Adult male health maintenance case file

Adult male health maintenance case file

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 1

A 52-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He has no significant medical history and takes no medications regularly. His father died at the age of 74 of a heart attack. His mother is alive at the age of 80. She has hypertension. He has two younger siblings with no known chronic medical conditions. He does not smoke cigarettes, drink alcohol, or use any recreational drugs. He does not exercise. On examination, his blood pressure is 127 /82 mm Hg, pulse is 80 beats/min, respiratory rate is 18 breaths/min, height is 67 in, and weight is 190 lb. On careful physical examination, no abnormalities are noted.

⯈ What screening test(s) for cardiovascular disease should be recommended for this patient?

⯈ What screening test(s) for cancer should be recommended?

⯈ What immunization(s) should be recommended?

ANSWER TO CASE 1:

Adult Male Health Maintenance

Summary: A 52-year-old man with no active medical problems is being evaluated during an "annual physical:' He has no complaints on history and has a normal physical examination.

• Recommended screening tests for cardiovascular conditions: Blood pressure measurement (screening for hypertension) and lipid measurement (screening for dyslipidemia)
• Recommended screening tests for cancer: Fecal occult blood testing, flexible sigmoidoscopy (with or without occult blood testing), colonoscopy or doublecontrast barium enema to screen for colorectal cancer; there is insufficient evidence to recommend for or against universal prostate cancer screening by prostate-specific antigen (PSA) testing
• Recommended immunizations: Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) if he has not had one before and if it has been 10 years or more since he has had a tetanus-diphtheria (Td) vaccine, or if he requires booster protection against pertussis; influenza vaccine annually, in the fall or winter months

ANALYSIS

Objectives

1. Know the components of an adult health-maintenance visit.
2. Learn the screening tests and immunizations that are routinely recommended for adult men.

Considerations

The patient described is a healthy 52-year-old man. Health maintenance should be employed to prevent future disease. In general, the approach is immunizations, cancer screening, and screening for common diseases. Generally, colon cancer screening should be initiated at age 50 and beyond. The influenza vaccine should be recommended annually, and the tetanus vaccine every 10 years. The acellular pertussis vaccine is also recommended as many adults have had waning immunity to pertussis and occasional outbreaks of whooping cough have been noted. Other vaccinations, including pneumococcal, meningococcal, hepatitis A and B, are recommended in those who have certain risk factors but are otherwise not routinely used for someone of his age and overall health. Since cardiovascular disease is the most common cause of mortality in his age group, screening for cardiovascular disease or risk factors is appropriate.

Approach To:

Health Maintenance

DEFINITIONS

SCREENING TEST: Assessment device or test that should be cost-effective with high sensitivity and can be used on a large population to identify persons with disease

HEALTH MAINTENANCE: Systematic program or procedure planned to prevent illness, maintain maximum function, and promote health

CLINICAL APPROACH

For years, one of the cornerstones of primary care was the "annual physical;' which often consisted of a complete physical examination, blood tests, including complete blood counts (CBCs) and multichemistry panels, and, frequently, annual chest x-rays and electrocardiograms (ECGs). The concept of the "annual physical;' or " health-maintenance examination" is still important; however, the components of the examination have changed over time.

The purposes of the health-maintenance visit are to identify the individual patient's health concerns, manage the patient's current medical conditions, identify the patient's risks for future health problems, perform rational and cost-effective health screening tests, and promote a healthy lifestyle. Prevention is divided into primary, secondary and tertiary approaches. Primary prevention is an intervention designed to prevent a disease before it occurs. It usually involves the identification and management of risk factors for a disease. Examples of this would be immunization against communicable disease, public health education about good nutrition, exercise and stress management, or removal of colon polyps to prevent the development of colon cancer. Secondary prevention is an intervention intended to promote early detection of a disease or condition, so prompt treatment can be initiated. Examples of secondary prevention are the use of mammography for the detection of breast cancer or eye examinations for the detection of glaucoma. Tertiary prevention involves both therapeutic and rehabilitative measures once a disease has been diagnosed. Examples of tertiary prevention include core measure medications for congestive heart failure, rehabilitation programs for stroke patients to improve functioning, and chronic pain management programs.

