TALK MORE EXAMINE LESS

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TALK MOREEXAMINE LESS

• Health Maintenance for Adults

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Making Each Visit Count

• Careful history
• Identify risk factors in Hx to focus the exam
• Select screening (exam and tests) based on age,
  gender and other risks such as
• low socioeconomic status, coronary risks, unsafe
  sex practices, tobacco exposure, ETOH, substance/
  drug abuse, post-menopause status, personal or Fm
  Hx of cancer, diabetes mellitus or gestational DM
  

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Leading Causes of Death

• 20-40 years
• Unintentional injuries, MVAs, Homicide/Violence,
  Suicide, HIV/AIDS, STDs
• 40-65 years
• Cardio-Vascular Disease
• Malignant Neoplasm
• Pulmonary Disease

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20-40 Age Group

• Contributing causes
• Homicide, Suicide, Violence access to weapons,
  substance use/abuse-drugs and ETOH, illegal
  behaviors, emotional issues
• MVA, Accidentssubstance use/abuse,
  inattention/distraction
• STDs and HIV unsafe sexual practices, multiple
  partners, substance use/abuse especially ETOH,
  emotional issues

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40 to 65 Age Group

• Contributing Causes
• Cardio-Vascular Disease smoking/tobacco use,
  diet/nutrition/hyperlipidemia, genetics
• Malignant Neoplasms smoking/tobacco use,
  diet/nutrition, exposure to toxic/noxious agents,
  genetics
• Pulmonary Disease smoking, exposure to
  toxic/noxious agents in environment/occ

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Malignant Neoplasms Women

• Women (in order)
• Incidence Breast, Lung, Colorectal, Uterus,
  Ovaries
• Death Lung, Breast, Colorectal, Ovary, Pancreas
• Cancer eventually develops in 30 of Americans. 3
  of 4 families affected

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Malignant Neoplasms Male

• Men (in order)
• Incidence Prostate, Lung, Colorectal, Bladder,
  Lymphoma, Melanoma,Oral
• Death Lung, Prostate, Colorectal, Pancreas,
  Lymphoma, Leukemia
• Cancer eventually develops in 30 of Americans. 3
  of 4 families affected

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Screening Exams and Tests

• Height
• once in early 20s then in women at 40 begin q
  2-3 yr, if risks for Osteoporosis begin at 35 or
  when risk assumed.
• Weight
• Dependent on risk factors establish a baseline
  observe for fluctuations, BMI (body mass index)
  each yr. Wt (kg)/Ht (m sq), adult growth charts

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Screening Exams and Tests

• Obesity major public health concern 1/3 of all
  Americans over-weight
• Def of Obesity - excess body fat
• Def of Overweight - excess body weight to height
• Most Authorities state periodic as the
  recommendation for Wt screening or per risks and
  body habitus (what they look like).

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Screening Exams and Tests

• Blood Pressure
• q 1-2 x each year if within normal range then prn
  depending on results and risk factors
• if diastolic BP 85-89 mmhg then each visit
• Risk Factors that affect frequency of screening.
  African American descent, moderate obesity, first
  degree relative with HTN, personal Hx of HTN
• Most Authorities state periodic in their
  recommendations for screening depends on risk
  factors

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Screening Exams and Tests

• Cholesterol
• Total in early 20s then q 5 yr depending on
  results and on risk factors. Men begin greater
  vigilance at 35 yr. Women at 45 yr. Rx abn
  lipids in those with gt risk CAD
• Lipid screening includes total cholesterol (TC),
  and high density (HDL-C). Some clinicians will
  do total panel including trigylcerides esp if
  risk Factors CAD risks, family hx, early
  menopause, first degree relative with
  HTN/CAD/CVD, DM, Smoker.

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Screening Exams and Tests

• Eye/Vision Exams
• Authorities vary depending on constituent
  members. USPSTF recommends routine vision
  screening in elderly (gt65 yr).
• May do earlier and more frequently it depends on
  risk factors ie DM, Glaucoma
• Patients at high risk for glaucoma African
  Americans gt 40 yr Caucasian gt 65 yr, Pts with
  DM, severe myopia, or Fm Hx of glaucoma.
• Yrly Ophthalmolgy referral for person with DM

