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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 1. Screening/Physical Exam/Health…
31
nicated during the initial appointment, require clear explanation on how and when (1) results and (2) next steps will be
communicated. This is relevant in the context of wide use of
patient portals where patients will likely view both results
and lab/radiology interpretation before their clinician does
[19, 20].
Best practices when communicating with patients guide
clinicians to start with open-ended questions and then narrow
the focus with close-ended questions. Similarly, different
degrees of screening can be utilized as clinical decision support tools. Starting off with a broad screening process (one
with high sensitivity and low specificity, yielding increased
false positives) will allow the clinical team to gauge if there is
a need to further investigate. A screening tool that can better
hone in on a relevant issue (ideally, a process with a high sensitivity and a high specificity, yielding decreased false positives) can be used in a secondary manner if necessary. A
clinical example of this concept is the process used for screening for substance use. Through the process known as screening, brief intervention, and referral to treatment (SBIRT) for
substance use [21, 22], a prescreening is completed. If the
patient screens positively with the prescreening tool, a follow up screening is conducted which will further identify a patient
who is using alcohol beyond the healthy drinking guidelines,
potentially increasing the risk for health and psychosocial
consequences [23].
It is important to highlight that screening guidelines, protocols, and processes are ever evolving based on clinical
research investigating benefits vs. risks and patient feedback.
Over the years, certain screenings have triggered controversial debates based on review of mortality and morbidity rates
related to screening. Certain screenings may yield an increased
number of false positives, leading to further invasive investigations that can increase the degree of risk to patients.
Identifying patients at risk of overmedicalization may be
referred to as quaternary prevention [24].
32
J. Conigliaro and S. Kapoor
One example is the prostate-specific antigen (PSA) blood
test for detection of prostate cancer. As of 2018, PSA testing
has been listed as a grade “C” for men aged 55–69 and grade
“D” for those aged 70+ years old [25]. Multiple clinical trials
have shown evidence that a substantial percentage of men
who have asymptomatic cancer detected by PSA screening
have a tumor that either will not progress or will progress so
slowly that it would have remained asymptomatic for the
man’s lifetime (i.e., “overdiagnosis” or “pseudo-disease”)
[26]. Subsequent biopsies for positive PSA testing have led to
a multitude of complications (pain, discomfort, bleeding, psychological harm from false-positive results, etc.), and certain
studies even recommend that if PSA testing is to continue,
the threshold triggering biopsy or need for treatment should
be increased [27, 28]. The evolution of this discussion and
research has deemed that the benefits of PSA testing may not
outweigh the harms.
Conversely, there has been a paradigm shift in the thinking
and evidence around alcohol use screening, moving from the
CAGE to the AUDIT questionnaire [29]. Historically, the
CAGE, a tool with high specificity (low false positive rate),
was the standard screen used to detect lifetime alcohol abuse
and/or dependence [30], yet it failed to optimally identify current heavy drinking [31]. Based on current research, alcohol
screenings which tend to have a higher false positive rate,
such as the AUDIT, have been received differently. There is
more comfort with the false positives resulting from these
screenings versus that of the PSA screening due to the lack of
potential downstream harm (i.e., invasive confirmatory tests,
psychological distress, etc.). The research in this realm has led
to a change in the guidelines recommending the use of
evidence- based tools to standardize screening protocols
which will more likely detect risky use of substances, not just
dependence and substance use disorders.
Clinicians should both understand for themselves and be able
to explain to their patients that no screening test is 100% sensitive or specific. Screening tools should be used to supplement
physical exam and clinical judgement, but not replace them [32].
Chapter 1. Screening/Physical Exam/Health…
33
Physical Exam
While the concept of the comprehensive physical exam in
practice remains controversial [33, 34], few could dispute the
value it holds as an opportunity to discover vital clues to
diagnose [35] and build trust and rapport with a patient [36,
37]. The physical exam is a skillful art form that with time and
experience clinicians can master. This is an iterative process
where knowledge, coupled with experience, yields the ability
to conduct the appropriate and focused physical exams.
