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The Periodic Health Examination in College Students Revisited Paul Reith MD
a
a
Clinical Medicine , University of Illinois College of Medicine , Rockford, USA Published online: 09 Jul 2010.
To cite this article: Paul Reith MD (1991) The Periodic Health Examination in College Students Revisited, Journal of American College Health, 40:3, 119-123, DOI: 10.1080/07448481.1991.9936267 To link to this article: http://dx.doi.org/10.1080/07448481.1991.9936267
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
The Periodic Health Examination in College Students Revisited
Downloaded by [Southern Illinois University] at 09:37 24 December 2014
Paul Reith, MD
Abstract. The periodic health examination is a group of tasks carried out by physicians and nurses at regular intervals, but not always yearly, to determine either the risk of subsequent disease or to identify disease in its early, asymptomatic state. The Guide to Clinical Preventive Services, published in 1989 by the United States Preventive Services Task Force, sets common American standards for these procedures. The guide lists those preventive activities recommended for persons aged 19-39 years. Every patient encounter in our student health services should be considered an opportunity for preventive activities. This article offers a simple check list for office use. Key Words. Health education, immunization, patient education, periodic health examination
I
s there any basis for the belief that the periodic health exam can promote health and prevent disease? Only two retrospective studies looking at mortality in a group of people who had received periodic health examinations have been reported. One is the 16year study of more than 10,ooO persons by the Kaiser Permanente Medical Care Program, which found that mortality rates for those who had had regular health exams were no different from those in a control group, except in the case of hypertension and colorectal cancer deaths.' A second survey, the South-East London Screening Study of mortality and hospitalization of about 6,400 people, also showed no difference between treatment and control groups over a 9-year period.* Nevertheless, there is no doubt that immunizations, such as those for poliomyelitis and rubella, screening for cervical cancer by means of the Papanicolaou smear, and early identification and treatment of hypertension have had significant impacts on mortality and m~rbidity.~ The author's suggested guidelines for the periodic health exam, published in the Journal of American College Health in 1989,4were based in large part on reports
Pad Reith is an mistant profwor of clinical medicine at the University of Illinois College of Medicine at Rockford. VOL 40, NOVEMBER 1991
of the Canadian Task Force on the Periodic Health Examination (CTFPHE) .5-7 The United States Preventive Semces Task Force (USPSTF) released its report, the Guide to Clinical Preventive Services on May 2, 1989.' Both the US task force and its Canadian counterpart initially evaluated potentially preventable conditions in terms of the quality of evidence for the effectiveness of intervention. The USPSTF then classified the strength of the recommendations on a scale of A through E. Since 1988, however, the USPSTF had used additional epidemiological and statistical methods to answer the following questions: (1) Is the preventable condition important? (2) Is preventive intervention effective in research settings? (3) Do effective screening tests exist? (4) Would use of the measure be effective in routine office practice?' The guide, including recommendations for clinical practice for 100 preventive interventions for 60 target conditions, is available from Williams & Wilkins, PO Box 14%, Baltimore, MD 21298-9724 (1-80@638-0672). Table 5 of the guide, reproduced here as Figure 1, covers ages 19-39 years. The first page lists the leading causes of death in this age group-motor vehicle crashes, homicide, suicide, nonmotor vehicle injuries, and heart disease. The schedule is further divided into three sections for screening, counseling, and immunization activities. Risk is stratified in the USPSTF system. Only a small number of preventive activities are recommended for all college students. These include a history of dietary intake, physical activity, tobacco, alcohol, and drug use, and sexual practices; a physical examination, including height, weight, and blood pressure; counseling activities, including diet and exercise, substance use, sexual practices, injury prevention, and dental health; and immunizations, including the tetanus-diphtheria booster every 10 years. New Communicable Disease Center guidelines recommend two doses of live measles vaccine for college students who were born after 1957. A larger number of preventive activities are recommended for students at high risk, who are designated 119