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Screening Exams and Tests

• Skin
• Authorities vary- USPSTF /- for routine
  screening. ACS q 3 yr age 20-39 and yrly 40
• Dont pass up opportunity to observe skin when
  clients seen for other reasons. Always Educate!
• Risk factors Melonocytic percursors, or maker
  moles, large numbers of common moles,
  immuno-suppression, Fm or Personal Hx of skin
  cancer, Hx of sun exposure, fair skin, hair, eyes

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Screening Exams and Tests

• Oral Exam
• In US 90 of oral and pharyngeal cancer
  attributable to tobacco and the synergistic
  effect of ETOH

• USPSTF /- routine screening. ACS -Q yearly in
  persons who do/did chew, or smoke tobacco, and in
  those especially gt50 who combine/d it with ETOH.
  All clients Yrly Dental exam espgt65yr

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Screening Exams and Tests

• Clinical Breast Exams
• Women lt 40 yr For Breast Cancer USPSTF no
  direct evidence of superior effectiveness of CBE
  alone compared with no other screening.
  Sensitivity 45 overall.
• Standard of Practice - follows ACOG Women over
  18 should have CBE during the periodic exam
  yearly or as approp depending on risk factors.
• Risk Factors Fm Hx of 1st degree relative before
  age 50, prior hx of Breast Ca, or atyp
  hyperplasia CBE q yr

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Screening Exams and Tests

• Clinical Breast Exam
• ACS, ACOG, ACP recommend yearly clinical breast
  exam on women 40 yr or gt
• Standard of practice, do CBE with periodic exam
  in gt 40 yr
• USPSTF Clinicians who advise BSE or who do
  routine CBE should understand currently insuff
  evidence that practice affects breast ca
  mortality, likely to gt incidence clinical
  assessment and biopsy.

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Screening Exams and Tests

• Mammography with Informed Consent
• Most effective approach to early detection of
  breast cancer, sensitivity of 70-90 and
  specificity of 90-95. When done by accredited
  screening centers
• Controversy When to begin how often to do?
• USPSTF recommends screening mammography,
  with/without CBE every 1 2 yrs for women aged 40
  70 yrs. (B rating). Some major studies have
  questioned if mammography screening reduces
  mortality in women younger than 50 yrs, more
  recently in all women! In studies frequency
  varied from 12 33 months. HIGH RISK DO
  ANNUALLY!

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Screening Exams and Tests

• Mammography More!
• Should refer pts to mammography screening centers
  with proper accreditation and quality assurance
  standards. http//www.fda.gov/cdrh/mammography/cer
  tified.html
• You must have office/clinic system in place to
  ensure timely and adequate follow-up for abn
  results often issue of liability cases.

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Screening Exams and Tests

• Mammography in Women gt70 yr
• Routine mammograms for All! Trends of women
  life-span longer more healthy live gt 90s
• USPSTF recommends frequency of 1-2 yrs but based
  on only two randomized trials of women gt 69 yr.
  no trials enrolled womengt 70yr Need for studies!
• Increased risk of breast ca in
• older women but greater chance
• of dying form comorbid illness.

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Screening Exams and Test

• Pap Smear (and Pelvic Exam)
• All women who are/have been sexually active
  should have regular Pelvic exams and Pap Smear.
• Exams all testing (including for STIs) begin
  when the woman first engages in
• sexual intercourse.
• If onset is not reliable assume 18 yrs.
• Def of regular depends on authority

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Screening Exams and Tests

• A little more consensus here than with Breast
  issues
• All women who are non-high risk. Should have two
  annual pap smears and pelvic exam and if pap WNL
  then may offer q 3 yrs.
• Risk factors Hx STDs, especially HPV, early age
  first intercourse, multiple sexual partners, long
  term use of OCs (gt5yr), low socioecon status, cig
  smokers.

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Screening Exams and Tests

• Paps (and Pelvics) Continued.
• CTFPHE USPSTF
• Routine pelvic exam is not recommended for the
  detection of ovarian cancer. (not sens or
  specific)
• insufficient evidence /- for screening of
  asymptomatic women who are not at increased risk.
  However the CTFPHE gets off the hook if you
  are doing a pelvic for another reason, then it is
  reasonable to do bimanual/adnexa

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Screening Exams and Tests

• Paps (and Pelvics) recommendationsMay begin to
  do Pap screen q 3yrs at 30ys if meet all the
  criteria.
• Criteria reg screened, has had two previously
  norm paps and has had no abn smears no new sex
  partners. (continue to screen in immigrants with
  hx. lack of reg screening prog).ACS PAP
  screening stopped at 70 if has been reg screened
• Hysterectomy no cervix, no Pap. If had
  hysterectomy for cancer, continue with Pap

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Screening Exams and Tests

• Large proportion, particularly elderly
  African-American, women of lower socioecon status
  do not have regular Paps. In some geographic
  areas, 75 of women gt 65 yr report no pap within
  previous 5 yr.

