1 Prevention and ScreeningDr. hassan raji
2 “ Don’t just keep your patients alive for along time – keep them young young while they are alive”
3 Preventive Medicine in Family Practice:Health: Physical, Psychological social well being & spiritual. Health fluctuate & change in health is normal. Disease: abnormalities of structure and function named pathological entities. Identified by Dr. Illness: response of p.t to problem, is related to the personality & experience of p.t.
4 The continuing and comprehensive nature of the care provided by family physicians (FP) enable them to accept responsibilities for the whole process of prevention. Because of their personal knowledge of patients and families they may be able to identify risks to health that would not apparent to another observer. There relationship with patients and the trust they acquire can be important factors in motivating patient to comply with measures designed to maintain health. Anticipatory care includes all measures which promote good health and prevent or delay the onset of disease or their complications. It includes the three distinct level of preventive intervention.
5 Primary Prevention: Removing the causal agents e. gPrimary Prevention: Removing the causal agents e.g. sanitation, immunization, health education. Secondary Prevention: Identifying presymptomatic disease (or disease risk factors) before significant damage is done e.g. screening. Tertiary Prevention: Management of established disease so as to minimize disability e.g. treatment of hypertension to prevent stroke. Screening: detect condition before symptoms occur in the hope of altering the natural history of the disease. It is an application of certain procedures to population by doctor initiative with the aim of identifying asymptomatic disease or people at particular risk from it.
6 Main types of preventive activity practicedby F.P: Immunization. Health education e.g. preparation for child birth, nutrition education, counseling on smoking and w.t reduction. Developmental assessment: the monitoring of growth and development in infancy and childhood.
7 Screening and case finding: screening procedure is one that is applied to an unselected population to identify those members who are either disease or at risk for a disease e.g. population of town may be screened for hypertension. In case finding person is identified as diseased or at risk by the physician responsible for his or her health care e.g. p.t may be identified as hypertension while attending for skin infection. Methods of screening - Case finding: (opportunistic or anticipatory care). - True screening by questionnaire, letters, home visit or purpose designed clinic.
8 Requirements of screening program (WilsonCriteria): The condition must be: a) Common b) Important c) Diagnosable by acceptable method 2) There must be latent interval in which effective intervention treatment is possible.
9 3) Screening must be: a) Simple and cheep if possible and in any case cost effective. b) Continuous. c) On group agreed by policy to be at high risk. Also the disease is treatable and that screening test are highly sensitive (few false negative), highly specific (few false positive), safe, non-invasive, acceptable to patient and easy to interpret. The test should have high positive predictive value.
10 Setting up a screening program:Identifying problem which meets the Wilson Criteria and which the practice agrees in priority. Auditing the records to establish abase line performance of the practice and then deciding whether to proceed. Counting the numbers: how big is the under taking, do we know the name of high risk group? Defining objective e.g. measure the blood pressure of all males over 40 years old.
11 5) Defining methods: a) opportunisticb) by patient invitation c) by patient visiting 6) Defining the participant e.g. practice nurse. 7) Participants may need training and equipment and need to have protocol and time to do the job. 8) Review after a trial period. Has the performance improved, are objective being met? Decide whether to continue.
12 Prevention: Clean water, balanced diet & good housing are still major determinants of health. Scope for improving health by legislation in areas as industrial hazards, smoking, environmental pollution and traffic accident.
13 Purpose of the Periodic Health Examination PME):Preventing disease (Pry prevention) e.g. immunization. Identifying risk factor for common disease such as hyperlipidaemia and obesity. Case finding (zry prevention) to detect asymptomatic disease such as screening for cervical or colorectal cancer, hypertension & glaucoma. 4. Counseling and educating patients to promote health behavior such as diet, exercise & smoking cessation. 5. Updating the patients clinical data including any new medical condition such as surgeries or allergies. 6. Enhancing patient / physician communication: It is imp. that the p.t. knows and trusts the physician & becomes an active partner in his or her own health.
14 Screening for cervical cancer:Pap smears should be performed at least every 3 years in sexually active women who have cervix Screening for colon cancer: With annual fecal occult blood, flexible sigmoidscopy or colonoscopy every 3-5 years. Screening for breast cancer: With physician – performed clinical breast exam. In combination with annual mammography in women over the age of 50 years.
15 Major risk factors for atheroscleroticcardiovascular disease: Fixed: 1) Advanced age. 2) Male gender or postmenopausal female. 3) Family history of premature coronary heart disease. Modifiable: 1) Cigarette smoking 2) Hypertension 3) Sedentary life 4) D.M. 5) Obesity
16 Benefits of exercise: Reduced risk of CHD. Reduced serum lipids. Reduced obesity. Reduced D.M. Reduced hypertension. Protects against osteoporosis. Promotes mental well being.
17 Which patients should take aspirin?All p.t with known CHD (dose mg/day). For men over 40 years old without CHD but with one or more risk factors for C.V.D (dose mg/day). For all p.t with history of non-cardiogenic stroke or transient ischaemic attach (dose may need to be as high as mg/day) although lower dose may be equally effective.
18 Risk factors for stroke are:Age, hypertension, atrial fibrillation (A.F), history of transient ischaemic attack smoking, hyperlipidaemia, diabetes also may play a role. The important steps physician can take to prevent stroke: Control of both systolic & diastolic hypertension. Anticoagulation of in pt. with A.F. Antiplatelet in p.t with history of transient ischaemic attack either with aspirin or ticlopidin. Smoking cessation.
19 Screening for Tuberculosis (TB):Screening programs represent critical component of (TB) control and should focus on high-risk population including: House holds members and close contacts of persons with known or suspected TB. People with HIV infection. People with medical risk factors known to increase the risk of disease e.g. D.M, gastrectomy, C.R.F, p.t on prolonged high dose corticosteroid therapy.
20 4. Medically underserved, low-income populations.5. High-risk racial or ethnic minority. 6. Persons who inject illicit drugs. 7. Residents & employees of congregate settings e.g. nursing homes, mental institutions, homeless shelters. 8. Health care workers who care for high risk patients. 9. Infant, children & adolescents exposed to adults in high-risk categories.
21 Screening methods for (TB):Tuberculin test is the standard method for demonstrating TB infection. Purified protein derivative (PPD) used in dose of 5 tuberculin units T.U (0.1mm of PPD) tuberculin administered intracutaneously (Mantoux test) or with multiple- puncture technique & should be read at hrs.
22 Persons are considered to have (+) reactions with theMantoux test in the following situations: Induration ≥ 5mm: people with HIV infection, close contact of infectious case and people with fibrotic lesions on CXR. Induration ≥ 10mm: all other persons with risk factors for TB. Induration ≥ 15mm: all other persons (e.g. low risk persons for whom screening is not recommended). People with (+) skin reaction should be evaluated further to asses whether they have active disease e.g. clinical exam. CXR & sputum exam.
23 Screening for Diabetes Mellitus (D.M) high-risk indiv.:Obesity (> 20% over ideal body w.t). F.H of D.M. Age > 40 years plus one other high risk condition. Previously identified impaired glucose tolerance. Hypertension & Hyperlipidaemia. History of gestational diabetes or delivery of infant weighing > 4kg. Classic symptoms-polyuria, fatigue, w.t loss. Recurrent skin, genital or urinary tract infections.