COLLEGE HEALTH
FIGURE 1 Preventive Activities Recommended by the US Preventive Services Task Force*
Ages 19-39
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Schedule: Every 1-3 Years*
Leading Causes of Death: Motor iehicle crashes Homicide Suicide Injuries (nonmotor vehicle) Heart disease
SCREENING
COUNSELING
IMMUNIZATIONS
History Dietary intake Physical activity Tobacco/alcohol/drug use Sexual practices
Diet and Exercise Fat (especially saturated fat), cholesterol, complex carbohydrates, fiber, sodium; iron,z calciumZ Caloric balance Selection of exercise program
Tetanus-diphteria (Td) boostela
Physical Exam Height and weight Blood pressure HIGH-RISK GROUPS Complete oral cavity exam (HRl) Palpation for thyroid nodules (HR2) Clinical breast exam (HR3) Clinical testicular exam (HR4) Complete skin exam (HR5) Laboratory/Diagnostic Procedures Nonfasting total blood cholesterol Papanicolaou smear’ HIGH-RISK GROUPS Fasting plasma glucose (HR6) Rubella antibodies (HR7) VDRL (HR8) Urinalysis for bacteriuria (HR9) Chlamydial testing (HR10) Gonorrhea culture (HR11) Counseling and testing for HIV (HR12) Hearing (HR13) Tuberculin skin test (PPD) (HR14) Electrocardiogram (HRl5) Mammogram (HR3) Colonoscopy (HR16)
This list of preventive services is not exhaustive. It reflects only those topics reviewed by the U.S. Preventive Services Task Force. Clinicians may wish to add other preventive services after considering the patient’s medical history and other individual circumstances.
Substance Use Tobacco: cessation/primary prevention Alcohol and other drugs: Limiting alcohol consumption Driving/other dangerous activities while under the influence Treatment for abuse HIGH-RISK GROUPS Sharinghsing unsterilized needles and syringes (HR18) Sexual Practices Sexually transmitted diseases: partner selection, condoms, anal intercourse Unintended pregnancy and contraceptive options
HIGH-RISK GROUPS Hepatitis B vaccine (HR24) Pneumococcal vaccine (HR25) Influenza vaccine5 (HR26) Measles-mumps-rubella vaccine (HR27)
Remain Alert For: Depressive symptoms Suicide risk factors (HR17) Abnormal bereavement Malignant skin lesions Tooth decay, gingivitis Signs of physical abuse
Injury Prevention Safety belts Safety helmets Violent behavior’ Firearms3 Smoke detector Smoking near bedding or upholstery HIGH-RISK GROUPS Back-conditioning exercises (HR19) Prevention of childhood injuries (HR20) Falls in the elderly (HR21) Dental Health Regular tooth brushing, flossing, dental visits Other Primary Preventive Measures HIGH-RISK GROUPS Discussion of hemoglobin testing (HR22) Skin protection from ultraviolet light (HR23)
*The recommended schedule applies only to the periodic visit itself. The frequency of the individual preventive services listed in this table is left to clinical discretion, except as indicated in other footnotes. 1. Every 1-3 years. 2. For women. 3. For young men. 4. Every 10 years. 5. Annually.
120
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HEALTH EXAMlNATloNS
FIGURE 1 (continued)
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High-Risk Categories Ages 19-39 HRl Persons with exposure to tobacco or excessive amounts of alcohol, or those with suspicious symptoms or lesions detected through selfexamination. H2 Persons with a history of upper-body irradiation. HR3 Women aged 35 and older with a family history of premenopausally diagnosed breast cancer in a fist-degree relative. HR4 Men with a history of cryptorchidism, orchiopexy, or testicular atrophy. HR5 Persons with family or personal history or skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions (eg, dysplastic nevi, certain congenital nevi). HR6 The markedly obese, persons with a family history of diabetes, or women with a history of gestational diabetes. HR7 Women lacking evidence of immunity. HR8 Prostitutes, persons who engage in sex with multiple partners in areas in which syphilis is prevalent, or contacts of persons with active syphilis. HR9 Persons with diabetes. HRlO Persons who attend clinics for sexually transmitted diseases; attend other high-risk health care facilities (eg, adolescent and family planning clinics), or have other risk factors for chlamydial infection (eg, multiple sexual partners or a sexual partner with multiple sexual contacts, age less than 20). H R l l Prostitutes, persons with multiple sexual partners or a sexual partner with multiple contacts, sexual contacts of persons with culture-proven gonorrhea, or persons with a history of repeated episodes of gonorrhea. HR12 Persons seeking treatment for sexually transmitted diseases; homosexual and bisexual men; past or present intravenous (IV)drug users; persons with a history of prostitution or multiple sexual partners; women whose past or present sexual partners were HIV-infected, bisexual, or IV drug users; persons