• gt25 of invasive cervical cancers occur in women
  gt 65 yr. 40-50 of all women who die of cervical
  cancer are gt 65 yr

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Screening Exams and Tests

• DRE, FOBT Sigmoidoscopy
• Risk factors for colorectal cancer include hx of
  one of the familial polyposis syndromes, Fm
  cancer syndromes colorectal ca in first degree
  relative, personal hx of IBDz (Inflammatory
  bowel), polyps, endometrial, ovarian or breast
  cancer

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Screening Exams and Tests

• DRE of NO value as a screening test for colo
  (rectal) cancer, fewer than 10 of colorectal
  cancers can be palpated. Probably a better exam
  for detecting rectal ca/masses. Can do FOBT at
  same time but neither adequate for CR Ca
  screening.
• USPSTF no recommendation made regarding use of
  DRE for colorectal screening. CTFPHE if do exam
  for men 50-70 yr, no need to discontinue
  practice. Women?????
• USPSTF screening if no risk gt 50 yr either by
  home FOBT annually, Sigmoidoscopy q 5 yr, BE q
  5yrs? or Colonoscopy q 10yr. If has risks screen
  when detected!

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Screening Exams and Tests

• Examination using a Flex Sig is very specific but
  sensitivity depends on skill of examiner and
  length of instrument (if no sedation ?? get to
  35cm few to 60 cm, if need to use sedation then
  Colonoscopy better)
• 30 of cancers within reach of 25 cm rigid
• 40-50 within reach of 35 cm flex
• 50-60 within reach of 60 cm flex
• No risk begin at 50 yrs repeat q 5-10 yrs
• FOBT q yr. High variable sens 26-92 but good
  specificity 90-99. Many false pos second to
  diet, meds, other GI conditions then must do
  follow-up.

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Screening Exams and Tests

• Colonoscopy detects 80-95 of CR cancers the Most
  Sensitive and Specific but comes with gt risk,
  expense, discomfort?
• CTFPHE does not recommend FOBT for routine
  screening, also does not recommend for at risk.
  Patients with true cancer family syndrome
  should be screened with colonoscopy, not FOBT or
  sigmoidoscopy
• USPSTF sigmo FOBT is preferable combining both
  results in superior results.

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Screening Exams and Tests

• Prostate Cancer
• most freq dx cancer in men, second leading cause
  of death in men.
• Risk factors increasing age, 80 of it dx in men
  over 65 yr. African American, FM Hx, ?/-
  increase fat intake. Autopsy studies show that
  30 of men over age 50 have histologic evidence
  of prostate cancer, yet carry only a 3 lifetime
  risk for death from it.
• ?Ethics should you screen in those who predicted
  life expectancy is lt 10 yrs!

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Screening Exams and Tests

• DRE/Prostate Exam
• Exam affords opportunity for limited palp of the
  prostate. Sensitivity 33-69 and the specificity
  49-97. Scant evidence that exam decreases
  mortality from prostate ca.
• Do in 50-70yr age group.
• ACS annual exam 50 gt yr, Am Uro
• for 40 gt yr if high risk, 45 yr AA.

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Screening Exam and Tests

• Prostate Specific Antigen Blood Test Must
  include informed consent!
• Gylcoprotein specific to the prostate NOT
  prostate cancer, produced by all types of
  prostate tissue. Sensitivity and Specificity a
  problem due to this. Pos predictive Value -
  (i.e. if you have cancer it will show it!) for
  lab values gt than 4 ng/ml range 20-30.
• However a sig of early cancers 10 20 will
  be missed with PSA testing alone.

