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PREVENTIVE
HEALTH CARE
DANA BARTLETT, BSN, MSN, MA, CSPI
Dana Bartlett is a professional nurse and
author. His clinical experience includes 16 years
of ICU and ER experience and over 20 years of
as a poison control center information
specialist. Dana has published numerous CE
and journal articles, written NCLEX material,
written textbook chapters, and done editing
and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written
widely on the subject of toxicology and was recently named a contributing editor,
toxicology section, for Critical Care Nurse journal. He is currently employed at the
Connecticut Poison Control Center and is actively involved in lecturing and mentoring
nurses, emergency medical residents and pharmacy students.
ABSTRACT
Screening is an effective method for detecting and preventing acute
and chronic diseases. In the United States healthcare tends to be
provided after someone has become unwell and medical attention is
sought. Poor health habits play a large part in the pathogenesis and
progression of many common, chronic diseases. Conversely, healthy
habits are very effective at preventing many diseases. The common
causes of chronic disease and prevention are discussed with a primary
focus on the role of health professionals to provide preventive
healthcare and to educate patients to recognize risk factors and to
avoid a chronic disease.
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Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 4 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity. Pharmacology content is 0.5 hours (30 minutes).
Statement of Learning Need
Health professionals need to know the recommended screening tests
that may lead to early detection or prevention of medical problems
that cause morbidity and mortality if left undiagnosed and untreated.
Course Purpose
To provide health clinicians with up-to-date knowledge of the current
recommendations for preventive health screening tests and
techniques, as well as recommendations in lifestyle changes that will
promote preventive healthcare.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas
Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no
disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1.
One of the limitations of screening tests is:
a.
b.
c.
d.
2.
Screening tests must be used with the understanding that
a.
b.
c.
d.
3.
are males over age 35.
drink hard liquor.
use illicit drugs.
engage in risky drinking behavior.
Breast cancer is
a.
b.
c.
d.
5.
they are seldom able to detect diseases.
most of them are associated with harmful side effects.
they are not diagnostic.
they cannot be used for children.
Adults should be screened for alcohol misuse if they
a.
b.
c.
d.
4.
Guidelines are often changed and updated.
They rarely provide a high degree of specificity or sensitivity.
They can only be used for adolescents and adults.
The benefits seldom outweigh the risks.
only found in post-menopausal women.
the second most common cancer in women.
primarily caused by cigarette smoking.
not detectable without a biopsy.
Breast cancer screening may include
a.
b.
c.
d.
an x-ray.
a CT scan.
a biopsy.
mammography and genetic testing.
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Introduction
Screening is an effective method for detecting and preventing acute
and chronic diseases. Instead, healthcare in the United States is
typically provided after someone has become unwell. People generally
seek a physician or medical attention when sick and not before.
Additionally, poor health habits play a large part in the pathogenesis
and progression of many common, chronic diseases. Often people view
illnesses, such as atherosclerosis, diabetes, hypertension, or obesity,
as acute and unexpected rather than conditions that can be prevented
through screening and follow-up with their health clinician.
Collaboration In Preventative Medicine
In many cases, the signs and symptoms of chronic medical problems
that cause morbidity and mortality in most Americans are just
confirmation of an illness that has been present for many years. For
example, approximately 34% of the adults in the U.S., are obese.
Obesity is a major risk factor for the development of type 2 diabetes.
The primary cause of obesity is harmful patterns of food intake and
energy expenditure; too many calories and not enough exercise.
Studies have clearly shown that type 2 diabetes can be prevented by
weight loss, dietary changes, and exercise. Healthy habits are very
effective at preventing many other diseases, as well.
Preventative medicine involves a collaborative effort by the healthcare
community and individual patients. These include the following local
healthcare and individual efforts to promote health prevention.
 The healthcare community identifies the diseases that affect, or
are likely to affect a specific population.
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 The healthcare community screens for acute and chronic health
problems and identifies people at risk.
 The healthcare community delivers specific interventions and
therapies that will prevent disease, i.e., vaccinations.
 The healthcare community provides consumers with information
about behaviors and interventions that can help prevent chronic
illness.
 The healthcare community supports consumers in a life-long
commitment to healthy life style choices
 The individual makes the changes in diet, exercise, and other life
style factors that influence his/her health.
Screening For Disease Detection And Prevention
Screening is an effective method for detecting and preventing acute
and chronic diseases. However, it is important to remember the
following points when broad screening guidelines are used for a
heterogeneous population.

Not all cases of disease can or will be detected.

Screening guidelines are always being changed and updated.

Screening should be done on a case-by-case basis and when
appropriate, screening should be accompanied by an
examination and interview with a healthcare professional.

A screening test is not a diagnostic test.
In addition, screening is most effective when a disease or disorder
1) is an important public health problem, 2) has an early,
asymptomatic phase, 3) has an effective screening test that can
accurately identify people who will benefit from treatment, 4) has an
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available treatment, and 5) involves screening tests with benefits that
outweigh the risks. Screening tests should be simple to perform, costeffective, and easy to interpret and they must be sensitive and
specific.
The primary source of information used in this learning module is the
U.S. Preventive Services Task Force’s (USPSTF) Guide to Clinical
Preventive Services 2014. The USPSTF Guide discusses many diseases
and disorders. This module will for the most part only discuss ones for
which the Guide provides screening recommendations but some
exceptions have been made. The Guide to Clinical Preventive Services
2014 is available online.1
Alcohol Use Disorder And Addiction
The unhealthy use of alcohol by Americans is endemic. The 2014
National Survey on Drug Use and Health noted that 60.9 million
Americans reported binge alcohol use in the past month and 16.3
million reported heavy drinking in the past month.2 Over 17 million
American adults have an alcohol use disorder, and the twelve-month
and lifetime prevalence of alcohol use disorder has been estimated to
be 13.9% and 29.1%, respectively.3
The unhealthy use of alcohol is often unrecognized in the primary care
setting and studies support screening of the population for unhealthy
alcohol use.4 Who should be screened for alcohol use, when people
should be screened, and how often screening should be done depends
on factors such as age and an individual’s experience with alcohol
and/or drugs; and, different screening guidelines are available. The
USPSTF recommendations are shown below.5
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USPSTF Recommendations for Screening for Alcohol Misuse
Screen for alcohol misuse and provide brief behavioral counseling
interventions to persons engaged in risky or hazardous drinking.
There is a moderate net benefit to alcohol misuse screening and brief
behavioral counseling interventions in the primary care setting for adults
aged 18 years or older.
Counseling interventions in the primary care setting can improve
unhealthy alcohol consumption behaviors in adults engaging in risky or
hazardous drinking.
Behavioral counseling interventions for alcohol misuse vary in their
specific components, administration, length, and number of interactions.
Brief multi-contact behavioral counseling seems to have the best evidence
of effectiveness; very brief behavioral counseling has limited effect.
Numerous screening instruments can detect alcohol misuse in adults with
acceptable sensitivity and specificity. The USPSTF prefers the following
tools for alcohol misuse screening in the primary care setting: AUDIT, the
abbreviated AUDIT-C, and single-question screening such as asking, “How
many times in the past year have you had 5 (for men) or 4 (for women
and all adults older than 65 years) or more drinks in a day?”
The AUDIT and the Audit-C screening tools are accurate and well
validated, widely accepted and used in primary care settings for
alcohol misuse. These screening tools have been shown to be useful in
identifying hazardous drinking and to help initiate behavioral changes
in patients who engage in harmful or hazardous drinking.6-8
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The Alcohol Use Disorders Identification Test – AUDIT
In the AUDIT, the answers are scored as: 0 for never and 1-4 for
ascending frequency of use. Questions 9 and 10 are scored as 0, 2,
and 4 for ascending frequency. A score of ≥8 is associated with
harmful or hazardous drinking; and, a score of ≥13 in women and ≥
15 or more in men is likely to indicate alcohol dependence. The
healthcare professional will ask the following questions when using the
AUDIT screening tool.9
1.
How often do you have a drink containing alcohol?
a. Never
b. Monthly or less
c. 2-4 times a month
d. 2-3 times a week
e. 4 or more times a week
2.
How many alcoholic drinks do you have on a typical day drinking?
a. 1 or 2
b. 3 or 4
c. 5 or 6
d. 7 to 9
e. 10 or more
3.
How often do you have six or more drinks on one occasion?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily
4.
During the past year, how often have you found that you were unable
to stop drinking?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily
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5. During the past year, how often have you failed to do what was
normally expected of you because of drinking?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily
6. During the past year, how often have you needed a drink in the
morning to get yourself going after a heavy drinking session?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily
7. During the past year, how often have you had a feeling of guilt or
remorse after drinking?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily
8. During the past year, have you been unable to remember what
happened the night before because you had been drinking?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
a. No
b. Yes, but not in the past year
c. Yes, during the past year
10.Has a relative or friend, doctor or other health worker been concerned
about your drinking or suggested you cut down?
a. No
b. Yes, but not in the past year
c. Yes, during the past year
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Alcohol Use Disorders Identification Test-Consumption AUDIT-C
For men a score of ≥ 4 is considered positive. In women, a score of ≥
3 or more is considered positive. Generally, the higher the AUDIT-C
score the more likely drinking is affecting health and safety. The
questions are listed in the table below.10
1.
How often did you have a drink containing alcohol in the past
year? If the answer is never, score questions 2 and 3 as zero.
a. Never - 0 points
b. Monthly or less - 1 point
c. 2 to 4 times a month - 2 points
d. 3 or 4 times per week - 3 points
e. 4 or more times a week - 4 points
2.
How many drinks did you have on a typical day when you were
drinking in the past year?
a. 1 or 2 - 0 points
b. 3 or 4 - 1 point
c. 5 or 6 - 2 points
d. 7 to 9 - 3 points
e. 10 or more - 4 points
3.
How often did you have 6 or more drinks on one occasion in the
past year?
a. Never - 0 points
b. Less than monthly - 1 point
c. Monthly - 2 points
d. Weekly - 3 points
e. Daily or almost daily - 4 points
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The four question CAGE screening test for alcohol use is familiar to
many healthcare professionals. This test asks the following:

Have you ever felt you should Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever taken a drink first thing in the morning (Eyeopener) to steady your nerves or get rid of a hangover?
The CAGE test is not recommended as a screening tool for alcohol use
as it is not highly sensitive or specific.4
Tobacco Or Nicotine Use And Addiction
Tobacco use and its correlating problems are enormous public health
concerns. Tobacco use is the leading cause of preventable death in the
United States. The number of Americans who smoke has decreased by
more than one-half in the past 50 years, but tobacco and cigarette
smoking are still the primary causes of, or contributors to certain
cancers, heart disease, common respiratory diseases, and many other
acute and chronic pathology. A 2014 report from the Surgeon General
noted that tobacco and smoking have “... killed ten times the number
of Americans who died in all of our nation’s wars combined.”125
It has also been proven that second-hand smoke is a significant cause
of serious acute and chronic heath problems in children and adults.
Second-hand smoke (also called side stream smoke) is very
dangerous. Second-hand smoke is smoke that is produced from
burning tobacco or smoke that has been exhaled by someone using a
cigarette and there is no safe level of second-hand smoke.
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Smoking and tobacco use are still common in the United States.
Statistics from the Centers of Disease Control and Prevention (CDC)
and the Substance Abuse and Mental Health Services Association
(SAMHSA) are listed in the tables below.126-128
Smoking and Tobacco Use in the United States

In 2014, almost 17 of every 100 U.S., adults aged 18 years or older
(16.8%) currently smoked cigarettes. This means an estimated 40
million adults in the United States currently smoke cigarettes. There
are also millions of people who use smokeless tobacco and ecigarettes.

Cigarette smoking is the leading cause of preventable disease and
death in the United States, accounting for more than 480,000 deaths
every year, or 1 of every 5 deaths.

More than 16 million Americans live with a smoking-related disease.

Current smoking has declined from nearly 21 of every 100 adults
(20.9%) in 2005 to nearly 17 of every 100 adults (16.8%) in 2014.

In 2014, an estimated 66.9 million Americans aged 12 or older were
current users of a tobacco product (25.2%). Young adults aged 18 to
25 had the highest rate of current use of a tobacco product (35%),
followed by adults aged 26 or older (25.8%), and by youths aged 12
to 17 (7%).

