Preventative Health

AHRQ ePSS Online
USPTF Guidelines
ASCVD Risk
METs Calculator
Online Wellness Screen :
Mayo Clinic Online Health Assessment Tool

Wellness Exam
- ASCVD RFs: __ smoker, __ hx CVA/MI/DM, __ HTN, __HLD, __ ASA candidate
- CA Screening: mammogram __ , pap smear __, CRC __; fhx CA ___
- Vaccinations:  UTD. Flu vaccine __
- Conditioning: __ regular exercise, __ physical limitations to regular activity.
- Psych: denies depression / anxiety; good energy/sleep/appetite/concentration
- Social: Tobacco __; Etoh __ ; Drugs __ ; home violence __ ; lives with __ ; work __
- Dx/Rx reviewed.
- Code status:            

- Repro/BCM: no abnormal VB/discharge/rash/ulcers; __,; Sexual activity __ ; BCM method __ ; PNVs __

 
WWE
- OBhx: G P ; BCM:
- Gynhx: denies hx STI
- pap hx
- menses: 
- mammogram hx:

Geriatrics- see geriatrics page for wellness exam
 
Specific PE templates:
Breast: b/l exam non-tender and no palpable masses, no discharge, no rash, dimpling, or skin retraction. b/l axillae w/o LAD or masses. 
Pelvic: nl external F genitalia. uterus firm w/o palpable nodules, size nl. adnexae mobile, nontender. 
Sterile speculum exam: vaginal wall w/o lesions or lacerations. no blood in vaginal vault. cervical os w/o notable lesions or discharge. no foul odor.
Digital Rectal Exam: no external hemorrhoids or anal fissures. *** prostate is smooth, nontender, no palpable masses or nodules, size:

In-house Tools 
 - ABI
- Spirometry
- EKG
- Vision screening

General Recs
> diet: slow carb/Na; calorie restricted. increase vegetables. ===> Print:
> exercise: cardio 3x/wk x20 min w/ partner. ====> Print:
> GI health: Psyllium husk: 1-2 tablespoons qday; Probiotics: rec PO daily tab (culturelle) ====> Print:
> Hydration: if no CHF/CKD hx, consider 2-3L water/d.

> Skin care / sun exposure: sunscreen SPF >45 daily, hats, sun glasses.
> Sleep hygiene: PM sleep ritual, no screen time, limit late caffeine.
> Homework: documentaries / youtube information videos?
- Forks Over Knives
short version youtube
> Code: (Living Will ; Healthcare POA; DNR)

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Screening Lab Panels: 
- Standard: lipid panel; A1C; TSH; BMP/CMP; CBC
- STD: urine GC/CT; HIV; Hep C Ab; RPR; HSV2
- Drug-user: UDS; HIV; Hep C Ab
 
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Preventative Health Template AP
 
#.
ASA 81mg/d for primary prevention CVD, colorectal CA in 50-60 yo

#. Tobacco / Smoker
- # pack years; since yr
- pack/day current
- cx:

- pre-contempt -> contemp -> preparation -> action -> maintenance
>
risks of smoking reviewed. Recommend cessation, extensively counseling provided.
> #cig goal at next visit
> discussed rx options: chantix, nicotine gum, e-cig/vaporizer, bupropion.

#. Obesity/Weight Loss: --> lose weight in the kitchen, gain muscle in the gym. ===> 8min :
Slow Carb Diet (meh)
- Wt today: ; BMI: 
- counseled extensively on diet/exercise: LCHF / 3x/wk cardio
- goal next visit: wt
> diet: high protein, low carb/Na; calorie restricted,
> exercise: cardio 3x/wk x20 min w/ partner.
> bupropion: for wt loss? reduce appetite. acarbose, orlistat.

#. Diet
> 1 glass of water before every meal
> Slow-carb diet:
- yes: eggs, beans, pico, green vegetables, chicken, pork, soy
- no: sugar, soda, juices, tortilla, bread, pasta etc
> Na restriction
> Fluid restriction <2L /d
 
#. Exercise
> cardio focus 20-30 min 3-5x/week
> create habit daily, do it w/ partner

#. STD Screen
- HIV: screen everyone
- Hep C, Hep B
- STI screen: GC/CT/RPR/HIV
- high risk women screen q1yr.
- <24 yo + sexually active: chlamydia q1yr
- teen-65 yo: HIV screen

