Transcript PREVENTIVE CARE-MORE THAN JUST A PAP SMEAR

PREVENTIVE CAREMORE THAN JUST A PAP
SMEAR
2009
ANN HONEBRINK MD
UNIVERSITY OF PENNSYLVANIA
DEPARTMENT OF OB GYN
WHAT MAKES A GOOD
PREVENTIVE INTERVENTION?
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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
ORGANIZE BY AGE
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13-18
19-39
40-64
65+
ORGANIZE BY
ASSESSMENT/INTERVENTION
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SCREENING HISTORY/EXAM/LABS
EVALUATION AND COUNSELING
IMMUNIZATIONS
LEADING CAUSES OF MORBIDITY AND
MORTALITY-TRY TO ADDRESS THESE
WITH ABOVE TOOLS
13-18
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First, set the ground rules
History
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Sex/Drugs/Etc!!!
Exam
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Labs
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Height/Weight/BP
Secondary sexual characteristics
What about that first pelvic
Pap- Begin annually 3 years after first sexual contact
STD screen
HIV-opt out?
13-18
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Sexuality
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Contraception-don’t forget Plan B
STD prevention
Orientation
Cardiovascular Risk Factors
Fitness and Nutrition
Psychosocial Eval
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Evaluation and Counseling
Safe at home?
Suicide/Depression
Health Risk Behaviors
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Seat Belts
Gun exposure
Sun Screen
Tobacco/Alcohol/Drug abuse
13-18
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Immunizations
TDP booster
Hep B
HPV
Menignococcal conjugate vaccine
Influenza
13-18 – LEADING CAUSES OF
DEATH
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Accidents
Cancer
Homicide
Suicide
Congenital Anomalies
Diseases of the heart
Chronic lower respiratory diseases
Influenza and pneumonia
Septicemia
Pregnancy, childbirth, postpartum complications
19-39
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History
Exam
Labs
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Pap- what about lower risk women?
STD screen-when to stop?
HIV-opt out?
19-39
Evaluation and Counseling
 Sexuality
 Fitness and Nutrition-remember folic acid
and calcium
 Psychosocial Eval
 Cardiovascular Risk Factors
 Health Risk Behaviors
19-39
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Immunizations
TDP booster
Hep B
HPV??
19-39 – LEADING CAUSES OF
DEATH
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Cancer
Accidents
Diseases of the heart
Suicide
HIV
Homicide
Cerebrovascular disease
Diabetes
40-64
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History
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Exam
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Start asking about incontinence
Don’t forget to look in the mouth!
Labs-it gets a little more complicated!
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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
Colon Cancer at 50
Dexa- when?
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????
40-64
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Immunizations
TDP booster
Flu Vaccine at 50
40-64 – LEADING CAUSES OF
DEATH
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Cancer
Diseases of the heart
Cerebrovascular disease
COPD
Accidents
Diabetes
Chronic Liver Disease
Septicemia
Suicide
HIV
Over 65
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History
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Exam
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Keep asking about incontinence/atrophy
Don’t forget to look in the mouth!
Labs-it gets a little more complicated!
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Pap- what about lower risk women?
Mammogram yearly
Lipids- q 5 yr
FBS at 45 and q 3 yr
Colon cancer screen- FOBT/Sigmoidoscopy/Colonoscopy
Urinalysis
Bone Density???
When to stop????
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????
Over 65
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Immunizations
TDP booster
Flu Vaccine
Pneumococcal Vaccine
Over 65 – LEADING CAUSES OF
DEATH
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Diseases of the heart
Cancer
Cerebrovascular disease
COPD
Alzheimer’s Disease
Pneumonia and Influenza
Diabetes
Renal disease
Accidents
Special Issues- Cancer
Screening/Prophylaxis
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Ovarian cancer screening issues
BRCA1- 45% lifetime risk ovarian cancer
BRCA2 – 25% lifetime risk ovarian cancer
Lynch Type II- consider prophylactic
oophorectomy
Special Issues- Cancer
Screening/Prophylaxis
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Chemoprophylaxis for Breast Cancer in High Risk
Groups
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RR>4-genes, 2+ 1st degree relatives with breast
cancer, personal hx br ca, Age>65
RR 2.1-4-One 1st degree relative with br ca, nodular
densities on mamm, Atypical Hyperplasia, Hi dose
chest radiation
GAIL Model- age at menarche, age first child, current
age, number first degree relavies with breast cancer,
prior breast biopsy, prior atypical hyperplasia
PAP SMEAR TRIAGE
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Bethesda Systemadequate?
Reading
Normal
 Ascus (+ or – HPV)
 ASC-H
 AGUS
 LGSIL
 HGSIL
 Cancer
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As with everything we teach you
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This is all subject to change without notice
US Preventive Services Task Forcewww.ahrq.gov/clinic/uspstfix/.htm
American College of Obstetricians and
Gynecologists-www.acog.org
American Cancer Society-www.cancer.org