The approach toward a physical exam includes consideration of patient particulars (i.e., age, gender, disposition, personal risk factors, family history, etc.) in addition to the
historical account of a patient’s overall health and psychosocial status, as well as their presenting concerns. Additionally,
taking account of the expectations and perceptions of a
patient [38, 39] can influence the use of physical examinations
in a clinical visit. Placing a stethoscope on a patient’s chest
and palpation of one’s abdomen can satisfy the expectations
of a patient and lead to improved trust [40–42].
Examinations can be comprehensive “head to toe,” systematically following the review of systems and/or more
focused and based on the presenting complaint. The physical
exam can be employed for screening, investigation, and/or for
confirmation of diagnostic possibilities; however, with the
rapidly evolved utilization of telehealth, driven by response
to the coronavirus disease-19 (COVID-19) pandemic, the element of touch was significantly challenged, and at times,
removed.
Telehealth has become an essential component of providing care. This medium is especially useful when people are in
quarantine or regulations limit in-person interactions and
enables patients, in real-time, through contact with a healthcare provider, to seek advice and care for their health problems [43].
The use of virtual visits requires physicians to think proactively about what information they wish to obtain from the
examination that can be performed remotely. While video
34
J. Conigliaro and S. Kapoor
can provide visual clues that one may also obtain on an inperson examination, it is possible to elicit additional valuable
clinical information through various patient-assisted maneuvers [44]. When feasible, obtaining a baseline in-person exam
and setting expectations prior to beginning virtual encounters should improve diagnostic accuracy [45].
Vaccinations
The Centers for Disease Control and Prevention (CDC) recommends vaccinations from birth through adulthood to provide a lifetime of immunity [46] and that all adults need
immunizations to help them prevent acquiring and transmitting serious diseases that could result in poor health, missed
work, medical bills, and not being able to care for their family
[47]. In contrast to the pediatric and adolescent vaccination
recommendations and schedule, adult vaccinations are typically focused toward at-risk populations and those in certain
occupations. Despite efforts to raise awareness about how
vaccinations help reduce the prevalence of diseases (e.g.,
COVID-19 [48], influenza, human papillomavirus (HPV)
[49], pertussis, pneumococcal disease, etc.), vaccination compliance remains low [50, 51].
Similar to the communication strategies utilized when normalizing screening, discussion of results, or elements of a
physical exam, there needs to be an active effort to discuss
vaccinations. Physician and consumer surveys conducted by
the National Foundation for Infectious Disease (NFID) highlight communication breakdowns between doctor and patient,
leaving many adults unaware of the need for vaccines [47].
In December of 2020, an updated version of the Advisory
Committee on Immunization Practices (ACIP) vaccination
table was approved (Table1.5) [52, 53]. It is vital for clinicians
to be very familiar with this guidance as it details vaccines
routinely recommended for adults, contains important footnotes for each vaccine, and highlights the primary contraindications and precautions for commonly used vaccines [54].