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Screening Exams and Tests

• Controversy! No data indicating PSA screening
  decreases mortality from cancer. Address on indiv
  basis. Pts who seek screening fully informed
  before testing of risks and lack of est benefit
  of DRE PSA. Elevated PSA unreliable for dx of
  cancer. Only 20-30 of time. As PSA rises the
  proportion of pts with ca rises. However, 20 of
  pts with sig ca have N PSA.
• USPSTF insufficient evidence for routine
  screening by PSA, DRE or Utrasound.
• ACS, A Uro Assoc, Annual test gt 50 yr

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Screening Exams and Tests

• Testicular Exam
• 1 of all cancers most common in white men aged
  20-34 yr. Prognosis very good. 100 curable with
  early detection. Rate controversy 1/10,000 vs
  3/10,000?
• Risk factors cryptorchidism, Previous testicular
  ca, gonadal dysgenesis, Klinefelters syndrome, in
  utero DES
• No info on sensitivity or specificity of CTE or
  TSE exam. Published evidence re TSE detection,
  in asymp individ in small number of case reports.
  Screening not been studied but if 100,000 age
  15-35 were screened at most 10-30 cases detected.

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Screening Exams and Tests

• Testicular clinical exam
• USPSTF CTPHE no routine screening, but if being
  seen for other issues, ie STDs, Contraception,
  Sports PE, etc. then a good opportunity to
  examine 20-35 yr male and discuss issue, in high
  risk counseling, and TSE.
• Even though most lesions detected by Pt/Partner-
  no evidence for promotion of TSE per USPSTF but
  we do it! Be on alert if pt presents with
  hydrocele, epididymitis or testicular trauma.
• ACS exam q 3 yrs from 20-39 yrs.

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Screening Exams and Tests

• Asymp DM Fasting Plasma Glucose, best choice in
  asymp pts. GHbg (Ha1c) unreliable as screening
  tool as is RBS, and OGTT (inconvenient).
• DM affects 6.2 of US pop (14 mill), the
  prevalence of DM sig high among, Hispanics,
  African Americans, and American Indians. Leads
  to enormous amt of morbid and mortality,
  synergistic with other Dzs.
• Screening for Dm in asymptomatic non-pregnant
  adults is not recommended. Selected case finding
  for adults who are
• RISKS obese, older age gt40, HTN, Hyperlipids,
  Fm Hx, high risk ethnic group.

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Screening Exam and Tests

• Thyroid Screening rare cancer 4/100,000
• Female 77 cases 2x more than males
• Risk factors exposed to head neck x-rays
• in childhood, fm hx, or other endocrine
• neoplasms, post partum.
• Sens of thyroid palp 15 LOW
• Rx for thyroid ca is very effective overall
• 5 yr survival is 95 even in absence of
• formal screening. High false pos rate
• for palpation. TSH excllnt for screening
• for Dz if suspected per Hx and PE.
• USPSTF insuff evidence /- thyroid palp.

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Screening Exams and Tests

• Asymptomatic Anemia Hgb, Hct
• Anemia most common cause Fe def in young and
  those lt65y in gt 65 yr blood loss (GI bleed)
• Most prevalent in young women (4.5) and elderly
  men (4.8), more common in individuals of low
  socio-economic status, in African Americans.
  Hemaglobinopathies found in individuals of
  Mediterranean descent, Caribbean, Latin American,
  Asian and African American.
• No routine screening recommended

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Screening Exams and Tests

• STIs
• Syphilis, Gonorrhea, Chlamydia, HIV
• High risk sexually active persons, those who have
  had multiple sex partners, prior hx of STD,
  practice anal intercourse, prostitutes and
  persons who exchange sex for other goods, users
  of illicit drugs, inmates of detention centers.
  Rediscovered sexuality. Abused persons. Pregnant
  women.
• Offer STI screening, even if asymptomatic,
  especially Chlamydia, to all sexually active
  women 25 yrs and younger. Offer STI screening to
  those whose hx reveals risk factors or if one STI
  is present. In all age groups!

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Screening Exams and Tests

• Osteoporosis
• More than 25 million Americans have Osteoprosis.
  Each year 1.3 million . High morbidity and
  mortality assoc.
• After age 65 most common s are hip and arm
• 70 of s in people gt 45 yrs related to
  osteoporosis.
• common sites are lower thoracic lumber
  vertebrae
• Risk factors female, low dietary intake of
  Ca, during adolescence, early menopause,
  Caucasian or Asian ancestry, Fm Hx of
  osteoporosis, demineralizing states cancer,
  menopause, pregnancy, eating disorders, low
  estrogen states.

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Screening Exams and Tests

• USPSTF recommends that women 65 gt yr be screened
  routinely for Osteoporosis risk, begin at 60 yr
  in women at risk using the Osteoporosis Risk
  Assessment Instrument (ORAI).
• IF at risk- densitometry DXA
• Local standard of practice intital screen women
  gt 50 yrs, if not 2 SD below N for age ok screen
  in 10 yrs, encourage Ca intake exercise. If
  1 SD screen in 5 yrs, Ca, exercise, consider
  meds based on other risks. If 2 SD then all
  above and meds and follow up in 1 yr.

