UNDER 65 HEALTH MAINTENANCE v2

Health Maintenance
 
BP screen/control performed today
Next screen due in 2 years as BP <120/80
- Next screen due in 1 year as BP <140/90 and patient under 60
- Next screen due in 1 year as BP <150/90 and patient 60 or greater
- See HTN plan above
 
Dyslipidemia
- Patient has risk factors for dyslipidemia (HTN, obesity, DM, personal or family history) and is 20 or greater and has elected to undergo lipid screen (Grade B)
- Patient has risk factors for dyslipidemia (listed above) and is 45 or greater and has elected to undergo lipid screen (Grade A)
- Screening recommended, patient declines screening
- No risk factors present, screening not indicated
 
Patient’s ASCVD risk score is _ per 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol
- No further interventions required
- See plan above
 
Weight Control
BMI screening performed today
- Patient BMI <18.5, see underweight plan above
- Patient BMI WNL, discussed ACC/AHA diet and exercise recommendations to maintain weight
- Patient BMI 25 or greater, see overweight plan above
- Patient’s BMI >25 and CVD risk factors (HTN, HLD, DM, personal or family history) or >30, see obesity plan above
 
Diabetes:
Asymptomatic adult with sustained blood pressure >135/80 (treated or untreated)
Patient is >45 years of age, or BMI >25 and risk factors:
-Physical inactivity
-First degree relative
-High-risk race/ethnicity (African American, Latino, Native American, Asian, Pacific Islander)
-Women who delivered a baby weighing 9.0 lbs or were diagnosed with GDM
-Hypertension (140/90 or on therapy), HDL <35 and/or a triglyceride level >250
-Women with polycystic ovarian syndrome
-A1C 5.7%, IGT, or IFG on previous testing
-Clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans)
-History of CVD
 
Based on the above risk factors:
- Screening is not indicated
- Screening indicated, patient elects to be screened for diabetes with a hemoglobin A1C
- Patient with evidence of pre-diabetes and will be screened yearly
- Patient without evidence of pre-diabetes and will be screened every 3 years
- Screening indicated, patient declines screening
 
Cervical Cancer
Patient is 30 or above and requires PAP every 3 years, or PAP + HPV every 5 years
- Patient's last PAP was normal, her next PAP is due:
- Patient's last PAP was abnormal see plan above 
 
BRCA-Related Cancer
Patient is 18 years or older and has a family member with Breast, Ovarian, Tubal, or Peritoneal Cancer
- Patient found to be at risk for BRCA-related cancer and will undergo genetic counseling and possibly BRCA mutation testing
- Patient not found to be at risk for BRCA-related cancer, assess patient for changes in family history in 5 to 10 years
- Patient found to be at risk for BRCA-related cancer and refuses genetic counseling and screening
 
Breast Cancer
- I counseled the patient regarding the risks and benefits of annual vs. biennial screening (USPSTF recommends biennial screening, other organizations recommend annual).
- We discussed approximately 0.1-1.6 per 1000 women (NNT = 1000) will avoid death due to breast cancer with early screening, however, there has been no overall mortality benefit shown.
- We discussed approximately 510-690 per 1000 women (NNH = 1.67) will have at least 1 "false alarm" 60-80 of whom (NNH = 14) will undergo a biopsy.
- We discussed approximately 0-11 per 1000 women (NNH = 200) will be over diagnosed and treated needlessly with surgery, radiation, and/or chemotherapy.
- We discussed no increased risk of advanced stage or large breast cancers in women aged 50 to 74 years who had biennial, compared with annual, mammography.
- We discussed the lower rates of false positives, over diagnosis, and unnecessary treatment with biennial screening.
 
