACOG: • Every 2 years (age 21 -29) • Every 3 years (age 30+) ACS: • Every 2 years if liquid-based test (under age 30) • Every 2 -3 years after 3 normal results in a row OR every 3 years with HPV typing (age 30+) USPSTF: • At least every 3 years

Bimanual exam

Breast self-exam?

Smoking cessation

What about “routine blood tests? ”

Sam 53 -year-old “I need this form filled out for work”

Sam’s complete history reveals…

“Oh, and I need this form filled out. ”

Colon Cancer Screening • Fecal occult blood testing • Flexible sigmoidoscopy • Colonoscopy

Prostate Cancer Screening?

Lipid Screening and CHD prevention

ASPIRIN: 10 -year CHD risk levels at which benefit of treatment outweighs risk CHD = coronary heart disease.

Summary for Sam Complete history Body mass index Blood pressure HDL and total cholesterol Colon cancer screening

Davida 52 years old Healthy Non-smoker One male sexual partner

Mammography USPSTF: Every 2 years age 50 -74 “B” recommendation ACOG: Every 2 years age 40 -49 Every year age 50+ ACS: Every year age 40+

“A” Recommendations

“B” Recommendations

What about Screening for Diabetes?

“C” Recommendations Depression – when staff supports NOT in place HIV – for those NOT at increased risk Lipids – for women without CHD risk factors Osteoporosis – for women < age 60 or women age 60 - 64 NOT at increased risk

“D” Recommendations Aspirin for women < age 55 (& for men < age 45) Carotid Artery Stenosis screening Cervical Cancer screening in women who have had a hysterectomy Genital Herpes (without symptoms) Hepatitis B and C (without symptoms) Gonorrhea (low risk) EKG, stress test (low risk) Ovarian Cancer

Blair New to your practice 77 -year-old grandmother Here for “my yearly Pap”

When should we stop cervical cancer screening? ACS Age 70 in women who have had 3 normal pap smears in the past 10 years USPSTF Age 65 – “if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer” ACOG Age 65 -70 in women who have had 3 normal pap smears in the past 10 years

Osteoporosis Screening

Breast Cancer Screening

“D” Recommendations DO NOT SCREEN FOR: • • Scoliosis Herpes simplex virus Hep B, Hep C, Gonorrhea, Syphilis with low risk AAA in women, or in men who haven’t smoked Ovarian Cancer Cervical Cancer after Benign Hysterectomy Asymptomatic bacteriuria or bladder cancer CHD with low risk (<5 -10% 10 -year risk) and…

“D” Recommendations, cont. • • Carotid artery stenosis Beta-carotene supplementation Testicular cancer Prostate cancer age > 75 Bladder cancer COPD Colorectal cancer age > 85 Lead in asymptomatic pregnant women