Routine prenatal laboratory tests + Rh(D) type & antibody screen Hemoglobin/hematocrit, MCV, ferritin HIV, VDRL/RPR, HBsAg, anti-HCV Ab Rubella & varicella immunity Urine culture Initial prenatal visit Urine dipstick for protein Chlamydia PCR ((f risk factors are present) Pap test (if screening indicated) Hemoglobin/hematocrit 24-28 weeks * Antibody screen if Rh(D)-negative * 1-hr 50-g GCT 36-38 weeks * Group B Streptococcus rectovaginal culture anti-HCV Ab = hepatitis C antibody; GCT = glucose challenge test; HBsAg = hepatitis B surface antigen; MCV = mean corpuscular volume; PGR = polymerase chain reaction; RPR = rapid plasma reagin.Screening: abdominal aortic aneurysm Patient + Men population + Age 65-75 Risk factor wee ea + Any smoking history + One-time abdominal duplex ultrasonography Test Abdominal aortic aneurysm (AAA) is a common disorder with a long asymptomatic phase. The mortality rate for patients with ruptured AAA is very high (75%-90%), but the risk is mitigated if the aneurysm is repaired prior to rupture, making it an appropriate subject for screening in patients at risk. The primary risk factors for AAA include male gender, smoking history, and age >65. ‘The US Preventive Services Task Force recommends screening for AAA with a one-time abdominal ultrasound in men age 65-75 who have ever smoked (ie, any lifetime exposure >100 cigarettes). Screening and surgical repair of large AAAS (25.5 om) have been found to decrease AAA-specific mortality in this, Population. Ultrasonography is the recommended screening modality because of its high sensitivity (>95%), low cost, noninvasive nature, and lack of ionizing radiation. Screening for AAA may also be beneficial for men age 65-75 who have not smoked but have other significant risk factors (eg, first-degree family to have little, if any, benefit anc tory of AAA rupture). Screening in younger men and in women appears not recommended.Abdominal Aortic Aneurysm Screening ‘Screening a. ONLY for men that have EVER smoked b. Ages 65-75 c. One-time ultrasound AAA > 5.5cm usually need surgical repair Terrell Suggs “you get sugged right in the gut”Follow-up frequency for AAA surveillance |") ‘Maximum diameter of the abdominal aorta Recommended follow-up interval |) 25-2.9¢m ‘© Repeat ultrasound after 10 years, 3-3.9¢m |. utrasound very years 5.0-5.4cm ‘© Ultrasound every 6 months | ease ce cereale cee ee ees ee cea rupture.Cervical Cancer screening (Choice 0) Canical cancer serening is raconmende for women ag@ 21:85, Options indude ‘confcaleytlogy (eg, Pap tes) every 3 years or for woman age 20-65, highs human pepllomavinus len (wih r without elegy coestin) every S years. Women who have had adequate sreering can seb ree ate ES, Cervical cancer screening Age <21 + No screening Age 21-29 + Otology every 3 years + Otology every 3 years oR ‘Age 20-65 + Otology plus HPY testing every 5 years oR + Primary HPY testing every 5 years ‘Age >65 + No screening ifnegaive prior sereens & Jon risk Hysterectomy + Noscecning i negatve por serons& on sk (with cervix removed) a a + Onset of sexual intercourse or time of HIV diagnosis. HIV (whichever is first) + Annually uni 23 normal suits, then routine testing Wea iite resed | onset of sexual intercourse organ | « Annual Pap test with HPV cote transplant) a i eV = human papllomavius; SLE = systemiclupus enthemsiosus. ‘Normal Pap tes exclu persistent HPV infection, and patents wth adequate serening by age 65 ar at low isk of evetoping cervical cancer. In such patents, Pap tests may be stopped.Management of CIN3 CINS | Age >25 Not currently pregnant * LEEP * Cold knife conization * Cryoablation Pap test with HPV 1 and 2 years postprocedure *CIN3 = cervical intraepithelial neoplasia 3; LEEP = loop electrosurgical excision procedure; HPV = human papillomavirus.Endometrial biopsy indications Age 245 * Abnormal uterine bleeding le Postmenopausal bleeding Age <45 Abnormal uterine bleeding PLUS: * Unopposed estrogen (obesity, anovulation) * Failed medical management le Lynch syndrome (hereditary nonpolyposis colorectal cancer) Age >35 i» Atypical glandular cells on Pap testThis postmenopausal woman has endometrial cells on Pap testing. The reporting of endometrial cells on Pap tests is age based: + Women age <45 do not have endometrial cells reported on their Pap tests