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Effective disease screening should meet several established criteria. In general,
the disease should be of high enough prevalence in the population to make the
screening effort worthwhile. There should be a time frame during which the person is asymptomatic, but during which the disease or risk factor can be identified.
There should be screening test(s) available for the disease that have sufficient sensi-
tivity and specificity, are cost-effective, and are acceptable to patients. Screening tests
should have high sensitivity to minimize risk of false-negative results. Finally, there
must be an intervention that can be made during the asymptomatic period that will
prevent the development of the disease or reduce the morbidity and mortality of
the disease process.
The USPSTF is a panel of experts that reviews current evidence and makes
recommendations on the effectiveness of clinical preventive services, specifically
in the areas of screening, immunization, preventive medications, and counseling.
USPSTF recommendations are considered “gold standards” for clinical preventive
medicine across five categories that reflect evidence strength and overall benefit of
an intervention (see Table 1-1).
Table 1–1 • USPSTF GRADING OF RECOMMENDATIONS
Recommendation
Grade Definition Suggestion for Practice
A There is high certainty that the net ben-
efit of the intervention is substantial.
B There is high certainty that the net ben-
efit of the intervention is moderate or
moderate certainty that it is moderate to
substantial.
C There may be considerations that sup-
port providing the service in an individual patient. There is moderate or high
certainty that there is no net benefit or
harm.
D There is moderate or high certainty that
there is no net benefit or that the harms
outweigh the benefits.
I There is insufficient evidence, or the
available evidence is of such poor quality, that the balance of benefits and
harms cannot be weighed and recommendations for or against the service
cannot be made.
Offer or provide this service.
Offer or provide this service.
Offer or provide the service
only if there are other considerations that support
offering or providing for the
individual.
Discourage use of this service.
If service is offered, patients
should understand the uncer-
tainty about the balance of
benefits and harms.
SCREENING TESTS
Cardiovascular Diseases
Diseases of the cardiovascular system are the leading cause of death in adult
men over 50 years of age, and the management of risk factors reduces both
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morbidity and mortality. The USPSTF strongly recommends screening of
adults (ages 18years and older) for hypertension by measurement of blood pressure (Grade A), as the management of hypertension is effective at reducing the
risk of cardiovascular diseases. Lipid screening should be performed in men 40
to 75 years of age (Grade B); there is insufficient evidence to support screening below this age regardless of risk. Lipid screening should include nonfasting
serum total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density
lipoprotein (LDL) cholesterol, and triglycerides. Men 50 to 69 years of age are no
longer recommended to take a baby aspirin daily to reduce the risk of a myocardial infarction, as the risk of gastrointestinal hemorrhage may outweigh potential benefit men in that age group with cardiovascular risk factors may benefit
from low dose aspirin. One-time screening Doppler ultrasonography to assess
for abdominal aortic aneurysm is recommended for men aged 65 to 75 years who
have ever smoked cigarettes (Grade B), while men 65 to 75 years who have never
smoked can be selectively screened (Grade C).
The routine use of electrocardiogram or exercise stress testing is not recommended for screening for coronary artery disease in adult men (Grade D). There is
insufficient evidence for screening peripheral artery disease or coronary artery disease with ankle-brachial index, high sensitivity C-reactive protein level, or coronary
artery calcium score (Grade I).
Cancer
Adult men older than 50 years are recommended to undergo screening for colorectal cancer (Grade A). Colonoscopy, flexible sigmoidoscopy, FIT, and Cologuard are
options. Any positive result on FIT, Cologuard, or sigmoidoscopy requires followup colonoscopy.
The USPSTF recommends that prostate cancer screening should be individual-
ized for men 55 to 69 years of age while discussing benefits versus harms of PSA
screening, taking into account patient values and preferences as well as comorbid
conditions (Grade C). Men at higher risk of prostate cancer (eg, family history,
African American) should be offered screening through shared decision-making.
Men over 70 years of age should not be screened for prostate cancer (Grade D).