with longterm residence or birth in an area with high prevalence of HIV infection; or persons with a history of transfusion between 1978 and 1985. HR13 Persons exposed regularly to excessive noise. HR14 Household members of persons with tuberculosis or others at risk for close contact with the disease (eg, staff of tuberculosis clinics, shelters for the homeless, nursing homes, substance abuse treatment facilities, dialysis units, correctional institutions); recent immigrants or refugees from countries in which tuberculosis is common, migrant workers; residents of nursing homes, correctional institutions, or homeless shelters; or persons with certain underlying medical disorders (eg, HIV infection). VOL 40, NOVEMBER 1991
HR15 Men who would endanger public safety were they to experience sudden cardiac events (eg, commercial airline pilots). HR16 Persons with a family history of familial polyposis coli or cancer family syndrome. HRl7 Recent divorce, separation, unemployment, depression, alcohol or other drug abuse, serious medical illnesses, living alone, or recent bereavement. HR18 Intravenous drug users. HR19 Persons at increased risk for low back injury because of past history, body configuration, or type of activities. HR20 Persons with children in the home or automobile. HR21 Persons with older adults in the home. HR22 Young adults of Caribbean, Latin American, Asian, Mediterranean, or African descent. HR23 Persons with increased exposure to sunlight. HR24 Homosexually active men, intravenous drug users, recipients of some blood products, or persons in health-related jobs with frequent exposure to blood or blood products. HR25 Persons with medical conditions that increase the risk of pneumococcal infection (eg, chronic cardiac or pulmonary disease, sickle cell disease, nephrotic syndrome, Hodgkin’s disease, asplenia, diabetes mellitus, alcoholism, cirrhosis, multiple myeloma, renal disease, or conditions associated with immunosuppression). HR26 Residents of chronic care facilities or persons suffering from chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction. HR27 Persons born after 1956 who lack evidence of immunity to measles (receipt of live vaccine on or after fist birthday, laboratory evidence or immunity, or a history of physician-diagnosed measles).
121
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COLLEGE HEALTH
HR in the table. College students would be at especially high risk for sexually transmitted diseases and for measles, mumps, and rubella. What is special is the emphasis given by the guide to counseling activities in the periodic health examination. The USPSTF recommends that primary care physicians and nurses help their patients understand the important role of behavior in the maintenance of good health. Counseling activities included are those concerning tobacco use, exercise, nutrition, motor vehicle injuries, household and environmental injuries, HIV infection and other sexually transmitted diseases, unintended pregnancy, and dental disease. The guide’s recommendations differ little from those in my previous a r t i ~ l eThe . ~ Canadians had recommended breast and testicular self-examination5;the USPSTF did not find compelling evidence for or against this. It emphasized, rather, the clinical breast exam for those women and testicular exam for those men who are at higher risk. The USPSTF targeted the tuberculin skin test only for persons at high risk for tuberculosis, which would apply primarily to some international students. Counseling for fire safety is welcome. Additional recommendations for mammography, colonoscopy, and the electrocardiogram pertain only to a few college students.* Ideally, it would be best to integrate as much preventive activity as possible into our student health clinic routines. My suggestions for doing this in the office setting follow. 1. The student’s basic health history should be as complete as possible. A thorough health history identifies those students at higher risk who would especially benefit from specific preventive activities. For example, students who have had a splenectomy are at higher risk for serious pneumococcal infections and should be given the pneumococcal vaccine. 2. Immunization requirements, especially for measles, mumps, and rubella, should be made mandatory for college admission. This is already being implemented by many colleges. 3. Some screening tests can be packaged. For example, routine screening for Chlamydia trachomatis can be done during the periodic pelvic examination, along with the Papanicolaou smear.” The periodic pelvic examination is an important opportunity for counseling about how to prevent sexually transmitted diseases. 4. Family practice clinics have tried putting check lists for preventive activities into the front of the medical record. Madlon-Kay” found that compliance with all screening activities improved with physician and patient education, but that compliance still fell short of expectation, except for selected immunizations. 5. A periodic health examination check list might well be entered into a computer file for every first-year student. Each clinic encounter would then offer an opportunity, simply by a glance at the computer screen, 122
