1

Preventive Medicine
So to say, we in our life have always been asked to be Pro-active rather than reactive, repeating
up the words Prevention is the best cure. Now is the time to act on it- to our common goal of
Incidence 0% of those diseases that can be prevented. Too many Human Deaths and sufferings
can be prevented and has been shown to be prevented -just by following the recommended screening
strategy as given below in an age chronicle.
A. Patients who have single 1st degree relative with Colorectal Ca diagnosed before the age of 60yrs,
or who have multiple 1st degree relative diagnosed with this cancer - Screening should begin at 40
yrs of age or 10 yrs younger than the age at which the youngest affected relative was diagnosed,
whichever comes 1st.
B. R/F for osteoporosis are
Family history
Smoking
Alcohol
Chronic Steroid use
Low Body weight
C. FOB= Fecal Occult Blood test
D. DRE=Digital Rectal Examination/ PSA=Prostate Specifc Antigen
E. DEXA= Dual-Energy-X-ray-Absorptiometry
For Pap-smear look at Oncology chapter.
From
this Age
In what patient group?
Start screening
for
With test Frequency
18
Female 18-25 of age - who
are sexually active
Chlamydia
Trachomatis
Antigen detection
methods
q 1 yr
20
Only in patient with R/F for
Hyperlipidemia
High cholesterol
Random Total
cholesterol + HDL
At Regular
intervals
35
All Males-
High cholesterol
Random Total
cholesterol + HDL
At Regular
intervals
40
All female Breast Ca Mammography q 1 yr
Patients with R/F for colon
cancer
A
Colon Ca Colonoscopy q 5 yrs
45
All female High cholesterol
Random Total
cholesterol + HDL
At Regular
intervals
All patients-
screening can start earlier if
therere additional R/F
Diabetes
Fasting Blood
glucose
At Regular
intervals
50
All patients Colorectal Ca
FOB
C
q 1yr
Sigmoidoscopy q 5 yrs
Colonoscopy q 10 yrs
Only If patient has clear
family H/O Prostate Ca
Prostate Ca DRE/PSA
D
At Regular
intervals
60
Only In Female patients with
R/F for Osteoporosis
B
Osteoporosis DEXA scan
E
At regular
intervals
65
All female patients Osteoporosis DEXA scan
At regular
intervals
Only in Male patients with
H/O signifcant smoking
Abdominal Aortic
Aneurysm
USG of abdomen
Once is
enough
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2
Preventive Medicine
Preventive management of Lipid Disorders
Atherosclerotic disease is the No. 1 cause of Death in this World. Know that this disease can really be prevented
by well managed care of patients, with the best of all treatment DIET AND LIFESTYLE MODIFICATION-
but sadly it is the Hardest to implement. And as High Cholesterol is a major contributor to the formation of
Atherosclerotic plaques in Arteries, we should be screening all patients for High Cholesterol from an appropriate
age.
If patient has any of the following, then start screening for Hyper-Cholesterolemia from 20 yrs of age
Diabetes Mellitus. 1.
Family H/O hyperlipidemia. 2.
Multiple R/F for Atherosclerotic Vascular disease for e.g. smoking and HTN. 3.
Family H/O 4. Coronary Artery Disease (CAD) in a Male relative < 50 yrs or Female relative < 60 yrs
- termed as premature CAD.
If all of the above R/Fs are absent, then regular screening for high cholesterol should be done after 35 yrs in
Male and 45 yrs in Female patients. Screening for high cholesterol should include measurement of Total
Cholesterol and Total HDL. If Random total cholesterol level is Abnormal then NSIM is to do Fasting
cholesterol levels, the levels obtain would dictate the Tx.
Note that Total HDL/ Total cholesterol is a better predictor of risk for Coronary Artery Disease (CAD) than
Total LDL/ Total cholesterol level.
Now what are the management guidelines for High Cholesterol?
Patient has following
LDL goal
(target LDL)
Start Lifestyle
and diet modif-
cation
Start Statins
CAD or its Equivalent
1
< 100 mg/dl 100 mg/dl 130 mg/dl
2 or more R/F
2
< 130 mg/dl 130 mg/dl 160 mg/dl
No R/F or just 1 R/F < 160 mg/dl 160 mg/dl 190 mg/dl
MRS lDl, I see
101 in LDL. To
make it easy, use
the number 100
rather than 101.
Now add + 30 to go
downwards and +
30 to go sideways.
This strategy
will be helpful
in remembering
the values and to
construct this table
denovo.
1. So what are the conditions that fall into CAD and its equivalent? They are
Symptomatic Atherosclerotic Diseases- for e.g. Claudication , TIA etc.
Abdominal Aortic Aneurysm.
DM
Patient diagnosed with Stable Angina MRS. SAD patient
2. R/F that are taken into consideration for management of High cholesterol are, as pertaining to the
above table
Age 45 in males and 55 in females
HyperTenNsive patient
Cigarette smoking.