Effective screening for diseases or health conditions should meet several established criteria. First, the disease should be of high enough prevalence in the population to make the screening effort worthwhile. There should be a time frame during which the person is asymptomatic, but during which the disease or risk factor can be identified. There needs to be a test available for the disease that has sufficient sensitivity and specificity, is cost-effective, and is acceptable to patients. Finally, there must be an intervention that can be made during the asymptomatic period that will prevent the development of the disease or reduce the morbidity I mortality of the disease process.

The United States Preventive Services Task Force (USPSTF) is an independent panel of experts in primary care and preventive medicine that reviews evidence and makes recommendations on the effectiveness of clinical preventive services, specifically in the areas of screening, immunization, preventive medications, and counseling. USPSTF recommendations are "gold standards" for clinical preventive medicine. The recommendations of the USPSTF are available online for free at uspreventiveservicetaskforce.org. USPSTF grades its recommendations in five categories to reflect evidence strength and overall benefit of an intervention.

SCREENING TESTS

Cardiovascular Diseases

Diseases of the cardiovascular system are the leading cause of death in adult men and the management of risk factors for these diseases reduces both morbidity and mortality from these diseases. The USPSTF strongly recommends (Level A) screening of adults (age 18 and older) for hypertension by measurement of blood pressure, as screening causes little harm and management of hypertension is effective at reducing the risk of cardiovascular diseases. USPSTF also strongly recommends (Level A) screening men aged 35 or more and women aged 45 or more for lipid disorders and recommends (Level B) screening adults older than 20 years who are at increased risk for cardiovascular diseases. The screening can take the form of nonfasting total cholesterol and high-density lipoprotein (HDL)-cholesterol levels or fasting lipid panels that include the low-density lipoprotein (LDL)-cholesterol. Men aged 45 to 79 are recommended (Level A) to take aspirin daily to reduce the risk of a myocardial infarction (MI) as long as the benefit outweighs their risk of a gastrointestinal hemorrhage. Ultrasonography to assess for abdominal aortic aneurysm (AAA) is recommended (Level B) for men aged 65 to 75 who have ever smoked. There is no recommendation (Level C) for AAA screening for men who have never smoked and it is recommended against (Level D) for women who have never smoked. For women aged 65 to 75 who have smoked, there is insufficient evidence (Level I) whether screening for AAA would be beneficial.

The routine use of ECG, exercise stress testing, or computed tomography (CT) scanning for coronary calcium is not recommended (Level D) for screening for coronary artery disease in adults at low risk for coronary events. There is insufficient evidence to recommend for or against these modalities (Level I) in adults at higher risk of coronary events. There is insufficient evidence (Level I) for screening peripheral artery disease and coronary artery disease with ankle-brachial index (ABI). There is evidence to suggest against screening asymptomatic individuals among the general adult population for carotid artery stenosis.

Cancer

Adults (men and women) older than 50 years are strongly advised (Level A) to have screening for colorectal cancer. This screening can take the form of fecal occult blood testing (FOBT) using guaiac cards on three consecutive bowel movements collected at home, flexible sigmoidoscopy with or without occult blood testing, or colonoscopy. The optimal intervals for testing are not clear, but FOBT is generally recommended annually, sigmoidoscopy every 3 to 5 years, and colonoscopy every 10 years. An abnormal test result of FOBT or sigmoidoscopy leads to the performance of a colonoscopy.

The USPSTF currently recommends against (Level D) routine screening for prostate cancer using digital examination or PSA. Men and women aged 50 to 80 with a 30 or more pack-year history who continue to smoke or who quit less than 15 years ago should undergo annual low-dose CT of chest to screen for lung cancer (Level B ), but screening for lung cancer with routine chest x-ray is not recommended.