for a quick review of the student’s preventive health status. 6. I use a simple health screening check list in the office. The list, typed onto a small sheet of paper and photocopied, includes the following items: measles, mumps, rubella booster; tetanus-diphtheria booster within 10 years; tuberculin skin test (especially for all international students); weight; height; blood pressure; cholesterol; Papanicolaou smear in women; smoking cessation; exercise; and seat belt and bicycle helmet use. Those items warranting further information or discussion are checked and the slip is given to the student to take home. The INSURE study (Industrywide Network for Social, Urban, and Rural Efforts) recently published short-term prospective data on the changes in healthrisk behavior in 2,218 adults who had visited primary care physicians. They reported that a study group, when compared with controls, showed an increased percentage of patients exercising, quitting smoking, using seat belts, losing weight, reducing problem drinking, and women doing monthly breast self-exams. This study, however, consisted only of the subjects’ responses to printed survey questions asked 1 year later.” A majority of college health service encounters are illness visits for medical care. The challenge to student health physicians and nurses is to incorporate preventive activities into these visits. Every patient encounter, whether in the office or emergency room setting, is an opportunity for a review of the student’s healthcare screening status. For the majority of college students, an illness visit may be their only encounter with preventive activities. REFERENCES 1. Friedman GD, Collen MF, Bireman BH. Multiphasic health checkup evaluations: A l6year follow-up. J Chron Dk. 1986;6453-463. 2. South-East London Study Group. A controlled trial of multiphasic screening in middle age: Results from the SouthEast London Screening Study. Int J Epidemiol. 1977;6:357363. 3. Holbrook JH. Periodic health examination for adults. In: Stults BM, Dere W, eds. Practical Care of the Ambulatory Patient. Philadelphia: W. B. Saunders; 1989:415. 4. Reith P. Adapting the selective periodic health exam to a college-aged population. J A m ColI Health. 1989;38: 109-113. 5 . Canadian Task Force on the Periodic Health Examination. Can Med Assoc J. 1984;130:1278-1285. 6. The periodic health examination: 2. 1985 update. Canadian Task Force on the Periodic Health Examination. Can Med A s o c J. 1985;134:724-729. 7. The periodic health examination: 2. 1987 update. Canadian Task Force on the Periodic Health Examination. Can Med Ascioc J. 1988;138:618-626. 8. US Preventive Services Task Force. The Guide to Clinical Preventive Services. Baltimore: Williams 8~Wilkins; 1989: I
fi-a.
9. Kern DE. Preventive medicine in ambulatory practice. In: Barker LR, Burton JR, Zieve PD, eds. PrincipIes of Ambulatory Medicine, 3rd ed. Baltimore: Williams & Wilkins; JACH
HEALTH D(AMiNATKI" 1990: 13-24. 10. Periera CA, Paquette GE, Wood PB, et al. Clinical laboratory testing for Chlamydia trachomatk in women at a university health service. J Am Coil Health. 1987;3639-42. 11. Madlon-Kay DJ. Improving the periodic health ex-
amination: Use of a screening flow chart for patients and physicians. J Fam Prac. 1987;25:470-473. 12. Logsdon DN, Lazar0 CM, Meier RV. The feasibility of behavioral risk reduction in primary medical care. A m J Prev Med. 1989;5 :249-256.
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Other Panelists and Presenters will include educators, counselors, clinicians, and students working to promote sexual health in a variety of colleges and universities-including community, urban, and commuter campuses. They will: identify, discuss, and illustrate major strategic5 for effective campus sexual health promotion focus on special concerns for women, people of color, and gay, lesbian, and bisexual students demonstrate a spectrum of approaches to changing behavior, including peer education, theater, and health counseling highlight methods of enhancing self-esteem and building skills suggest ways to develop a sense of community that supports healthier behavior Present4 B ~ :Labow & Inassociationwith:
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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
The Periodic Health Examination in College Students Revisited Paul Reith MD
a
a
Clinical Medicine , University of Illinois College of Medicine , Rockford, USA Published online: 09 Jul 2010.
