Family Medicine 02: 55-year-old male wellness visit User: Beatriz Duque Email: bettyd2382@stu.southuniversity.edu Date: September 24, 2020 2:10PM

Learning Objectives

The student should be able to:

Define the characteristics of a good screening test. Describe the recommendation for cancer screening for common cancers for an adult male patient (e.g., lung, colorectal, and prostate). Describe the significance of nutrition and obesity in health promotion and disease prevention. Propose an exercise program for a sedentary patient. Formulate timely vaccinations based on age, medical conditions, lifestyle, and environment. Perform smoking cessation counseling for patients who smoke. Describe principles that guide behavior change counseling. Soap Note Assignment Essay

Knowledge

RISE Mnemonic for Preventive Visits

Risk factors: Identify risk factors for serious medical conditions during history and physical exam. Immunizations: Provide recommended immunizations/chemoprophylaxis. Screening tests: Order appropriate screening tests. Education: Educate patients on ways to live healthier while reducing risks for disease.

Most Frequent Causes of Death for a 55-Year-Old Male in the U.S.

malignant neoplasm heart disease unintentional injury (accident) chronic lower respiratory disease diabetes mellitus chronic liver disease and cirrhosis CVA

Risk Factors for CVD and ASCVD

Most of a person’s risk for CVD and for stroke (together called atherosclerotic cardiovascular disease, or ASCVD) can be determined by a limited set of major risk factors. Major risk factors:

hypertension high cholesterol diabetes tobacco use

Other minor risk factors are only helpful if they adjust a patient’s risk category from that determined by the major risk factors. sedentary lifestyle stress premature family history excess alcohol use and many more (e.g. obesity, poor diet, high homocysteine levels, etc.)

American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend assessing major ASCVD risk factors every four to six years in adults age 20 to 79 who are free from ASCVD. For more required information about risk factors for ASCVD, read the Aquifer Cholesterol Guidelines Module. Although a complete review of systems should always be asked, symptoms related to cardiovascular disease should definitely be included: Soap Note Assignment Essay

Leg pain with activity may indicate claudication, a manifestation of peripheral atherosclerotic disease.

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Chest pain with activity may indicate angina pectoris, a manifestation of coronary artery atherosclerosis.

Effects of Alcohol

The effect of alcohol on health is complex. For some people, even mild alcohol use carries major risks. For others, moderate alcohol use may offer a degree of protection. At this time, there is no consensus about whether one form of alcohol is better or worse than another. Regardless of type of alcohol, drinkers should drink in moderation: up to one drink per day for women; up to two drinks per day for men. Effects of moderate alcohol intake: The best-known effect of moderate alcohol intake is a small increase in HDL cholesterol. However, regular physical activity is another effective way to raise HDL cholesterol, and niacin can be prescribed to raise it to a greater degree. Alcohol or some substances such as resveratrol found in alcoholic beverages may prevent platelets in the blood from sticking together. That may reduce clot formation and reduce the risk of heart attack or stroke. (Aspirin may help reduce blood clotting in a similar way.)

How alcohol or wine affects cardiovascular risk merits further research, but right now the American Heart Association does not recommend drinking wine or any other form of alcohol to gain these potential benefits. Effects of red wine: Over the past several decades, many studies have been published about how drinking alcohol may be associated with reduced mortality due to heart disease in some populations. Some researchers have suggested that the benefit may be due to wine, especially red wine.

Others are examining the potential benefits of components in red wine such as flavonoids and other antioxidants in reducing heart disease risk. The linkage reported in many of these studies may be due to other lifestyle factors rather than alcohol. Such factors may include increased physical activity, and a diet high in fruits and vegetables and lower in saturated fats. No direct comparison trials have been done to determine the specific effect of wine or other alcohol on the risk of developing heart disease or stroke.

