Case 2. 55-year-old male annual exam - Mr.

Reynolds
Amimi Osayande, M.D. University of Texas Southwestern Medical Center

Mr. Reynolds, a 55-year-old man with no significant past medical history, presents for a general physical
exam after deferring medical care for several years. History and physical exam reveal that Mr. Reynolds
is at risk for developing cardiovascular disease. He is counseled on smoking cessation, diet
improvement, and an exercise program. His immunizations are updated, and he is scheduled for a
screening colonoscopy. At follow-up a few weeks later, he has quit smoking and lost some
weight. During colonoscopy, a tubular adenoma with low-grade dysplasia was removed from the
descending colon. Labs reveal Mr. Reynolds has elevated lipids and glucose. He is educated about his
risk of heart disease, stroke, and developing diabetes. He elects to enact lifestyle changes to reduce this
risk with the understanding that he may need to start medication if these changes arent effective.
Final diagnosis: Men's health maintenance exam

Learning objectives
1. The student will be able to state the characteristics 1. of a good screening test.

2. The student will be able to individualize the recommendation for cancer
screening for common cancers for an adult male patient (e.g., lung,
colorectal, and prostate).

3. The student will be able to state the significance of nutrition and obesity in
health promotion and disease prevention.

4. The student will be able to prescribe an exercise program for a sedentary
patient.

5. The student will be able to recommend timely vaccinations based on age,
medical conditions, lifestyle, and environment.

6. The student will be able to perform smoking cessation counseling for
patients who smoke.

7. The student will be able to state principles that guide behavior change
counseling.

Introduction
RISE mnemonic for preventive visits
Risk factors - Identify risk factors for serious medical conditions during history and physical exam.
Immunizations - Provide recommended immunizations / chemoprophylaxis.
Screening tests - Order appropriate screening tests.
Education - Educate patients on ways to live healthier while reducing risks for disease.
The most frequent causes of death for a 55-year-old male in the US:
malignant neoplasm
heart disease
unintentional injury (accident)
diabetes mellitus
chronic lung disease
chronic liver disease
cirrhosis

History
Question
What history related to Mr. Reynolds' risk of cardiovascular disease do you want to obtain?
Multiple Choice Answer:
A: X Exercise
B: X Tobacco use
C: X Stress
D: O Travel history
E: X Family history
F: X History of leg pain with exercise
G: X History of chest pain with exercise
H: X Excess alcohol use
Answer Comment
Risk Factors for CVD and ASCVD

Many risk factors have been independently associated with cardiovascular disease (CVD) including:
sedentary lifestyle (A)
stress (C)
premature family history (E)
excess alcohol use (H)
and many more (e.g. obesity, poor diet, low selenium levels, high homocysteine levels, etc.).
Most of a person's risk for CVD and for stroke (together called atherosclerotic cardiovascular disease, or ASCVD)
can be determined by a limited set of major risk factors. Other minor risk factors are only helpful if they adjust a
patient's risk category from that determined by the major risk factors.
Of those listed above, only current smoking (B) is considered a major risk factor. But except for family history,
they are all modifiable risk factors.
American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend assessing major
ASCVD risk factors every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD.
For more required information about risk factors for ASCVD, read the MedU Cholesterol Guidelines Module.
Travel history (D) is not a major risk factor for developing cardiac disease.

Although a complete review of systems should always be asked, symptoms related to cardiovascular disease should
definitely be included.
Leg pain with activity (F) may indicate claudication, a manifestation of peripheral atherosclerotic disease.
Chest pain with activity (G) may indicate angina pectoris, a manifestation of coronary artery
atherosclerosis.
Smoking

