Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Periodic Health Assessment

Periodic Health Assessment/Screening - Key Features

1. Do a periodic health assessment in a proactive or opportunistic manner (i.e., address health maintenance even when patients present with unrelated concerns).

2. In any given patient, selectively adapt the periodic health examination to that patient’s specific circumstances (i.e., adhere to inclusion and exclusion criteria of each manoeuvre/intervention, such as the criteria for mammography and prostate-specific antigen [PSA] testing).

	General Population [by grade of evidence]	Specific Population
Discussion	Dental hygiene (fluoridation, brushing, flossing) [A] Noise control and hearing protection Smokers: counsel on cessation, provide: NRT, referral to smoking cessation program, dietary advice on leafy green veggie and fruits [A] Seat belt use [B] Injury prevention, smoke detectors, bike helmets [B] Moderate Physical Activity [B] Sun exposure, protection [B] Problem drinking [B] STI prevention counseling [B] Dietary advise on fat and Cholesterol [B]	Peds: developmental milestones [B] home visit for high risk family [A] Adolescents: counsel on sex and contraception [B], counsel to prevent smoking initiaton Perimenopausal women: osteoporosis & risks/benefits of HRT [B] Adults >65: cognitive impairment, Multi-disciplinary post-fall assessment [A]
PE	Clinical breast exam (women 50-69) [B]: no longer recommended 2011 BP measurement [B] BMI measurement in obese [B]	Peds: repeat hips, eyes, hearing (esp in first year) [A] Serial heights, weight, and HC [B] Visual acuity after age 2 [B] Adults>65: Visual acuity [B] Hearing testing (otoscope, whisper test, inquire) [B] 1st Degree Relative with Melanoma: full body skin exam
Tests	Colon cancer screening Stool Occult blood (FIT preferred) q1-2 yrs (50-74 yrs, no known risk factor): sensitivity 5% Flexible sigmoidoscopy: > 50 yr, average risk, or combined with FOBT Air contrast barium: no role Colonoscope: 50-74yr high risk factor q 5-10 yrs [B] -strong fx:one 1st degree relative	Not to screen > 74 yrs old unless specific indications
Tests	Women: mammography (50-74)q 2-3 yrs [A] Pap smear: all girls > 9 yr should have HPV vaccines. 20 – 69 yrs, annually 3, every 2 yrs if normal x 3 yrs. Blood Chol for men >40 or post-menopausal women Serum Glucose q 3yrs or more frequent if risk-factors Bone mineral density: screen if 1 major or 2 minor risk factors PSA screening not established. But if fx of P ca or African descent, start ageg 40 yr	Peds: hgb for high risk infants [B] Blood lead screening for high risk infants [B] Diabetics: fundsocopy [B] Urine micro alb (annual) Hgb AIC (q 3 month) TB high risk: mantouz skin test [A] STI high risk: voluntary HIV screen [A] Gonorrhea screen [A] Chlamydia screen [B] FAP: sigmoidoscopy and genetic testing [B] HNPCC: colonoscopy [B]
Therapy	Folic acid supplementation for women of child bearing age [A] Varicella vax for children 1-12 [A] Rubella vax for all non-pregos of child-bearing age [B] Tetanus vaccine q 10 yrs Pertussis booster once during adulthood. Can be given as dTap.	Peds: routine immunz [A] Hep B immuniz [A] Influenza high-risk or >65: immuniz [A] now for all 2011 Pneumonia high-risk or >65: pneumoncoccal vax [A] TB high-risk: INH prophylaxis for household contacts/skin test converters [B] INH prophylaxis for high-risk sub-groups

3. In a patient requesting a test (e.g., PSA testing, mammography) that may or may not be recommended:
a) Inform the patient about limitations of the screening test (i.e., sensitivity and specificity).
b) Counsel the patient about the implications of proceeding with the test.

PSA – sensitivity is ~80% & Specificity is ~70% at cut off of 4.0 (SN increased with higher cut off, serial testing and in conjunction with DRE)

Mammography – sensitivity 75-90% and specificity 90-95% over age of 50. Very high false positive rate in women under age 50. The NNS to prevent one death from breast cancer for women aged 40–49 years is 2108, as compared with 721 for women aged 50–69 years. In addition, the risk of a false-positive result from mammography is higher for women younger than 50 years. Thus, screening about 2100 women aged 40–49 years once every 2–3 years for about 11 years would prevent a single death from breast cancer, but it would also result in about 690 women having a false-positive result on a mammogram, leading to unnecessary follow-up testing, and 75 women having an unnecessary biopsy of their breast

Pap smear: False negative 10-40% for single test, false positive 5-10 %.

Stool occult blood: Sensitivity of FOBT has been shown to range from 12% (any neoplasia) to 36% (high grade neoplasia). The positive predictive value (probability that a person with a positive test has neoplasia) was 54% for any neoplasia, and 40% for advanced neoplasia; the negative predictive value (probability that a person with a negative test does not have neoplasia) was 64% and 88% respectively.

HPV: prevent up to 70% of cervical cancer

4. Keep up to date with new recommendations for the periodic health examination, and critically evaluate their usefulness and application to your practice.

See Periodic Assessment form from CFPC website below. Dec 2010 updated

Study Guide

Periodic Health Assessment/Screening

Resources

CFPC Preventative Check list forms for office use: www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=1184&langType=4105
Toronto notes, 20011 edition
Canadian Task Force on Preventative Health Care 2011 www.canadiantaskforce.ca/
CMA guidelines www.cma.ca/cpgs/
CFPC guidelines www.cfpc.ca/ClinicalPracticeGuidelines/