Men aged 55 to 80 years with a 30 or more pack-year history who either continue to smoke or who quit fewer than 15 years ago should undergo annual lowdose CT of the chest to screen for lung cancer (Grade B). Screening for testicular
cancer in asymptomatic adults is not recommended (Grade D). There is insufficient evidence to recommend skin cancer screening via a whole-body skin examination (Grade I).
Other Health Conditions
All adult men should be screened for obesity via BMI, and men with a BMI over
30 kg/m2 should be offered or referred for intensive multicomponent behavioral intervention (Grade B). Men 40 to 70 years of age who are overweight or
obese should be screened for type 2 diabetes mellitus (Grade B) via fasting glucose, hemoglobin A1c or oral glucose tolerance test. Depression screening is recommended if there are systems in place for ensuring accurate diagnosis, treatment, and
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follow-up (Grade B). Routine spirometry is not recommended to screen asymptomatic patients for chronic obstructive pulmonary disease (Grade D).
IMMUNIZATIONS
The Centers for Disease Control and Prevention (CDC) recommends all adults
between 19 and 65 years of age receive a Tda p booster if they have not had one at
or after the age of 11. They should then get a Td or Tdap booster every 10 years.
The CDC recommends annual/seasonal influenza vaccination for all adults.
Pneumococcal conjugate (PCV13) and PPSV23 vaccinations are recommended for
all adults aged 65 years or older. An adult aged 19 to 64 years who smokes cigarettes
should receive the PPSV23 vaccination. The PCV13 and/or PPSV23 vaccination
may also be recommended for men aged 2 to 64 years if immunocompromised or
in the presence of certain chronic medical conditions such as chronic lung diseases
and diabetes mellitus.
Other vaccinations may be recommended for specific populations of men.
Hepatitis B vaccination should be recommended for those at high risk of exposure,
including health care workers, those exposed to blood or blood products, dialysis
patients, intravenous drug users, men with multiple sexual partners or recent sexually transmitted infections (STIs), and men who have sex with men. Hepatitis A
vaccine is recommended for persons with chronic liver disease, who use clotting factors, who have occupational exposure to the hepatitis A virus, who use intravenous
drugs, men who have sex with men, or who travel to countries where hepatitis A is
endemic. Varicella vaccination is recommended for those with no reliable history of
immunization or disease or who are seronegative on testing for varicella immunity.
Meningococcal vaccine is recommended for persons in high-risk groups, such as college dormitory residents and military recruits, and for patients with certain complement deficiencies, with functional or anatomic asplenia, or who travel to countries
where the disease is endemic. The CDC recommends herpes zoster vaccination for
healthy adults over age 50, preferably with the two-dose recombinant zoster vaccine.
Human papillomavirus (HPV) vaccination is indicated in adult men up to age 45.
HEALTHY LIFESTYLE
Screening and counseling to identify and promote cessation of tobacco use is
strongly recommended (Grade A). Screening and counseling to identify and prevent the overuse of alcohol are also recommended (Grade B), with a recommendation of no more than two drinks on one occasion. Screening for illicit substance
use should be offered when services for accurate diagnosis, effective treatment, and
appropriate care can be offered or referred (Grade B).
All men between 15 and 65 years of age should be screened for HIV (Grade A), and
those with high-risk sexual practices should also be screened for syphilis (Grade A).
Routine screening for STIs should be offered for men at high risk, and behavioral
counseling should be provided when appropriate (Grade B). Condoms should be
recommended to prevent contraction of STIs. Men who have sex with men should
be screened for genital, oropharyngeal, and anorectal STIs and HIV when considered to be at high risk. There is no current guideline for screening for anorectal
HPV infection.
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Exercise has been consistently shown to reduce the risk of cardiovascular disease, diabetes, obesity, and overall mortality. Current recommendations for exercise
posit 30 minutes of moderate-intensity exercise 5 days per week. Counseling to
promote a healthy diet centered on limiting carbohydrates and sugars, as well as
reasonable portion sizes and caloric intake, in men with risk factors for cardiovascular disease or diabetes is recommended. Intensive counseling by primary care
providers or, when appropriate, referral to dietary counselors or nutritionists, can
improve health outcomes. Finally, all men should be encouraged to wear seat belts
and helmets, practice gun safety, and avoid driving while under the influence of alcohol or drugs. Suicide and accidental death due to opioid overdose are the leading
causes of mortality in men ages 18 to 45 years.