Addressing Tobacco Use
Three Cs of Addiction:
1. Compulsion to use
2. lack of Control
3. Continued use despite adverse consequences
The Five A's of Counseling for Behavior Change:
Ask or Address the behavior needing change.
Assess for interest in behavior change.
Advise on methods to change behavior.
Assist with motivation to change behavior.
Arrange for follow-up.
Stages of Behavior Change:
Pre-contemplative - Not aware of need to change or not interested in changing behavior.
Contemplative - Currently interested in changing behavior.
Active - Currently making a behavior change.
Relapse - Attempted behavior change but no longer making the change.
Question
How effective are oral medications, such as bupropion (Wellbutrin, Zyban, Budeprion) or varenicline (Chantix), in
helping smokers quit? Choose the one best answer.
Multiple Choice Answer:
A: O Not effective (quit rate at 12 months no higher than placebo quit rate)
B: X Somewhat effective (quit rate at 12 months 1.5-3 times the placebo quit rate)
C: O Moderately effective (quit rate at 12 months 3-5 times the placebo quit rate)
D: O Very effective (quit rate at 12 months 5-10 times the placebo quit rate)
Answer Comment
Most smokers quit multiple times before being truly successful. It is helpful to view tobacco abuse as a chronic
disease and continue to work with smokers who relapse.
The annual quit rate for smokers without any medical interventions is about 2-3% per year.

Interventions which improve quit rates:
1. Quit rates are highest when patients are engaged in a group setting.
2. Oral medications are somewhat effective at helping people stop smoking, with q uit rates at 12
months 1.5 - 3 times the placebo quit rate (B) .
3. When combined with medication, a series of one-on-one counseling sessions (as in a physician's office),
enhances quit rates.
4. Providing practical problem-solving skills, assistance with social supports, and use of relaxation/breathing
techniques can increase quit rates.

Choosing medication to assist with smoking cessation:
Many physicians prefer prescribing bupropion to help smokers quit. Due to side effects, varenicline is often
reserved for those that have failed bupropion or if a patient specifically requests it.
ETOH
Screening for alcohol misuse: CAGE questions
Have you ever:
1. felt the need to Cut down your drinking?
2. felt Annoyed by criticism of your drinking?
3. had Guilty feelings about drinking?
4. taken a morning Eye opener?
The CAGE question has been validated as a useful tool in conjunction with quantifying the amount of alcohol being
used. When positive answers to any of the CAGE questions is received, further probing questions regarding other
affects of alcohol are indicated to help determine whether a problem with alcohol use exists.
Effects of Alcohol
The effect of alcohol on health is complex. For some people, even mild alcohol use carries major risks. For others,
moderate alcohol use may offer a degree of protection. At this time, there is no consensus about whether one form
of alcohol is better or worse than another. Regardless of type of alcohol, drinkers should drink in moderation: up to
1 drink per day for women, up to 2 drinks per day for men.

Effects of moderate alcohol intake: It is not clear at this point whether moderate alcohol drinking is beneficial to
the heart. Recent research suggests moderate alcohol consumption (wine or beer) does offer some protection against
heart disease. Alcohol can cause small increases in HDL cholesterol. Alcoholic beverages may contain other
chemicals that act as anti-oxidants or inhibit platelet aggregation. These population studies are suggestive of a
benefit, but there are no good intervention studies documenting clear benefit from drinking alcohol.
Effects of red wine: Red wine contains more anti-oxidant polyphenols, in particular flavonoids and resveratrol, than
white wine or other alcoholic beverages. These anti-oxidants have been associated with less heart disease and cancer
in animal models.
Effects with certain chronic diseases: Patients with heart failure, cardiomyopathy, diabetes, hypertension,
arrhythmia, obesity, hypertriglyceridemia, or who are taking medications may have adverse effects from alcohol
ingestion.

It is not always possible to identify those who will develop alcoholism. The American Heart Association cautions
people to NOT start drinking if they do not already drink alcohol.

References:
American Heart Association. AHA Science Advisory - Wine and Your
Heart:http://circ.ahajournals.org/cgi/content/full/103/3/472. Accessed June 28, 2010.
American Heart Association. Alcohol, Wine, and Cardiovascular
disease:http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Alcohol-Wine-and-Cardiovascular-
Disease_UCM_305864_Article.jsp. Accessed August 5, 2011.

Ewing JE. Detecting Alcoholism - CAGE Questionnaire: http://jama.ama-
assn.org/cgi/data/300/17/2054/DC1/1 Accessed June 28, 2010.

Diet
Question
Based on what you know so far, Mr. Reynolds dietary habits appear poor. What are three ways to gather a more
complete nutrition history?