In 2014, the prevalence of current use of a tobacco product was
37.8% for American Indians or Alaska Natives, 27.6% for whites,
26.6% for blacks, 30.6% for Native Hawaiians or other Pacific
Islanders, 18.8% for Hispanics, and 10.2% for Asians.
The CDC as well as several other sources have published the health
effects of second-hand smoke, as well as recommendations to
recognize the potential and ways to avoid it.129-130
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Health Effects of Second-Hand Smoke
Asthma attacks
Bronchitis
COPD
Ear infections
Heart disease
Lung cancer
Pneumonia
Stroke
Sudden infant death syndrome (SIDS)
Second-hand smoke has been estimated to increase the relative risk of
developing chronic obstructive pulmonary disease (COPD), stroke, and
ischemic heart disease by 1.66, 1.35, and 1.22, respectively.131
Children are especially vulnerable to the harmful effects of secondhand smoke and prenatal exposure to second-hand smoke has been
identified as a risk factor for developing asthma.132 Also, close
proximity is not necessary for exposure to second-hand smoke; many
studies have shown that living in a multi-residential building can
expose non-smokers to second-hand smoke.133
Smoking Cessation Interventions
There are interventions that can prevent people from smoking and
there are behavioral counseling techniques and medications that have
been shown to be effective at helping smokers quit. But nicotine, the
primary active component of cigarette smoke, is strongly addictive and
since tobacco is legal the prevention of smoking and smoking
cessation are considerable challenges. Behavioral-based interventions
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that can be helpful as aids to smoking cessation include direct provider
to patient interaction, group therapy, specialized clinics, self-help
intervention using educational resources like printed material or
videos, web-based and text-based resources, and telephone
applications and telephone contact counseling have all been
successfully used. The specific intervention chosen will depend on
availability, cost, and patient preference. Important aspects of
medication and behavioral interventions as aids to smoking cessation
that can increase the chance of success are discussed below.134-138
Pharmacotherapy
Pharmacotherapy (with or without behavioral interventions) can
significantly influence smoking cessation rates in adults. There are
three drugs that are approved by the Food and Administration (FDA)
for assisting patients with smoking cessation: bupropion, nicotine
replacement therapy (NRT), and varenicline. Alternative approaches to
support patients during their course of care in a smoking cessation
program have been reported to provide value and good results of
quitting smoking, such as acupuncture, hypnosis and e-cigarettes.
Each year approximately two out of every three smokers will try and
quit but the majority will be unsuccessful.139,140 There are many
reasons why smokers find it difficult to quit and difficult to maintain
abstinence, including but not limited to: side effects of cessation such
as cravings and withdrawal, weight gain, mood changes, poor social
support, access problems for smoking cessation programs, poor
preparation for quitting, and incorrect use of medications. These
issues, along with the addictive properties of nicotine, clearly present
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smokers with a considerable challenge when they try to quit and to
cease the smoking habit long-term.
Screening and Prevention Through the Electronic Health Record
Improving tobacco use screening and exposure to second-hand smoke
has become an area of focus for many electronic health records (EHRs)
with smoking prevention and cessation patient teaching tools built into
the admission process. Most clinic and hospital providers will screen for
tobacco use, such as asking patients how many years or how much
they smoke each day. A patient who reports a smoking history may be
offered educational handouts that promote health prevention and
resources for smoking cessation; several examples are listed below.

Freedom from Smoking® is a program offered by the American
Lung Association. Use this link: http://www.lung.org/stopsmoking/i-wantto-quit/how-to-quit-smoking.htmlv and scroll
down the page to the section title Get Help.

The American Lung Association also has a help line, 1- 800 LUNG
USA.

Smokefree.gov is a website of the United States Department of
Health and Human Services. It includes information on healthy
habits, how smoking affects one's health, and tips on preparing
to quit. It also includes resources specifically for women, teens,
and Spanish-speaking patients.

1-800-QUIT Now (1-800-784-0669) is a toll free number that
connects smokers to the Quit For Life® program, sponsored by
the American Cancer Society.
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Lung Cancer
Lung cancer is the most common cause of death from cancer in
American adults.73 The National Cancer Institute estimates that in
2016 there will 224,390 new cases of lung cancer and that lung cancer
will account for more than one-fourth of all cancer deaths.74 Cigarette
smoking is the primary cause of lung cancer. Most lung cancers are
discovered when they are in the late stage. Targeted screening is
advised.
The USPSTF and the American Cancer Society recommends that
asymptomatic adults aged 55 to 80 years who have a 30 pack-year
history of smoking and currently smoke or have quit smoking within
the past 15 years should have annual screening with low dose
computed tomography.5,75 The 2014 Clinical Guidelines state: “Annual
screening for lung cancer with low-dose computed tomography is of
moderate net benefit in asymptomatic persons who are at high risk for
lung cancer based on age, total cumulative exposure to tobacco
smoke, and years since quitting smoking.”5
Breast Cancer
Breast cancer is the most common cancer in women, excluding skin
cancer. In 2013, 230,815 women and 2109 men were diagnosed as
having breast cancer. That same year, 40,860 women and 464 men
died from breast cancer in the United States.11
Risk factors for breast cancer include age, age at first live childbirth,
age at menarche, alcohol use, body mass index, breast density, diet,
estrogen and progesterone use, menopause status or age, number of
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first-degree relatives with breast cancer, personal history of ductal or
lobular carcinoma in situ, personal history of breast biopsy, physical
activity, and race/ethnicity.5
Screening for breast cancer includes screening for neoplasms and
screening for genetic susceptibility to breast cancer.
American Cancer Society Screening Recommendations
The American Cancer Society’s breast cancer screening
recommendations are outlined below.12

Women ages 40 to 44 should have the choice to start annual
breast cancer screening with mammograms (X-rays of the breast)
if they wish to do so.

Women age 45 to 54 should get mammograms every year.

Women 55 and older should switch to mammograms every 2
years, or can continue yearly screening.

Screening should continue as long as a woman is in good health
and is expected to live 10 more years or longer.

All women should be familiar with the known benefits, limitations,
and potential harms linked to breast cancer screening. They also
should know how their breasts normally look and feel and report
any breast changes to a healthcare provider right away.
USPSTF Screening Recommendations
The USPSTF recommendations for breast cancer screening are
reviewed in this section.5 Women aged 40-49 should be considered for
a biennial mammogram. The decision to do a mammogram should be
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made on an individual basis, depending on the woman’s circumstances
and values. Women aged 50-74 should have a mammogram every two
years. The USPSTF does not include a recommendation for the use of
mammograms in women age 75 or older.
The USPSTF recommendations apply to women aged ≥40 years that
are not at increased risk by virtue of a known genetic mutation or
history of chest radiation. Increasing age is the most important risk
factor for most women.
There is convincing evidence that using mammography to screen for
breast cancer reduces overall mortality from breast cancer. This
reduction in risk becomes increased for women aged 50 to 74 years.
Harms of screening include psychological effect, additional medical
visits, imaging, and biopsies in women without cancer, inconvenience
due to false-positive screening results, harms of unnecessary
treatment, and radiation exposure. The level of harm appears to be
moderate for each age group.
USPSTF Recommendations for Genetic Testing
The population for screening is asymptomatic women who have not
been diagnosed with BRCA-related cancer. Genetic testing for breast
cancer is recommended for women whose family history may be
associated with an increased risk for potentially harmful breast cancer
mutations.5
Genetic risk assessment and breast cancer mutation testing involves
identification of women who may be at increased risk for potentially
harmful mutations, genetic counseling, and genetic testing of selected
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high-risk women when indicated. If the screening tests are positive
women should receive genetic counseling and, if indicated after
counseling, breast cancer mutation testing.
Tests for breast cancer mutations are highly sensitive and specific for
known mutations, but interpretation of results is complex and
generally requires post-test counseling. In women whose family
history is associated with an increased risk for potentially harmful
BRCA mutations, the net benefit of genetic testing and early
intervention is moderate. Interventions in women who are BRCA
mutation carriers include earlier, more frequent, or intensive cancer
screening, use of risk-reducing medications such as tamoxifen or
raloxifene, and risk-reducing surgery such as mastectomy or salpingooophorectomy. Genetic counseling and testing for breast cancer
mutations is not recommended for women whose family history is not
associated with an increased risk for potentially harmful breast cancer
mutations.
Cervical Cancer
In 2103, 11,955 women in the United States were diagnosed with
cervical cancer and 4,217 women died from the disease.13 Risk factors
for cervical cancer include cigarette smoking, early onset of sexual
activity, infection with high-risk strains of human papilloma virus
(HPV), immunosuppression, multiple sex partners, oral contraceptive
use, and persistent HPV infections.14
Cervical cancer screening decreases the incidence and mortality of
cervical cancer. In the U.S., it has been estimated that screening has
decreased mortality from this disease by 70%,15 and “… reviews and
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meta-analyses of observational studies provide consistent and
compelling evidence that screening leads to a decrease in incidence
and mortality from cervical cancer.”14
The harmful effects of cervical cancer screening include cost,
psychosocial consequences, and discomfort. In addition, screening
may lead to unneeded diagnostic and/or treatment procedures (which
have risks), particularly in women <21 years in whom HPV testing
may detect abnormalities that are transient.14
The USPSTF recommendations for cervical cancer screening are listed
below. These recommendations are identical to the recommendations
of the American Congress of Obstetricians and Gynecologists.16
USPSTF Screening Recommendations
The USPSTF recommendations for cervical cancer screening are
highlighted below.5

Women aged 21-65: screen three years with a Pap smear.

Women aged 30-65: screen every three years with a Pap
smear or a Pap smear and HPV testing.

Women < 21 years: Do not screen.

Women older than age 65 who have had adequate prior
screening and are not high risk: Do not screen.

Women after hysterectomy with removal of the cervix and
with no history of high-grade pre-cancer or cervical cancer:
Do not screen.

Screening women ages 21 to 65 years every 3 years with
cytology provides a reasonable balance between benefits and
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harms. Screening with cytology more often than every 3
years confers little additional benefit, with large increases in
harm.

HPV testing combined with cytology (co-testing) every 5
years in women ages 30 to 65 years offers a comparable
balance of benefits and harms, and is therefore a reasonable
alternative for women in this age group who would prefer to
extend the screening interval.

Screening earlier than age 21 years, regardless of sexual
history, leads to more harm than benefits. Clinicians and
patients should decide to end screening based on whether the
patient meets the criteria for adequate prior testing and
appropriate follow-up, per established guidelines.
Prostate Cancer
Prostate cancer is the most commonly diagnosed cancer in men.81
Each year more than 200,000 men in the United States are diagnosed
with prostate cancer and it is the second leading cause of death from
cancer in men in the United States.81,82 Risks for prostate cancer
include age, African American ethnicity, and a family history of the
disease.
The need for and the usefulness of screening for prostate cancer is a
complex and controversial topic and a full discussion of the issue is
beyond the scope of this module. Prostate cancer is very common but
death from this disease is relatively uncommon. The death rate of men
who have prostate cancer has been estimated to be 2.9% and the
disease progresses so slowly that most men with prostate cancer die
from other causes.83 Screening for prostate cancer by measuring
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prostate-specific antigen (PSA) and digital rectal examination can
reduce the mortality rate prostate cancer but this reduction is very
small and does not outweigh the risks.83
The USPSTF does not recommend routine screening for prostate
cancer and the 2014 Guidelines state: “There is convincing evidence
that PSA-based screening programs result in the detection of many
cases of asymptomatic prostate cancer, and 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., PSA-based screening results in considerable overdiagnosis).”5
The 2014 Guidelines further state that, “The reduction in prostate
cancer mortality 10 to 14 years after PSA-based screening is, at most,
very small, even for men in the optimal age range of 55 to 69 years
[and the] benefits of PSA-based screening for prostate cancer do not
outweigh the harms.”5
The American Urological Association (AUA) and the American Cancer
Society (ACS) advise that the decision to screen or not screen should
be made by the patient and his primary care physician after a
discussion of the risks and benefits.82,83
Skin Cancer
Skin cancer is divided into two categories, non-melanoma and
melanoma. Basal cell carcinoma and squamous cell carcinoma are the
two non-melanoma skin cancers. These cancers are not usually
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reported to cancer registries so their true incidence and prevalence are
not known:84,85 They account for approximately 97% of all skin
cancers but the incidences of morbidity and mortality from these
neoplasms are very small.86,87
Malignant melanoma is much less common than the non-melanoma
skin cancers but it is much more serious. Malignant melanoma can
metastasize to any organ (most often the skin and lymph nodes) and
the incidence of malignant melanoma and deaths from this cancer
have been increasing for years.88 Risk factors for non-melanoma and
melanoma skin cancer include (but are not limited to: 1) Caucasian
ethnicity, 2) exposure to sunlight, 3) indoor tanning, 4)
immunosuppression, 5) fair skin, 6) family history of melanoma, 7)
atypical nevi, 8) advanced age, 9) psoralen, and 10) UVA light
therapy.
Unfortunately, there does not seem to be any benefit from universal
screening for skin cancer.5,87,89 The USPSTF does not recommend
routine screening for skin cancer, noting that there is “… insufficient
evidence to assess the balance of benefits and harms of whole body
skin examination by a clinician or patient….“5 Clinicians and patients
should remember that skin lesions should be considered potentially
malignant if they are rapidly changing or if A, B, C, D is present, as
shown below:
Asymmetry
Border irregularity
Color variability
Diameter > 6 mm
Colorectal Cancer
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In 2103, 136,119 people in the U.S., were diagnosed with colorectal
cancer and 51,813 people in the U.S., died from colorectal cancer.17
Colorectal cancer is the second leading cause of death from cancer in
the U.S., and approximately one of three people diagnosed with the
disease will die five years after it is discovered.18
Risk factors for colorectal cancer include a family history for colorectal
cancer, African American ethnic status, alcohol use, cigarette smoking,
Crohn’s disease, diabetes mellitus and insulin resistance, diet,
inflammatory bowel disease, obesity, and radiation therapy for
abdominal cancer.
There is unequivocal evidence that colorectal cancer screening and
removal of pre-malignant adenomas can decrease the incidence and
mortality of colorectal cancer.5,18,19 The specific risks of the invasive
screening procedures, of colonoscopy and sigmoidoscopy, include
infection, adverse effects from sedating drugs used during the
procedures, perforation and bleeding. Major adverse effects after
flexible sigmoidoscopy and colonoscopy examinations are very
unusual, occurring is less than 1% of all patients.20-22 The risk of
contrast enemas and CT colonography is exposure to radiation.
Several methods are used to detect colorectal cancer. An individual’s
risk profile will determine which one is appropriate.
USPSTF Screening Recommendations
The USPSTF recommendations for colorectal cancer screening are
highlighted below.
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
Age 50-75: Screen with high sensitivity fecal occult blood
testing (FOBT), sigmoidoscopy, or colonoscopy.