Screening for testicular and pancreatic cancer in asymptomatic adults is not recommended (Level D). There is insufficient evidence to recommend screening for bladder cancer in asymptomatic individuals (Level I).

Other Health Conditions

All adults (Level B) should be screened for obesity by calculating their body mass index (BMI). Individuals with a BMI greater than 30 kg/m3 should be offered or referred for intensive multicomponent behavioral intervention. There is insufficient evidence to recommend screening of asymptomatic adults for type 2 diabetes mellitus (Level I), although screening is recommended (Level B) for adults with hypertension (135/89 or more sustained or untreated) or hyperlipidemia. Depression screening is recommended (Level B) if there are mechanisms in place for ensuring accurate diagnosis, treatment, and follow-up. Screening and counseling to identify and promote cessation of tobacco use is strongly recommended (Level A). Screening and counseling to identify and prevent the misuse of alcohol is also recommended (Level B ). The USPSTF states there is insufficient evidence (Level I) for or against routine screening of thyroid disease in asymptomatic individuals.

IMMUNIZATIONS

As is the case for well-child care, the provision of age- and condition-appropriate immunizations is an important component of well-adult care. Recommendations for immunizations change from time to time and the most up-to-date source of vaccine recommendations is the Advisory Committee on Immunization Practices. Its immunization schedules are widely published and are available at the Centers for Disease Control and Prevention (CDC) Website (among other places), www.cdc.gov.

The CDC has recently recommended that all adults between 19 and 65 years of age should receive a booster of Tdap in place of a scheduled dose of Td due to waning immunity against pertussis and the presence of an increasing number of cases of pertussis nationwide. Adults who have not had a Td booster in 10 years or more and who have never had a dose of Tdap as an adult should receive a booster vaccination with Tdap. Persons who may need an increase in protection against pertussis, including health-care workers, childcare providers, or those who anticipate having close contact with infants younger than 1 year, should also receive a Tdap booster.

In a 2010 update, the CDC recommended routine vaccination against influenza for everyone 6 months of age and older. T his replaced a recommendation of vaccination based upon risk factors.

Pneumococcal polysaccharide (PPSV-23) and pneumococcal conjugate (PCV-13) vaccination are recommended for all adults aged 65 or older. PPSV-23 and/ or PCV-13 may also be recommended for previously unvaccinated adults younger than 65 in the presence of immunocompromising or certain chronic medical conditions.

Other vaccinations may be recommended for specific populations, although not for all adults. Hepatitis B vaccination should be recommended for those at high risk of exposure, including health-care workers, those exposed to blood or blood products, dialysis patients, intravenous drug users, persons with multiple sexual partners or recent sexually transmitted diseases, and men who engage in sexual relations with other men. A new recommendation also suggests routine vaccination against hepatitis B for all patients with diabetes who have not previously been immunized. Hepatitis A vaccine is recommended for persons with chronic liver disease, who use clotting factors, who have occupational exposure to the hepatitis A virus, who use IV drugs, men who have sex with men, or who travel to countries where hepatitis A is endemic. Varicella vaccination is recommended for those with no reliable history of immunization or disease, who are seronegative on testing for varicella immunity, and who are at risk for exposure to varicella virus. Meningococcal vaccine is recommended for persons in high-risk groups, college dormitory residents and military recruits, with certain complement deficiencies, functional or anatomic asplenia, or who travel to countries where the disease is endemic.

