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🌱 來自: Huppert’s Notes
Health Care Maintenance and Disease Screening🚧 施工中
Health Care Maintenance and Disease Screening
These health care maintenance and disease screening guidelines summarize recommendations from the U.S. Preventative Services Task Force (USPSTF) guidelines, other guidelines as indicated, and general best practices. Of note, screening tests aim to identify disease in asymptomatic individuals. Recommendations are population-based and may need to be tailored to individual patients based on the clinical context. The decision to stop routine disease screening should be based on shared-decision making with the patient and should take into account the patient’s functional status, life expectancy, goals, and preferences.
All patients
• History:
- Diet/weight, exercise
- Alcohol, tobacco, substance use
- Sexual history
- Depression/anxiety
- Intimate partner violence
- Advance care planning: Discuss future health care decisions related to the patient’s priorities and values, document code status, identify a surrogate medical decision maker, and complete appropriate documentation (may vary by state: advanced directive, durable power of attorney, physician’s orders for life-sustaining treatment [POLST]); Recommended for all adults, and especially important for patients with multiple co-morbidities and/or advanced age
• Screening tests:
- HIV screening for all patients age 15–65 yr. Offer pre-exposure prophylaxis (PrEP) to persons who are at high risk of HIV acquisition
- Latent tuberculosis infection (LTBI) screening in persons at increased risk
- Hepatitis B virus (HBV) screening in persons at increased risk
- Hepatitis C screening in adults age 18–79 yr
- Depression screening
• Physical exam: Body mass index (BMI), blood pressure
• Vaccinations: Td(ap) every 10 yr
Women
• 18–39 years:
- H+P: See list above under “all patients”. Also ask about contraception and sexual health.
- Screening tests:
• Pap smear (q3 yr if age 21–29 yr; q3 yr or q5 yr if pap/HPV co-testing if age ≥30 yr)
• If sexually active, gonorrhea/chlamydia screening annually until age 25 yr (and then discretionary). If high risk sexual behavior, offer STD testing more frequently (i.e., q3–6 months)
• Rubella serology once
- Vaccinations: Annual flu shot, HBV series, varicella, HPV vaccination if not already completed (recommended for individuals age 9–26 yr, expanded approval up to age 45 yr)
• 40–49 years:
- H+P: See list above under “all patients”
- Screening tests:
• Lipids screening q5 yr starting at age 45 yr, or earlier if risk factors
• HgA1c q3 yr starting at age 45 yr, or earlier if risk factors
• USPSTF recommends biennial screening mammogram starting at age 50 yr, but other guidelines recommend starting at age 40 yr so can consider with shared decision-making
• Pap smear q3 yr or q5 yr if pap/HPV co-testing
- Vaccinations: Annual flu shot
• 50–64 years:
- H+P: See list above under “all patients”
- Screening tests:
• Lipids q5 yr
• HgA1c q3 yr
• Mammogram q2 yr
• Pap smear q3 yr or q5 yr if pap/HPV co-testing
• Colon cancer screening (options: FIT q1 yr, flexible sigmoidoscopy q5 yr, colonoscopy q10 yr)
• Osteoporosis screening if high risk
• Annual low-dose CT if age 50–80 yr, with >20 pack-yr history and current smoker or quit within the past 15 yr
- Vaccinations: Annual flu shot, shingles vaccine after age 60 yr
• Age≥65 years:
- H+P: See list above under “all patients”. Also ask about functional status/falls, safety in current living situation, caregiver support, nutritional status, vision/hearing, memory/cognition, urinary continence, and polypharmacy.