Age 76-85: Do not automatically screen.

Age > 85: Do not screen.

Screening intervals: Annual screening with high-sensitivity
fecal occult blood testing; sigmoidoscopy every 5 years, with
high-sensitivity fecal occult blood testing every 3 years; or
screening colonoscopy every 10 years.

For all populations, evidence is insufficient to assess the
benefits and harms of screening with computerized
tomography colonography (CTC) and fecal DNA testing.
Dental And Periodontal Disease And Oral Cancer
Regular examinations and periodic cleanings by a dental hygienist
clearly help prevent dental caries and periodontal disease. In addition,
there is evidence that dental caries and periodontal disease are
associated with systemic illnesses. The American Dental Association
recommends that the frequency of dental visits and professional
cleanings be determined on a case-by-case basis. People who have
risk factors that increase the chances of developing dental caries and
periodontal disease.
Oral cavity and oropharyngeal cancers are a serious pathology. The
American Cancer Society estimates that in 2016 approximately 48,000
Americans will develop oral cavity or oropharyngeal cancer and
approximately 9,500 will die from one of these cancers.24
Most of these cancers are not detected in the early stages and the
five-year survival rate is 80% if they are detected when still in Stage I
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or Stage II.25 The primary risk factors for these cancers are alcohol
use, tobacco use, and HPV infection.
Although screening is recommended by many dental associations and
dental professionals, unfortunately there is a lack of evidence to
support the effectiveness of screening for oral cancer.25 By example,
“The USPSTF found inadequate evidence on the diagnostic accuracy,
benefits, and harms of screening for oral cancer. Therefore, the
USPSTF cannot determine the balance of benefits and harms of
screening for oral cancer in asymptomatic adults.”5
The American Dental Association in 2010 published guidelines about
oral cancer screening. In brief, these guidelines noted that oral
inspection and tactile palpation were the recommended screening
tools. These guidelines also noted that the use of devices that rely on
auto-fluorescence or tissue reflectance to detect oral cancers do not
appear to be superior for this purpose when compared to conventional
visual inspection and tactile palpation.26
Coronary Heart Disease
Coronary heart disease and its associated conditions are the leading
cause of death in the U.S. Risk factors for the development of coronary
heart disease includes those that are modifiable and non-modifiable.
Modifiable risk factors include cigarette smoking, diabetes, diet,
elevated serum lipids and cholesterol, hypertension, obesity, and
sedentary life style. Non-modifiable risk factors are age, gender, and
family history of coronary heart disease.
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The USPSTF does not recommend specific screening for coronary heart
disease for asymptomatic adults who do not have coronary heart
disease or diabetes.5 The USPSTF does recommend that people be
screened for the presence of the risk factors for coronary heart disease
and counseled on smoking cessation, diet, exercise and management
of diabetes and hypertension.
The American Heart Association’s specific guidelines for coronary heart
disease risk factor screening are outlined below.

Blood pressure:
Starting at age 20, blood pressure measurement at each
regular healthcare visit or at least once every two years if
blood pressure is < 120/80 mm Hg.

Blood glucose:
Starting at age 45, measure blood glucose every three years.

Cholesterol:
Starting at age 20, measure total cholesterol, HDL and LDL
cholesterol, and triglycerides every four to six years for
normal people, more often if someone has an elevated risk for
heart attack or stroke.

Starting at age 20, discuss smoking and physical activity at
every regular healthcare visit.

Starting at age 20, measure waist circumference as needed. This
is a supplemental measure that should be used if the BMI is ≥
25/kg/m2.
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The American Heart Association’s specific guidelines for coronary heart
disease risk factor screening may be found on its website.23
Hypertension
Hypertension is one of the most important preventable causes of
cardiovascular disease, diabetes, stroke, and renal failure.59, 60
Approximately 72 million Americans have hypertension, more than half
are undiagnosed, and of those that are diagnosed, control of the
disease has been described as suboptimal.60,61 Risk factors for the
development of primary hypertension (the most common form of the
disease) include but are not limited to the factors are listed in the table
below.60
Risk Factors for Hypertension
Age
Cigarette smoking
Obesity
Family history
Race – African American
Excess sodium intake
Excessive alcohol consumption
Physical inactivity
Diabetes and dyslipidemia
Personality traits and depression
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Hypertension is defined as a blood pressure of 140/90 mm Hg or
higher.59 The USPSTF screening recommendations, derived from the
the Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure - JNC 7
Report, include the following.5

All adults be screened for hypertension

Screening every two years if the blood pressure is > 120/80 mmHg

Screening every year for systolic blood pressure of 120-139 mmHg

Adults with hypertension should be screened for diabetes
The diagnosis of hypertension cannot be confirmed until an elevated
blood pressure is present on several occasions. Blood pressure can be
measured in a physician’s office, by using ambulatory blood pressure
monitoring, or using home blood pressure monitoring.60
Diabetes
Approximately 21 million Americans have diabetes and 37% percent of
the population 20 years of age or older have pre-diabetes.35
Approximately 27.8% of people who have diabetes are undiagnosed,
and almost half of Asian Americans and Hispanic Americans who have
diabetes are undiagnosed.35,36 The prevalence of diabetes is
increasing,37 and diabetes is the primary cause of, or a major
contributing factor in, the development of many serious diseases such
as blindness, heart disease, and kidney failure.
There is evidence that suggests screening for and early treatment of
diabetes can be beneficial.38-41 The American Diabetes Association
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(ADA) has recommendations for testing for diabetes or pre-diabetes in
asymptomatic adults as set forth in the following table.
Testing for Diabetes/Pre-diabetes in Asymptomatic Adults
Testing should be considered in all adults who are overweight (BMI
≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and have additional risk
factors, as outlined below.42

Physical inactivity

First-degree relative with diabetes

High-risk race/ethnicity (i.e., African American, Latino, Native
American, Asian American, Pacific Islander)

Women who have delivered a baby weighing >9 lb. or were
diagnosed with gestational diabetes mellitus

Hypertension (≥140/90 mmHg or on therapy for hypertension)

HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a
triglyceride level >250 mg/dL (2.82 mmol/L)

Women with polycystic ovary syndrome

HbA1c ≥5.7% (39 mmol/mol), IGT, or IFG on previous testing

Other clinical conditions associated with insulin resistance (i.e.,
severe obesity, acanthosis nigricans)

History of CVD
 For all patients, testing should begin at age 45 years
 If results are normal, testing should be repeated at three year
 More frequent testing should be done, depending on initial
results and risk status
 Diabetes may be diagnosed based on plasma glucose criteria –
either fasting plasma glucose or the 2-hour plasma glucose
value after a 75-gram oral glucose tolerance test - or HbA1c
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USPSTF Screening Recommendations
The USPSTF screening recommendations for symptomatic adults with
sustained blood pressure greater than 135/80 mmHg are
recommended to screen for type 2 diabetes mellitus. These
recommendations apply to adults with no symptoms of type 2 diabetes
mellitus or evidence of possible complications of diabetes.5
Blood pressure measurement is an important predictor of
cardiovascular complications in people with type 2 diabetes mellitus.
The first step in applying this recommendation should be measurement
of blood pressure (BP). Adults with treated or untreated BP >135/80
mm Hg should be screened for diabetes.
The American Diabetes Association recommends screening with fasting
plasma glucose (FPG), and defines diabetes as FPG ≥ 126 mg/dL; and,
recommends confirmation with a repeated screening test on a
separate day. The optimal screening interval is not known. The ADA,
on the basis of expert opinion, recommends an interval of every 3
years.
To determine whether screening would be helpful on an individual
basis, information about 10-year coronary heart disease (CHD) risk
must be considered. For example, if CHD risk without diabetes was
17% and risk with diabetes was >20%, screening for diabetes would
be helpful because diabetes status would determine lipid treatment. In
contrast, if risk without diabetes was 10% and risk with diabetes was
15%, screening would not affect the decision to use lipid-lowering
treatment. The diagnostic criteria for diabetes are outlined below.42
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
Fasting plasma glucose of 126 mg/dL or higher. The fasting
plasma glucose test is a measurement of plasma glucose that is
performed after the patient has been fasting for at least eight
hours. The test should be repeated twice to confirm the presence
of diabetes. The normal fasting plasma glucose is considered to
be < 100 mg dL.

A 2-hour plasma glucose level ≥ 200 mg/dL during an oral
glucose challenge test. The patient should be fasting for eight
hours prior to the test. A plasma glucose level is obtained and if
it is < 140 mg/dL, the patient is given 75 grams of an oral
glucose solution. Two hours after administration of the glucose
solution the plasma glucose is measured, and the result should
be < 140 mg/dL. (It should be noted that the level considered to
be normal varies somewhat with age).

A hemoglobin A1c (HbA1c) level of > 6.5%. The HbA1c, aka the
glycosated hemoglobin level, measures glucose that is attached
to hemoglobin and it provides an indication of what the average
blood glucose has been for several months prior to the test.