To cite this article: Paul Reith MD (1991) The Periodic Health Examination in College Students Revisited, Journal of American College Health, 40:3, 119-123, DOI: 10.1080/07448481.1991.9936267 To link to this article: http://dx.doi.org/10.1080/07448481.1991.9936267
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
The Periodic Health Examination in College Students Revisited
Downloaded by [Southern Illinois University] at 09:37 24 December 2014
Paul Reith, MD
Abstract. The periodic health examination is a group of tasks carried out by physicians and nurses at regular intervals, but not always yearly, to determine either the risk of subsequent disease or to identify disease in its early, asymptomatic state. The Guide to Clinical Preventive Services, published in 1989 by the United States Preventive Services Task Force, sets common American standards for these procedures. The guide lists those preventive activities recommended for persons aged 19-39 years. Every patient encounter in our student health services should be considered an opportunity for preventive activities. This article offers a simple check list for office use. Key Words. Health education, immunization, patient education, periodic health examination
I
s there any basis for the belief that the periodic health exam can promote health and prevent disease? Only two retrospective studies looking at mortality in a group of people who had received periodic health examinations have been reported. One is the 16year study of more than 10,ooO persons by the Kaiser Permanente Medical Care Program, which found that mortality rates for those who had had regular health exams were no different from those in a control group, except in the case of hypertension and colorectal cancer deaths.' A second survey, the South-East London Screening Study of mortality and hospitalization of about 6,400 people, also showed no difference between treatment and control groups over a 9-year period.* Nevertheless, there is no doubt that immunizations, such as those for poliomyelitis and rubella, screening for cervical cancer by means of the Papanicolaou smear, and early identification and treatment of hypertension have had significant impacts on mortality and m~rbidity.~ The author's suggested guidelines for the periodic health exam, published in the Journal of American College Health in 1989,4were based in large part on reports
Pad Reith is an mistant profwor of clinical medicine at the University of Illinois College of Medicine at Rockford. VOL 40, NOVEMBER 1991
of the Canadian Task Force on the Periodic Health Examination (CTFPHE) .5-7 The United States Preventive Semces Task Force (USPSTF) released its report, the Guide to Clinical Preventive Services on May 2, 1989.' Both the US task force and its Canadian counterpart initially evaluated potentially preventable conditions in terms of the quality of evidence for the effectiveness of intervention. The USPSTF then classified the strength of the recommendations on a scale of A through E. Since 1988, however, the USPSTF had used additional epidemiological and statistical methods to answer the following questions: (1) Is the preventable condition important? (2) Is preventive intervention effective in research settings? (3) Do effective screening tests exist? (4) Would use of the measure be effective in routine office practice?' The guide, including recommendations for clinical practice for 100 preventive interventions for 60 target conditions, is available from Williams & Wilkins, PO Box 14%, Baltimore, MD 21298-9724 (1-80@638-0672). Table 5 of the guide, reproduced here as Figure 1, covers ages 19-39 years. The first page lists the leading causes of death in this age group-motor vehicle crashes, homicide, suicide, nonmotor vehicle injuries, and heart disease. The schedule is further divided into three sections for screening, counseling, and immunization activities. Risk is stratified in the USPSTF system. Only a small number of preventive activities are recommended for all college students. These include a history of dietary intake, physical activity, tobacco, alcohol, and drug use, and sexual practices; a physical examination, including height, weight, and blood pressure; counseling activities, including diet and exercise, substance use, sexual practices, injury prevention, and dental health; and immunizations, including the tetanus-diphtheria booster every 10 years. New Communicable Disease Center guidelines recommend two doses of live measles vaccine for college students who were born after 1957. A larger number of preventive activities are recommended for students at high risk, who are designated 119
COLLEGE HEALTH
FIGURE 1 Preventive Activities Recommended by the US Preventive Services Task Force*
Ages 19-39
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Schedule: Every 1-3 Years*
Leading Causes of Death: Motor iehicle crashes Homicide Suicide Injuries (nonmotor vehicle) Heart disease
SCREENING
COUNSELING
IMMUNIZATIONS
History Dietary intake Physical activity Tobacco/alcohol/drug use Sexual practices
Diet and Exercise Fat (especially saturated fat), cholesterol, complex carbohydrates, fiber, sodium; iron,z calciumZ Caloric balance Selection of exercise program
Tetanus-diphteria (Td) boostela
Physical Exam Height and weight Blood pressure HIGH-RISK GROUPS Complete oral cavity exam (HRl) Palpation for thyroid nodules (HR2) Clinical breast exam (HR3) Clinical testicular exam (HR4) Complete skin exam (HR5) Laboratory/Diagnostic Procedures Nonfasting total blood cholesterol Papanicolaou smear’ HIGH-RISK GROUPS Fasting plasma glucose (HR6) Rubella antibodies (HR7) VDRL (HR8) Urinalysis for bacteriuria (HR9) Chlamydial testing (HR10) Gonorrhea culture (HR11) Counseling and testing for HIV (HR12) Hearing (HR13) Tuberculin skin test (PPD) (HR14) Electrocardiogram (HRl5) Mammogram (HR3) Colonoscopy (HR16)
This list of preventive services is not exhaustive. It reflects only those topics reviewed by the U.S. Preventive Services Task Force. Clinicians may wish to add other preventive services after considering the patient’s medical history and other individual circumstances.
