Preventive Medicine
Guidelines
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:
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
-
Guide to Clinical Preventive Services, 2nd Ed., U.S. Preventive Services Task
Force, 1995.
-
Clinicians Handbook of Preventive Services, U.S. Dept of Health and Human Services
1998.
-
TRICARE Prime Clinical Preventive Services Benefits, Dec 1995. Office of the Assistant
Secretary of Defense-Health Affairs.
-
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).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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