In a patient with classic symptoms of hyperglycemia or
hyperglycemic crisis, a random plasma glucose ≥200 mg/dL.
Screening for medical complications that are caused by or associated
with diabetes is very important. The following recommendations are
from the ADA, Standards of Medical Care in Diabetes - 2016.43
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 Hypertension:
Patients who are at risk for, or who have diabetes, should be
screened for hypertension and blood pressure should be measured
at every routine visit. A systolic blood pressure of ≤ 140 mm Hg or
a blood pressure of < 140/90 m Hg is desirable. These levels have
been associated with a reduction in CVD, nephropathy, and stroke
in patients who have diabetes.
 Lipid Profile:
The Standards recommend that “... it is reasonable to obtain a lipid
profile at the time of diabetes diagnosis, at an initial medical
evaluation, and every 5 years thereafter, or more frequently if
indicated.”43
 Diabetic Nephropathy:
Measure urinary albumin level and eGFR at least once a year in
patients who have had type 1 diabetes ≥ 5 years, in all patients
who have type 2 diabetes, and in all patients who have diabetes
and hypertension.
 Diabetic Retinopathy:
Adults who have type 1 diabetes should have a dilated and
comprehensive eye examination within five years of the time of
diagnosis. Patients who have type 2 diabetes should have a dilated
and comprehensive eye examination at the time of diagnosis. If the
patient does not have retinopathy after one or more yearly
examinations, then biennial examinations may be considered. If
any level of retinopathy is discovered then dilated retinal
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examination should be done at least every year and if the
retinopathy is progressing, more frequent examinations may be
needed.
For pregnant women who have diabetes, an eye examination should
be done before pregnancy or in the first trimester. Subsequently,
patients should be monitored each trimester and for one year, postpartum, as indicated by the degree of retinopathy.
 Diabetic Peripheral Neuropathy:
Patients who have type 1 diabetes should be assessed for the
presence of diabetic five years after the diagnosis is made. For
patients who have type 2 diabetes, this assessment should be done
at the time the diagnosis is made. The assessment should include a
patient history, 10-g monofilament testing, and at least one of the
following tests: pinprick, temperature, or vibration sensation.
 Diabetic Foot Ulcers:
A comprehensive foot evaluation should be done every year. The
examination should include inspection of the skin, assessment of
foot deformities, and a neurological assessment including 10-g
monofilament testing and pinprick or vibration testing or
assessment of ankle reflexes. The pulses in the feet and legs should
be checked, as well.
 Cardiovascular Disease:
Asymptomatic patients should not be screened for cardiovascular
disease but cardiovascular risk factors should be assessed annually,
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at least. These risk factors include dyslipidemia, hypertension,
family history of premature cardiovascular disease, presence of
albuminuria, and smoking.
Lipid Disorders
The lipid disorders of elevated cholesterol and elevated triglycerides
are an important factor in the development of atherosclerosis.
Atherosclerosis contributes to the development of coronary heart
disease, it is a risk factor for stroke, and it is considered to be the
major cause of premature death in developed countries.72 Libby
(2015) writes: “Abnormalities in plasma lipoproteins and
derangements in lipid metabolism rank among the most firmly
established and best understood risk factors for atherosclerosis.”72
The USPSTF advises that the benefits of lipid screening definitely
outweigh the risks and that these populations should be screened for
lipid disorders:5

Men age 35 years and older

Women age 45 years and older who are at increased risk for
coronary heart disease

Men ages 20 to 35 years who are at increased risk for coronary
heart disease

Women ages 20 to 45 years who are at increased risk for
coronary heart disease
Increased risk would be the presence of atherosclerosis or coronary
heart disease, diabetes, family history of coronary heart disease,
hypertension, obesity and smoking.
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Fasting total serum cholesterol, high-density and low-density
cholesterol should be measured. The optimal interval for screening is
not certain, but lipid measurement every five years in patients who are
below the treatment threshold, and measurement at shorter intervals
for people who have lipid levels that are close to those requiring
therapy is recommended as a reasonable approach.5 Screening can be
done at longer intervals if someone has no risk factors and repeated
lipid measurements are normal.
Obesity
Obesity is a significant public health problem worldwide and in the
United States. The prevalence of obesity in the U.S., has been
estimated to be 35% for men and 40.4% for women.76 Obesity is a
contributing factor for the development of many diseases, and people
who are obese have an increased risk for cancer, coronary heart
disease, depression, type 2 diabetes, gallbladder disease,
osteoarthritis, respiratory problems, sleep apnea, and stroke.77
Screening for obesity is recommended5,78 and the USPSTF advises that
adults age 18 and older be screened by using body mass index (BMI)
and anyone with a BMI ≥ 30 kg/m2 “… should be offered or referred to
intensive, multi-component behavioral interventions.”5 Additionally,
“Screening combined with interventions can improve glucose tolerance
and decrease risk factors for cardiovascular disease and the harms of
this approach are considered to be small.”5
It should be noted that body mass index (BMI) is calculated by
dividing weight in kilograms divided by the square of height in meters.
Body mass index may not always be the most accurate way to
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determine whether or not someone is obese and in some
circumstances measuring weight circumference is preferable.
Osteoporosis
Osteoporosis is a skeletal disorder that is characterized by decreased
bone mass. Osteoporosis is very common, especially in the elderly. It
is more common in women than in men, although with advancing age,
many men develop osteoporosis as well. The National Osteoporosis
Foundation estimates that 54 million Americans have osteoporosis/low
bone mass,79 and the health consequences of this disease are
significant. Osteoporosis does not produce symptoms, but there are
estimated 1.5 million fragility fractures that happen in the United
States every year, and one out of every two women and one out of
every four men 50 years old or more will have a fracture caused by
osteoporosis.79,80
Risk factors for osteoporosis are outlined below as:80

Asian or white race

Current tobacco use

Estrogen deficiency and < 45 years of age

Excessive use of alcohol

Family history of osteoporosis

Female > 65 years of age

History of fragility fracture or fragility fracture in a first-degree
relative

Long-term use of glucocorticoids

Low calcium intake

Male > 70 years of age

Low body weight: < 127 pounds or BMI < 20
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
Sedentary life style

Testosterone deficiency

Vitamin D deficiency
The USPSTF recommendations for osteoporosis screening5 state that
dual-energy x-ray absorptiometry of the hip and lumbar spine should
be done for the following groups of women.

Women age ≥ 65 years without previous known fractures or
secondary causes of osteoporosis.

Women age < 65 years whose 10-year fracture risk is equal to
or greater than that of a 65-year-old white woman without
additional risk factors.
Hepatitis B And Hepatitis C
Hepatitis B is a viral infection of the liver. Hepatitis B is transmitted
primarily by contact with infected blood, and it can also be transmitted
through other body fluids, by sexual contact, and from mother to child.
The risk of developing a chronic infection after an exposure is
approximately 2%-6%, and the Centers for Disease Control and
Prevention (CDC) estimates that there are between 850,000 to 2.2
million Americans who are chronically infected with the Hepatitis B
virus.52 Factors that increase the risk of being infected with Hepatitis B
include intravenous drug use, hemodialysis, a healthcare occupation,
men who have sex with men, unprotected sex with multiple partners,
or travel to an area where there is a high infection rate of Hepatitis B.
The signs and symptoms of a Hepatitis B infection are temporary and
for the most part, non-specific.
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The CDC recommends screening the following groups for Hepatitis B
by testing for the presence of Hepatitis B surface antigen (HBsAg):53

Persons born in geographic regions with HBsAg prevalence of
≥2%

U.S., born persons not vaccinated as infants whose parents were
born in geographic regions with HBsAg prevalence of ≥8%

Injection-drug users

Men who have sex with men

Persons with elevated ALT/AST of unknown etiology

Persons with selected medical conditions who require
immunosuppressive therapy

Pregnant women

Infants born to HBsAg-positive mothers

Household contacts and sex partners of HBV-infected persons

Persons who have had blood or body fluid exposures that might
warrant post-exposure prophylaxis (i.e., needle-stick injury to a
healthcare worker)

Persons infected with HIV
The USPSTF recommends that at the first prenatal visit, all pregnant
women should be screened for Hepatitis B by checking for HBsAg.5 The
USPSTF also recommends rescreening women with unknown HBsAg
status or new or continuing risk factors at admission to hospital, birth
center, or other delivery setting.
Hepatitis C is a viral infection of the liver. Hepatitis C is primarily
transmitted by contact with infected blood, and infection after contact
with other body fluids and from sexual contact is also possible.
Approximately 85% of people who have an acute infection with
Hepatitis C will develop a chronic Hepatitis C infection,54 and the CDC
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estimates that 2.7-3.9 million people in the U.S., have chronic
Hepatitis C.55 Hepatitis C is one of the most common indications in the
U.S., for liver transplantation.54
Factors that increase the risk of being infected with Hepatitis C include
the following: 1) current or former IV drug users, 2) hemodialysis
patients, 3) healthcare workers who are exposed to blood or body
fluids, 4) anyone who was given clotting factors before 1987,
5) anyone who received a blood transfusion or a sold organ transplant
prior to July of 1992, 6) persons infected with HIV, and 7) children
born to mothers who are infected with Hepatitis C. The signs and
symptoms of a Hepatitis C infection are temporary, for the most part
non-specific, and the patient often has no signs or symptoms.
Hepatitis C Screening
The USPSTF recommendations for hepatitis screening are highlighted
here.5
 Persons at high risk for infection and adults born between 1945 and
1965 should be screened.
 Persons with continued risk for HCV infection should be screened
periodically.
 Anti-HCV antibody testing should be used for screening. This can be
followed with confirmatory polymerase chain reaction testing, as
needed.
The CDC’s recommendations for Hepatitis C screening are essentially
the same as the USPSTF but are more specific about who should be
screened.52
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CDC Recommendations for Hepatitis C Screening
 Persons born from 1945 through 1965
 Persons who have ever injected illegal drugs, including those who
injected only once many years ago
 Recipients of clotting factor concentrates made before 1987
 Recipients of blood transfusions or solid organ transplants before
July 1992
 Patients who have ever received long-term hemodialysis treatment
 Persons with known exposures to HCV, such as healthcare workers
after needle sticks involving HCV-positive blood or recipients of
blood or organs from a donor who later tested HCV-positive
 All persons with HIV infection
 Patients with signs or symptoms of liver disease, i.e., abnormal liver
enzyme tests
 Children born to HCV-positive mothers (to avoid detecting maternal
antibody; these children should not be tested before age 18
months)
Human Immunodeficiency Virus
Infection with the human immunodeficiency virus (HIV) can cause
acquired immunodeficiency syndrome (AIDS). An acute infection with
HIV after exposure may produce mild, non-specific signs and
symptoms or the infected person may feel fine. The acute infection
period lasts approximately two weeks and then the virus enters the
dormant phase. During this time HIV is reproducing at a slow rate and
the infected person is asymptomatic.
The dormant phase of the virus lasts approximately 10 years and at
that point viral replication increases rapidly and HIV begins to cause
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serious, irreversible damage to the immune system. At that point the
infected person has AIDS. The average survival time after
development of AIDS is three years and death is typically caused by
an opportunistic infection.
The CDC estimates that there are 1.2 million Americans infected with
HIV, and that the number of new infections has been decreasing each
year since 2005.56 People who are infected with HIV are asymptomatic
for approximately 10 years while the virus is in the dormant stage but
during that time the virus can be transmitted so screening for HIV is
an important public health concern.
The human immunodeficiency virus is primarily transmitted by sexual
contact and contact with infected blood and the USPSTF recommends
HIV screening for the following individuals.5
1. Adolescents and adults aged 15 to 65 years
2. Younger adolescents and older adults at increased risk for infection
3. Pregnant women
Younger adolescents and adults considered to be at increased risk
include:5
 Men who have sex with men
 Active injection drug users
 People who have a sexually transmitted disease
 Anyone having unprotected vaginal or anal intercourse
 Being a sex partner of someone who is HIV-infected, bisexual or an
injection drug user
 Anyone exchanging sex for drugs or money
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 People exposed to HIV contaminated blood as an occupational
hazard, i.e., a needle-stick injury in healthcare workers
 Anyone who has multiple sex partners
A one-time screening test is sufficient unless risk factors are present
and then screening should be done once a year, or in some cases,
every three to six months.55 Screening for HIV is done by testing blood
for HIV antibodies and HIV antigen. Rapid HIV testing can be done
(results within 5-40 minutes) and over-the-counter HIV testing
products are available, but when these methods are used formal
laboratory testing is required to confirm the results.5,58
Illicit Drug And Prescription Drug Use
Illicit drug use is a significant public health problem. The USPSTF
advises that clinicians should be aware of, and alert to the signs and
symptoms of illicit drug use but that “… the evidence is insufficient to
determine the benefits and harms of screening for illicit drug use.”5
An area of increased concern is the rise of prescription drugs as
sources of illicit drug use and addiction. This has become a serious
health and social concern within all age groups where the use of
prescribed controlled substances have led to heightened monitoring
requirements by providers when reviewing patient history of use and
exposure to controlled substances in the home. The American College
of Preventive Medicine defines the term abuse of a controlled
substance as “the self-administration of substances to alter one’s state
of consciousness and an intentional and maladaptive pattern of using a
medication leading to significant impairment or distress.”141 An
individual noted to be abusing controlled substances is using a drug in
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a detrimental way to one’s health and wellbeing. Health providers as
well as many employer policies for workers may receive special
training on how to recognize impaired individuals in a health agency or
workplace, and are guided on steps to report impairment as a public
safety concern.
Prescription drug abuse has been identified as a very real threat to
society and the numbers of patients abusing these types of drugs has
increased dramatically in recent decades. In 2011, the CDC declared
that prescription drug abuse is a nationwide epidemic.142 Without
keeping restraints on controlled substances, including those that are
prescribed for medical use, the potential for misuse and abuse of these
drugs continues to increase.
The risk factors for developing addiction to controlled substances may
vary depending on the age of the patient, life circumstances, medical
history, and physical health. While prescription drug abuse and the
numbers of overdoses that occur every year is not necessarily
consistent with one particular age group, there are differences
between social, physical, and environmental factors that can increase
the risks of abuse and addiction more for some age groups. According
to the National Council on Drug Abuse, risk factors can affect people at
different stages of their lives; however, with each risk, there are
preventive measures that can change the gravity of the risk through
intervention.143
Health providers can identify a potential problem relative to an
individual’s level of exposure and risk to develop a substance use and
addiction disorder, and can educate about the risk factors involved to
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abuse prescription medication. For instance, an adolescent who
witnesses misuse of prescription sedatives by a parent to aid in sleep
may be more likely to develop a substance use disorder with a similar
type of controlled substance as well. Not enough has been said about
the effect of prescription drug abuse on children and adolescents
however a recent retrospective nationwide study focused on
admissions to emergency departments from 2006 to 2012 found that
“poisonings by prescription opioids largely impact both young children
and adolescents,” and that future screening and preventive strategies
need to focus on this age group.144
Glaucoma
More than 2 million Americans 40 years and older have glaucoma. It is
estimated that more than one-half of these people have not been
diagnosed or are not being treated.44,45 Common risk factors for the
development of glaucoma include:45,46 1) African-American or Hispanic
heritage, 2) age > 40, 3) Asian heritage, 4) circulatory problems,
5) corneal thinness, 6) diabetes, 7) family history of glaucoma,
8) myopia, 9) history of an eye injury, 10) hypertension or
hypotension, 11) migraine headache, 12) obstructive sleep apnea, and
13) smoking.
The USPSTF has no recommendation for glaucoma screening, and the
2014 Guidelines state: “Evidence on the accuracy of screening tests,
especially in primary care settings, and the benefits of screening or
treatment to delay or prevent visual impairment or improve quality of
life is inadequate. Therefore, the overall certainty of the evidence is
low, and the USPSTF is unable to determine the balance of benefits
and harms of screening for glaucoma in asymptomatic adults.”5
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Jacobs (2016) writes that: “It remains controversial which (if any)
populations should be screened, what screening tests should be
performed, and with what frequency.”47 On the other hand, the
American Academy of Ophthalmology provides these guidelines for
screening.46

