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 (http://www.ahcpr.gov/clinic/ppipix.htm). 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 http://www.ahrq.gov/clinic/ppipix.htm Wright JC, Weinstein MC: Gains in life expectancy from medical interventions— standardizing data on outcomes. N Engl J Med 339:380, 1998 [PMID: 9691106] . 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. 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. 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,