HDL < 40 mg/dl- (note that HDL > 60 mg/dl removes 1 R/F from this list).
Family H/O premature Coronary Artery disease i.e. CAD occurring at < 55 yrs of age in a Male
relative and < 65 yrs of age in a Female relative.
LDL target is < 70 mg/dl in Patients considered as very high risk. This includes patient with Acute-
coronary syndrome or the combination of stable angina + either DM or tobacco use
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3
Preventive Medicine
LOW HDL management (HDL< 40 mg/dl)
What do we do in this case?
1. The target LDL should always be reached before starting Tx for Low HDL.
2. If theres HDL with TriGlyceride then, correction of TG should be done 1
st
.
3. Only then treat for HDL. The TxOC is Lifestyle modifcation and diet changes. Note
Omega-3 Fatty acid in diet can increase HDL.
4. Then the pharmacological DOC is Fibrate (Gemfbrozil or Clofbrates). Niacin also can be
used, but it causes intense generalized pruritus and Flushing - because Niacin induces release
of Prostaglandins and histamine. Co-Tx with low dose Aspirin will reduce those S/E.
Lets try some CCS, using above-mentioned guidelines
60 y/o Male with H/O intermittent claudication. Total LDL is 100 mg/dl. NSIM start Diet and
lifestyle modifcation. Note that Intermittent claudication is a form of Symptomatic Atherosclerotic
disease.
65 y/o M patient diagnosed with type II DM. Total LDL is 135 mg/dl. NSIM Statin Tx.
65 y/o M diagnosed with HTN. Total LDL is 140 mg/dl. HDL is 65 mg/dl. NSIM Do nothing. This
patient has 2 R/F of age and HTN, but he has HDL > 60 mg/dl. So subtract 1 R/F.
The Statins (Atorvastatin, Simvastatin etc.) are very good drugs to lower LDL levels and they also have
been shown to Stabilize plaques in Acute-coronary Syndrome. Their MOA is inhibition of HMG CoA
reductase, which is the Rate-limiting enzyme for Bio-synthesis of cholesterol. Their Major S/E are Myo-
pathy (S/S of muscle generalized pain with in serum CreatineKinase), and Hepatotoxicity (ALT/
AST). Theres increased incidence of Myopathy with associated Conditions like Hypothryroidism and
Co-administration of Fibrates. If Myopathy develops then NSIMstop Statin (or else his condition may
worsen).
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4
Preventive Medicine
ADULT VACCINATION
When is not prevention better than cure anyway? All patients should specifc vaccination when it is required
and recommended. It is our duty and imperative to do so.
1
st
step in determining when and what vaccine should be given to the patient - is all about whether the patient
is Immuno-compromised or not.
Does the patient have H/O of any of the following?
HIV
steroid use
organ transplant
Diabetes Mellitus
Alcoholism
cancer
any form of chronic liver, kidney or lung disease? (For e.g. Cystic fbrosis, Chronic Renal Fail-
ure, Cirrhosis of liver, COPD, Bronchiectasis etc.).
If YES, then the patient should get these two preventive vaccinations regardless of age, they are-
The Flu vaccine thats usually given IM on a yearly basis. If the patient is allergic to eggs, then this IM
Flu vaccine isnt given, as this vaccine contains egg antigens. Another formulation of vaccine is given
which is commercially available in Intra-nasal form, in which egg isnt used for the manufacturing
process.
Strep vaccine (pneumovax) One Booster doses of this vaccine should be given after 5 years of the 1
st

dose.
Well if the patient doesnt have any of those above conditions, only then take into consideration our patients
age
If patients age is >50 years then, start yearly Flu vaccine shot. MRS Flu Fifty
Then as our patient reaches 65 years of age, we give one-time-shot of Pneumovax and no boosters of
Strep pneumovax are required in Immunocompetent patients. MRS strep sixty fve
Remember that all patients regardless of age should get Diptheria and Tetanus (DT) vaccine every 10 years.
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5
Preventive Medicine
Miscellaneous
Now lets try some CCS using above mentioned Guidelines
A 25 y/o man with Cystic fbrosis came to your clinic for regular checkup and his last checkup was 10
years ago. He hasnt received Booster dose of Pneumovax.
Ans: He gets all of the above vaccinations i.e. DT q10 years, Flu q1year and one booster dose of Pneumovax.
A 35 y/o man with Diabetes Mellitus came to your clinic. His last checkup was 6 years ago - All his vac-
cinations are up-to-date. He has already received one booster dose of Pneumovax.
Ans: He gets the Flu shot (q1yr).
A 47 y/o female with HTN or Hypercholesterolemia or H/O of MI. Her last checkup was 7 years ago and
all her vaccinations are up-to-date.
Ans: She will get no vaccination. Remember the differences between DM and HTN or other chronic metabolic
disease i.e. the latter ones arent considered as high risk or in other words Immuno-compromised.