People of any age with glaucoma symptoms or glaucoma risk
factors should have an ophthalmologic examination.

By the age of 40 all adults should have a complete eye
disease screening.
Hearing Impairment
Hearing loss or hearing impairment is common in older adults, and
advancing age is one of the primary risk factors for decreased hearing
ability.5 Other risk factors for hearing loss are diabetes, genetic
susceptibility, exposure to loud noise, exposure to ototoxic drugs, and
recurrent ear infections.5
The USPSTF does not recommend routine screening for hearing loss in
asymptomatic adults 50 years and older, noting that there is no
convincing evidence to determine the benefits and harms of screening
in this population.5 The USPSTF does recommend universal hearing
screening for all infants before one month of age, and infants who do
not pass the screening test should have audiologic and medical
evaluation before 3 months of age.5
Hearing loss is the most common congenital condition in the U.S. Each
year approximately three in every 1,000 infants born in the United
States will have moderate, severe, or profound hearing loss48 and half
of these children have no identifiable risk factors.49 Common causes or
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risk factors for childhood hearing loss include (but are not limited to)
congenital anomalies, infection, trauma, and the use of ototoxic drugs
like aminoglycosides and platinum antineoplastics.50 Hearing loss in
the first few years of life can cause delays in cognitive, language, and
speech development, but early identification of hearing impairment
can prevent these.50
Hearing testing for newborns is mandatory in all 50 states. For the
specific regulations of each state the American Academy of Pediatrics
web link may be used,51 or the website of the American Academy of
Pediatrics may be accessed to search for State Early Hearing Detection
and Intervention (EHDI) Laws and Regulations, 2016.
Genitourinary Infections And Sexually Transmitted Diseases
Bacteriuria
Asymptomatic bacteriuria is defined as the presence of at least 105
colony forming units of bacteria per 1 mL of urine.90 Asymptomatic
bacteriuria has been reported to occur in 2%-10% of pregnant women
and can result in pyelonephritis, low birth weight, and pre-term
birth.90,91
The USPSTF recommends that all pregnant women be screened for
asymptomatic bacteriuria.5 This should be done by obtaining a midstream, clean catch urine sample at 12-14 weeks of the pregnancy or
if later than that, at the first prenatal visit. The USPSTF 2014
Guidelines note that there are adverse effects from antibiotics and the
possibility of developing antibiotic resistance but “… detection and
treatment of asymptomatic bacteriuria with antibiotics significantly
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reduces the incidence of symptomatic maternal urinary tract infections
and low birthweight.”5
Chlamydial Infection
Chlamydia trachomatis is bacteria that can cause many types of
infections, but it is most often a sexually transmitted disease.92
Chlamydia is the most common sexually transmitted disease in the
United States93 and it can be transmitted by anal, oral and vaginal sex.
Signs and symptoms of a sexually transmitted chlamydial infection
may include vaginal discharge and pain when urinating.
Sexually transmitted chlamydial infections are much more common in
women than men93 and a genital infection with C trachomatis can
cause pelvic inflammatory disease (PID) and PID can result in chronic
pain and/or infertility and pre-term birth. Transmission of the C
trachomatis infection to an infant can cause conjunctivitis and/or
pneumonia.94
Genital chlamydial infections in women are very common. The
infections may not produce symptoms and the consequences of an
untreated genital chlamydial infection can be quite serious. For these
reason and because screening is simple (either a urine sample or a
cervical swab is used) and essentially has no risks, the USPSTF
recommends screening women for chlamydial infections.5
USPSTF Screening Recommendations
The USPSTF screening recommendation for women 24 years and
younger, including adolescents, and for women 25 years and older and
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at increased risk, is to be screened for chlamydial infection. This
recommendation also applies to women who are pregnant. Increased
risk is considered to exist for women who have had a previous
chlamydial infection or other sexually transmitted infections, had new
or multiple sexual partners, do not consistently use condoms, or are in
sex work.
In non-pregnant women the optimal interval for screening is not
known, but the CDC recommends that women at increased risk be
screened at least annually. In pregnant women ages 24 years and
younger and older women at increased risk, screening should be
provided at the first prenatal visit. For patients at continuing risk, or
who are newly at risk, screening should be offered in the 3rd
trimester.
Gonorrhea
Gonorrhea is a common sexually transmitted disease caused by
infection with the Neisseria gonorrhoeae bacterium. Gonorrhea
infections can occur after anal, oral, or vaginal intercourse, and the
infection can be transmitted from a pregnant woman to her child.
There were 350,062 reported cases of gonorrhea in the United States
in 2104, but this number is considered to be far less than the actual
incidence of the disease.95
High rates of gonorrhea infection are especially common in adolescents
and young adults aged 15-24 and in non-Hispanic blacks.94 In women
the signs and symptoms of gonorrhea are non-specific, they are often
mild, and a large majority of women with a gonorrhea infection are
asymptomatic.95 Untreated gonorrhea can have serious consequences
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for women.96,97 Between 10%-20% will develop PID95 and fallopian
tube infection and scarring and infertility are relatively common
sequelae of PID.95
The USPSTF recommendations for gonorrhea screening women are
outlined below.5 Testing is done by obtaining a cervical swab or a urine
sample.
USPSTF Screening Recommendations
Sexually active women, including pregnant women, should be
screened when at risk for gonorrhea infection. Risk factors for
gonorrhea include a history of previous gonorrhea infection, other
sexually transmitted infections, new or multiple sexual partners,
inconsistent condom use, sex work, and drug use.
Screening is recommended at the first prenatal visit for pregnant
women who are in a high-risk group for gonorrhea infection. For
pregnant women who are at continued risk, and for those who acquire
a new risk factor, a second screening should be conducted during the
third trimester.
The optimal interval for screening in the non-pregnant population is
not known. The USPSTF concluded that the benefits of screening
women at increased risk for gonorrhea infection outweigh the potential
harms.
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Syphilis
Syphilis is a sexually transmitted disease caused by the Treponema
pallidum bacterium. Syphilis can be transmitted by anal, oral, or
vaginal intercourse. In its early stages a syphilis infection does not
cause dramatic or highly specific signs or symptoms but a late stage
syphilis infection may cause severe cardiovascular, dermal, and
neurological complications.
Syphilis can be transmitted from an infected mother to an unborn
child: this is called congenital syphilis. Congenital syphilis that is
untreated can cause early infant death, miscarriage, spontaneous
abortion, still birth, late complications in the infant, and other serious
sequelae.107-109
Syphilis can be effectively treated and prevented with antibiotics and
public education and behavioral modification and in some areas of the
world congenital syphilis has been eradicated. However, in the United
States the incidences of syphilis and congenital syphilis have been
increasing.109,110 The USPSTRF recommends that all pregnant women
be screened for syphilis at the first prenatal visit; the venereal disease
research laboratory (VDRL) or rapid plasma regain (RPR) test can be
used.5 If needed, positive VDRL or RPR test results can be confirmed
using fluorescent treponemal antibody absorbed (FTA-ABS) or
Treponema pallidum particle agglutination (TPPA) tests.5
Iron Deficiency Anemia
Iron deficiency anemia is relatively common in pregnant women. Older
data indicated that the prevalence of anemia in pregnant women was
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18.6%99 and pregnant women are much more likely to be anemic than
non-pregnant women.100 Anemia during pregnancy can cause, or has
been associated with increased maternal mortality, premature birth,
spontaneous abortion, fetal death, low birth weight, and in utero
abnormalities.101-104
Causes of iron deficiency anemia during pregnancy include poor
intake, poor nutrition, gastrointestinal disease, vegetarian diet,
medications that interfere with iron absorption, and multiple
pregnancies.99,105,106
The USPSTF recommends that all asymptomatic pregnant women be
screened for iron deficiency anemia by measuring hematocrit and
hemoglobin levels.5
Depression
Depression is a significant public health problem in the U.S. and the
most common psychiatric disorder.27 The National Institute of Mental
Health estimated that in 2014, 15.7 million American adults had one
episode of major depression28 and the lifetime prevalence of
depression of Americans is estimated to be 7% to 16.6%.29,30
Depression is a major cause of disability, mental and physical
impairment from mild to major, and lost productivity, and it is one of
the most important causes of suicide.31 Risk factors for depression
include (but are not limited to) childbirth, family history, female
gender, serious medical illness, stressful life occurrences, and
substance use.5,27,31
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The USPSTF recommends screening for depression in non-pregnant
adults 18 years and older “… when staff-assisted depression care
supports are in place to assure accurate diagnosis, effective treatment,
and follow-up.”5
In 2009, the USPSTF recommended screening all adults when staffassisted depression care supports are in place and selective screening
based on professional judgment and patient preferences when such
support is not available. In recognition that such support is now much
more widely available and accepted as part of mental health care, the
current recommendation statement has omitted the recommendation
regarding selective screening, as it no longer represents current
clinical practice. The current statement also specifically recommends
screening for depression in pregnant and postpartum women,
subpopulations that were not specifically reviewed for the 2009
recommendation.5
Staff-assisted depression care support “refers to clinical staff that
assists the primary care clinician by providing some direct depression
care and/or coordination, case management, or mental health
treatment.”5 The optimal interval for screening is not known.5 The
USPSTF guidelines do not comment on the benefits of screening for
depression.
Narayana and Wong (2015) write in their review of office-based
screening for mental disorders that screening for depression “… is
most likely cost-effective in the setting of high prevalence and the
availability of treatment using a collaborative care model. Despite the
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availability of screening tools, the overall cost-effectiveness of general
screening for anxiety or depression is uncertain.”33
Major Depressive Disorder
The criteria for major depressive disorder are listed in the section
below.113
Diagnostic Criteria
The diagnostic criteria for major or depressive disorder include that
five or more of the following symptoms have been present during a
two-week period, are a significant change from the patient’s previous
mood and functioning, at least one of the symptoms is depressed
mood or loss of pleasure or interest, and the symptoms are not caused
by a medical condition. The criteria include:

Depressed mood most of the day, nearly every day. The
depressed mood can be subjective (i.e., the patient reports
feeling sad, hopeless) or can be observed by others. In children
or adolescents, irritation is often present.

Markedly diminished interest or pleasure in daily activities. This
happens nearly every day and is reported by the patient or by
others.

Significant weight loss (> 5% of body weight) when not dieting
or a decrease or increase in appetite nearly every day. (Note: In
children, consider failure to make expected weight gain.)

Insomnia or hypersomnia nearly every day.
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
Psychomotor agitation or retardation nearly every day: this
should be observable by others and not just the patient’s
feelings of restlessness or feeling lethargic.

Fatigue or loss of energy nearly every day.

Feelings of worthlessness or excessive or inappropriate guilt
nearly every day.

