Health Maintenance and Disease Prevention

Introduction to the diagnostic process

Primary Preventative Medicine

remove or reduce disease risk factors

Secondary Preventative Medicine

early detection of disease (screenings)

Tertiary Preventative Medicine

Limit impact of established disease (procedures to maintain health or help)

Leading causes of death in the USA

Heart disease and cancer

Top causes from all deaths

(note that all causes attribute to common preventable risk factors)

tobacco smoking, hypertension, overweight obesity, and physical inactivity

Functions of the history and physical exam

1. information collection

2. determination of patient values

3. assessment and communication of prognosis

4. establishment of a therapeutic relationship

5. discussion of diagnostic testing and therapeutic options

6. counseling, education and motivation for behavioral changes

Compliance

the extent to which the patient’s behavior coincides with clinical advice (negative connotation the physician as a dictator)

Adherence

the extent to which a patient’s behavior corresponds with agreed recommendations from a health care provider (patient and physician work together)

Ways to improve adherence

clinical patient goals agreement, education, provide more convenient care, simplify treatment regimens, reminders, monitoring, and support system

What are screening tests used for?

used to identify a disease/condition in a seemingly well person

Criteria used to determine if screening test is worthwhile

1. burden of disease sufficiency

2. test used must be high quality

3. evidence shows screening decreases morbidity and morality

4. risk of harm

Levels of certainty

net benefit - harm (high, moderate, low)

Grade A recommendations

USPSTF recommends service with high certainty

Grade B recommendations

USPSTF recommends service with moderate certainty (is it worth it for this specific patient)

Grade C recommendations

USPSTF selectively recommends small benefit

Grade D recommendations

USPSTF recommends against service

Grade I recommendations

insufficient evidence

Prevention of infectious diseases

Immunization (pediatric vs adult schedule vs travel recommendations)

strategies to improve vaccination rates

What app is used for vaccination recommendations for traveling

CDC travel planning app

Prevention of obesity: physical activity recommendations and benefits (adults)

Minimum of 150min of moderate intensity aerobic activity+ muscle strengthening activity at least 2 days a week

Benefits: weight management and decreased risk for chronic health conditions and improve quality of life

Components of physical fitness

Cardiorespiratory fitness

musculoskeletal fitness

flexibility

balance

speed

cardiorespiratory fitness

aerobic exercise

how well your heart, lungs, and blood vessels supply oxygen to your muscles during sustained physical activity

Musculoskeletal fitness

ability for muscles, bones, and joints to work together

Prevention of obesity: weight management (diet)

Diet the single most significant risk factor for disability and premature death!!

Diet is shot term like fad diets

Nutrition is a lifestyle with small goals and is sustainable

Dietary patterns:

Dietary approaches to stop hypertension (DASH)

Mediterranean diet

2015 dietary guidelines for Americans (My Plate)

Vegetarian/vegan (have to ensure they are getting proper nutrients)

Prevention of cardiovascular disease

one of the most significant in the United States

coronary heart disease and cerebrovascular accidents are two of the most significant causes of morbidity and mortality in developed countries

There are risk factors that are both modifiable (can be improved) and non modifiable (can not be improved)

Cigarette smoking

SIGNIFICANT cause of preventable morbidity and mortality

increases the risk for almost EVERYTHING

quitting at any Ange can increase life expectancy

Active smoking

the direct act of smoking

Passive smoking

non smoker breaths in smoke from smokers around them

Prevention of cancer

Primary prevention: smoking cessation, uv light restriction/ sunscreen, diet and physical activity, and vaccines

screening and early detection

Prevention of injuries and violence

Injuries remain the most important cause of loss of potential years of life before the age of 65

injury prevention- PATIENT EDUCATION

patient demographics dictate specific topics (examples: seat belts, smoke detectors, CO monitors, poison control knowledge, sunscreen usage, helmet use, texting and driving, gun safety)

Intimate partner violence

Prevalent WORLDWIDE health problem that is largely UNDER RECOGNIZED and UNDERDRESSED

can include physical, emotional, sexual, and financial abuse by current or former partner

IPV tends to be repetitive with an escalation in frequency and severity over time

occurs in heterosexual and same sex relationships

Types of IPV behaviors

physical violence

sexual violence

stalking

phsycclogcial aggression

Possible health outcomes of IPV

The severity of abuse correlates with the impact on physical and mental health (cumulative over time and effects persist long after the abuse has stopped)

Physical effects: related directly to the abuse, develop of chronic medical conditions

Psychological effects: anxiety, depression, substance abuse, eating disorders, PTSD, sleep disorders, low self esteem, and fear of intimacy

Screening of IPV

Patients who present with suspicious symptoms or PE signs

Pregnant women

Initial primary care and OB/GYN visits

All ED visits

All hospital admissions

General principles for IPV screenings

Avoid using the words domestic violence, victim, abused, battered instead use hurt, frightened, treated badly or mirror the patient’s word choice

Never blame the victim

must assess for risk of immediate significant harm

Tools for screening intimate partner violence (IPV)

HITS, STAT, WAST

HARK (Humiliation afraid rape kick), SAFE

OVAT (ongoing violence assessment tool)

Substance Use Disorder

A medical illness caused by repeated misuse of a substance or substances. Characterized by clinically significant impairments in health, social/occupational function, and relationships. May range from mild-severe. Each substance is classified individually

Substance use

the use, even once of any psychoactive compound

Substance misuse

the use of any substance in a manner, situation, amount or frequency that can cause harm to users or to those around them

Addiction

old term used for a sever SUV (no longer used)