Substance Use Tobacco: cessation/primary prevention Alcohol and other drugs: Limiting alcohol consumption Driving/other dangerous activities while under the influence Treatment for abuse HIGH-RISK GROUPS Sharinghsing unsterilized needles and syringes (HR18) Sexual Practices Sexually transmitted diseases: partner selection, condoms, anal intercourse Unintended pregnancy and contraceptive options
HIGH-RISK GROUPS Hepatitis B vaccine (HR24) Pneumococcal vaccine (HR25) Influenza vaccine5 (HR26) Measles-mumps-rubella vaccine (HR27)
Remain Alert For: Depressive symptoms Suicide risk factors (HR17) Abnormal bereavement Malignant skin lesions Tooth decay, gingivitis Signs of physical abuse
Injury Prevention Safety belts Safety helmets Violent behavior’ Firearms3 Smoke detector Smoking near bedding or upholstery HIGH-RISK GROUPS Back-conditioning exercises (HR19) Prevention of childhood injuries (HR20) Falls in the elderly (HR21) Dental Health Regular tooth brushing, flossing, dental visits Other Primary Preventive Measures HIGH-RISK GROUPS Discussion of hemoglobin testing (HR22) Skin protection from ultraviolet light (HR23)
*The recommended schedule applies only to the periodic visit itself. The frequency of the individual preventive services listed in this table is left to clinical discretion, except as indicated in other footnotes. 1. Every 1-3 years. 2. For women. 3. For young men. 4. Every 10 years. 5. Annually.
120
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HEALTH EXAMlNATloNS
FIGURE 1 (continued)
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High-Risk Categories Ages 19-39 HRl Persons with exposure to tobacco or excessive amounts of alcohol, or those with suspicious symptoms or lesions detected through selfexamination. H2 Persons with a history of upper-body irradiation. HR3 Women aged 35 and older with a family history of premenopausally diagnosed breast cancer in a fist-degree relative. HR4 Men with a history of cryptorchidism, orchiopexy, or testicular atrophy. HR5 Persons with family or personal history or skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions (eg, dysplastic nevi, certain congenital nevi). HR6 The markedly obese, persons with a family history of diabetes, or women with a history of gestational diabetes. HR7 Women lacking evidence of immunity. HR8 Prostitutes, persons who engage in sex with multiple partners in areas in which syphilis is prevalent, or contacts of persons with active syphilis. HR9 Persons with diabetes. HRlO Persons who attend clinics for sexually transmitted diseases; attend other high-risk health care facilities (eg, adolescent and family planning clinics), or have other risk factors for chlamydial infection (eg, multiple sexual partners or a sexual partner with multiple sexual contacts, age less than 20). H R l l Prostitutes, persons with multiple sexual partners or a sexual partner with multiple contacts, sexual contacts of persons with culture-proven gonorrhea, or persons with a history of repeated episodes of gonorrhea. HR12 Persons seeking treatment for sexually transmitted diseases; homosexual and bisexual men; past or present intravenous (IV)drug users; persons with a history of prostitution or multiple sexual partners; women whose past or present sexual partners were HIV-infected, bisexual, or IV drug users; persons with longterm residence or birth in an area with high prevalence of HIV infection; or persons with a history of transfusion between 1978 and 1985. HR13 Persons exposed regularly to excessive noise. HR14 Household members of persons with tuberculosis or others at risk for close contact with the disease (eg, staff of tuberculosis clinics, shelters for the homeless, nursing homes, substance abuse treatment facilities, dialysis units, correctional institutions); recent immigrants or refugees from countries in which tuberculosis is common, migrant workers; residents of nursing homes, correctional institutions, or homeless shelters; or persons with certain underlying medical disorders (eg, HIV infection). VOL 40, NOVEMBER 1991