Diminished ability to think or concentrate, or indecisiveness,
nearly every day, reported by the patient or observed by others.

Recurrent thoughts of death; recurrent suicidal ideation without
a specific plan; a suicide attempt or a specific plan for
committing suicide.
The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

The episode is not attributable to a substance or another medical
condition.

The occurrence of the major depressive episode is not better
explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified
and unspecified schizophrenia spectrum and other psychotic
disorders.

There has never been a manic episode or a hypomanic episode.
The incidence of major depressive disorder in children and adolescents
has been estimated as between 3.9% to 12.8%, depending on the age
group that was surveyed and how the data was collected.114
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Depression in children is often undertreated and it can cause serious
impairment of psycho-social functioning.115 Risk factors for depression
in children and adolescents include:5,115

Abuse, neglect

ADHD

Anxiety disorder

Bullying

Chronic illness

Family conflict

Family history of depression

Gender dysphoria

Learning disabilities

Oppositional defiance disorder

Substance use disorder

Traumatic brain injury
The USPSTF advises that adolescents age 12-18 should be screened
for depression when there are resources in place for diagnosis,
treatment, and follow-up.5 The Patient Health Questionnaire for
Adolescents (PHQ-A) and the Beck Depression Inventory Primary Care
Version (BDI-PC) have been shown to useful for assessment of
adolescents for depression.5
There are many well-validated screening tools that can be used for
detecting depression; for example, the Beck Depression Inventory,
Hamilton Depression Scale, and the Patient Health Questionnaire-9
(PHQ-9) screening tool. A 2014 review showed that the commonly
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used ones are essentially equal in sensitivity and specificity.34 The
PHQ-9 is often used because it is free and easy to use.
PHQ-9 Screening Tool
Over the last 2 weeks, how often have you been bothered by any of the
following problems?
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself, or that you are a failure, or have let
yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or
watching television.
8. Moving or speaking so slowly that other people could have noticed?
Or the opposite, being so fidgety or restless that you have been
moving around a lot more than usual.
9. Thoughts that you would be better off dead or of hurting yourself in
some way.
The possible answers and their respective scores are:
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
Depression score ranges:
5 to 9: Mild
10 to 14: Moderate
15 to 19: Moderately severe
20 to 27: Severe
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Screening For Newborns, Children And Adolescents
Congenital Hypothyroidism
The thyroid hormone tri-iodothyronine (T3) is essential for normal
childhood growth and development, especially in the first few years of
life.111 During the first trimester the fetus is dependent on maternal
thyroid hormones and maternal thyroid hormone requirements are
increased at this time, as well.111,112 An increased maternal need,
dependency of the fetus on maternal thyroid function, and
hypothyroidism in a pregnant woman can cause serious consequences:
impaired cognitive functioning in the child and complications of
pregnancy such as low birth weight, miscarriage, preterm birth, and
preeclampsia.112
Screening newborns for congenital hypothyroidism is mandatory in all
50 states and in the District of Columbia. The USPSTF recommends
that T4 and TSH be measured when the infant is between two to four
days old. If the tests are abnormal confirmatory testing should be
done.5
Obesity
The prevalence of obesity in children and adolescents in the United
States is approximately 17% and it is expected to increase.116,117
The USPSTF recommends that children and adolescents age 6 to 18 be
screened for obesity.5 Obesity is defined as an age and gender specific
BMI ≥ 95th percentile.5
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Phenylketonuria
Phenylketonuria (PKU) is a relatively common inborn error of
metabolism. People who have PKU do not have normal activity of the
liver enzyme phenylalanine hydroxylase. Phenylalanine is an amino
acid, a breakdown product of many proteins. Accumulations of
phenylalanine can cause mental retardation, seizures, and other
serious neurological problemns.111
Screening for PKU is mandated in all 50 states, and infants should be
screened at or near seven days of age.5 The Guthrie Bacterial Inhibition
Assay (BIA), automated fluorometric assay, or tandem mass
spectrometry can be used.5
Sickle Cell Disease
Sickle cell disease is an inherited hematologic disorder. People who
have sickle cell disease have hemoglobin S and when oxygen binds to
hemoglobin S, red blood cells form an abnormal shape (the sickle
shape) and they hemolyze, causing an anemia that deprives the
tissues of oxygen and blocking blood vessels. Sickle cell disease
primarily affects African Americans, and approximately 1 in every 365
African Americans has the disease.118
The USPSTF recommends that all newborn infants be screened for
sickle cell disease using either thin-layer isoelectric focusing (IEF) or
high performance liquid chromatography (HPLC).5
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Visual Impairment in Children Ages 3 to 5
Children ages 3 to 5 years should be screened for ambylopia.
Ambylopia, often called lazy eye, is defined as decreased vision in one
eye. The term lazy eye is used because the affected eye often is fixed
to the lateral or medial side. Ambylopia can result from an imbalance
in the muscles that move and position the eyes or from neurological
abnormalities and if it is untreated it can cause permanent vision loss.
Effective treatments for ambylopia are available so early detection is
critical. The USPSTF recommends that children three to five years of
age have vision scrrening.5
Amblyopia is defined as a functional reduction in visual acuity that is
caused by abnormal visual development during childhood. Amblyopia
is the most common cause of visual impairment in children116,117 with a
reported prevalence of 1%-4%.116-119 Ambylopia develops during a
critical period of three months to eight years when the vision is
maturing. Risk factors for ambylopia include having a first-degree
relative with amblyopia; neurodevelopmental delay; premature birth;
and, small size in relation to gestational age.116 Amblyopia affects boys
and girls equally.
The USPSTF recommends that children age three to five have vision
screening4 and screening for, and early detection of amblyopia can
improve the prognosis for normal visual development.116,120,121
Screening is also important because amblyopia is an asymptomatic
condition; certain types of amblyopia are characterized by an obvious
lateral deviation of one eye (commonly called lazy eye) but some are
not; and, the treatments for amblyopia are most effective when they
are used early.121
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Children who are pre-verbal are screened by using the fixation reflex
test or the objection to occlusion test.116 Children who are three years
of age or older can have their visual acuity checked by using the
Snellen chart (the classic eye chart with letters and number, viewed
from 20 feet away) or by using Allen figure cards.116
In the fixation reflex test one eye is occluded, the examiner moves an
object back and forth across the child’s visual space, and the child’s
ability to maintain contact - to fixate - is assessed. During the
occlusion test the examiner watches the child’s response as each eye
is alternately occluded. Children who have amblyopia will usually
become upset when the good eye is occluded.
Intimate Partner Violence And Elderly Abuse
Intimate partner violence is defined by the CDC as physical violence,
sexual violence, stalking and psychological aggression (including
coercive acts) by a current or former intimate partner.62 Breiding, et
al., (2014, 2008) noted that a substantial number of American women
and men have suffered from one or more types of intimate partner
violence (as many as one in four women and one in seven men)63,64
and intimate partner violence is often unreported and undiagnosed.63
Risk factors for suffering intimate partner violence include (but are not
limited to 1) female gender, 2) prior history of intimate partner
violence, 3) experiencing or witnessing violence as a child, and 4)
chronic mental illness. Risk factors for perpetrating intimate partner
violence include (but are not limited to) exposure to violence during
childhood, marital difficulties, post-traumatic stress disorder (PTSD),
substance use, and job loss.
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The USPSTF recommends that asymptomatic women of childbearing
age be screened for intimate partner violence and that screening and
interventions provide a moderate benefit.5 There are many screening
tools that can be used to detect intimate partner violence but there is
no agreement as to which one is best.63,64 A recent (2016) survey65 of
intimate partner violence screening tools found that the Women Abuse
Screen Tool (WAST), Abuse Assessment Screen (AAS) and Humiliation,
Afraid, Rape and Kick (HARK) are particularly useful.66,67 The WAST
screen is provided below as an example.
Women Abuse Screen Tool
1. In general, how would you describe your relationship?
A lot of tension; some tension; no tension
2. Do you and your partner work out arguments with:
Great difficulty; some difficulty; no difficulty?
3. Do arguments ever result in you feeling down or bad about yourself?
Often; sometimes; never
4. Do arguments ever result in hitting, kicking or pushing?
Often; sometimes; never
5. Do you ever feel frightened by what your partner says or does?
Often; sometimes; never
6. Has your partner ever abused you physically?
Often; sometimes; never
7. Has your partner ever abused you emotionally?
Often; sometimes; never
8. Has your partner ever abused you sexually?
Often; sometimes; never
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Elder abuse is a common problem in the United States and elsewhere.
As with intimate partner violence, elder abuse is underreported but
several studies have found a prevalence of 7.6% to 10%.68 Elder
abuse has been defined and classified into five categories.68

Physical abuse or acts carried out with the intention to
cause physical pain or injury

Psychological or verbal abuse

Sexual abuse, i.e., non-consensual sexual contact

Financial exploitation

Neglect
Risk factors for elder abuse include dementia, isolation, low income,
poor social support, a shared living situation with a large number of
relatives, and perpetrator characteristics such as alcohol use, mental
illness, and exposure to violence as a child.69-71
The USPSTF does not have recommendations for elder abuse
screening, noting that “… there were no studies on the accuracy,
effectiveness, or harms of screening in this population.”5 However,
screening for or inquiry about elder abuse is recommended by
organizations such as the National Center on Elder Abuse, the National
Academy of Sciences, and the American Academy of Neurology and
the American Medical Association recommend routine screening.71
Prevention and Personal Health Counseling
Counseling is a vital component of preventive medicine. Screening
tests detect health problems and identify people at risk. But screening
tests should be followed by counseling and patient education if the
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patient has, or is at risk for a specific disease or disorder. The USPSTF
recommends that when appropriate, adult patients should be
counseled about the following.5

Alcohol misuse

Breastfeeding

Falls

Healthful diet and physical activity

Motor vehicle occupant restraints

Obesity

Sexually transmitted infections

Skin cancer

Tobacco use
Children and adolescents should be counseled, when appropriate,
about:5