- Screening tests:
• Lipids q5 yr
• HgA1c q3 yr
• Mammogram q2 yr, insufficient data to support continued mammographic screening in women ≥75 yr
• Colon cancer screening (options: FIT q1 yr, flexible sigmoidoscopy q5 yr, colonoscopy q10 yr), insufficient data to support continued colon cancer screening in patients ≥75 yr
• Osteoporosis screening (DEXA)
• Annual low dose CT if age 50–80 yr, with >20 pack-yr history and current smoker or quit within the past 15 yr
- Vaccinations: Annual flu shot, pneumococcal vaccine, replace one dose of q10 yr Td booster with Tdap
Men
• 18–39 years:
- H+P: See list above under “all patients”. Also ask about contraception and sexual health
- Screening tests:
• Lipid screening q5 yr starting at age 35 yr, or earlier if risk factors
• Insufficient evidence to assess the benefits/risks of gonorrhea/chlamydia screening in men, but can discuss and offer STD screening
- Vaccinations: Annual flu shot, HBV series, varicella, HPV vaccination if not already completed (recommended for individuals age 9–26 yr, expanded approval up to age 45 yr)
• 40–49 years:
- H+P: See list above under “all patients”
- Screening tests:
• Lipids q5 yr
• HgA1c q3 yr starting at age 45 yr, earlier if risk factors
- Vaccinations: Annual flu shot
• 50–64 years:
- H+P: See list above under “all patients”
- Screening tests:
• Lipids q5 yr
• HgA1c q3 yr
• Colon cancer screening (options: FIT q1 yr, flexible sigmoidoscopy q5 yr, colonoscopy q10 yr)
• Consider discussion about prostate cancer screening with PSA (insufficient evidence per USPSTF, but some societies recommend it so can utilize shared decision making with the patient)
• Annual low-dose CT if age 50–80 yr, with >20 pack-yr history and current smoker or quit within the past 15 yr
- Vaccinations: Annual flu shot, shingles vaccine after age 60 yr
• Age ≥65 years:
- H+P: See list above under “all patients”. Also ask about functional status/falls, safety in current living situation, caregiver support, nutritional status, vision/hearing, memory/cognition, urinary continence, and polypharmacy.
- Screening tests:
• Lipids q5 yr
• HgA1c q3 yr
• Colon cancer screening (options: FIT q1 yr, flexible sigmoidoscopy q5 yr, colonoscopy q10 yr), insufficient data to support continued colon cancer screening in patients ≥75 yr
• Abdominal aortic aneurysm (AAA) screening in men age 65–75 yr who have ever smoked
• Consider discussion about prostate cancer screening with PSA in men <75 yr
• Annual low-dose CT if age 50–80 yr, with >20 pack-yr history and current smoker or quit within the past 15 yr
- Vaccinations: Annual flu shot, pneumococcal vaccine, replace one dose of q10 yr Td booster with Tdap
Screening recommendations by problem/condition
• Hypertension:
- Adults ≥18 yr: Screen every 2 yr or annually if pre-HTN
• Hyperlipidemia:
- Men ≥35 yr, women ≥45 yr, or any patient ≥20 yr with risk factors for HLD (e.g., CAD, diabetes, obesity)
- If total cholesterol <200 mg/dL and HDL >35 mg/dL, repeat screening in 5 yr
• Diabetes:
- Screen all patients ≥45 yr; consider earlier screening if risk factors for diabetes (e.g., obesity, family history, history of gestational diabetes, PCOS, HTN, HLD)
- Testing options: HgA1c, fasting blood glucose, random blood glucose, oral glucose tolerance test
• Abdominal aortic aneurysm (AAA):
- Perform screening ultrasound for men age 65–75 yr who have ever smoked
• Gonorrhea/chlamydia screening:
• -Women: If sexually active, screen annually until age 25 yr, then discretionary screening after that based on risk factors
• -Men: Insufficient evidence to assess the benefits/risks of gonorrhea/chlamydia screening in men, but can discuss and offer STD screening
• HIV:
• -Screen all adults age 15–65 yr
• -Offer pre-exposure prophylaxis (PrEP) to persons who are at high risk of HIV acquisition
• Hepatitis C:
- One-time screening for all patients born between 1945 and 1965
• Breast cancer:
- Breast self-exam: USPSTF recommends against self-breast exams (no mortality benefit, more benign breast biopsies)
- Physical exam: Insufficient evidence for physician breast exam
- Mammography:
• Age 40–49 yr: American Cancer Society and others recommend offering mammogram at age 40 yr but USPSTF recommends starting at age 50 yr. Therefore, can consider in women age 40–49 after shared decision-making with the patient.