HR15 Men who would endanger public safety were they to experience sudden cardiac events (eg, commercial airline pilots). HR16 Persons with a family history of familial polyposis coli or cancer family syndrome. HRl7 Recent divorce, separation, unemployment, depression, alcohol or other drug abuse, serious medical illnesses, living alone, or recent bereavement. HR18 Intravenous drug users. HR19 Persons at increased risk for low back injury because of past history, body configuration, or type of activities. HR20 Persons with children in the home or automobile. HR21 Persons with older adults in the home. HR22 Young adults of Caribbean, Latin American, Asian, Mediterranean, or African descent. HR23 Persons with increased exposure to sunlight. HR24 Homosexually active men, intravenous drug users, recipients of some blood products, or persons in health-related jobs with frequent exposure to blood or blood products. HR25 Persons with medical conditions that increase the risk of pneumococcal infection (eg, chronic cardiac or pulmonary disease, sickle cell disease, nephrotic syndrome, Hodgkin’s disease, asplenia, diabetes mellitus, alcoholism, cirrhosis, multiple myeloma, renal disease, or conditions associated with immunosuppression). HR26 Residents of chronic care facilities or persons suffering from chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction. HR27 Persons born after 1956 who lack evidence of immunity to measles (receipt of live vaccine on or after fist birthday, laboratory evidence or immunity, or a history of physician-diagnosed measles).
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COLLEGE HEALTH
HR in the table. College students would be at especially high risk for sexually transmitted diseases and for measles, mumps, and rubella. What is special is the emphasis given by the guide to counseling activities in the periodic health examination. The USPSTF recommends that primary care physicians and nurses help their patients understand the important role of behavior in the maintenance of good health. Counseling activities included are those concerning tobacco use, exercise, nutrition, motor vehicle injuries, household and environmental injuries, HIV infection and other sexually transmitted diseases, unintended pregnancy, and dental disease. The guide’s recommendations differ little from those in my previous a r t i ~ l eThe . ~ Canadians had recommended breast and testicular self-examination5;the USPSTF did not find compelling evidence for or against this. It emphasized, rather, the clinical breast exam for those women and testicular exam for those men who are at higher risk. The USPSTF targeted the tuberculin skin test only for persons at high risk for tuberculosis, which would apply primarily to some international students. Counseling for fire safety is welcome. Additional recommendations for mammography, colonoscopy, and the electrocardiogram pertain only to a few college students.* Ideally, it would be best to integrate as much preventive activity as possible into our student health clinic routines. My suggestions for doing this in the office setting follow. 1. The student’s basic health history should be as complete as possible. A thorough health history identifies those students at higher risk who would especially benefit from specific preventive activities. For example, students who have had a splenectomy are at higher risk for serious pneumococcal infections and should be given the pneumococcal vaccine. 2. Immunization requirements, especially for measles, mumps, and rubella, should be made mandatory for college admission. This is already being implemented by many colleges. 3. Some screening tests can be packaged. For example, routine screening for Chlamydia trachomatis can be done during the periodic pelvic examination, along with the Papanicolaou smear.” The periodic pelvic examination is an important opportunity for counseling about how to prevent sexually transmitted diseases. 4. Family practice clinics have tried putting check lists for preventive activities into the front of the medical record. Madlon-Kay” found that compliance with all screening activities improved with physician and patient education, but that compliance still fell short of expectation, except for selected immunizations. 5. A periodic health examination check list might well be entered into a computer file for every first-year student. Each clinic encounter would then offer an opportunity, simply by a glance at the computer screen, 122
