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Operational Medicine 2001
GMO Manual

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General Medical Officer (GMO) Manual: Clinical Section

Preventive Medicine Guidelines

Department of the Navy
Bureau of Medicine and Surgery

Peer Review Status: Internally Peer Reviewed

Physical Exams

HIV

Pregnancy

U.S. Preventive Services

Counseling Service

Abuse

Skin Cancer

Tuberculosis

Male Specific Interventions

Colorectal Cancer

Immunization

Testicular Cancer

Thyroid Cancer

Female Specific Interventions

Prostate Cancer

Cholesterol Screening

Breast Cancer

Violence

Hypertension (HTN) Screening

Cervical Cancer

Final notes on Counseling

Vision Screening

Osteoporosis

References

Introduction

Good clinical practice demands comprehensive efforts in disease prevention and health promotion. A key element of this is providing appropriate preventive services to one's patient population.

Periodicity of Physical Exams

The current periodicity of physical exams for most active duty members is every 5 years until age 50, at intervals of 2 years through age 60, then annually after age 60. The exception is for all officers upon their selection to flag or general rank. A complete physical exam for these members shall be performed annually within 30 days of their birth date. More guidance on this type of exam can be found in MANMED 15-14. The routine physical exam should be tailored to a patient's individual risk factors. This is an opportunity to provide counseling on health behaviors and referral for appropriate preventive services.

U.S. Preventive Services Task Force Recommendations on Periodic Screening

Controversy and contradiction among major authorities abound regarding recommendations for screening services. Listed below are the screening examinations or services currently recommended for Navy beneficiaries. The current recommendations from the U.S. Preventive Services Task Force (USPSTF) are also given, where significant differences are present.

Skin Cancer

Skin examination should be performed annually for individuals with a family or personal history of skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions. Physicians should remain alert for skin lesions with malignant features (i.e., asymmetry, border irregularity, color variability, diameter > 6mm, or rapidly changing lesions.)

Colorectal Cancer

Colorectal cancer is the third leading cause of death from cancer in the United States. Screening for colorectal cancer is recommended for all persons starting at the age of 50. Fecal occult blood testing and Sigmoidoscopy are effective methods for screening. USPSTF states that there is insufficient evidence to recommend for or against routine screening with digital rectal examination, barium enema, or colonoscopy. However, some organizations (i.e. American Cancer Society) do recommend annual fecal occult blood testing and sigmoidoscopy every 5 years.

Thyroid Cancer

Palpation of the thyroid gland should be performed in adults with a history of upper body irradiation.

Cholesterol Screening

Beginning at age 18, non-fasting blood cholesterol should be obtained at least every 5 years. USPSTF states that routine periodic cholesterol screening should be performed on all men aged 35-65 and all women aged 45-65, with no recommended periodicity.

Hypertension (HTN) Screening

Blood pressure screening should be performed at least once every 2 years. Screening should occur annually for patients in the following categories:

    • Initial diastolic pressure 85-89 mmHg.

    • African-American males.

    • Family history of HTN in first degree relative.

    • Obesity.

    • Diabetes.

Vision Screening

For individuals requiring corrective lenses, examination of the eyes should occur at least every 2 years. Otherwise, routine vision screening is performed every 5 years. Comprehensive eye examination should be performed every 3 to 5 years in African Americans aged 20-39 years. For individuals aged 40-64 years of age, vision screening should occur every 2-4 years.

HIV

All active duty are routinely screened. Medical department personnel and personnel subject to deployment must have annual HIV testing. Other personnel are tested at their periodic physical exam. It is very important to counsel patients regarding high-risk behaviors and preventive measures.

Counseling Service

The following subjects are expected components of good clinical practice and should be integrated into the appropriate patient visit.

  • dietary assessment and nutrition

  • physical activity and exercise

  • cancer surveillance

  • safe sex practices

  • tobacco, alcohol, and other substance abuse

  • accident and injury prevention

  • promoting dental health

  • stress management

  • bereavement and suicide risk assessment

Tuberculosis

Tuberculin skin testing should be performed every 3 years for individuals on active duty, and annually, if deployable, health care worker, or at high risk.

Immunization

  • Tetanus/diphtheria
    Primary series then booster every 10 years or single booster age 50.