Alcohol misuse

Illicit drug use

Motor vehicle occupant restraints

Obesity

Sexually transmitted infections

Skin cancer
Vaccinations
Vaccinations are a critically important part of preventive medicine. The
vaccination schedules presented here are the recommendations of the
CDC.
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CDC Vaccination Schedules
Vaccine
Age Group 19-21
years
Influenza
50-59
years
60-64
years
≥ 65
years
←1 dose annually→
3,
Substitute 1-time dose of Tdap for Td booster; then boost
with Td every 10 yrs
←2 doses→
4,
Human
papillomavirus (HPV)
Female 5,
Human
papillomavirus (HPV)
Male 5,
Zoster
27-49
years
2,
Tetanus, diphtheria,
pertussis (Td/Tdap)
Varicella
22-26
years
←3 doses→
←3 doses→
←1 dose→
6
Measles, mumps,
rubella (MMR) 7,
Pneumococcal 13valent conjugate
(PCV13)8,
←1 dose→
←1 or 2 doses→
Pneumococcal
polysaccharide
(PPSV23)9,10
Meningococcal
←1 or 2 doses→
11,
←1 or more doses→
Hepatitis A
12,
←2 doses→
Hepatitis B
13,
←3 doses→
Haemophilus
influenzae type b
(Hib)14,
←1
dose→
←1 or 3 doses→
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Pediatrics: 0 – 15 Months Vaccination Schedule
Vaccine
Birth
Hepatitis B1 (HepB)
←1st
dose→
1 mo 2 mos
4
mos
6
mos
←2nd dose→
9
mos
12
mos
15
mos
←3rd dose→
Rotavirus2(RV)
RV1 (2-dose series); RV5
(3-dose series)
←1st
←2nd
dose→ dose→
See
footnote
2
Diphtheria, tetanus, &
acellular pertussis3(DTaP:
<7 yrs)
←1st
←2nd
dose→ dose→
←3rd
dose→
←4th
dose
→
Tetanus, diphtheria, &
acellular pertussis4 (Tdap:
≥7 yrs)
←1st
←2nd
Haemophilus influenzae
type b5 (Hib)
dose→ dose→
Pneumococcal conjugate6
(PCV13)
←1st
←2nd
dose→ dose→
See
footnote
5
←3rd or 4th
dose,
See footnote
5→
←3rd
dose→
←4th dose→
Pneumococcal
polysaccharide6(PPSV23)
Inactivated poliovirus7
(IPV)(<18 yrs)
Influenza8(IIV; LAIV) 2
doses for some: See
footnote 8
←1st
←2nd
dose→ dose→
←3rd dose→
Annual vaccination (IIV only)
Measles, mumps, rubella9
(MMR)
←1st dose→
Varicella10 (VAR)
←1st dose→
Hepatitis A11 (HepA)
←2 dose
series, See
footnote
11→
Human papillomavirus12
(HPV2: females only; HPV4:
males and females)
Meningococcal13 (Hib-MenCY ≥ 6 weeks; MenACWYD≥9 mos; MenACWY-CRM ≥
2 mos)
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Pediatrics: 15 Months to 18 Years Vaccination Schedule
Vaccines
Hepatitis B1 (HepB)
1918 mos 23
mos
2-3
yrs
4-6 yrs
7-10
yrs
11-12
yrs
13-15
yrs
16-18
yrs
←3rd
dose→
Rotavirus2(RV)
RV1 (2-dose series); RV5 (3dose series)
Diphtheria, tetanus, & acellular
pertussis3 (DTaP: <7 yrs)
←4th
dose→
←5th
dose→
Tetanus, diphtheria, & acellular
pertussis4 (Tdap: ≥7 yrs)
(Tdap)
Haemophilus influenzae type b5
(Hib)
Pneumococcal conjugate6
(PCV13)
Pneumococcal
polysaccharide6(PPSV23)
Inactivated poliovirus7
(IPV)(<18 yrs)
Influenza8(IIV; LAIV) 2 doses
for some: See footnote 8
←3rd
dose→
Annual
vaccination
(IIV only)
←4th
dose→
Annual vaccination (IIV or LAIV)
Measles, mumps, rubella9
(MMR)
←2nd
dose→
Varicella10 (VAR)
←2nd
dose→
Hepatitis A11 (HepA)
←2 dose
series, See
footnote 11→
Human papillomavirus12 (HPV2:
females only; HPV4: males and
females)
Meningococcal13 (Hib-Men-CY ≥
6 weeks; MenACWY-D≥9 mos;
MenACWY-CRM ≥ 2 mos)
←(3 dose
series)→
See footnote
13
←1st
dose→
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Booster
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Summary
Screening is an effective method for detecting and preventing acute
and chronic diseases. Health professionals need to know the
recommended screening tests or practice tools that may lead to early
detection or prevention of medical problems that cause morbidity and
mortality if left undiagnosed and untreated. These include the
recommendations contained in the U.S. Preventive Services Task
Force’s (USPSTF) Guide to Clinical Preventive Services 2014, and
recommendations on screening by applicable organizations such as the
National Center on Elder Abuse, the National Academy of Sciences, the
American Academy of Neurology and the American Medical
Association. Other public health concerns raised in this study are
currently being developed within public health circles for improved
standardized screening tools to help identify high risk health issues
and guide patient education, such as those related to smoking
cessation and exposure to second-hand smoke and varied health and
public safety hazards related to illicit drug abuse in terms recognition
and prevention. Health professionals are guided to stay informed of
the evolving area of preventive health and the many resources
available to educate patients and their families to avoid illness.
Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
article, and providing feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1. One of the limitations of screening tests is
a.
b.
c.
d.
guidelines are often changed and updated.
they rarely provide a high degree of specificity or sensitivity.
they can only be used for adolescents and adults.
the benefits seldom outweigh the risks.
2. Screening tests must be used with the understanding that
a.
b.
c.
d.
they are seldom able to detect diseases.
most of them are associated with harmful side effects.
they are not diagnostic.
they cannot be used for children.
3. Adults should be screened for alcohol misuse if they
a.
b.
c.
d.
4.
Breast cancer is
a.
b.
c.
d.
5.
only found in post-menopausal women.
the second most common cancer in women.
primarily caused by cigarette smoking.
not detectable without a biopsy.
Breast cancer screening may include
a.
b.
c.
d.
6.
are males over age 35.
drink hard liquor.
use illicit drugs.
engage in risky drinking behavior.
an x-ray.
a CT scan.
a biopsy.
mammography and genetic testing.
Screening for cervical cancer
a.
b.
c.
d.
significantly decreases mortality from the disease.
should begin during adolescence.
has no effect on mortality from the disease.
can also help prevent breast cancer.
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7.
Colorectal cancer screening can be done using
a.
b.
c.
d.
8.
Screening adolescents age 12-18 for depression is
recommended if
a.
b.
c.
d.
9.
a simple x-ray.
fecal occult blood testing and colonoscopy.
a biopsy of the colon.
endoscopy.
the patient misuses alcohol.
the clinician is comfortable talking about depression.
follow-up care and support is available.
depression symptoms have lasted 12 months or longer.
True or False: Almost 30 percent of people who have
diabetes go undiagnosed.
a. True
b. False
10.
The American Diabetes Association recommends
screening for diabetes using
a.
b.
c.
d.
11.
People who have diabetes should periodically be screened
for
a.
b.
c.
d.
12.
HbAC1
fasting plasma glucose.
oral glucose tolerance test.
urine testing or glucose.
gallbladder disease.
lung disease.
cardiovascular disease.
liver disease.
Screening for Hepatitis B is recommended for
a.
b.
c.
d.
people who misuse alcohol and people > age 50.
IV drug users and men who have sex with men.
pregnant women and adolescents.
anyone born between 1945 and 1965.
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13.
Screening for Hepatitis C is recommended for
a.
b.
c.
d.
14.
Screening for HIV is recommended for
a.
b.
c.
d.
15.
people who misuse alcohol and people > age 50.
all persons who have diabetes.
pregnant women and adolescents.
anyone born between 1945 and 1965.
anyone
anyone
anyone
anyone
having unprotected anal or vaginal intercourse.
born between 1945 and 1965.
who misuse alcohol.
who has hypertension and diabetes.
True or False: The USPSTF recommends that all adults
should be screened for hypertension.
a. True
b. False
16.
Intimate partner violence
a.
b.
c.
d.
17.
Screening for obesity is done by measuring
a.
b.
c.
d.
18.
involves physical harm to the victim.
includes physical, sexual, psychological harm.
is limited to violence done by men to women.
is a very rare occurrence.
body weight.
body weight and height.
waist and upper arm circumference.
body mass index.
Osteoporosis is very common in
a.
b.
c.
d.
young African American males
all men under the age of 50.
elderly white females.
people who have hypertension.
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19.
All pregnant women should be screened for
a.
b.
c.
d.
20.
depression and illicit drug use.
bacteriuria.
alcohol misuse and coronary heart disease.
osteoporosis and syphilis.
True or False: The benefits of prostate cancer screening
far outweigh the risks.
a. True
b. False
21.
All newborns should be screened for
a. lipid disorders.
b. iron deficiency anemia.
c. phenylketonuria.
d. hypertension.
22.
All pregnant women should be screened for
a.
b.
c.
d.
23.
All newborns should be screened for
a.
b.
c.
d.
24.
gonorrhea.
syphilis.
sickle cell disease.
skin cancer and lipid disorders.
sickle cell disease.
elevate cholesterol.
autism.
Hepatitis C.
True or False: Screening infants for hearing impairment is
mandatory.
a. True
b. False
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25.
All newborns should be screened for
a.
b.
c.
d.
26.
Which of the following is the leading cause of preventable
deaths in the United States?
a.
b.
c.
d.
27.
HIV.
diabetes.
Hepatitis B.
congenital hypothyroidism.
Diabetes
Alcohol
Tobacco
HIV
Which of the following is NOT true regarding cigarette
smoking in the United State?
a. An estimated 40 million adults currently smoke cigarettes.
b. It accounts for more than 480,000 deaths every year.
c. Less than one million adults live with a smoking-related
disease.
d. Smoking has declined from 20.9% adults in 2005 to nearly
16.8% in 2014.
28.
Heath effects of second-hand smoke include
a.
b.
c.
d.
29.
sudden infant death syndrome (SIDS).
ear infections.
pneumonia.
All of the above
Which of the following is one of the three drugs that are
approved by the Food and Administration (FDA) for
assisting patients with smoking cessation?
a.
b.
c.
d.
Tamoxifen
Prescription opioids
Varenicline
Raloxifene
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30.
The USPSTF and the American Cancer Society
recommends asymptomatic adults, aged 55 to 80 years,
have annual screening with low dose computed
tomography if they have a 30 pack-year history of
smoking and currently smoke or have quit smoking
a.
b.
c.
d.
31.
within the past 15 years.
within the past 5 years.
but started smoking again.
within the past year.
True or False: Second-hand smoke is smoke that is
produced from burning tobacco or smoke that has been
exhaled by someone using a cigarette and although
second-hand smoke may be dangerous, there are safe
levels of second-hand smoke.
a. True
b. False
32.
The USPSTF advises or states that
a. clinicians should be aware of, and alert to the signs and
symptoms of illicit drug use.
b. the evidence supports the benefits and harms of screening for
illicit drug use.
c. drug use disorders and overdoses are consistent with one
particular age group.
d. All of the above
33.
Risk factors for non-melanoma and melanoma skin cancer
include
a.
b.
c.
d.
indoor tanning.
a family history of melanoma.
the use of psoralen.
All of the above
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34.
The American Dental Association in 2010 published
guidelines about oral cancer screening stated or
recommended
a. auto-fluorescence screening as the only proven tool.
b. tissue reflectance as the primary screening tool.
c. auto-fluorescence and tissue reflectance as the most effective
screening tools.
d. oral inspection and tactile palpation as screening tools.
35.
Congenital syphilis that is untreated can cause
a.
b.
c.
d.
36.
Which of the following is a modifiable risk factor for
coronary heart disease?
a.
b.
c.
d.
37.
spontaneous sequelae.
phenylketonuria.
early infant death.
neonatal phenylketonuria.
diabetes.
family history of coronary heart disease.
gender.
age.
True or False: The four question CAGE screening test for
alcohol use, which is familiar to many healthcare
professionals, is NOT recommended as a screening tool
for alcohol use as it is not highly sensitive or specific.
a. True
b. False
38.
The USPSTF recommendations for cervical cancer
screening for women aged 30-65 is
a.
b.
c.
d.
to screen with cytology more often than every 3 years.
screen three years with a Pap smear and HPV testing.
to not screen.
screen three years with a Pap smear.
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39.
The USPSTF recommendations for cervical cancer
screening for women over the age of 65 who have had
adequate prior screening and are not high risk is
a.
b.
c.
d.
40.
The USPSTF states that screening for cervical cancer
earlier than age 21 years
a.
b.
c.
d.
41.
to screen every 5 years.
screen three years with a Pap smear and HPV testing.
to not screen.
screen three years with a Pap smear.
leads to more harms than benefits.
depends on the patient’s sexual history.
provides a modest decrease in cervical cancer.
should be done on a case-by-case basis.
True or False: The USPSTF recommends routine screening
for skin cancer.
a. True
b. False
42.
The diagnosis of hypertension cannot be confirmed until
an elevated blood pressure is present
a.
b.
c.
d.
43.
and there is no causal event.
on one or more occasions.
using ambulatory blood pressure monitoring.
on several occasions.
Blood pressure measurement is an important predictor of
cardiovascular complications in people with
a.
b.
c.
d.
type 2 diabetes mellitus.
colorectal cancer.
iron deficiency anemia.
lipid disorders.
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44.
People who have sickle cell disease have hemoglobin S
and when oxygen binds to _______________, red blood
cells form an abnormal shape (the sickle shape).
a. hemoglobin
b. hemoglobin
c. hemoglobin
d. hemoglobin
45.
Basal cell carcinoma and squamous cell carcinoma are the
two
a.
b.
c.
d.
46.
C.
A.
A2.
S
melanoma skin cancers.
non-melanoma skin cancers.
cancers reported in the cancer registries.
malignant melanomas.
True or False: Because of the increased use of sunscreens,
incidences of malignant melanoma, and deaths from this
cancer, have been decreasing for years.
a. True
b. False
47.
The USPSTF recommends that __________ asymptomatic
pregnant women be screened for iron deficiency anemia
by measuring hematocrit and hemoglobin levels.
a.
b.
c.
d.
48.
diabetic
vegetarian
all
first-time
Which of the following causes iron deficiency anemia
during pregnancy?
a.
b.
c.
d.
A high protein, meat diet
A vegetarian diet
Iron deficiencies are limited to first-time pregnancies
Consuming a single beer each day
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49.
Anemia during pregnancy can cause, or has been
associated with
a.
b.
c.
d.
50.
spontaneous abortion.
high birth weight.
overdue births.
breast cancer.
Malignant melanoma can metastasize to
a.
b.
c.
d.
the lymph nodes only.
the skin but not other organs.