A perfectly healthy 70 y/o female came for her routine checkup. Her last visit to a doctor was 15 years
ago.
Ans: she should get the DT Booster dose, Flu shot, Strep pneumovax single shot.
Remember another two specifc situation of (1) surgical Splenectomy and (2) Autosplenectomy cases
in Sickle cell anemia. These group of patients should get the following vaccinations designed for
encapsulated organism
1. N. meningitis one shot.
2. Strep Pneumomia - two shot pneumovax within a period of 5yrs.
All HIV +ve patients, if Asymptomatic and not severly Immunocompromised, should Receive MMR
vaccination even though its a live Vaccine.
Patients who are allergic to eggs should not get IM inFluenza vaccine and MMR and Yellow fever
vaccine.MRS FRY Eggs
is the patent
immuncompromised?
Give IM fu (q1yr)
Pneumovax (q5yr)
DT (q10yr)
YES NO
then look at the
patents age
<50 y/o
DT (q10yrs)
>50 y/o
IMfu (q1yr)
DT (q10yrs)
>65 y/o
Pneumovax (justonetme)
Give IM fu (q1yr)
DT (10yrs)
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6
Preventive Medicine
Rabies Prophylaxis
Tetanus prevention
The most imp question to answer is, does our patient get both active and passive immunization or neither of
them? The vaccination shouldnt be given if theres no need for that, i.e. when we are sure that the animal
doesnt have Rabies.
CCS- H/O Domestic animal bite - then see if the animal has any signs of rabies virus infection (i.e. exces-
sive salivation and violent aggressive behavior). If yes, then kill the animal and then send for pathology
examination of the brain. If pathology report is +ve for rabies then our patient should be vaccinated with
both Active and Passive immunization.
CCS H/O domestic animal bite and the animal doesnt show any signs of rabies. Here we can observe
the dog for 10 days, to see if the dog develops any signs of rabies or not. If the signs develop then kill the
animal and send for pathology examination and henceforth manage according to the pathology report. But
if the animal doesnt develop any signs of rabies for the period of 10 observed days, then dont have to do
anything - just reassure the patient.
CCS- H/O animal bite in the face or neck region dont wait for anything. NSIM is immediately vac-
cinate patient - no time for evaluation.
CCS- H/O wild animal bite - then immediately vaccinate with both active and passive immunization,
because usually the wild animals cant be caught and hence their brains cant pried open to see if there are
signs of rabies infection or not.
Remember that all bite-injuries for e.g. human, dog, cat or raccoon bite should get Px for Pasteurella
Multicoda - DOC is Amoxicillin + Clavulanate combination.
H/O tetanus immunization
>1cm deep wounds or wound > 6 hr
ago
1
, or Dirty wounds for e.g. wounds
due to burn or crush injuries
Wounds that dont fall into the
previous category for e.g. Clean
wound < 6 hr ago.
never vaccinated or
< 3 doses of vaccine in the past
TT + TIG TT
3 doses of vaccine TT, only if last dose is > 5 yrs ago
TT only if last dose > 10 yrs
ago
1. 6 hrs is the average time for Lag stage in bacterial growth sigmoidal curve, after 6 hrs the bacteria are
multiplying like hell and their population growth is exponential, hence increased risk.
TT- Tetanus Toxoid- Active vaccination
TIG- Tetanus ImmunoGlobulin- Passive vaccination
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7
Preventive Medicine
TRAVEL AND VACCINE
All travelers to the developed world for e.g. to North America and European countries usually
require no travel Vaccinations.
All travelers to the developing world should get Hepatitis A Vaccine - One dose of Active vaccination
will induce immunity within 4 weeks. So if the patient is travelling within 2 weeks then both Active and
Passive immunization is given. If the patient is travelling after 2 weeks then only the Active vaccination
is given
To simplify the cases for travel medicine, lets remember the two projections or the two big peninsulas
in the world map, they are (1) the Sub-Saharan African continent and (2) the Sub-Himalayan Indo-Nepal
territory. Two important points when patients are travelling to these 2 territories
1. Chloroquine resistant regions Hence Mefoquine (DOC) or Doxycycline is given for Malaria
prophylaxis (Px). If the patient is pregnant then Atovaquone Proguanil is given as Mefoquine
and Doxycyline is C/I in pregnancy. MRS- we become MAD when malaria is resistant to
chloroquine.
2. Get N. Meningitidis Prophylaxis with either Ciprofoxacin or Rifampin
And remember the Latin American region- another big peninsula in the world map. They are Chloroquine
sensitive region, so Travellers to this region are given Chloroquine for Malaria Px.
Note that patients travelling to make the Hajj to Mecca in Saudi Arabia are legally mandated to have N.
Meningitidis vaccination.
Other vaccines like vaccines for Yellow fever, Typhoid, Cholera, Rabies - it all depends upon where our
patient is going? What kind of disease are endemic in that area? What are their travel schedule and pur-
poses? That information should be researched properly before sending the patient to travel.
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