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Screening Tests and Exams

• Depression Screen those at high risk prior
  suicide attempt, recent life event (neg gt pos),
  worsening health self or sig other, unexplained
  fatigue, sleep disorder or unexplained somatic
  problems, female gender, post partum, lack of
  social support, hx of sex abuse, current subs
  abuse, hx of dom violence.
• USPSTF insuff evidence /- routine screening.
  Practitioner should maintain a high index of
  suspicion.
• Use one of formal screening tools.
• Have sys/protocol in place for pos screen- full
  work-up, treatment and close follow-up

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Screening Exams and Tests

• Cognitive Functional Impairment
• Will cover screening test specifics in more depth
  in Age gt 65yrs group.
• USPSTF insufficient evidence /- for routine
  screening in asymptomatic persons.
• Screening requires multiple aspects of mental
  function orientation, short term memory,
  receptive express language ability, attention
  and visual/spatial ability Mini Mental Status
  Exam (MMSE).

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Screening Exams and Tests

• Domestic Violence, Partner Violence USPSTF
  insufficient evidence /- use of specific
  screening instruments for family violence.
  Judicious for Examiner to include a few direct
  questions about abuse (physical or sexual) as
  part of routine hx.
• Risk presentation of multiple injuries and
  implausible explanation. Elderly in care of
  another at increased risk. Non-emancipated
  individuals- dev disabled, those with barriers of
  language or self-expression. Pregnant Women,
  young maternal age, substance abuse, single
  parent.

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Immunizations

• Tetanus-Diptheria (Td) q 10 yr,
• ACP single booster at 50 yrs if received initial
  series
• Varicella high prob of Immunity
• even with negative hx but do
• sero test and if neg vaccinate esp if high risk
• Health care workers, families with immunocomp
  members, workers in day care centers

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Immunizations

• Pneumoccocal
• CTFPHE all persons 55 yr or gt
• USPSTF all persons 65 yr or gt, or if younger and
  have any of the following risks
• Cardiac, Pulmonary, Renal disease, DM, Sickle
  Cell Disease, post chemo, living conditions that
  place at risk ie. Poverty, homelessness etc.
• USPSTF revaccinate especially in high risk folks
  who were vaccinated gt 5 yrs previous

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Immunization

• Influenza, offer annually to all individuals 65
  yrs of age or older. Also offer to adults who
  are at increased risk for influenza related
  complications
• Chronic Pulmonary and Cardiac disorders or those
  who may transmit influenza to individuals at risk
  i.e. health care worker and household members of
  immunocompromised

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Other

• PPD skin test with Mantoux all individuals at
  high risk.
• Close contact with persons known or suspected to
  have TB, HIV, inject illicit drugs or other high
  risk substance abusers (crack cocaine),
  immunocompromised, residents and employees of
  high-risk congregate setting (correctional,
  nursing home, mental institutions,
  homeless/residential facilities, health care
  workers, immigrant refugees

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Pharmaceuticals

• ASA Strong Recommend in Adults who are at
  increased risk for CHD. Discuss harms and
  benefits.
• AAFP (initially only men then added women) aged
  40 to 84 yrs with risk factors for CHD informed
  of the risk/benefit of prophylaxis

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Pharmaceuticals

• Estrogen, Progestin (HRT)
• ACOG, ACP, USPSTF, CTFPHE All peri and post Meno
  women should be counseled regarding the probable
  risks and benefits of HRT so they can make
  informed choice. USPSTF recommends against
  routine use of combined Estrogen/Progestin for
  prevention of chronic conditions of in postmeno
  women.
• Recommends against unopposed Estrogen in women
  who have had hysterectomy.

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Pharmaceuticals

• HRT for menopausal symptomsUSPSTF did not
  consider the use of HRT for the management of
  menopausal symptoms, which is the subject of
  recommendations by other expert groups. Women
  and clinicians should discuss the balance of
  risks and benefits.
• Stay tuned.