 
Patient is 50 or greater, or is 40 to 49 with risk factors for early BCx
- Opt in for mammography screening now, continue annual CBE
- Patient declines screening
- Patient's last mammogram was normal, her next mammogram is due:
- Patient's last mammogram was abnormal, her next mammogram is du:
 
Colorectal Cancer
- We discussed colonoscopy (associated with 271 life-years gained for every 1000 persons screened, Hemoccult II, and flexible sigmoidoscopy (218 and 199 life-years gained, respectively, per 1000 persons screened).
- Patient elects to undergo colonoscopy every 10 years
- Patient elects to undergo flexible sigmoidoscopy every 5 years
- Patient elects to undergo yearly FOBT/Hemoccult screening
- Patient declines screening
 
Lung Cancer
 Patient is >55 years with 30 pack-year smoking history and currently smokes or quit within the past 15 years
- We discussed the risks and benefits of low-dose CT.
- I rec'd low-dose CT based on the 20% reduction in lung cancer mortality with screening (NNT 5), and all-cause mortality of 6.7% (NNT 15) based on the NLST randomized trial.
- We discussed the potential harms of screening including high rates of "false-positive" (non-cancer) findings leading to additional testing (usually serial imaging), which may include invasive procedures.
- Will continue with annual screening until the patient has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
- Patient elects for annual screen, next screening due: _
- Patient declines screening
 
Vaccines
Seasonal influenza: 
Td/Tdap
Pneumococcal vaccine
 
-PPSV23 only. Indication: Patient with at intermediate risk of pneumococcal disease (cigarette smoker; chronic heart disease, chronic lung disease, diabetes mellitus, alcoholism, and/or chronic liver disease)
 
-PCV13 followed at least eight weeks later by PPSV23. Indication: Patient is at high risk of pneumococcal disease (functional or anatomic asplenia, an immunocompromising condition [eg, HIV infection, cancer], cerebrospinal fluid leak, a cochlear implant, and/or advanced kidney disease)
 
Hepatitis A Indication: Patient with risk factors (MSM, IVDU, chronic liver disease or receive clotting factor concentrates, working with HAV-infected primates or with HAV in a research laboratory setting, travel to high or intermediate endemicity of hepatitis A, close personal contact (eg, household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity)
 
Hepatitis B Indication: Patient with risk factors (Sexually active with >1 partner during the previous 6 months, seeking evaluation or treatment for a STD, IVDU, MSM, Healthcare personnel and public safety workers, DM, end-stage renal disease, HIV, and/or chronic liver disease)
 
Meningococcal (two doses at least two months apart due) Indication: Patient with risk factors (anatomical or functional asplenia, persistent complement component deficiencies, microbiologists routinely exposed to isolates of Neisseria meningitides (1 dose), military recruits, First-year college student up through age 21 (if not vaccinated at 16). Booster rec’d every five years is recommended for adults previously vaccinated who remain at increased risk for infection as above, patient due:
 
- Patient elects for the following vaccines: _
- Patient declines the following vaccines: _
 
STD
Indication: Patient without risk factors, no further testing indicated
Indication: Patient with risk factors (MSM, IVDU, multiple partners, or seeking STD screening/treatment)
- Patient elects to be screened for:
- GC/Chlamydia, HIV, and Hepatitis B, annually for risk factors listed above
- Syphilis, annually for risk factors (commercial sex worker, pregnancy, and/or person in correctional facilities)
- Patient declines screening
 
HIV
- All low risk adults should receive 1 HIV screen during their lifetime. For patient with high risk sexual activity see above STD screening recommendations.
- Patient elects to be screened today
- Patient declines screening
 
Hepatitis C:
-history of illicit injection drug use or intranasal cocaine use, even if only used once
-received clotting factors made before 1987
-received blood/organs before July 1992
-received blood from a donor who later tested positive for HCV
-born to HCV-infected mother
-needle stick injury or mucosal exposure to HCV-positive blood
-current sexual partner of an HCV-infected person
-liver disease (persistently elevated alanine aminotransferase [ALT] level)
-born in the United States between 1945 and 1965
-chronic hemodialysis
-HIV
-Incarcerated
 
- We discussed the risks and benefits of screening.
- I rec'd screening based on the all-cause mortality reduction, decrease in rates of progression to chronic liver disease, and hepatocellular carcinoma in patients with sustained serologic response to antiviral treatment.
- We discussed the risk of screening, including false positives which may lead to unnecessary liver biopsy or treatment with antivirals.
 