because this is a common, benign finding, particularly if Pap testing is performed during the first 10 days of the menstrual cycle. + In contrast, women age 245 do have endometrial cells reported on their Pap tests because this finding is more concerning for an abnormality. In this age group, particularly in postmenopausal womer ‘endometrial shedding may be due to endometrial hyperplasialcancer, regardless if the patient has no other symptoms (eg, post menopausal or abnormal uterine bleeding). The risk of endometrial hyperplasia/cancer is further increased if the patient has additional risk factors (eg, obesity, prior chronic anovulation), Therefore, postmenopausal women with endometrial cells on Pap testing require further evaluation with an endometrial biopsy. Patients diagnosed with endometrial cancer typically undergo a hysterectomy with bilateral salpingo-oophorectomy for treatment (Choice C).OSTEOPOROSIS SCREENING DXA (Dual-energy x-ray absorptiometry) SCAN WOMEN > 65, OR <65 YEARS WITH INCREASED RISK OF OSTEOPOROSIS Popiston YEARS men eS ya ace ‘The SPaTErmorrencening or esenprss WW bane east ‘wing trent aseopactocussin ner Sears noe Posen een sounge tan yea Thr ik ote ‘The SPT commen senna earns wth bane seus wig pre asap aun pozenocn women unger 30 ‘asthe atrrsn ielazrpace a een Fore ric beretsancharnsf wrong fe extoprssto prt aso Tacs ‘ete cine Coane sent gto br rn ang teColon cancer (holes A) Colon cancer screening i Seonminid for pSensg=45:70 and may be conidared ‘younger patents wih a sgnifcant amy istry of eoorecal cance. Screening options nude ‘nigh sont focal occult Hes! testing anualy uitiarget tol DNA ist ere 13 yo=s, or ‘olonesopy every TOs Ths patent hd a clanoecopy S years ago and doesnot ned furor searing atti ie, Snag | muernonmam omg b aonca nen AEST A mae, [moor annecnuren one narrate me B Iattssoe | ReUSSS neonates salty oe stern eae nce i ‘Smaumpanenr oh th pena aya pee ea rea y Colon cancer sereeningin the general population starts atthe age of 45, ‘The most common WRONG answer is 0.Family history of adenomatous polyps or CRC « First-degree relative at age <60 Inflammatory bowel disease ¢ Ulcerative colitis * Crohn colitis adenomatous polypo: Hereditary nonpolyposis CRC (Lynch syndrome) Colon cancer screening in high-risk patients Colonoscopy at age 40 or 10 years before the age of diagnosis in the relative (whichever comes first) Repeat every 3-5 years Begin 8 years post diagnosis (12-15 years if disease only in left colon) Colonoscopy with biopsies every 1-2 years « Begin at age 10-12 Colonoscopy every year © Begin at age 20-25 Colonoscopy every 1-2 yearsIntervals for follow-up colonoscopy after polypectomy No polyps . 10 years Hyperplastic polyps <10 mm Hyperplastic polyps 210 mm 3-5 years 4-2 tubular adenomas <10 mm 7-10 years ] 3-4 tubular adenomas <10 mm 3-5 years 5-10 tubular adenomas <10 mm Tubular adenoma 210 mm | 3 years: Tubulovillous or villous adenoma Adenoma with high-grade dysplasia >10 adenomas 1 year Large (+20 mm) adenoma removed by piecemeal excision) 6 monthsColon Cancer Screening Screening Direct Visualization -Colonoscopy -Sigmoidoscopy -CT Angiography Stool Based Testing -FOBT -FIT -FIT-DNA Q 10 years QS5years Sigmund FREUD Q 5 years ANGIO Q yearly Q yearly Q 1-3 years DNARecommendations for lung cancer screening Recommended + Low-dose CT scan of the chest test Recommended interval | * Yearly je for fee's + 50-80 screening + 220-pack-year history Eligibility & z + Currently smoking or quit smoking within the past 15 years + Patient successfully quit smoking for 215 years Termination of OR screening + Patient has medical conditions that significantly limit life expectancy Cigarette smoking is the single greatest risk factor for lung cancer. Because early diagnosis reduces lung cancer morbidity and mortality, annual screening with a low-dose CT scan of the chest is recommended for those who have smoked 220 pack-years. Screening should begin at age 50 and continue to age 80 or until 215 years of smoking cessation is achieved. Screening is therefore indicated for this patient (age 56, 42 pack-year history) (Choice E).Breast cancer screening US Preventive Services Task Force recommendations for breast cancer screening" Dafiitly bonefcial: “4 “+ Mammogram every 2 years for women age 50-74 recommended Possibly