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Young Adult Advice

• Rejoice, O young man, in thy youth and let thy
  heart cheer thee in the days of thy youth, and
  walk in the ways of thine heart, and in the sight
  of thine eyes but know thou, that for all these
  things God will bring thee into judgment.
  Therefore remove sorrow from thy heart, and put
  away evil from thy flesh for childhood and youth
  are vanity.
• Old Testament Ecclesiastes 119-10

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Young Adult Advice

• What old people tell you you cannot do, you try
  and find you can. I am convinced that to
  maintain ourself on this earth is not a hardship,
  but a pastime, if we may live simply and
  wisely. Henry David Thoreau
• Life is a big canvas throw all the paint on it
  you can
• Danny Kaye

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Counseling Young Adult 20-40

• Smoking tobacco issues q visit
• Safe Sex q visit
• Contraception if appropriate q visit esp on
  annual exams/pap smear
• Injury and Accident Issues q visit
• Seatbelts, helmets, safety gear/personal
  protection at work/home/hobbies, smoke and CO
  detectors, DUI of ETOH or drugs, dont get in car
  with others, weapons/ ammunition.

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Counseling Young Adult 20-40

• ETOH, substance use vs abuseq visit
• Exercise 30mins q day or at least 3x/wk or more
  recent combination rec of time and frequency any
  opportunity
• Sun Protection sunscreen, hat, clothing any
  opportunity

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Counseling Young Adult 20-40

• Nutrition Cholesterol any opportunity
• Variety of foods, food pyramid, increase fruit,
  veg, low fat dairy, calcium intake, increase
  fiber, limit fats cholesterol, limit salt,
  adequate water 6 8oz glasses H20/day
• Self care self exams any opportunity
• Testicular, Breast, Skin, Oral, Immunizations.
  More to encourage personal investment in healthy
  body.

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Counseling Young Adult 20-40

• Anticipatory Guidance 20-35 yr PRN
• Independence own place, college, career,
  financial
• Establishing intimacy and relationships
• Marriage, adjusting life style
• Buying home, financial management
• Starting family, time management, changing roles,
  stressful times/emotional issues

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Counseling Young Adult 20-45

• Anticipatory guidance 35-45 yr PRN
• Balancing work/family
• Dealing with adolescent children, launching,
  communication issues
• Expanding family to admit new members
• Changing body image
• Stress, emotional issues

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Middle Age thoughts

• Forty is the old age of youth
• Fifty is the youth of old age
• (Victor Hugo)

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Middle Aged Opinions

• The Younger generation complains about what we
  are and do!
• They say theyll do better.
• They should! Theyre standing on our shoulders.
  (unknown)

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Mid-life Advice

• The most important words in midlife are Let Go.
  Let it happen to you. Let it happen to your
  partner. Let the feelings. Let the changes You
  are moving out of roles and into the self. It
  would be surprising if we didnt experience some
  pain as we leave the familiarity of one adult
  stage for the uncertainty of the next. But the
  willingness to move through each passage is
  equivalent to the willingness to live abundantly.
  If we dont change, we dont grow. If we dont
  grow, we are not really living. Gail Sheehy
  

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Counseling Middle Adult 40-65

• Smoking, Tobacco use q visit
• Blood Pressure
• If WNL, monitor at least annually
• Discuss prn Stress, relaxation, salt limit,
  exercise
• Injury and Accident Issues q visit
• Seatbelts, helmets, safety gear/personal
  protection at work/home/hobbies, smoke and CO
  detectors, DUI of ETOH or drugs, dont get in car
  with others,weapons/ ammunition.

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Counseling Middle Adult 40-65

• ETOH, substance use vs abuse q visit
• Exercise 30mins q day or at least 3x/wk any
  opportunity
• Sun Protection sunscreen, hat, clothing any
  opportunity
• Immunizations prn

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Counseling Middle Adult 40-65

• Nutrition Cholesterol any opportunity
• Variety of foods, food pyramid, increase fruit,
  veg, low fat dairy, calcium intake, increase
  fiber, limit fats cholesterol, limit salt,
  adequate water 6 8oz glasses H20/day
• Self exams and clinical exams prn
• SELF??? Skin, breast, oral, FOBT
• CLINICAL Sigmoidoscopy/colonoscopy, Pap, Mammo,
  Osteoporosis.

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Counseling Middle Adult 40-65

• Pharmaceuticals q visit
• Vts, Calcium, ASA.
• Anticipatory Guidance PRN
• Time of largest earning power, reassess goals
• New roles executive, retiree, grandparent.
• Losses job, home, spouse
• Insurance life, medical (Medicare)
• Durable power, advanced directives