Effects with certain chronic diseases: Patients with heart failure, cardiomyopathy, diabetes, hypertension, arrhythmia, obesity, hypertriglyceridemia, or who are taking medications may have adverse effects from alcohol ingestion. It is not always possible to identify those who will develop alcoholism, therefore screening all adult primary care patients to identify at-risk people and counseling is recommended as a preventive strategy.

The Alcohol Use Disorders Identification Test (AUDIT) is the most widely validated screening tool. It consists of 10 items and takes two to three minutes to complete, and longer to score. AUDIT-C is a brief version of the AUDIT comprising three questions scaled 0 to 12:

“How often do you have a drink containing alcohol?” “How many standard drinks containing alcohol do you have in a typical day?” “How often do you have six or more drinks on one occasion?”

A score of 4 in men and 3 in women is considered positive. An even briefer screening test, the Single-Item Alcohol Screening Questionnaire (SASQ), has been shown to be highly effective in primary care. “How many times in the past year have you had X drinks in a day (X = 4 for women, 5 for men). Any answer above zero is considered a positive screen. The American Heart Association cautions people to NOT start drinking if they do not already drink alcohol.

Adult Immunization Recommendations

Immunization resources:

CDC website and free immunizations app (called “Shots”) from The Society of Teachers of Family Medicine. Relevant immunization recommendations:

Influenza is recommended annually. Current recommendations recommend substituting a one-time dose of Tdap for Td booster (tetanus and diphtheria) for ages 11 to 64 to provide additional pertussis protection, then boost with Td every 10 years. Adults who smoke should receive a pneumococcal 23-valant polysaccharide vaccine (PPSV23). The CDC now recommends the recombinant zoster vaccine (Shingrix) be given to every adult at age 50. This is a two- vaccine series given two to six months apart. Adults over 60 who previously received the live zoster vaccine (Zostavax) should be re-vaccinated with the recombinant vaccine.

Immunocompromising conditions:

Live vaccines, like Zostavax (also MMR, OPV, and Varicella), should not be administered to immunocompromised patients, their close contacts, or to pregnant women.

Characteristics of a Good Screening Test

Medical screening should be considered for conditions that are important health problems that can be treated and have a latent phase of a disease enabling early detection and more timely treatment, impacting the outcome of the disease. The screening test should be acceptable to patients at reasonable cost. Since patients without symptoms are being screened, the overall prevalence of the condition in the population will be low. The goal is to identify cases at an early stage; thus, an effective screening test should have very good sensitivity (identify most or all potential cases) and high specificity (label incorrectly as few as possible as potential cases).

Remember that even a test with a specificity of 95% will lead to many false positives when the prevalence of the condition is very low. Soap Note Assignment Essay

USPSTF Grading System

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The USPSTF grades each recommendation according to one of five classifications:

A: The USPSTF recommends this service. There is high certainty that the service improves health outcomes; net benefit is substantial. B: The USPSTF recommends this service. There is high certainty that the service improves health outcomes; net benefit is fair or fair certainty that the net benefit is moderate – substantial. C: The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences.

There is at least moderate certainty that the net benefit is small. D: The USPSTF recommends against providing this service. There is moderate or high certainty that the service does not have any net benefits, or harms outweigh benefits. I: There is insufficient evidence to recommend for or against the service. Soap Note Assignment Essay

United States Preventive Services Task Force Screening Recommendations for a 55-Year-Old Asymptomatic Man Who Smokes

A Recommendations (Recommended)

Colorectal cancer Adults ages 50 to 75 years

High blood pressure

Tobacco smoking cessation

HIV Adolescents and adults

Syphilis Adults at increased risk for syphilisinfection

B Recommendations (Recommended)

Alcohol misuse Screening and behavioral counseling interventions in primary care

Depression

Diabetes mellitus (Type 2) and abnormal blood glucose Adults age 40 to 70 who are overweight or obese

Obesity

Hepatitis B Adults at high risk

Hepatitis C Adults at high risk and adults born between 1945 and 1965

Latent tuberculosis infection Asymptomatic adults at increased risk for infection