benefi inghea® “+ Mammogram in women age 40-48 Uncertain benefit ‘+ Mammogram in women age 275 “For average-tisk individuals, Society and expert recommendations for routine mammographic screening in women at average risk Initiation of screening for women at average risk Frequency __ omen at or soto Group(date) screening <0t049 6970 (years) years of years ee a | ae . Jt age a orate eayanested area Us preventive | 2 tndiviualize® | Yes | Yes, Services Task eee Force (2016)(1) 74BRCA Mutation: 25-29 years :-> Annual MRI >30 years :-> Annual MRI + Mammogram BRCA TESTING: Family history of Breast Cancer in >_2 first degree relatives (1 of whom diagnosed at age of <_50) OR Family history of Ovarian cancer ID: 20888SCREENING FOR LIPID DISORDERS Lipid dsorders _Scraen and treat men 235 years and women 2 years of age for lipid disrsers by obtaining at ‘the minimum, total cholestero and high-density lipoprotein levels. These canbe checked ina nontating state ee a eka fr tps ar oe hee rae eri eg betes peeieste peeeaeben ty eae bre age So mae eaves rags 60 eal ee Ors OMA TO sagen of familial hyperkpideméa) {Choice B) Cholesterol screening with a serum lipid pane! is écomimendad formost suis; wih \iesoweting theta (0g, statins) indicated for those with a calculated 10-year rk >7%-10%. Lipid values typically change slowly over time; for average-tisk patients in whom a statin isnot indicated, & SCREENING FOR HYPERTENSION Hypertension Screen men and vomen 218 years!Blood Pressure Screening Screening: a. Adults 40+ with risk factors Q Yearly b. Adults 18-39 WITHOUT risk factors Q 3-5 years Clinical Scenario: Ambulatory 2 A patient has a BP of 158/98 in the office, now what? ‘in itoring Goals of Treatment: a. Age 60+ 150/90 b. Age <60 140/90 Treatments: a. Black CCB, Thiazides b. Non-black ACE/ARB, CCB, Thiazides__ Thyroid Scree! ning (Choice E) There is currently insufficient evidence to recommend for or against thyroid disease ‘Screening In asymptomatic patlnts (eg, weight changes, tachycardia) Bladder cancer Screening Prostate Cancer Screening Prostate Cancer Screening ‘Screening ‘a. General: ages 55-69 let to discretion of the patient . PSA is NOT recommended Protty Shitty AssessmentCardiovascular Disease Prophylaxis: a. Ages: 50-59 b. Treatment: Aspirin c. Must have >10% 10-year CVD risk d. Must NOT be high risk for bleeding e. Must have >10 year life expectancy Aspen ski slope 50 degree slope 10 degree weather 4 SMiscellaneous Chlamydia & Gonorrhea screening for ALL sexually active women age 24 yrs and younger Screen for and treat asymptomatic bacteriuria in pregnancy Fluoride on primary teeth in kids, and fluoride supplementation at age 6 Screen for MDD between ages 12-18 Blood glucose screening for all overweight patients aged 40-70 Gestational diabetes screening at 24 weeks of pregnancy Prophylactic ocular topical in all newborns to prevent gonococcal ophthalmia neonatorum. HIV screening in all patients age 15-65 Syphillis screening in anybody at increased risk (other STI's)‘A Bo;yeariald woman comes tothe offce ae a new patient She recently moved to the Contolled with inhaled filoasone and inhaled albutrol as neaded. According to the ‘medical records she brought wih her, a mamimegraphy 6 months aga showed no ‘and colonoscopy S\vSars ago showed no abnormalities. Her past three Pap smears have Shown no abnormalities: the most recont Pap sinoar Was YSarago, Her matyor has (ype 2 diabetes molitus, and her maternal sunt had breast cancer atthe age of 55 years ‘The pant aoa tisk aaa. Sv drinks two gas of wine woos. She “emir, respirations are 1elmin, and blood presaure ls 132/88 mm Mg. Examination hows no abnormalities. Screening for which of the flowing ls the most appropriate Next © ©. Chlamydia trachomatis infection 1. Coton cancer UptoDate’ (eater “a ‘A Sryea-oka man comes to tho pysclan fora routine heath maintenance examination, He has no histor af erousiiness and takes ne medications. He dows ot smoke ‘Ggareles, and he exercise four tinea weeky Fle mother dd ot {ag60075 years. He 2 183 em (60) tal an weighs 100 Hg (220 1b, BMI 30 kan too 68min and ood prossure ls 138/74 mm Hg. The remainder o the examination shows no abnormalities, Wich ofthe fotowing ithe mosl appropiate net step? © 8. Complete bood count im thyoi. stimulating hormone concentration