CASE CORRELATION
See also Case 7 (Tobacco Use and Cessation), Case 18 (Geriatric Health
Maintenance and End-of-Life Issues), and Case 30 (Hypertension).
COMPREHENSION QUESTIONS
1.1 A 24-year-old man who has sex with men presents for his yearly health main-
tenance examination. He wants to be “tested for everything” but is completely
asymptomatic. His BMI is 22 kg/m2, blood pressure is 125/76 mm Hg, and he
has no significant medical history. According to the USPSTF, for which of the
following should this man be screened?
A. Testicular cancer
B. Marijuana abuse
C. Diabetes
D. Hyperlipidemia
E. Depression
1.2 A 49-year-old sedentary man has made an appointment because his best friend
died of a myocardial infarction at age 50. He asks your advice about exercise
and weight loss to prevent cardiovascular disease. In counseling him, which of
the following statements regarding exercise is most accurate?
A. To be beneficial, exercise must be performed for at least 15 minutes
every day.
B. Walking for exercise has not been shown to improve meaningful clinical
outcomes.
C. Counseling patients has not been shown to increase the number of patients
who exercise.
D. Intense exercise offers no health benefit over mild-to-moderate amounts
of exercise.
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1.3 A 52-year-old man comes into the outpatient clinic for an annual “checkup.” He
is in good health and has a relatively unremarkable family history. He has never
smoked cigarettes. For which of the following disorders should a screening test
be performed?
A. Prostate cancer
B. Lung cancer
C. Abdominal aortic aneurysm
D. Colorectal cancer
E. Skin cancer
1.4 A 62-year-old man with recently diagnosed chronic obstructive pulmonary
disease presents to your office in November for a routine examination. He has
not had any immunizations in more than 10 years. Which of the following
immunizations would be most appropriate for this individual?
A. Tetanus-diphtheria only
B. Tdap, pneumococcal, and influenza
C. Pneumococcal and influenza
D. Tdap, pneumococcal, influenza, and meningococcal
ANSWERS
1.1 E. The USPSTF recommends screening for depression in this man. The
USPSTF recommends against testicular cancer screening (answer A). There
is insufficient evidence to recommend for or against screening for illicit substance use, including marijuana (answer B). Since this man is not obese or
hypertensive and has no medical history, screening for diabetes (answer C) or
hyperlipidemia (answer D) is not indicated.
1.2 C. Exercise decreases cardiovascular risk, increases insulin sensitivity, decreases
the incidence of metabolic syndrome, and decreases cardiovascular mortality regardless of obesity. Sadly, the benefits of counseling patients regarding
exercise are unclear, and counseling does not seem to increase the number of
patients who exercise. Answer A (15 minutes of exercise per day) is not necessary since many studies have shown that exercise for at least three sessions per
week have been effective. Answer B (walking has not been shown to improve
outcomes) is incorrect since walking, especially in older adults, is associated
with lower all-cause mortality. Answer D (intense exercise showing no benefits
over mild or moderate levels) is incorrect since the degree of intensity of exercise does have a greater impact on mortality risk.
1.3 D. Colorectal cancer screening has a Grade A recommendation by the USPSTF
and is routinely offered or provided to all adults older than 50 years. Lung
cancer screening (answer B) should not be offered for a patient who has never
smoked. Prostate cancer screening (answer A) should be individualized in men
55 to 69 years of age. Abdominal aortic aneurysm screening (answer C) is recommended in men aged 65 to 75 years who have smoked. Routine skin cancer
screening (answer E) is not recommended.
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1.4 B. In an adult with a chronic lung disease, vaccination with pneumococcal
vaccine and annual vaccination with influenza vaccine are recommended.