HEALTHY LIFESTYLE

Along with the discussion of screening and promotion of tobacco cessation and prevention of alcohol misuse, other aspects of healthy living should be promoted by physicians. Exercise has been consistently shown to reduce the risk of cardiovascular disease, diabetes, obesity, and overall mortality. Even exercise of moderate amounts, such as walking for 30 minutes on most days of the week, has a positive effect on health. T he benefits increase with increasing the amount of exercise performed. Studies performed on counseling physically inactive persons to exercise have shown inconsistent results. However, the benefits of exercise are clear and should be promoted. Counseling to promote a healthy diet in persons with hyperlipidemia, other risk factors for cardiovascular disease, or other conditions related to diet is beneficial. Intensive counseling by physicians or, when appropriate, referral to dietary counselors or nutritionists, can improve health outcomes. In selected patients, recommendations regarding safer sexual practices, including the use of condoms, may be appropriate to reduce the risk or recurrence of sexually transmitted diseases. Finally, all patients should be encouraged to use seat belts and avoid driving while under the influence of alcohol or drugs, as motor vehicle accidents remain a leading cause of morbidity and mortality in adults.

COMPREHENSION QUESTIONS

1.1 A 52-year-old man comes into the outpatient clinic for an annual "checkup:' He is in good health, and has a relatively unremarkable family history. He has never smoked cigarettes. For which of the following disorders should a screening test be performed?

A. Prostate cancer

B. Lung cancer

C. Abdominal aortic aneurysm

D. Colon cancer

1.2 A 62-year-old man with recently diagnosed emphysema presents to your office in November for a routine examination. He has not had any immunizations in more than 10 years. Which of the following immunizations would be most appropriate for this individual?

A. Tetanus-diphtheria (Td) only

B. Tdap, pneumococcal, and influenza

C. Pneumococcal and influenza

D. Tdap, pneumococcal, influenza, and meningococcal

1.3 A 49-year-old sedentary man has made an appointment because his best friend died of an MI at age 50. He asks about an exercise and weight loss program. In counseling him, which of the following statements regarding exercise is most accurate?

A. To be beneficial, exercise must be performed every day.

B. Walking for exercise has not been shown to improve meaningful clinical outcomes.

C. Counseling patients to exercise has not been shown consistently to increase the number of patients who exercise.

D. Intense exercise offers no health benefit over mild to moderate amounts of exercise.

ANSWERS

1.1 D. Colon cancer screening is given a Level A recommendation by the USPSTF and is routinely offered or provided to all adults older than 50 years. T here is insufficient evidence to recommend for or against routine lung or prostate cancer screening. Abdominal aortic aneurysm screening is recommended in men aged 65 to 75 years who have smoked.

1.2 B. In an adult with a chronic lung disease, one-time vaccination with pneumococcal vaccine and annual vaccination with influenza vaccine are recommended. A Tdap booster should be recommended to all adults who have not had a Td booster within 10 years and have never had a Tdap vaccine as an adult.

1.3 C. T he benefits of exercise are clear. Exercise decreases cardiovascular risk factors, increases insulin sensitivity, decreases the incidence of the metabolic syndrome, and decreases cardiovascular mortality regardless of obesity. T he benefits of counseling patients regarding exercise are not so clear and counseling does not seem to increase the number of patients who exercise.

CLINICAL PEARLS

⯈ There is no such thing as a "routine blood test" or a "routine chest x-ray:' All tests that are ordered should have evidence to support their benefit .

⯈ High-quality, evidence-based recommendations for preventive health services are available at www.uspreventiveservicestaskforce.org.

REFERENCES

Blaha, MJ, Bansal S, RoufR, Golden SH, Blumenthal RS, Defilippis AP. A practical"ABCDE" approach to the metabolic syndrome. Mayo Clin Proc. 2008 Aug;83(8):932-941. 

Centers for Disease Control and Prevention. Vaccines and immunizations . Available at: http:/ /www. cdc.gov/vaccines/. Accessed May 24, 2015. 

Mosby's Marie T. O'Toole, editor Medical Dictionary. 8th ed. St Louis, MO: Mosby Elsevier; 2008. 

United States Preventive Services Task Force. Recommendations for primary care practice. Available at: http://www.uspreventiveservicestaskforce.org/Page/Name/recommendations. Accessed May 24, 2015.

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