#. Elderly >65 yo
- Osteoporosis: DEXA q4-5 years. Vit D3 (800-2000 IU/d) + Ca (1200-1500mg/d)
- Fall risk: get up and go test; up from seating --> 10 ft --> walk back; + if gait instability or  >20 sec
- Exercise: balance training, resistance training. --> 4min series :
Intro / Aerobic / Strength
- Post-menopause: vaginal estrogen
- Code status. Living will. Emergency contact. ===> 11min :
Advance Care Planning
- Exercise :

#. Sleep hygiene
-
Sleep hygiene recommendations: tea, wind-down time 30min before bed (no caffeine after 4-5pm; non-caffeine warm drink; brust teeth; read something; NO screen time)
- Contoured pillow, cool room, eye cover / ear plugs, comfortable bed.
- Melatonin; hydroxyzine trial
- GAD7 screen:
- TSH, CBC.
- RTC 2 wk re-evaluation

#. Disability policy
#. Quality of Life & Life Goals
- *from palliative / hospice theories; what is pt living for? can you help them achieve those goals? or even get out of the way?


BCM:print for pt RepdroductiveAcess.org
-  UPT neg. non-smoker; advised against smoking due to inc risk of VTE.
#. OCP: not advised. Progestin vs combination. Sprintec course. C/w condom use 2 weeks after.
#. Nexplanon:  q3 yr. 20% menometrorrhagia; trial for 3-6 mo.
#. Depo: q3 mo.

 
Code Status & Living Will Forms
• Living Will 
• Healthcare POA
• DNR

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Adult Vaccinations
18-65 yo:
#. Influenza q1yr
#. Tetanus: at least 1x Tdap, then boosters with Td.
#. HPV: women <26 yo, men up to 26 yo. series of 3 (#1. day 0 --> #2. 0+1 or 2 mo --> #3. 0+6 mo)
#. Hep B: series of 3.
#. MMR: 1x. 2x if college student, healthcare worker

>65 yo
#. Td: 1x booster q10 yrs. at least 1x after 65 yo.
#. Influenza: q1yr
#. Prevnar / Pneumovax :
- if no hx Pneumovax23: Prevnar13 after 65 yo, AND then Pneumovax23 6-12 mo after Prevnar 13 (better immunogenicity!)
- Hx Pneumovax23 after 65: Prevnar13 after 65 (1 yr after PPSV23)
- Hx Pneumovax23 before 65: Prevnar13 after 65 yo, AND Pneumovax23 1yr after Prevnar 13 and 5 yrs after last Pneumovax23
- special groups: DM, smokers, CHF, COPD, etoh abuse --> get PPSV23

#. Hep B: series x3.

#. Shingles vaccine: Shingrix = RZV (ACIP preferred): CDC rec for all immunocompetent adults >50 yo, 2 doses separated by 2-6 months
? even if already had singles ? yes. ? even if already had zostavax? yes.
if active shingles outbreak, defer vaccine until after resolution.
Alternative Zostavax = ZVL (available since 2006): CDC rec 1x after 60 yo.

CA Screening
#. Lung CA :
- annual low dose CT (LDCT): 55-80 yo w/ >30 pack yr hx who still smoking or quit within past 15 yrs
 
#. Prostate: 
- USPSTF: do not rec screening.
- if hx prostate CA, trend PSA over time. 
- PSA interpretation: ***

 
#. Colon
- >50 yo q10yrs colonoscopy; up to 75 yo.
- iFOBT q1yr (replace FOBT)
 
#. Cervical: 
- (20-30 yo pap q3yr); (30-65 pap+hpv q5yr); 
- dc if >65 yo or s/p hysterectomy or kept cervix w/o hx cervical lesions.
- Pap App: pap and colpo recommendations

#. Breast:
- >50 yo q1-2yr mammograms; ACOG >40 yo q1yr; up to 75 yo (indeterminate rec after that)
-
start 40-50 yo if pt requests; "co-decision"
- BRCA testing recs: ***



Other Screening:
#. AAA: men 65-75 yo who has ever smoked; abdominal aortic US.
#. Lipid panel:
Men >35 yo (men, women <35 if increased CAD)
#. Osteoporosis: F >65 yo or RFs (ex. chronic steroid use), possibly men >75 yo. q4 years.
#. OSA: Mallampati score. STOP-BANG.
#. CV disease : ABI
#. Vit D deficiency:
#. Depression screening: PHQ9.
#. Hearing
#. Vision