• Age 50–74 yr: Screening mammogram q2 yr
• Age ≥75 yr: Per USPSTF, not recommended (insufficient evidence)
• Cervical cancer:
- Average risk:
• Age 21–29 yr: q3 yr pap smear (regardless of whether sexually active, no HPV testing <30 yr)
• Age 30–65 yr: q3 yr pap smear or q5 yr Pap/HPV co-testing
• Age >65 yr: Can stop testing if repeated negative tests and not at increased risk (more than one sexual partner in last 5 yr, immunosuppression); also stop if hysterectomy
- High risk: q1 yr (HIV+, immunocompromised, in-utero DES exposure, CIN 2/3, history of cervical cancer)
• Colorectal cancer:
- Forms of screening:
• Fecal occult blood test (FIT) q1 yr (if any one card positive, recommend proceeding to colonoscopy)
• Flexible sigmoidoscopy q5 yr
• Colonoscopy q10 yr
- Average risk: Begin screening at age 50 yr
- Moderate risk (family history of colorectal cancer or adenomatous polyps in a first degree relative): First colonoscopy age 40 yr or 10 yr younger than the youngest case in family; repeat q3–5 yr
- Familial adenomatous polyposis: Consider genetic testing at age 10 yr (if positive, consider colectomy) or colonoscopy q1–2 yr starting at puberty
- Hereditary nonpolyposis colorectal cancer: Consider genetic testing at age 21 yr. If positive, recommend colonoscopy q2 yr until age 40 yr, then annually.
- Ulcerative colitis: Recommend colonoscopy annually after ≥8 yr of disease
• Prostate cancer:
- Universal PSA screening is not currently recommended, but can be considered after shared-decision making with the patient
- No screening if <10 yr predicted survival (50% of men >75 yr)
• Lung cancer:
- Annual low-dose CT in patients age 50–80 yr, with >20 pack-yr history and currently smoke or have quit within the past 15 yr
• Osteoporosis:
- All women age >65 yr, or earlier if risk factors. Screen with DEXA scan.
- Per USPSTF, insufficient evidence to recommend universal screening in men, but can consider if risk factors for osteoporosis
- Frequency of repeat DEXA scans depends on the presence of low bone mass and risk factors for accelerated bone loss
• Vaccinations:
- COVID-19: Data forthcoming about recommended vaccination frequency
- Hepatitis A:
• Given in two doses 6 months apart
• Recommended for patients who travel internationally to certain regions and those with certain risk factors (e.g., HCV, chronic liver disease, intravenous drug use)
- Hepatitis B:
• Given as a primary series to infants (0, 1, and 6 months)
• Individuals born outside of the United States may not have been vaccinated as children so consider checking HBV titers
- HPV:
• Recommended for men and women ages 9–26 yr
• Two- or three-dose series depending on the age at initial vaccination
• Shared decision making for unvaccinated adults age 27–45 yr (consider in high-risk patients)
- Influenza:
• Annual flu vaccine recommended. Shot = killed vaccine, nasal spray = live vaccine.
• Contraindicated: Severe egg allergy
- Meningococcal:
• Given as a single dose injection age 11–18 yr
• Patients at particular risk for meningococcal infection: College students and miliary personnel living in close quarters, asplenic patients, travelers to endemic areas
- MMR (measles, mumps, rubella):
• Primary series in children, live vaccine
• Check prior to pregnancy and administer to patients who are not rubella immune
• Contraindications: Pregnancy, immunocompromised (ok in HIV if CD4 **>**200 cells/μl)
- Pneumococcal: PCV 13 and PPSV 23
• All adults age ≥65 yr or those age 19–64 yr with certain chronic medical problems (COPD, asthma, cirrhosis, diabetes, history of smoking, high-risk pregnancy, sickle cell disease, asplenia)
• If a patient is vaccinated at age <65 yr, revaccinate at age 65 yr or 5 yr after the first dose (whichever is longer, for example if vaccinated at age 62 yr revaccinate at age 67 yr)
• PCV13:
- Prevents invasive disease and pneumonia
- Ideally administer before PPSV23 if possible
- If patient received PPSV23 first, wait at least 8 weeks before administering PCV13
• PPSV23:
- Prevents invasive disease but not pneumonia
- Administer 1 yr after PCV13
- Polio:
• Primary series in children
• Not routinely given to unvaccinated adults unless traveling to an endemic area
- Tetanus/diphtheria:
• Tdap (tetanus, diphtheria, pertussis) administered as a primary series to infants (1, 2, and 6 months)
• Td booster q10 yr
• In adults **>**65 yr, replace one dose of q10 yr Td booster with Tdap
• Revaccinate all pregnant women between 27–36 weeks gestation every pregnancy
- Varicella:
• Live vaccine given as a primary series in children and adults without a history of chickenpox
• Two doses; administer the second dose 4–8 weeks after the first dose
• Contraindications: Pregnancy, immunocompromised patients
- Zoster:
• Live vaccine given to adults ≥60 yr
• Contraindications: Pregnancy, immunocompromised patients
- Live vaccines:
• Smallpox, yellow fever, chickenpox, shingles, Sabin’s polio, MMR, intranasal influenza, BCG, anthrax