  • Hepatitis A
    This includes a 2 dose series separated by 6-12 months. This is required of all service personnel.

  • Hepatitis B
    This is only required for health care workers, patients treated for a sexually transmitted disease, and those engaging in high risk behaviors (IV drug use, multiple partners, same sex relationships).

  • Influenza
    Yearly administration to all service personnel. Particular emphasis is placed with health care workers, the elderly, and patients with chronic illness.

Female Specific Interventions

Breast Cancer

For women aged 40 and older, an annual clinical exam should be performed. In women under age 40, physicians may elect to perform a clinical breast examination for those who are at high risk. Most authorities recommend baseline mammogram at age 40 years, then every 2 years for age 40-50, and annually for age 50 and over. For high risk women, mammography may start at age 35, and annually thereafter. USPSTF advises routine mammography to be performed alone or with clinical breast exam (CBE) every 1-2 years in women aged 50-69 years. They further state that there is insufficient evidence to recommend for or against routine mammography or CBE for women aged 40-49 or aged 70 or older.

Cervical Cancer

Pelvic examination with Papanicolaou smear should be performed annually on women 18 years and over, until three consecutive satisfactory examinations. Frequency may then be less often at the discretion of the physician, but at least every 3 years.

Osteoporosis

All women should be counseled on proper intake of calcium and regular exercise, especially in young adulthood.

Pregnancy

Family planning, contraceptive counseling, and sexually transmitted disease prevention will be performed during every annual health maintenance examination.

Abuse

Women are at high risk for both physical and mental abuse. Estimates indicate that up to 1 in 4 emergency room visits by females may be the result of abuse. All female patients should be asked about abuse.

Male Specific Interventions

Testicular Cancer

A clinical testicular exam should be performed annually for males aged 13-39 years, especially those with a history of cryptorchism, orchiopexy, testicular atrophy, or those with history of testis tumor in the contralateral testis. There is disagreement among authorities whether to encourage patients to examine their testes regularly, or to screen low risk men.

Prostate Cancer

Digital rectal examination (DRE) should be part of the periodic health examination of males 40 years and older, and annually for men 50 years and older. This test can be combined with the colorectal examination. Routine use of prostate specific antigen is not recommended. USPSTF now advises against routine prostate screening.

Violence

Counseling about violence and abusive behavior should be offered for all male patients.

Final notes on Counseling

Clinicians should focus counseling efforts on encouraging patients to make wise choices regarding tobacco, alcohol and drug use, physical activity, diet, and other personal behaviors. When combined, these factors account for more than 50 percent of all deaths in the U.S. Clinicians should be selective in providing preventive services. Some screening tests are more effective in a specific high-risk group and are of limited value in the general population. Consider cost, availability of follow up, and the patient's interests before performing screening.

Every encounter with a patient can be used as an opportunity to emphasize prevention (i.e. encourage quitting tobacco use or obtaining a mammogram). Apart from direct patient-physician interaction, other opportunities include posters, brochures, or videos with messages on preventive medicine practices placed in clinic and other medical spaces.

References

  1. Guide to Clinical Preventive Services, 2nd Ed., U.S. Preventive Services Task Force, 1995.

  2. Clinician’s Handbook of Preventive Services, U.S. Dept of Health and Human Services 1998.

  3. TRICARE Prime Clinical Preventive Services Benefits, Dec 1995. Office of the Assistant Secretary of Defense-Health Affairs.

  4. Gardner, Pierce, and Schaffner, William, Immunization of Adults, New Engl J Med, 328: 1252., 1993.

Submitted by LCDR Eric Holmboe, MC, USNR, Department of Internal Medicine NMC Portsmouth, Portsmouth, VA. Revised by CDR Wayne Z. McBride MC, USN, Bureau of Medicine and Surgery (MED-24), Washington, D.C. (1999).


Approved for public release; Distribution is unlimited.

The listing of any non-Federal product in this CD is not an endorsement of the product itself, but simply an acknowledgement of the source. 

Operational Medicine 2001

Health Care in Military Settings

Bureau of Medicine and Surgery
Department of the Navy
2300 E Street NW
Washington, D.C
20372-5300

Operational Medicine
 Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
  January 1, 2001

United States Special Operations Command
7701 Tampa Point Blvd.
MacDill AFB, Florida
33621-5323

This web version is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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