or
or
Chapter 1. Screening/Physical Exam/Health…
35
50–
64years ≥65years
a a a
1 dose annually
a
b b
a
1 dose annually
a
b
a
a b
2 doses
a
d
2 doses
e b b
e
a d
d
)
c
1 dose Tdap each pregnancy; 1 dose Td/Tdap for wound management (see
notes
1 dose Tdap and then Td or Tdap booster every 10years
1 or 2 doses depending on indication (if born in 1957 or later)
a
later)
27
through
45years
a
b b
age at initial vaccination
or condition
(continued)
Vaccine 19–26years 27–49years
Influenza inactivated (IIV) or
Influenza recombinant (RIV4)
Influenza live attenuated
(LAIV4)
Tetanus, diphtheria, pertussis
T . Recommended adult immunization schedule for ages 19years or older, United States, 2021 [52]
(Tdap or Td)
Measles, mumps, rubella
(MMR)
Varicella (VAR) 2 doses (if born in 1980 or
Zoster recombinant (RZV)
Human papillomavirus (HPV) 2 or 3 doses depending on
J. Conigliaro and S. Kapoor
36
e
a
1 dose
50–
64years ≥65years
1 dose
d
c
d
d d
1 dose
Vaccine 19–26years 27–49years
T . (continued)
Pneumococcal conjugate
1 or 2 doses depending on indication
(PCV13)
Pneumococcal polysaccharide
(PPSV23)
Hepatitis A (HepA) 2 or 3 doses depending on vaccinedHepatitis B (HepB) 2 or 3 doses depending on vaccinedMeningococcal A, C, W, Y
1 or 2 doses depending on indication, see notes
for booster recommendations
(MenACWY)
Chapter 1. Screening/Physical Exam/Health…
d
for booster recommendations
c
2 or 3 doses depending on vaccine
and indication, see notes
d d
37
d
e
d
19
through
23years
1 or 3 doses depending on indication
Meningococcal B (MenB)
Haemophilus influenzae type b
(Hib)
No recommendation/Not applicable
Administer recommended vaccines if vaccination history is incomplete or unknown. Do not restart or add doses to
Recommended vaccination for adults who meet age requirement, lack documentation of vaccination, or lack evidence
vaccine series if there are extended intervals between doses. The use of trade names is for identification purposes only
and does not imply endorsement by the ACIP or CDC
a
of past infection
Recommended vaccination for adults with an additional risk factor or another indication
Recommended vaccination based on shared clinical decision-making
See notes by visiting https://www.cdc.gov/vaccines/schedules/hcp/imz/adult- compliant.html
b
c
d
e
38
J. Conigliaro and S. Kapoor
Additionally, to assist physicians and patients with their
understanding of which vaccinations are relevant to care, the
CDC site has a user-friendly “Vaccine Quiz” available [55].
Health Maintenance
The primary care clinician follows their patient throughout
their medical journey, building a partnership to collaboratively discuss, plan for, and achieve one’s optimal health. The
interaction between the clinician and patient serves as a
springboard to motivate sustainable decisions the patient will
need to maintain.
Telehealth has added value to the continuum of care; however it is not the only major aspect that has changed the paradigm of healthcare due to COVID-19. Traditional “sick visits”
have relocated from primary care to urgent care, and the
reduction of primary care touchpoints impacts a primary care
clinician’s ability to appreciate the complete picture of an
individual’s health [56, 57]. To account for this and to bridge
the gap, it is important to ask about other healthcare utilization outside of the primary care practice [56, 57].
Capitalizing on the rapport, trust, and partnership built,
clinicians can focus efforts on clearly and transparently discussing the patient’s health and goals for care. Using evidencebased guidelines like the USPSTF gives the clinician the
power and the knowledge to help guide the conversation as
well as the overall care of the patient throughout the continuum, striving for optimal health in the physical as well as
psychosocial domains.
Clinical Pearls
• Some screening tests and examinations can be sensitive in
nature and embarrassing to the patient.
• Effective communication and normalization can help
reduce avoidance on the patients’ and clinicians’ part.
• Evidence-based guidelines assist the clinician to focus
encounters and help guide interventions.
Chapter 1. Screening/Physical Exam/Health…
39
Don’t Miss This!
• Excellent evidence exists to help guide clinical care—use
it to identify important clinical concerns as well as to avoid
testing that may lead to unnecessary cost and risk to the
patient with little known benefit.
• Become familiar with tools used to screen for behavioral
health issues and substance use. Comfortable use by the
provider will help build trust and partnership and will
encourage the patient to respond openly.
• Learning how to focus the physical exam based on the
patient’s demographics, history, and their presenting con-
cerns is critical to effective encounters in the clinical
setting.
• When using telehealth, it is possible to elicit additional
valuable clinical information through various patient-
assisted maneuvers.
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