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PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR

PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR. ANN HONEBRINK MD UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF OB GYN. WHAT MAKES A GOOD PREVENTIVE INTERVENTION?. DEALS WITH A COMMON PROBLEM ACCEPTABLE TO PATIENTS LOW FALSE POSITIVE AND FALSE NEGATIVE COST EFFECTIVE LOW RISK ”BACK UP TEST”

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PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR

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  1. PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR ANN HONEBRINK MD UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF OB GYN

  2. WHAT MAKES A GOOD PREVENTIVE INTERVENTION? • DEALS WITH A COMMON PROBLEM • ACCEPTABLE TO PATIENTS • LOW FALSE POSITIVE AND FALSE NEGATIVE • COST EFFECTIVE • LOW RISK ”BACK UP TEST” • INTERVENTION BASED ON TEST RESULTS HAS POSITIVE IMPACT ON OUTCOME

  3. ORGANIZE BY AGE • 13-18 • 19-39 • 40-64 • 65+

  4. ORGANIZE BY ASSESSMENT/INTERVENTION • SCREENING HISTORY/EXAM/LABS • EVALUATION AND COUNSELING • IMMUNIZATIONS • LEADING CAUSES OF MORBIDITY AND MORTALITY-TRY TO ADDRESS THESE WITH ABOVE TOOLS

  5. 13-18 • First, set the ground rules • History • Sex/Drugs/Etc!!! • Exam- • Height/Weight/BP • Secondary sexual characteristics • What about that first pelvic Labs • Pap- NO- start at 21 as long as patient immune competent • STD screen • HIV-opt out?

  6. 13-18 Evaluation and Counseling • Sexuality • Contraception-don’t forget Plan B • STD prevention • Orientation • Cardiovascular Risk Factors • Fitness and Nutrition • Psychosocial Eval • Safe at home? • Suicide/Depression • Health Risk Behaviors • Seat Belts • Gun exposure • Sun Screen • Tobacco/Alcohol/Drug abuse

  7. 13-18 • Immunizations TDP booster(once between 11-18 Hep B HPV(9-26yo) Menignococcal conjugate vaccine (before high school) Influenza Varicella/MMR (if not immune/no prior vaccination)

  8. 13-18 – LEADING CAUSES OF DEATH • Accidents • Cancer • Suicide • Homicide • Diseases of the heart • Congenital Anomalies/Chromosomal abnormalities • Chronic lower respiratory diseases • Cerebrovascular Diseases • Influenza and pneumonia • In situ and benign neoplasms, neoplasms of uncertain or unknown behavior • Pregnancy, childbirth, postpartum complications

  9. 19-39 • History • Exam • Labs • Pap- Age21-30- every 2 years, over 30q 3yrs +/- HPV if low risk • STD screen-when to stop? • HIV-opt out? • Think about Rubella Immunity testing if planning a pregnancy soon

  10. 19-39 Evaluation and Counseling • Sexuality, including pregnancy intentions • Fitness and Nutrition-remember folic acid and calcium • Preconceptual counseling (fam hx pt and partner, occupational exposures, etc) • Psychosocial Eval • Cardiovascular Risk Factors • Health Risk Behaviors

  11. 19-39 • Immunizations TDP booster Hep B HPV?? Flu Varicella if not immune

  12. 19-39 – LEADING CAUSES OF DEATH • Cancer • Accidents • Diseases of the heart • Suicide • HIV • Homicide • Cerebrovascular disease • Diabetes • Chronic Liver diseases/cirrhosis

  13. 40-64 • History • Start asking about incontinence and menopausal symptoms • Exam • Don’t forget to look in the mouth! • Labs-it gets a little more complicated! • Pap- what about lower risk women? • STD screen-when to stop? • HIV-opt out? • Mammogram • Lipids at 45 and q 5 yr • FBS at 45 and q 3 yr • TSH at 50 and then every 5 yrs • Colon Cancer at 50(colonoscopy seems best) • Dexa- when?