A Tdap booster should be recommended to all adults who have never had a
Tdap vaccine as an adult. Therefore, answer choices A (Td only) and C
(pneumococcal and influenza) are not correct. Answer D includes meningococcal vaccination, which is only recommended for high-risk groups (college
dormitory residents, military recruits, and patients with certain complement
deficiencies, with functional or anatomic asplenia, or who travel to countries
where the disease is endemic).
CLINICAL PEARLS
»
There is no such thing as “testing for everything” in a health maintenance
examination. All screening tests should have adequate evidence to support their benefit over harm.
»
Cardiovascular disease and cancer pose the greatest risk of mortality for
men in the United States.
»
High-quality, evidence-based recommendations for preventive health
services are available at https://www.uspreventiveservicestaskforce.org/
uspstf/.
»
Evidence-based recommendations for vaccines and immunizations are
available at https://www.cdc.gov/Vaccines.
REFERENCES
ASCVD Risk Calculator. http://www.cvriskcalculator.com. Accessed March 25, 2019.
Centers for Disease Control and Prevention. Leading causes of death (LCOD) by age group, all males—
United States, 2017. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm Accessed
April 21, 2020.
Centers for Disease Control and Prevention. Vaccines and immunizations. https://www.cdc.gov/
vaccines/. Accessed January 8, 2019.
Healthy Weight/Assessing Your Weight. https://www.cdc.gov/healthyweight/. Accessed March 25,
2019.
Heidelbaugh JJ. The adult well male examination. Am Fam Physician. 2018;98(12):729-737.
Martins C, Godycki-Cwirko M, Heleno, B, Brodersen J. Quaternary prevention: reviewing the con-
cept: quaternary prevention aims to protect patients from medical harm. Eur J Gen Pract.
2018;24(1):106-111.
Mayo Clinic Shared Decision Making National Resource Center. Home page. https://shareddecisions.
mayoclinic.org. Accessed March 25, 2019.
United States Food and Drug Administration. Use of aspirin for primary prevention of heart attack and
stroke. https://www.fda.gov/drugs/drug-information-consumers/use-aspirin-primary-prevention-
heart-attack-and-stroke. Accessed March 22, 2019.
United States Preventive Services Task Force. Recommendations for primary care practice. http://www
.uspreventiveservicestaskforce.org/Page/Name/recommendations. Accessed September 5, 2019.
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CASE 2
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A 62-year-old man presents to your office for an acute visit because of coughing
and shortness of breath. He is well known to you because of multiple office visits
in the past few years for similar reasons. He has a chronic “smoker’s cough” but
reports that in the past 2 days his cough has increased, his sputum has changed
from white to green in color, and he has had to increase the frequency with which
he uses his albuterol inhaler. He denies having a fever, chest pain, peripheral
edema, or other symptoms. His medical history is significant for hypertension,
peripheral vascular disease, and two hospitalizations for pneumonia in the past
5years. He has a 60 pack-year history of smoking and continues to smoke two
packs of cigarettes a day.
On examination, he is in moderate respiratory distress. His temperature is
98.4 °F, his blood pressure is 152/95 mm Hg, his pulse is 98 beats/min, his respiratory
rate is 24 breaths/min, and he has an oxygen saturation of 94% on room air. His
lung examination is significant for diffuse expiratory wheezing and a prolonged
expiratory phase of respiration. There are no signs of cyanosis. The remainder of
his examination is normal. A chest x-ray done in your office shows an increased
anteroposterior (AP) diameter and flattened diaphragm, but otherwise he has
clear lung fields.
▶ What is the most likely cause of this patient’s dyspnea?
▶ What acute treatment(s) are most appropriate at this time?
▶ What interventions would be most helpful to reduce the risk of future episodes
similar to this one?
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ANSWERS TO CASE 2:
Dyspnea (Chronic Obstructive Pulmonary Disease)
Summary: A 62-year-old man presents with
A long history of smoking
Dyspnea, coughing, and wheezing
Increased sputum production and a change in sputum character
Most likely cause of dyspnea: Acute exacerbation of chronic obstructive pulmonary
disease (COPD).
Appropriate acute treatments: Antibiotic, bronchodilators, systemic corticosteroids.