Lung cancer Age 55 to 80 who have a 30-pack-year smoking history and currently smoke orhave quit within the past 15 years

C Recommendations (Selectively Recommended)

Prostate cancer Screening – men age 55 to 69 years

D Recommendations (Not Recommended)

Asymptomatic bacteriuria

Carotid artery stenosis

Chronic obstructive pulmonary disease

Coronary heart disease By ECG for adults at low risk

Pancreatic cancer

Genital herpes infection

Testicular cancer

Thyroid cancer

I recommendations (Uncertain)

There are numerous I recommendations for screening males in this age group, including skin cancer, glaucoma, osteoporosis, and vitamin D.

Prostate Cancer Screening Recommendations

The U.S. Preventive Services Task Force (USPSTF) changed its recommendation for prostate-specific antigen (PSA) testing from a D (recommending against it) to a C (selective recommendation) for men ages 55 to 69. They found that there is a slight reduction in death from prostate cancer among men who have PSA testing.

The number needed to screen is 781 men to prevent one death from prostate cancer. There are also significant rates of complications from both PSA screening and treatment for prostate cancer as well as evidence of significant rates of overdiagnosis. Thus they concluded that the decision to screen should be an individualized one between a doctor and an individual patient.

Other organizations, such as the American Cancer Society (ACS) and the American Urology Association (AUA) recommended that men ages 55 to 69 thinking about having prostate cancer screening should make informed decisions based on available information, discussion with their doctor, and their own views on the benefits and side effects of prostate cancer screening and treatment.

PSA screening: Benefits and harms

The potential benefit of prostate-specific antigen (PSA) screening is that it may lead to prolonged life from early detection and treatment of prostate cancer. In addition to the potential benefit of early detection of malignant prostate cancer, some men may receive psychological reassurance that they probably do not have prostate cancer or they have probably caught it early so it can be treated.

A potential harm of PSA screening is serious complication (such as erectile dysfunction, urinary incontinence, bowel dysfunction) or even death from treatment of a prostate cancer that would not have caused symptoms if left undetected during his lifetime. Another potential harm is pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results. Soap Note Assignment Essay

Colon Cancer Screening Options

The USPSTF recommends screening for colorectal cancer beginning at age 50 years and continuing until age 75 years using: fecal occult blood testing sigmoidoscopy colonoscopy Fecal Immunochemical Testing (FIT Test) Fecal DNA Testing CT Colography

Indications for Exercise Stress Testing

Asymptomatic male patients over 45 years of age with one or more risk factors (hypercholesterolemia, hypertension, smoking, or family history of premature coronary artery disease) may obtain useful prognostic information from exercise testing.

Estimating ASCVD Risk

Pooled Cohort Equations risk calculator for estimating 10-year ASCVD risk.

Diet Recommendations to Lower Heart Disease Risk

The American Heart Association recommends eating fish twice a week. Eating more fatty fish like mackerel, lake trout, sardines, albacore tuna, and salmon, which are high in omega-3 fatty acids, can lower heart disease risk. Eating the oils contained in tofu or other forms of soybeans, canola, walnuts, and flaxseeds may also help lower heart disease risk. Unfortunately, studies are showing that vitamins C, E, and folic acid do not reduce heart attacks or strokes. Soap Note Assignment Essay

Clinical Skills

Lifestyle Change Counseling

Three Cs of Addiction:

1. Compulsion to use 2. Lack of Control 3. Continued use despite adverse Consequences

The Five A’s of Counseling for Behavior Change:

Ask or Address the behavior needing change. Assess for interest in behavior change. Advise on methods to change behavior. Assist with motivation to change behavior. Arrange for follow-up

Stages of Behavior Change:

Pre-contemplative: Not aware of need to change or not interested in changing behavior. Contemplative: Currently interested in changing behavior. Active: Currently making a behavior change. Relapse: Attempted behavior change but no longer making the change.