  14. 40-64 EVALUATION AND COUNSELLING • Sexuality- ask about postmenopausal atrophy symptoms, don’t forget contraception/std prevention • Fitness and Nutrition-remember folic acid and calcium • Psychosocial Eval • Sleep hygiene • Cardiovascular Risk Factors • Health Risk Behaviors-Menopausal symptoms????

  15. 40-64 • Immunizations TDP booster Flu Vaccine Zoster at 60 Varicella if no immunity

  16. 40-64 – LEADING CAUSES OF DEATH • Cancer • Diseases of the heart • Accidents • Chronic lower respiratory diseases(including COPD) • Cerebrovascular disease • Diabetes • Chronic Liver Disease and Cirrhosis • Septicemia • Suicide • HIV

  17. Over 65 • History • Keep asking about incontinence/atrophy • Exam • Don’t forget to look in the mouth! • When to stop pelvic exams? • Labs-it gets a little more complicated! • Pap- what about lower risk women? When to stop? • Mammogram yearly • Lipids- q 5 yr • FBS - q 3 yr • TSH-q 5 yr • Colon cancer screen- FOBT/Sigmoidoscopy/Colonoscopy • Urinalysis • Bone Density • HIV???

  18. Over 65 Evaluation and Counseling • Sexuality- ask about postmenopausal atrophy symptoms, reinforce “safer” sex • Fitness and Nutrition-remember calcium and Vitamin D • Psychosocial Eval- Sleep hygiene, Fall Prevention • Cardiovascular Risk Factors • Health Risk Behaviors-Menopausal symptoms????

  19. Over 65 • Immunizations TD booster every 10 yrs Flu Vaccine yearly Pneumococcal Vaccine- once Zoster if not already done Varicella if not immune

  20. Over 65 – LEADING CAUSES OF DEATH • Diseases of the heart • Cancer • Cerebrovascular disease • Chronic Lower respiratory diseases, including COPD • Alzheimer’s Disease • Pneumonia and Influenza • Diabetes • Renal disease • Accidents • Septicemia

  21. PAP SMEAR TRIAGE • Bethesda System- • adequate? • Reading • Normal • Ascus (+ or – HPV) • ASC-H • AGUS • LGSIL • HGSIL • Cancer

  22. Special Issues- Genetic Risk • BRCA1- 39-45% lifetime risk ovarian cancer • BRCA2 – 12-20% lifetime risk ovarian cancer • Both have 65-74% lifetime risk of developing Breast Cancer • 1in 300-800 Americans are carriers, 1/40 Ashekanazi Jews are carriers

  23. Who to screen?20-25%risk of having BRCA 1 Or 2 gene mutation: • Personal hx breast AND ovarian cancer • Personal hx ovarian cancer and close relative with ovarian cancer or premenopausal breast cancer • Ashkenazie Jewish descent with hx breast cancer dx before 40 OR ovarian cancer at any age • Women with dx Br cancer before 50 ewho have a close relative with ovarian cancer or a male relative with breast cancer • Close relative with known Br Ca mutation

  24. 5-10%risk • Breast cancer before age 40 • Ovarian, primary peritoneal or tubal cancer dx at any age • Bilateral breast cancer dx, especially if one dx pre 50 • Breast cancer dx at any age with 2 or more close relatives with Breast cancer dx at any age (especially if anyone <50 at dx) • Unaffected women with a close relative that meets any of the above criteria

  25. What can we do differently if screening positive? • Ca 125 and tvus annually starting at 35 or 5-10 years prior to youngest relative’s dx • Prophylactic BSO at 40 or when childbearing completed, this reduces risk by 85-90% • Semiannual CBE, annual MRI alternating with Mammogram starting at age 25 or sooner based on youngest age at dx in family hx • Tamoxifen chemoprevention • Bilateral prophylactic mastectomy (reduces risk by 90-95%)

  26. As with everything we teach you • This is all subject to change without notice • US Preventive Services Task Force- www.ahrq.gov/clinic/uspstfix/.htm • American College of Obstetricians and Gynecologists-www.acog.org • American Cancer Society-www.cancer.org

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