Interventions to reduce future exacerbations: Smoking cessation, long-acting bron-
chodilator, inhaled corticosteroid, influenza, and pneumococcal polysaccharide
vaccination.
ANALYSIS
Objectives
1. Be able to diagnose and determine the stage of COPD in adults. (EPA 1, 3)
2. Know the management of stable COPD and COPD exacerbations. (EPA 4, 10)
Considerations
Dyspnea is a common symptom in many diseases. It is important to do an appropriate history, physical examination, and diagnostic testing in order to correctly
identify and manage the cause. Two of the most common causes of dyspnea and
wheezing in adults are asthma and COPD. There can be substantial overlap
between the two diseases, as patients with asthma can develop chronic obstructive
disease over time. As in most medical situations, the patient’s history will usually
provide the key information for the appropriate diagnosis. Asthma often presents
earlier in life, may or may not be associated with cigarette smoking, and is characterized by episodic exacerbations with return to relatively normal baseline lung
functioning. COPD, on the other hand, tends to present in midlife or later, is usually the result of a long history of smoking, and is a slowly progressive disorder in
which measured pulmonary functioning never returns to normal.
In the setting of an acute exacerbation, the differentiation between an exacerbation of asthma and an exacerbation of COPD is not necessary for determination of
the immediate management. The assessment of the patient presenting with dyspnea
should always start with the ABCs—Air wa y, Breathing, and Circulation. Intubation with mechanical ventilation should be performed when the patient is unable to
protect his own airway (eg, when the patient has a reduced level of consciousness),
when he or she is tiring because of the amount of work required to overcome the
airway obstruction, or when adequate oxygenation cannot be maintained.
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For both asthma and COPD exacerbations, the mainstays of medical therapy are
oxygen, bronchodilators, and steroids. All dyspneic patients should have an assessment of their level of oxygenation. Clinical signs of hypoxemia, such as cyanosis of
the perioral region or digits, should be noted on examination. Objective levels of
oxygenation using pulse oximetry or arterial blood gas measurements should also
be performed. Hypoxemia must be addressed by providing supplemental oxygen.
Inhaled beta-2 agonists, most commonly albuterol, can rapidly result in bronchodilation and reduction in airway obstruction. The addition of an inhaled anticholinergic agent, such as ipratropium, may work synergistically with the beta-2 agonist.
Corticosteroids, given systemically (orally, intramuscularly, or intravenously), act
to reduce the airway inflammation that underlies the acute exacerbation. Clinically
significant effects of steroids take hours to occur; consequently, steroids should be
used with bronchodilators because bronchodilators act rapidly. Steroids used in
combination with bronchodilators significantly improve short-term outcomes in
the management of acute exacerbations of asthma and COPD.
APPROACH TO:
Chronic Obstructive Pulmonary Disease
DEFINITIONS
CHRONIC BRONCHITIS: Cough and sputum production on most days for at
least 3 months during at least 2 consecutive years.
EMPHYSEMA: Shortness of breath caused by the enlargement of respiratory
bronchioles and alveoli caused by destruction of lung tissue.
FEV1: FEV stands for forced expiratory volume; FEV1 is a value that can be used
to evaluate pulmonary function, determined by the amount of forced expiratory
volume in the first second of expiration.
FVC: Stands for forced vital capacity, which is a measure of the total amount of air
that can be expired after a maximal inspiration.
CLINICAL APPROACH
Epidemiology
As the third leading cause of death in the United States, COPD affects more than
5% of the adult population. COPD is defined as airway obstruction that is not
fully reversible, is usually progressive, and is associated with chronic bronchitis,
emphysema, or both. The most common etiology is cigarette smoking, which is
associated with 80% to 90% of cases of COPD. Other etiologies of COPD include
passive exposure to cigarette smoke (“secondhand smoke”) and occupational exposures to dusts (including mining, cotton, silica, and plastics); chemicals; and fumes
(eg, welding, heavy metals). Patients with symptoms of COPD who do not smoke
or work in high-risk occupations warrant further evaluation. A rare cause of COPD
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