any organ.
the skin and lymph nodes only.
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CORRECT ANSWERS:
1.
One of the limitations of screening tests is
a. guidelines are often changed and updated.
“However, it is important to remember the following points
when broad screening guidelines are used for a
heterogeneous population… Screening guidelines are always
being changed and updated.”
2.
Screening tests must be used with the understanding that
c. they are not diagnostic.
“However, it is important to remember the following points
when broad screening guidelines are used for a
heterogeneous population… A screening test is not a
diagnostic test.”
3.
Adults should be screened for alcohol misuse if they
d. engage in risky drinking behavior.
“Screen for alcohol misuse and provide brief behavioral
counseling interventions to persons engaged in risky or
hazardous drinking.”
4.
Breast cancer is
b. the second most common cancer in women.
“Breast cancer is the most common cancer in women,
excluding skin cancer."
5.
Breast cancer screening may include
d. mammography and genetic testing.
“There is convincing evidence that using mammography to
screen for breast cancer reduces overall mortality from breast
cancer… Genetic testing for breast cancer is recommended for
women whose family history may be associated with an
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increased risk for potentially harmful breast cancer
mutations.”
6.
Screening for cervical cancer
a. significantly decreases mortality from the disease.
“Cervical cancer screening decreases the incidence and
mortality of cervical cancer.”
7.
Colorectal cancer screening can be done using
b. fecal occult blood testing and colonoscopy.
“The USPSTF recommendations for colorectal cancer
screening are highlighted below. Age 50-75: Screen with high
sensitivity fecal occult blood testing (FOBT), sigmoidoscopy,
or colonoscopy…. Screening intervals: Annual screening with
high-sensitivity fecal occult blood testing;…”
8.
Screening adolescents age 12-18 for depression is
recommended if
c. follow-up care and support is available.
“The USPSTF advises that adolescents age 12-18 should be
screened for depression when there are resources in place for
diagnosis, treatment, and follow-up.”
9.
True or False: Almost 30 percent of people who have
diabetes go undiagnosed.
a. True
“Approximately 27.8% of people who have diabetes are
undiagnosed,…”
10.
The American Diabetes Association recommends
screening for diabetes using
b. fasting plasma glucose.
“The American Diabetes Association recommends screening
with fasting plasma glucose (FPG),…”
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11.
People who have diabetes should periodically be screened
for
c. cardiovascular disease.
“Asymptomatic patients should not be screened for
cardiovascular disease but cardiovascular risk factors should
be assessed annually, at least. These risk factors include
dyslipidemia, hypertension, family history of premature
cardiovascular disease, presence of albuminuria, and
smoking.”
12.
Screening for Hepatitis B is recommended for
b. IV drug users and men who have sex with men.
“The CDC recommends screening the following groups for
Hepatitis B … Injection-drug users… Men who have sex with
men.”
13.
Screening for Hepatitis C is recommended for
d. anyone born between 1945 and 1965.
“The USPSTF recommendations for hepatitis screening are
highlighted here… Persons at high risk for infection and adults
born between 1945 and 1965 should be screened.”
14.
Screening for HIV is recommended for
a. anyone having unprotected anal or vaginal intercourse.
“Younger adolescents and adults considered to be at
increased risk include:… Anyone having unprotected vaginal
or anal intercourse.”
15.
True or False: The USPSTF recommends that all adults
should be screened for hypertension.
a. True
“The USPSTF screening recommendations,… include the
following… All adults be screened for hypertension.”
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16.
Intimate partner violence
b. includes physical, sexual, psychological harm.
“Intimate partner violence is defined by the CDC as physical
violence, sexual violence, stalking and psychological
aggression (including coercive acts) by a current or former
intimate partner.”
17.
Screening for obesity is done by measuring
d. body mass index.
“Screening for obesity is recommended and the USPSTF
advises that adults age 18 and older be screened by using
body mass index (BMI)…”
18.
Osteoporosis is very common in
c. elderly white females.
“Risk factors for osteoporosis are outlined below as:… Asian
or white race… Female > 65 years of age.”
19.
All pregnant women should be screened for
b. bacteriuria.
“The USPSTF recommends that all pregnant women be
screened for asymptomatic bacteriuria.”
20.
True or False: The benefits of prostate cancer screening
far outweigh the risks.
b. False
“Screening for prostate cancer by measuring prostate-specific
antigen (PSA) and digital rectal examination can reduce the
mortality rate prostate cancer but this reduction is very small
and does not outweigh the risks.”
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21.
All newborns should be screened for
c. phenylketonuria.
“Screening for PKU is mandated in all 50 states, and infants
should be screened at or near seven days of age.”
22.
All pregnant women should be screened for
a. gonorrhea.
“The USPSTRF recommends that all pregnant women be
screened for syphilis at the first prenatal visit…”
23.
All newborns should be screened for
a. sickle cell disease.
“The USPSTF recommends that all newborn infants be
screened for sickle cell disease…”
24.
True or False: Screening infants for hearing impairment is
mandatory.
a. True
“Hearing testing for newborns is mandatory in all 50 states.”
25.
All newborns should be screened for
d. congenital hypothyroidism.
“Screening newborns for congenital hypothyroidism is
mandatory in all 50 states and in the District of Columbia.”
26.
Which of the following is the leading cause of preventable
deaths in the United States?
c. Tobacco
“Tobacco use is the leading cause of preventable death in the
United States.”
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27.
Which of the following is NOT true regarding cigarette
smoking in the United State?
c. Less than one million adults live with a smoking-related
disease.
“More than 16 million Americans live with a smoking-related
disease.”
28.
Heath effects of second-hand smoke include
a.
b.
c.
d.
sudden infant death syndrome (SIDS).
ear infections.
pneumonia.
All of the above [Correct Answer]
“Heath effects of second-hand smoke: ear infections,
pneumonia, sudden infant death syndrome (SIDS).”
29.
Which of the following is one of the three drugs that are
approved by the Food and Administration (FDA) for
assisting patients with smoking cessation?
c. Varenicline
“There are three drugs that are approved by the Food and
Administration (FDA) for assisting patients with smoking
cessation:… and varenicline.”
30.
The USPSTF and the American Cancer Society
recommends asymptomatic adults, aged 55 to 80 years,
have annual screening with low dose computed
tomography if they have a 30 pack-year history of
smoking and currently smoke or have quit smoking
a. within the past 15 years.
“The USPSTF and the American Cancer Society recommends
that asymptomatic adults aged 55 to 80 years who have a 30
pack-year history of smoking and currently smoke or have
quit smoking within the past 15 years should have annual
screening with low dose computed tomography.”
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31.
True or False: Second-hand smoke is smoke that is
produced from burning tobacco or smoke that has been
exhaled by someone using a cigarette and although
second-hand smoke may be dangerous, there are safe
levels of second-hand smoke.
b. False
“Second-hand smoke is smoke that is produced from burning
tobacco or smoke that has been exhaled by someone using a
cigarette and there is no safe level of second-hand smoke.”
32.
The USPSTF advises or states that
a. clinicians should be aware of, and alert to the signs and
symptoms of illicit drug use.
“’The USPSTF advises that clinicians should be aware of, and
alert to the signs and symptoms of illicit drug use but that’…
the evidence is insufficient to determine the benefits and
harms of screening for illicit drug use.”
33.
Risk factors for non-melanoma and melanoma skin cancer
include
a.
b.
c.
d.
indoor tanning.
a family history of melanoma.
the use of psoralen.
All of the above [Correct Answer]
“Risk factors for non-melanoma and melanoma skin cancer
include (but are not limited to: 1) Caucasian ethnicity,
2) exposure to sunlight, 3) indoor tanning,
4) immunosuppression, 5) fair skin, 6) family history of
melanoma, 7) atypical nevi, 8) advanced age, 9) psoralen,
and 10) UVA light therapy.”
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34.
The American Dental Association in 2010 published
guidelines about oral cancer screening stated or
recommended
d. oral inspection and tactile palpation as screening tools.
“The American Dental Association in 2010 published
guidelines… noted that oral inspection and tactile palpation
were the recommended screening tools. These guidelines also
noted that the use of devices that rely on auto-fluorescence
or tissue reflectance to detect oral cancers do not appear to
be superior for this purpose when compared to conventional
visual inspection and tactile palpation.”
35.
Congenital syphilis that is untreated can cause
c. early infant death.
“Syphilis can be transmitted from an infected mother to an
unborn child: this is called congenital syphilis. Congenital
syphilis that is untreated can cause early infant death,
miscarriage, spontaneous abortion, still birth, late
complications in the infant, and other serious sequelae.”
36.
Which of the following is a modifiable risk factor for
coronary heart disease?
a. diabetes.
“Modifiable risk factors include cigarette smoking, diabetes,
diet, elevated serum lipids and cholesterol, hypertension,
obesity, and sedentary life style. Non-modifiable risk factors
are age, gender, and family history of coronary heart
disease.”
37.
True or False: The four question CAGE screening test for
alcohol use, which is familiar to many healthcare
professionals, is NOT recommended as a screening tool
for alcohol use as it is not highly sensitive or specific.
a. True
“The CAGE test is not recommended as a screening tool for
alcohol use as it is not highly sensitive or specific.”
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38.
The USPSTF recommendations for cervical cancer
screening for women aged 30-65 is
b. screen three years with a Pap smear and HPV testing.
“The USPSTF recommendations for cervical cancer screening
are highlighted below… Women aged 30-65: screen every
three years with a Pap smear or a Pap smear and HPV
testing.”
39.
The USPSTF recommendations for cervical cancer
screening for women over the age of 65 is
c. to not screen.
“The USPSTF recommendations for cervical cancer screening
are highlighted below... Women older than age 65 who have
had adequate prior screening and are not high risk: Do not
screen.”
40.
The USPSTF states that screening for cervical cancer
earlier than age 21 years
a. leads to more harms than benefits.
“The USPSTF recommendations for cervical cancer screening
are highlighted below... Screening earlier than age 21 years,
regardless of sexual history, leads to more harms than
benefits.”
41.
True or False: The USPSTF recommends routine screening
for skin cancer.
b. False
“The USPSTF does not recommend routine screening for skin
cancer…”
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42.
The diagnosis of hypertension cannot be confirmed until
an elevated blood pressure is present
d. on several occasions.
“The diagnosis of hypertension cannot be confirmed until an
elevated blood pressure is present on several occasions.
Blood pressure can be measured in a physician’s office, by
using ambulatory blood pressure monitoring, or using home
blood pressure monitoring.”
43.
Blood pressure measurement is an important predictor of
cardiovascular complications in people with
a. type 2 diabetes mellitus.
“Patients who are at risk for, or who have diabetes, should be
screened for hypertension and blood pressure should be
measured at every routine visit. A systolic blood pressure of
≤ 140 mm Hg or a blood pressure of < 140/90 m Hg is
desirable. These levels have been associated with a reduction
in CVD, nephropathy, and stroke in patients who have
diabetes.”
44.
People who have sickle cell disease have hemoglobin S
and when oxygen binds to _______________, red blood
cells form an abnormal shape (the sickle shape).
d. hemoglobin S
“People who have sickle cell disease have hemoglobin S and
when oxygen binds to hemoglobin S…”
45.
Basal cell carcinoma and squamous cell carcinoma are the
two
b. non-melanoma skin cancers.
“Basal cell carcinoma and squamous cell carcinoma are the
two non-melanoma skin cancers.”
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46.
True or False: Because of the increased use of sunscreens,
incidences of malignant melanoma, and deaths from this
cancer, have been decreasing for years.
b. False
“Malignant melanoma can metastasize to any organ (most
often the skin and lymph nodes) and the incidence of
malignant melanoma and deaths from this cancer have been
increasing for years.”
47.
The USPSTF recommends that __________ asymptomatic
pregnant women be screened for iron deficiency anemia
by measuring hematocrit and hemoglobin levels.
c. all
“The USPSTF recommends that all asymptomatic pregnant
women be screened for iron deficiency anemia by measuring
hematocrit and hemoglobin levels.”
48.
Which of the following causes iron deficiency anemia
during pregnancy?
b. A vegetarian diet
“Causes of iron deficiency anemia during pregnancy include
poor intake, poor nutrition, gastrointestinal disease,
vegetarian diet, medications that interfere with iron
absorption, and multiple pregnancies.”
49.
Anemia during pregnancy can cause, or has been
associated with
a. spontaneous abortion.
“Anemia during pregnancy can cause, or has been associated
with increased maternal mortality, premature birth,
spontaneous abortion, fetal death, low birth weight, and in
utero abnormalities.”
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50.
Malignant melanoma can metastasize to
c. any organ.
“Malignant melanoma can metastasize to any organ (most
often the skin and lymph nodes) and the incidence of
malignant melanoma and deaths from this cancer have been
increasing for years.”
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