- Patient without ongoing risk factors and therefore elects to be screened only once
- Patient with ongoing risk factors and elects to be screened annually or sooner as needed
- Patient declines screening
 
Psycho-social:
- Patient without evidence of or risk factors for depression, anxiety, alcohol, tobacco, or domestic abuse
Health Maintenance

BP screen/control performed today
Next screen due in 2 years as BP <120/80
- Next screen due in 1 year as BP <140/90 and patient under 60
- Next screen due in 1 year as BP <150/90 and patient 60 or greater
- See HTN plan above

Dyslipidemia
- Patient has risk factors for dyslipidemia (HTN, obesity, DM, personal or family history) and is 20 or greater and has elected to undergo lipid screen (Grade B)
- Patient has risk factors for dyslipidemia (listed above) and is 45 or greater and has elected to undergo lipid screen (Grade A)
- Screening recommended, patient declines screening
- No risk factors present, screening not indicated

Patient’s ASCVD risk score is _ per 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol
- No further interventions required
- See plan above

Weight Control
BMI screening performed today
- Patient BMI <18.5, see underweight plan above
- Patient BMI WNL, discussed ACC/AHA diet and exercise recommendations to maintain weight
- Patient BMI 25 or greater, see overweight plan above
- Patient’s BMI >25 and CVD risk factors (HTN, HLD, DM, personal or family history) or >30, see obesity plan above

Diabetes:
Asymptomatic adult with sustained blood pressure >135/80 (treated or untreated)
Patient is >45 years of age, or BMI >25 and risk factors:
-Physical inactivity
-First degree relative
-High-risk race/ethnicity (African American, Latino, Native American, Asian, Pacific Islander)
-Women who delivered a baby weighing 9.0 lbs or were diagnosed with GDM
-Hypertension (140/90 or on therapy), HDL <35 and/or a triglyceride level >250
-Women with polycystic ovarian syndrome
-A1C 5.7%, IGT, or IFG on previous testing
-Clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans)
-History of CVD

Based on the above risk factors:
- Screening is not indicated
- Screening indicated, patient elects to be screened for diabetes with a hemoglobin A1C
- Patient with evidence of pre-diabetes and will be screened yearly
- Patient without evidence of pre-diabetes and will be screened every 3 years
- Screening indicated, patient declines screening

Cervical Cancer
Patient is 30 or above and requires PAP every 3 years, or PAP + HPV every 5 years
- Patient's last PAP was normal, her next PAP is due:
- Patient's last PAP was abnormal see plan above

BRCA-Related Cancer
Patient is 18 years or older and has a family member with Breast, Ovarian, Tubal, or Peritoneal Cancer
- Patient found to be at risk for BRCA-related cancer and will undergo genetic counseling and possibly BRCA mutation testing
- Patient not found to be at risk for BRCA-related cancer, assess patient for changes in family history in 5 to 10 years
- Patient found to be at risk for BRCA-related cancer and refuses genetic counseling and screening

Breast Cancer
- I counseled the patient regarding the risks and benefits of annual vs. biennial screening (USPSTF recommends biennial screening, other organizations recommend annual).
- We discussed approximately 0.1-1.6 per 1000 women (NNT = 1000) will avoid death due to breast cancer with early screening, however, there has been no overall mortality benefit shown.
- We discussed approximately 510-690 per 1000 women (NNH = 1.67) will have at least 1 "false alarm" 60-80 of whom (NNH = 14) will undergo a biopsy.
- We discussed approximately 0-11 per 1000 women (NNH = 200) will be over diagnosed and treated needlessly with surgery, radiation, and/or chemotherapy.
- We discussed no increased risk of advanced stage or large breast cancers in women aged 50 to 74 years who had biennial, compared with annual, mammography.
- We discussed the lower rates of false positives, over diagnosis, and unnecessary treatment with biennial screening.