Recovery

a process of change through which individuals improve their health and wellness, live a self directed life and strive to reach their full potential

Classification system for substance use disorders

DSM-5

10 specific substances detailed in DSM-5

alcohol

caffeine

cannabis

hallucinogens

inhalants

opioids

sedatives, hypnotics or anxiolytics

stimulants

tobacco

other/unknown substances

intoxication syndromes

intoxication occurs when a person develops a reversible set of symptoms due to the recent use of or exposure to a substance

withdrawal syndromes

the behavioral, physical, and cognitive symptoms that occur due to the abrupt reduction or cessation of substance use

Moderate drinking

up to 1 standard drink a day for woman and 2 drinks a day for men

Low risk drinking

Women: no more than 3 drinks on a single day and no more than 7 drinks a week

Men: no more than 4 drinks on any single day and no more than 14 drinks/week

Binge drinking

consuming an excessive amount of alcohol on a single occasion (or in about 2 hours) Men = +5 drinks, Women= 4+ drinks

Heavy Drinking

binge drinking on 5+ days or more in the past month

Screening for substance use disorder: alcohol use

Need to known amount, frequency, context, age at first use, last use

Past, current use

social use

Screening tools for alcohol use

CAGE/TACE questions

AUDIT alcohol screening tool

Screening for substance use: Illicit (recreational)

Includes street drugs and RX medications taken in ways other than prescribed or not prescribed to patient at all

Need to know specific drugs used, route taken, amount, frequency, context, age at first and last use

Screening tools for illicit substance use

Modified CAGE questions

DAST 10

Contextual environmental factors that a can give rise to health inequity

Poverty

Educational quality

Food insecurity

Access to transportation

Affordable housing

unemployment

maintenance of basic utilities

violence

public safety

Health maintenance and screening: infants and young children

Goals: screening for medical problems and psychosocial concerns

and anticipatory guidance/health promotion

Newborn screening tests

Monitoring of growth and development

Screening considerations for infants and young children

speech and langage

autism (30 month visit to denitrify and step in early to talk to parents)

developmental delay

lead levels

maternal depression

psychosocial concerns

Health maintenance and screening: School age children

Goals of health maintenance visit: health promotion, disease detection, and patient education

special considerations: developmental surveillance, psychosocial review, and school performance/chronic absenteeism

unintentional injury is the leading cause of death for school age children in the USA

Outpatient injury prevention counseling has been shown to decrease injury rates in children (educate children on safety precaution and encourage parents to act as role models)

Health maintenance and screening: adolescents and young adults

Traditionally defined as ages 10-24 years

adolescents are more likely to access health care, have a more favorable attitude about their clinicians, and share sensitive information when confidentiality is assured. However approximately 60% do not get time alone with their clinician for confidential discussions despite patient and parental preferences

Risky health behaviors in adolescents

Most common cause of death: MVA (22%), other unintentional injuries (20%), suicide (17%), and homicide (15%)

approximately 50% of new STIs occur in people ages 15-24

rates of chlamydia, gonorrhea, syphilis all INCREASED between 2015-2016

Must address topics in adolescents/ young adults

Mental health - depression/anxiety

Substance use

Sexual health

teen dating violence

diet/exercise eating disorders

safety

Depression screening adolescents

PHQ2 and PHQ9

self injury: indicative of poor coping mechanisms/diffiluty managing emotions

Preferred screening tool for adolescents substance use

CRAFT+N also looks at adjacent substance use

Adolescents:Sexual health

Opportunity to address sexual orientation and gender identity, safe sexual practices

Teen dating violence screening

TDV is different from adult IPV in many ways

No one screening modality utilize red flags approach and tailor to individual situation

Screening tool for teen dating violence

REDFLAGS approach

Adolescents: diet and physical activity

Recommendations for a healthy diet: expected growth spurt appetite surge, content similar to adult recommendations, considerations for athletes

screen for risk eating patterns for obesity and eating disorders (anorexia nervosa, avoidant restrictive food intake disorder bulimia nervosa, binge eating disorder, PICA), physical activity as per recommendations for school age children

Screening for eating disorders

SCOFF

S: do you make yourself sick because you feel uncomfortably full

C: do you worry you have lost control over how much you eat

O:have you recently lost more than one stone in a 3 month period

F: do you believe yourself to be fat when others say you are too thin

F: would you say that food dominates your life

Adolescents: safety

Violence, sports related concussion, and social media/technology

Diagnostic errors arise from

faulty knowledge, faulty data gathering, and faulty information processing

The diagnostic process

step 1: identify the problem - you must be certain that you understand what the patient is telling you

step 2: frame the differential DX (DDx)- use a problem specific framework organize the possible diseases/conditions subcategories

step 3: organize the Ddx- utilize pivotal points

step 4: limit the Ddx- Taylor Ddx using pivotal points to create a patient specific DDx

step 5: explore possible diagnoses using H and P findings- look for clinical clues that point toward the most likely Dx and fingerprint findings

step 6: rank the DDx- possibilistic approach, probabilistic approach, prognostic approach, and pragmatic approach

step 7: test your hypotheses

step 8: re rank the DDx based on new data

step 9: test the new hypothesis

Possibilistic approach

emphasizes human agency, choice, and potential outcomes over strict environmental or statistical determinism

Probabilistic approach

treats diagnosis, prognosis, and treatment as matters of likelihood rather than absolute certainties

prognostic approach

predicts the future course, progression, and outcome of a disease or health condition using individual patient data

pragmatic approach

focuses on practical, real-world solutions that work in routine clinical care rather than relying solely on ideal conditions