6: Screening

Question 1

What should be done during 9 month check up visit? What anticipatory guidance will you provide?

Answer 1

• Comprehensive history~include oral health assessment (evaluate risk factors for caries)
• At all visits, perform developmental surveillance by asking parents if they have any concerns about the child’s development.
• Start formal developmental screening during the 9-month visit using a validated tool such as Parents’ Evaluation of Developmental Status (PEDS)
• Unclothed physical exam
• Include all three growth parameters (weight, length, and head circumference).
• The unclothed requirement is a federal requirement to meet EPSDT standards and must be clearly documented
• Vision screening~Ask parent’s appraisal of vision every visit, and refer for further testing if there are any concerns.
• Hearing screening~ask parent’s appraisal of hearing every visit, and refer for further testing if there are any concerns.
• Lab testing and screening~ consider hemoglobin (Hb) screening at this visit (or definitely screen at 12 months).10
• Immunizations
• Health education and anticipatory guidance~Injury prevention

Violence prevention, Nutrition counseling

Question 2

What is the A1C goal in general?

Answer 2

7%

Question 3

What is a positive lead level, and what do you do about it?

Answer 3

● Normal is less than 5 mcg/dL

● In 2012, the CDC changed their definition of acceptable lead level to reflect the 97.5% of all blood lead levels of children in the US. Any level above 5 mcg/dL is abnormal and needs to be repeated (see CDC recommendations regarding frequency based on level); and levels above 69 mcg/dL require chelation.

Question 4

Which screening tests are performed in the newborn nursery?

Answer 4

• Newborn Screen- All states require sickle cell disease, PKU, hypothyroidism, and cystic fibrosis screening.
• Critical congenital heart defect (CCHD) screening
• Hearing screening
• Hyperbilirubinemia screening

Question 5

Who should be screened for DMT1?

Answer 5

Screening is not recommended. Check only individuals with symptoms.

Question 6

Immunization recommendations for DM?

Answer 6

Flu and pneumococcal (age appropriate)

Question 7

What universal screening is done at the 12-month visit?

Answer 7

• Comprehensive history
• Unclothed physical exam
• Vision screening (instrument-based screening may be used at 12 and 24 months)
• Hearing screening (ask about concerns)
• Immunizations
• Health education and anticipatory guidance
• Oral Health
• Lab testing and screening~Hemoglobin (if not performed at 9-month visit~Universally checked at (9 or) 12 months to evaluate for iron-deficiency anemia
• TB risk assessment
• lead risk assessment

Question 8

Who should be screened for DMT2 (2)?

Answer 8

1. Adults with BMI >25.
2. Overweight children (weight/length >85%).

Question 9

when should children be assessed for TB risk?

Answer 9

12 months and then yearly

Question 10

Antiplatelet therapy recommendations for DM?

Answer 10

75-162 mg ASA daily unless contraindicated.

Question 11

How soon after birth should a newborn be seen in the office?

Answer 11

● The AAP recommends that all infants are seen at birth, and then within 3 to 5 days of birth (usually 48 to 72 hours after hospital discharge) to evaluate for feeding problems, jaundice, and provide breastfeeding education and support.

● Infants discharged less than 48 hours after delivery should be examined within 48 hours of hospital discharge.

Question 12

General nutrition recommendations for DM (4)?

Answer 12

1. Concentrate on healthy options. 2. No advantage to nutritional/vitamin supplements. 3. Limit alcohol (1/day women, 2/day men). 4. Sodium <2300 mg/day.

Question 13

Exercise recommendations for DM?

Answer 13

Children: 60 minutes/day Adults: 150 minutes/week

Question 14

How often should eye and foot exams happen with DM?

Answer 14

Eye = 1x/year minimum Foot = 2x/year minimum

Question 15

when should new moms be screened for postpartum depression?

Answer 15

• Edinburgh Postnatal Depression Scale (EPDS) should be administered to mothers in the hospital and then at outpatient EPSDT visits through 6 months
• Screen for maternal depression by 1 month, and at 2-, 4-, and 6-month visits

Question 16

BP goals for DM?

Answer 16

<140/90. If treated, include ACE/ARB.

Question 17

How often do you check A1C in DM?

Answer 17

2x/year if controlled. 4x/year if not controlled or medication is changed or there is significant weight loss.

Question 18

What are initial options for medication in DM?

Answer 18

Type 1: Insulin Type 2: Metformin, 2nd PO agent, and/or insulin

Question 19

ADA recommends the first dental exam should occur when?

Answer 19

At emergence of teeth or age 1. Not widely practiced. More common to present around age 3.

Question 20

Lipid goals for DM?

Answer 20

<70 with CVD risk factors. <100 without CVD risk factors.

Question 21

when should children have their lead level checked?

Answer 21

-All children with Medicaid need a lead level sent two times: at 12 months and 24 months.

• Capillary (finger stick) lead can be used as a screening and venous sample as follow-up.
• If a child aged 3 to 6 years has not ever been screened they need a lead level sent at least once.

Question 22

when should screening for autism take place?

Answer 22

• Autism surveillance occurs at every visit (through direct observation and asking parents if they have any concerns about their child’s learning, development, or behavior).
• Formal autism screening is routine and recommended for all children at 18 and 24 months, or at other ages with parental concerns

Question 23

What universal screening is done at the 2-year visit?