for a quick review of the student’s preventive health status. 6. I use a simple health screening check list in the office. The list, typed onto a small sheet of paper and photocopied, includes the following items: measles, mumps, rubella booster; tetanus-diphtheria booster within 10 years; tuberculin skin test (especially for all international students); weight; height; blood pressure; cholesterol; Papanicolaou smear in women; smoking cessation; exercise; and seat belt and bicycle helmet use. Those items warranting further information or discussion are checked and the slip is given to the student to take home. The INSURE study (Industrywide Network for Social, Urban, and Rural Efforts) recently published short-term prospective data on the changes in healthrisk behavior in 2,218 adults who had visited primary care physicians. They reported that a study group, when compared with controls, showed an increased percentage of patients exercising, quitting smoking, using seat belts, losing weight, reducing problem drinking, and women doing monthly breast self-exams. This study, however, consisted only of the subjects’ responses to printed survey questions asked 1 year later.” A majority of college health service encounters are illness visits for medical care. The challenge to student health physicians and nurses is to incorporate preventive activities into these visits. Every patient encounter, whether in the office or emergency room setting, is an opportunity for a review of the student’s healthcare screening status. For the majority of college students, an illness visit may be their only encounter with preventive activities. REFERENCES 1. Friedman GD, Collen MF, Bireman BH. Multiphasic health checkup evaluations: A l6year follow-up. J Chron Dk. 1986;6453-463. 2. South-East London Study Group. A controlled trial of multiphasic screening in middle age: Results from the SouthEast London Screening Study. Int J Epidemiol. 1977;6:357363. 3. Holbrook JH. Periodic health examination for adults. In: Stults BM, Dere W, eds. Practical Care of the Ambulatory Patient. Philadelphia: W. B. Saunders; 1989:415. 4. Reith P. Adapting the selective periodic health exam to a college-aged population. J A m ColI Health. 1989;38: 109-113. 5 . Canadian Task Force on the Periodic Health Examination. Can Med Assoc J. 1984;130:1278-1285. 6. The periodic health examination: 2. 1985 update. Canadian Task Force on the Periodic Health Examination. Can Med A s o c J. 1985;134:724-729. 7. The periodic health examination: 2. 1987 update. Canadian Task Force on the Periodic Health Examination. Can Med Ascioc J. 1988;138:618-626. 8. US Preventive Services Task Force. The Guide to Clinical Preventive Services. Baltimore: Williams 8~Wilkins; 1989: I
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9. Kern DE. Preventive medicine in ambulatory practice. In: Barker LR, Burton JR, Zieve PD, eds. PrincipIes of Ambulatory Medicine, 3rd ed. Baltimore: Williams & Wilkins; JACH
HEALTH D(AMiNATKI" 1990: 13-24. 10. Periera CA, Paquette GE, Wood PB, et al. Clinical laboratory testing for Chlamydia trachomatk in women at a university health service. J Am Coil Health. 1987;3639-42. 11. Madlon-Kay DJ. Improving the periodic health ex-
amination: Use of a screening flow chart for patients and physicians. J Fam Prac. 1987;25:470-473. 12. Logsdon DN, Lazar0 CM, Meier RV. The feasibility of behavioral risk reduction in primary medical care. A m J Prev Med. 1989;5 :249-256.
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IMMUNIZATION RECORDS. EASY ...FAST ACCURATE
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A software package for IBM and compatible computers, manages immunization records, rosters and correspondence.
A print ready health service newsletter, written especially for the campus community; mailed four times during the school year, for reprint and distribution.
COMPUTER EXPERIENCE NOT REQUIRED! BERKSHIRE
Healthy Hints contains current information on health issues and promotes healthy living. For reprints, information, or brochure, call or write:
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Gretta Buller 410 13th Avenue SE Rochester, MN 55904 507-289-6859
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A Live-Interactive Teleconference February 25,1992 1:OO-4:00 PM Eastern Time
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Other Panelists and Presenters will include educators, counselors, clinicians, and students working to promote sexual health in a variety of colleges and universities-including community, urban, and commuter campuses. They will: identify, discuss, and illustrate major strategic5 for effective campus sexual health promotion focus on special concerns for women, people of color, and gay, lesbian, and bisexual students demonstrate a spectrum of approaches to changing behavior, including peer education, theater, and health counseling highlight methods of enhancing self-esteem and building skills suggest ways to develop a sense of community that supports healthier behavior Present4 B ~ :Labow & Inassociationwith:
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COLLEGE A HEALTH ASSOCIATION NationalAssociation of Student PersonnelAdministrators
NASPA VOL 40. NOVEMBER 1991
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