Nutrition History

Gathering a Complete Nutrition History

Dietary choices can affect a patient’s risk for coronary heart disease, diabetes, some cancers, and stroke. Thus, nutrition assessment is a critical aspect of the preventive routine exam. There are many ways to gather a nutrition history. A brief history should include the number of meals and snacks eaten in a 24- hour period; dining-out habits; as well as frequency of consumption of fruits, vegetables, meats, poultry, fish, dairy products, and desserts. Nutrients missing in the diet are equally important as those eaten in excess. When this initial history indicates a poor diet or there are medical indications for a more complete diet history, use of one or more of the following methods is indicated. 24-hour Dietary Recalls: Ask about each meal separately.

Be sure to include snacks and beverages as well as portion sizes. WAVE is a pocket card tool designed to encourage dialogue about the patient’s “Weight, Activity, Variety and Excess.” Based on the foods reported, the provider can determine whether the patient appears to be eating appropriate numbers of servings from the Food Guide Pyramid (Variety) and whether he or she is eating too much fat, salt, sugar, and calories (Excess) recommended in the Dietary Guidelines for Americans. The card also lists counseling tips to aid the practitioner in setting dietary goals with the patient. Food Frequency Questionnaire: Soap Note Assignment Essay

Usually covers food intake over the period of a month. Often used in combination with the 24-hour recall, it is the quickest way to determine nutritional deficiencies and excesses. Rapid Eating and Activity assessment for Patients (REAP) is a brief validated questionnaire that assesses diet related to the Food Guide Pyramid and the 2000 U.S. Dietary Guidelines. REAP includes questions to assess intake of whole grains; calcium-rich foods; fruits and vegetables; fat; saturated fat and cholesterol; sugary beverages and foods; sodium; alcoholic beverages; and physical activity.

REAP also includes questions regarding whether the patient shops and prepares his/her own food; ever has trouble being able to shop or cook; follows a special diet; eats or limits certain foods for health or other reasons; and how willing the patient is to make changes to eat healthier. Patients can either fill out the instrument in the waiting room or have it sent home to complete before their appointment. The REAP Physician Key includes sections on patients at risk, further evaluation and treatment as well as counseling points/further information for each major dietary area. Daily Dietary Intake Records (or Food Diaries): Soap Note Assignment Essay

Ask the patient to bring in a complete record of everything consumed over a three- to four-day period. Have the patient include Saturday and Sunday, since many people eat differently on the weekend. Usual Diet History:

Ask the patient to describe a typical day’s diet. In addition, ask how often and under what circumstances the patient varies from this typical intake. This method is often combined with a 24-hour dietary recall. Referral to a nutritionist or dietician may also be indicated, especially if covered by medical insurance. Patients may complete a sample nutrition history form in the waiting room prior to the visit.

Screening for Intimate Partner Violence

It is important to review safety at home because intimate partner violence occurs in all groups and across the lifespan.

Taking a Family History

1. Review the documented family history with the patient. 2. Make sure to ask specifically about immediate family members. 3. Check for new diagnoses. Soap Note Assignment Essay

Calculating the BMI and Understanding Its Importance

BMI = weight in kg / height in m 2

Category BMI (kg/m2)

Underweight below 18.5

Normal 18.5 – 24.9

Overweight 25.0 – 29.9

Obese 30.0 andabove

Some subcategorize obesity into obese 30 to 35; very obese 35 to 40; and extremely or morbidly obese 40+. Incidence:

The population of overweight and obese patients has increased steadily over the past 20 years. In the United States, the lifetime risk of becoming obese is 25%. Use:

BMI is used clinically because actual measurement of percent body fat is difficult. Importance:

BMI is important because high total body fat is a risk factor for Type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease. Other measurements:

Body fat distribution may provide additional risk stratification for coronary artery disease beyond BMI. Waist circumference and waist-hip ratio, as indicators of abdominal adiposity, are independent risk factors for coronary artery disease. Consider measuring these in overweight patients to further determine risk and need for weight loss. BMI Calculator:

http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

Signs of Dyslipidemia and Atherosclerosis

Changes associated with dyslipidemia:

Corneal arcus, xanthelasmas, acanthosis nigricans Changes associated with atherosclerosis:

Decreased peripheral pulses, carotid bruit

The ABCDE of Suspicious Skin Lesions

Asymmetry Border irregularity Color non-uniform Diameter > 6 mm Evolution or change over time

The USPSTF states that there is insufficient evidence to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in asymptomatic adults, but it is still commonly done at office visits as it is an easy and low-risk exam.

Management

Smoking Interventions

Most smokers quit multiple times before being truly successful. It is helpful to view tobacco abuse as a chronic disease and continue to work with smokers who relapse. The annual quit rate for smokers without any medical interventions is about 2% to 3% per year. Interventions that improve quit rates:

1. Quit rates are highest when patients are engaged in a group setting. 2. Oral medications are somewhat effective at helping people stop smoking, with quit rates at 12 months 1.5 to 3 times the

placebo quit rate. 3. When combined with medication, a series of one-on-one counseling sessions (as in a physician’s office) enhances quit rates. 4. Providing practical problem-solving skills, assistance with social supports, and use of relaxation/breathing techniques can

increase quit rates. 5. Financial or material incentives such as those provided in the workplaces, clinics and hospitals appear to increase cessation

rates while in place. Choosing medication to assist with smoking cessation:

Many physicians prefer prescribing bupropion to help smokers quit. Due to side effects, varenicline is often reserved for those that have failed bupropion or if a patient specifically requests it.

Smoking Cessation Strategies

When a patient is ready to quit smoking:

1. Set a quit date

2. Give instructions for taking bupropion

Start one week before the quit date with one pill a day for the first three days, then increase to one pill twice a day, morning and evening. After another four days, stop smoking and continue on the pills twice a day. Add nicotine gum for bad cravings, if needed. After about two months on the pills, gradually stop. Soap Note Assignment Essay

3. Provide other smoking cessation resources

1-800-QUIT NOW www.smokefree.gov

Note: According to studies, it is easier to quit smoking if you do so with a partner!

Lifestyle Recommendations to Lower Hypertension and ASCVD Risk

For more required information about lifestyle recommendations to lower hypertension and ASCVD risk, read the Aquifer Hypertension Module and the Aquifer Cholesterol Guidelines Module.

Weight Loss Counseling

1. Target a realistic weight goal. 2. Reduce calories consumed and increase calories burned. 3. Eliminate soft drinks; drink water instead. 4. Eat five servings of fruits and vegetables. 5. Meet with a dietitian.

Managing “Door Handle” Issues

Patients often bring up a question or issue at the end of a visit that can take more than a minute to discuss. There are conflicting priorities: service to this patient versus keeping on schedule as much as possible for the remaining patients on the schedule. Sometimes the “door handle” issue is more important than the original reason for visit. A quick assessment of whether the issue is life-threatening or requires an early return visit should be made. Usually the patient will understand if the issue is not completely dealt with at that visit but can be discussed at a future visit. It is not always possible to avoid this situation, but allowing the patient to state an agenda at the start of the interview has been shown to correlate with fewer late concerns. Studies of clinicians show that the average patient is allowed to talk uninterrupted by the physician for only 18 to 23 seconds.

Exercise Prescriptions

Generally, exercise prescriptions include the following specific recommendations: Type of exercise or activity: Patient preference should guide the choice of type of exercise. Swimming or water jogging is beneficial for those with musculoskeletal problems, such as arthritis. Varying the activity can increase compliance by providing variety. Precautions: Issues such as orthopedic concerns should be regarded. Specific workloads: E.g. watts, walking speed, etc. Soap Note Assignment Essay