Patient is 50 or greater, or is 40 to 49 with risk factors for early BCx
- Opt in for mammography screening now, continue annual CBE
- Patient declines screening
- Patient's last mammogram was normal, her next mammogram is due:
- Patient's last mammogram was abnormal, her next mammogram is du:

Colorectal Cancer
- We discussed colonoscopy (associated with 271 life-years gained for every 1000 persons screened, Hemoccult II, and flexible sigmoidoscopy (218 and 199 life-years gained, respectively, per 1000 persons screened).
- Patient elects to undergo colonoscopy every 10 years
- Patient elects to undergo flexible sigmoidoscopy every 5 years
- Patient elects to undergo yearly FOBT/Hemoccult screening
- Patient declines screening

Lung Cancer
Patient is >55 years with 30 pack-year smoking history and currently smokes or quit within the past 15 years
- We discussed the risks and benefits of low-dose CT.
- I rec'd low-dose CT based on the 20% reduction in lung cancer mortality with screening (NNT 5), and all-cause mortality of 6.7% (NNT 15) based on the NLST randomized trial.
- We discussed the potential harms of screening including high rates of "false-positive" (non-cancer) findings leading to additional testing (usually serial imaging), which may include invasive procedures.
- Will continue with annual screening until the patient has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
- Patient elects for annual screen, next screening due: _
- Patient declines screening

Vaccines
Seasonal influenza:
Td/Tdap
Pneumococcal vaccine

-PPSV23 only. Indication: Patient with at intermediate risk of pneumococcal disease (cigarette smoker; chronic heart disease, chronic lung disease, diabetes mellitus, alcoholism, and/or chronic liver disease)

-PCV13 followed at least eight weeks later by PPSV23. Indication: Patient is at high risk of pneumococcal disease (functional or anatomic asplenia, an immunocompromising condition [eg, HIV infection, cancer], cerebrospinal fluid leak, a cochlear implant, and/or advanced kidney disease)

Hepatitis A Indication: Patient with risk factors (MSM, IVDU, chronic liver disease or receive clotting factor concentrates, working with HAV-infected primates or with HAV in a research laboratory setting, travel to high or intermediate endemicity of hepatitis A, close personal contact (eg, household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity)

Hepatitis B Indication: Patient with risk factors (Sexually active with >1 partner during the previous 6 months, seeking evaluation or treatment for a STD, IVDU, MSM, Healthcare personnel and public safety workers, DM, end-stage renal disease, HIV, and/or chronic liver disease)

Meningococcal (two doses at least two months apart due) Indication: Patient with risk factors (anatomical or functional asplenia, persistent complement component deficiencies, microbiologists routinely exposed to isolates of Neisseria meningitides (1 dose), military recruits, First-year college student up through age 21 (if not vaccinated at 16). Booster rec’d every five years is recommended for adults previously vaccinated who remain at increased risk for infection as above, patient due:

- Patient elects for the following vaccines: _
- Patient declines the following vaccines: _

STD
Indication: Patient without risk factors, no further testing indicated
Indication: Patient with risk factors (MSM, IVDU, multiple partners, or seeking STD screening/treatment)
- Patient elects to be screened for:
- GC/Chlamydia, HIV, and Hepatitis B, annually for risk factors listed above
- Syphilis, annually for risk factors (commercial sex worker, pregnancy, and/or person in correctional facilities)
- Patient declines screening

HIV
- All low risk adults should receive 1 HIV screen during their lifetime. For patient with high risk sexual activity see above STD screening recommendations.
- Patient elects to be screened today
- Patient declines screening

Hepatitis C:
-history of illicit injection drug use or intranasal cocaine use, even if only used once
-received clotting factors made before 1987
-received blood/organs before July 1992
-received blood from a donor who later tested positive for HCV
-born to HCV-infected mother
-needle stick injury or mucosal exposure to HCV-positive blood
-current sexual partner of an HCV-infected person
-liver disease (persistently elevated alanine aminotransferase [ALT] level)
-born in the United States between 1945 and 1965
-chronic hemodialysis
-HIV
-Incarcerated

- We discussed the risks and benefits of screening.
- I rec'd screening based on the all-cause mortality reduction, decrease in rates of progression to chronic liver disease, and hepatocellular carcinoma in patients with sustained serologic response to antiviral treatment.
- We discussed the risk of screening, including false positives which may lead to unnecessary liver biopsy or treatment with antivirals.

- Patient without ongoing risk factors and therefore elects to be screened only once
- Patient with ongoing risk factors and elects to be screened annually or sooner as needed
- Patient declines screening

Psycho-social:
- Patient without evidence of or risk factors for depression, anxiety, alcohol, tobacco, or domestic abuse

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