For pts with DM, what things need to be screened every year?

Every visit?

Every 6 months?

Q year - microalbuminuria, BUN/creatinine, eye screen by ophthamologist, cholesterol level

Q visit - foot exam, BP

Q 6 months - check for neuropathy

According to the USPSTF, when should women begin getting the following, and how often?

1) Mammogram

2) Pap Smear

3) Lipid panel

4) Colonoscopy

Qid 4231

1) Mammogram - Q 2 yrs in women 50-74

2) Pap smear - starting at 21 (regardless of sexual activity) Q 2 yrs, after age 30 its Q 3 yrs (if 3 negative Pap smears); women beyond 65 who have 3 consecutive Pap smears no longer require screening

3) Lipid panel - for healthy individuals, start at 35 for men and 45 for women, Q 5 yrs (no more than that). For individuals DM, FHx of CAD, HL, or numerous RFs for CAD start at 20.

4) Colonoscopy - start at 50, Q 10 yrs

  -If first degree relative has Hx of colon cancer -> start 10 yrs earlier

According to USPSTF, what patient population should you routinely screen for AAA?

How do you screen for AAA?

What 3 vaccines are recommended for all HIV-infected pts?

What vaccine should be given to men who have sex with men?

What vaccines are under the same guidlines as all other adults?

HIV pts - influenza, Hep B, and S. pneumoniae

MSM - Hep A

Vaccines that fall under the same guidelines for both nml and HIV-infected adults include:

  -Meningococcal

  -HPV

  -H. flu type B

  -tetanus + diphtheria (Td) booster Q 10 yrs

When is it recommended for adults to receive:

1) Td vaccine

2) Intramuscular or Intranasal influenza vaccine

3) Pneumococcal polysaccharide vaccine

1) Td should be given Q 10 yrs after age 18, and a one time TdAP booster is rec'd for adults of all ages in place of Td (due to waning immunity against pertussis)

2) Intramuscular influenza vaccine for pts >50 y/o, pregnant women, and pts with comorbidities. Intranasal (live-attenuated) given to non-pregnant, healthy pts under 50

3) Pneumoccocal for adults 65 yrs +, unless pt has chronic disease, including CV, pulm, hepatic, renal, metabolic (DM), or pts who are immunosuppressed -> then you give it to them regardless of age

What are the current recommendations for screening for DM (what age do you start, and how often do you test)?

What is the screening test of choice?

Criteria for Dx? (see SU pg 181)

Screen all adults over age 45 Q 3 yrs

  -For those with risk factors (obesity, FHx, Hx of gDM) start screening earlier

Screening test of choice is fasting plasma glucose. Criteria for Dx:

  -Greater than 126 on 2 occasions

For pts with DM, what things need to be screened every year?

Every visit?

Every 6 months?

Q year - microalbuminuria, BUN/creatinine, eye screen by ophthamologist, cholesterol level

Q visit - foot exam, BP

Q 6 months - check for neuropathy

Risk category                LDL Goal        LDL where Life-      LDL where

                                    Style Mod begins  Drug Tx begins

CHD or CHD                   <100               >/= 100                >/=130

equivlanet

2+ RFs                           <130               >/= 130                >/=160

0-1 RF                            <160               >/=160                 >/=190

-CHD equivalents include: DM, CAD Sx (angina), AAA, PVD, 10 yr rks of CHD of 20% or greater.

-RFs: HTN, smoking, HDL <40, Male >45, Female >55, FHx of premature MI (male <55, female <65)

-Some authorities rec'd more aggressive approach (target LDL of 70 or less)

A 46 y/o male comes in w/ Hx of AAA. He has HTN and DM. LDL is 160, HDL 65. How many RFs for CAD, and CAD equivalents does this pt have?

NSIM?

SU pg 3

RFs - 1 (age & HTN, but subtract 1 for HDL >60)

CAD equivalents - 2 (AAA and DM)

Based on his LDL of 160, we should recommend lifestyle modification and persrcibe a statin

A 54 y/o female w/ Hx of DMII, LE claudication, stroke, and HTN presents for annual visit. She has and LDL of 130, and HDL of 70. How many CAD RFs and CAD equivalents does she have?

NSIM?

SU pg 3

RFs - 0 (HTN minus HDL [since its >60])

CAD equivalents - 2 (DMII and PVD [LE claudication and stroke])

NSIM: With an LDL of 130 and presence of CAD equivalents, this needs lifestyle modifications and a statin

When do you start screening pts for HL?

How often do you screen them?

-Begin at age 20 for individuals with DM, FHx of CAD, HL, numerous RFs for CAD

-For healthy men >/= 35, for healthy women >/= 45

-Repeat every 5 years

What are the current vaccination recommendations for all pts with chronic Hep C?

What is the Tx for Hep C?

All pts with chronic hep C should receive vaccinations to Hep A and B if not already immune. Both vaccinations are safe in pregnancy

Tx for Hep C is combination IFN-alpha and ribavirin, but BOTH of these are contraindicated in pregnancy

Pap smear w/ or w/o colposcopy and endocervical curettage Q 6 months until 3 negative samples are obtained

  -After pt received 3 negative samples, pt may have annual Pap smears until 65-70

  -If pt has 3 consecutive negative Pap smears, she may increase interval of screening to Q 2-3 yrs

According to the USPSTF, what population should be evaluated for osteoporosis?

What test is used to evaluate these pts?

All women > 65 y/o

Women >60 y/o if they have RFs for osteoporosis (poor calcium/VitD intake, cigarette smoking, corticosteroid use, lack of weight bearing exercise, EtOH ingestion, low body mass)

DEXA scan makes the Dx

  -T-score of less than -2.5 (-1.5 to -2.5 is osteopenia)

It is very controversial!!!

-USPSTF does not recommend screening as it doesn't save lives and places pt at unnecessary risk for pain, impotence, and incontinence

-American Cancer Society and American Urological Association do recommend screening in conjunction with DRE in men btwn 40-75 w/ a life expectancy of at least 10 years

Regardless UW says if you're given the option of PSA vs other invasive means of evaluating for prostate cancer (transrectal U/S, biopsy, etc., always chose PSA testing.

What 2 live vaccines can be given to HIV positive patients?

What requirements must these pts meet to be given these vaccines?

MMR and varicella vaccines

Only if CD4 count >200, and if they have no signs of opportunistic infections

Note: live vaccines they can't have are: BCG, antrax, oral typhoid, intranasal influenza, oral polio

What are the recommended screening tests for sexually active women under 25?

GC/CT and HIV

  -CDC recommends screening all women under 25 for chlamydia

  -USPSTF recommends screening for gonorrhea in high risk women and those under 25

  -ACP and CDC recommend HIV screening for pts in all health care settings

When should screening for DM begin?

What can be used to screen for DM?

Adults > 45 y/o

  -If multiple RFs (obese, FHx, Hx of gDM, HTN), start screening earlier

Screen by:

  -HbA1C > 6.5%

  -Fasting glucose > 125 mg/DL

       -If 100 < pt < 125, then do 75g glucose tolerance test

  -Glucose tolerance test > 200 mg/dL