Answer 23

• Comprehensive history
• Autism screening for the second time
• Unclothed physical exam
• At age 2, measure height (standing) and not length
• *BMI calculated starting at this visit and every visit hereafter**
• *BMI less than 5% → underweight**

BMI 5% to 85% → normal

BMI 85% to 94% → overweight

BMI greater than or equal to 95% → obese

• Vision screening (instrument-based screening may be used at 12 and 24 months)
• Hearing screening (ask about concerns)
• Lab testing and screening
• Lead level – second one (required if she has Medicaid or if she is otherwise at risk)
• Start dyslipidemia risk assessment at 2 years old; then at 4, 6, 8, and then yearly. You plan to send a fasting or non-fasting lipid profile once between 9 and 11 years and again at 17 to 21 years as long as they continue to be low risk. If risk factors, send a screening lipid profile now
• Anemia risk assessment continues
• Immunizations
• Health education and anticipatory guidance

Question 24

what screenings is done for every adult, every visit?

Answer 24

• hypertension screening
• obesity screening
• depression screening
• smoking cessation
• alcohol screening

Question 25

what is recommendation for screening for chlamydia and gonorrhea?

Answer 25

- It is a grade B recommendation for all sexually active women 24 years old or younger to be screened for chlamydia, whether there are other risk factors, and for women older than 25 if there are risk factors. - Defined risk factors for chlamydia include age less than or equal to 24 years, a history of chlamydia in the past, a history of any other sexually transmitted infection (STI) in the past, new or multiple sexual partners, inconsistent condom use, and those who exchange sex for money or drugs.

Question 26

What is the recommendation for folic acid and child bearing aged women?

Answer 26

-It is an grade A recommendation that all women capable of becoming pregnant or planning pregnancy take a daily supplement containing 400 to 800 micrograms of folic acid daily to prevent neural tube defects in infants during development

Question 27

what is the recommendation for HIV screening?

Answer 27

- Screening for HIV is a grade A recommendation for all adolescents and adults ages 15 to 65 - A one-time screening for all is appropriate with future screenings for patients with risk factors.

Question 28

what is the recommendation for screening for syphilis?

Answer 28

- Screening for syphilis is a grade A recommendation for persons who are at increased risk for infection - Populations at higher risk include men who have sex with men and engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities

Question 29

What is the recommendation for cervical cancer screening?

Answer 29

- Cervical cancer screening with a Pap smear (cytology) is an A recommendation for women ages 21 to 65 every 3 years - For women over 30, screening via cytology and testing for high-risk human papillomavirus (HPV) or via high-risk HPV testing alone is appropriate; if both tests are normal, a 5-year screening interval can be employed.

Question 30

Additional points regarding cervical cancer screening (DO NOT screen these populations)

Answer 30

- D recommendation to screen women under 21 years - D recommendation to screen women over 65 with no risk factors - D recommendation to screen women under 30 with HPV typing (alone or with Pap) - D recommendation to screen women without a cervix who have no history of invasive cervical neoplasm (that is cervical intraepithelial neoplasia (CIN) 2,3 or cervical cancer)

Question 31

what is the recommendation for breast cancer screening?

Answer 31

- If a patient has no increased risk, it is a B recommendation to start mammograms routinely at 50. - Teaching self–breast exams is a D and is not recommended. The clinical breast exams that we do in the office are rated an “I” or inconclusive if they are of any benefit

Question 32

What is the recommendation for cholesterol screening for women?

Answer 32

- Grade A recommendation if they are older than 45 years old with increased risk factors - Grade B recommendation for women age 20 to 45 years old with increased risk factors - Grade C recommendation for women ages older than 20 years old with no increased risk

Question 33

What is the recommendation for screening for colon cancer?

Answer 33

- Screening starting at age 50 is an A recommendation for men and women. Routine screening should continue until age 75. - For patients age 76 to 85, colon cancer screening is a C recommendation. - For patients age older 85, it is a D recommendation, and they should not be screened

Question 34

The American Cancer Society offers any of the following plans as reasonable for colon cancer screening

Answer 34

1) Flexible sigmoidoscopy every 5 years 2) Colonoscopy every 10 years. 3) Double-contrast barium enema every 5 years 4) Guaiac-based fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) every year 5) Stool DNA test (sDNA) every 3 years

Question 35

What is the recommendation for osteoporosis screening?

Answer 35

- The USPSTF updated these recommendations in 2011 - Osteoporosis screening is a B recommendation for all women age 65 or older, and for younger women whose risk is similar to women at 65 with no risk factors (which is 9.3% 10-year risk of fracture) - You can use the FRAX tool to estimate risk to make these decisions, which can be found at: http://www.shef.ac.uk/FRAX/.

Question 36

what is the recommendation for screening for Diabetes?

Question 37

What is the recommendation for screening for cholesterol?

Answer 37

The recommendation is to use a low- to moderate-dose statin for prevention IF patients are age 40 to 75 AND have one or more CVD risk factors (tobacco use, hypertension, diabetes, dyslipidemia) AND have a 10-year risk of CVD event that is greater than or equal to 10%. To calculate 10 years CVD event risk requires lipid screening

Question 38

what is the recommendation for hepatitis C screening?

Answer 38

-USPSTF recommends screening at periodic intervals for anyone at high risk for hepatitis C infection, and recommends offering a one-time screening for any adult born between 1945 and 1965. (This is because they estimate that 75% of all current cases of Hep C in the United States are in persons in this age range.) This is a B recommendation. **Beyond those born in the above age group (for which only one-time screening is recommended), those in these increased risk groups should be screened periodically:** Persons who use intravenous illicit drugs Those who received a blood transfusion before 1992 Persons on hemodialysis Persons born to a mother with hepatitis C Persons that have been incarcerated Those who use intravenous drugs Persons who have had unregulated tattoos placed

Question 39

what is the recommendation for screening for AAA in men?

Answer 39

It is a grade B recommendation that all men ages 65 to 75 with a history of smoking, be screened one time for AAA with an abdominal ultrasound.