* 24-hour Dietary Recalls * Daily Dietary Intake Records (or Food Diaries) * Food Frequency Questionnaire *
Usual Diet History * Observed Intakes * Weighed Intakes
Answer Comment
Gathering a Complete Nutrition History
Dietary choices can affect a patient's risk for coronary heart disease, diabetes, some cancers, and stroke.
Thus, nutrition assessment is a critical aspect of the preventive routine exam.
There are many ways to gather a nutrition history. A brief history should include the number of meals and snacks
eaten in a 24-hour period; dining-out habits; as well as frequency of consumption of fruits, vegetables, meats,
poultry, fish, dairy products, and desserts. Nutrients missing in the diet are equally important as those eaten in
excess.
When this initial history indicates a poor diet or there are medical indications for a more complete diet history, use
of one or more of the following methods is indicated.

24-hour Dietary Recalls:
Ask about each meal separately. Be sure to include snacks and beverages as well as portion sizes. WAVE is
a pocket card tool designed to encourage dialogue about the patient's "Weight, Activity, Variety and Excess". Based
on the foods reported, the provider can determine whether the patient appears to be eating appropriate numbers of
servings from the Food Guide Pyramid (Variety) and whether he or she is eating too much fat, salt, sugar, and
calories (Excess) recommended in the Dietary Guidelines for Americans. The card also lists counseling tips to aid
the practitioner in setting dietary goals with the patient.
Food Frequency Questionnaire:
Usually covers food intake over the period of a month. Often used in combination with the 24-hour recall, it is the
quickest way to determine nutritional deficiencies and excesses. Rapid Eating and Activity assessment for Patients
(REAP) is a brief validated questionnaire that assesses diet related to the Food Guide Pyramid and the 2000 U.S.
Dietary Guidelines. REAP includes questions to assess intake of whole grains, calcium-rich foods, fruits and
vegetables, fat, saturated fat and cholesterol, sugary beverages and foods, sodium, alcoholic beverages and physical
activity. REAP also includes questions regarding whether the patient shops and prepares his/her own food; ever has
trouble being able to shop or cook; follows a special diet; eats or limits certain foods for health or other reasons; and
how willing the patient is to make changes to eat healthier. Patients can either fill out the instrument in the waiting
room or have it sent home to complete before their appointment. The REAP Physician Key includes sections on
patients at risk, further evaluation and treatment as well as counseling points/further information for each major
dietary area.
Daily Dietary Intake Records (or Food Diaries):
Ask the patient to bring in a complete record of everything consumed over a 3-4 day period. Have the patient
include Saturday and Sunday, since many people eat differently on the weekend.
Usual Diet History:
Ask the patient to describe a typical day's diet. In addition, ask how often and under what circumstances the patient
varies from this typical intake. This method is often combined with a 24-hour dietary recall.
Observed Intake:
Patients are directly observed eating known food quantities. Performed primarily in research settings.
Weighed Intakes:
This is the most accurate method of assessing dietary intake. All food and drink are weighed before intake. It
requires a highly motivated patient.
Referral to a nutritionist or dietician may also be indicated, especially if covered by medical insurance. Patients may
complete a sample nutrition history form in the waiting room prior to the visit.
References:
Gans KM, Ross E, Barner CW, Wylie-Rosett J, McMurray J, Eaton C. REAP and WAVE: New tools to rapidly
assess/discuss nutrition with patients. J Nutr. 2003;133:556-562. http://jn.nutrition.org/cgi/content/full/133/2/556S
Accessed June 28, 2010.

Hark L, Deen D. Taking a nutrition history: a practical approach for family physicians. Am Fam Physician.
1999;59:1521-37. http://www.aafp.org/afp/990315ap/1521.html Accessed June 28, 2010.


Domestic Violence
Domestic violence
It is important to review safety at home because family violence occurs in all groups and across the lifespan.



Family History
1. Review the documented family history with the patient.
"I would like to see if there are any changes in your family history. I see that your mother died in her 70's of colon
cancer, diagnosed at age 69. Your paternal grandfather died in a car accident and your paternal grandmother has
hypertension (HTN), obstructive sleep apnea (OSA), and recent stroke. Your maternal grandfather died of old age at
86 and your maternal grandmother died of breast cancer and hypertension (HTN)."

2. Make sure to ask specifically about immediate family members.
"Is your father still alive?"
"How about your siblings?"
3. Check for new diagnoses.
"Any relatives with new diagnoses in the past few years?"

BMI
Height: 5' 10" (1.78 m)
Weight: 220 lbs (100 kg)
Blood pressure: 160/95 mmHg right and left arms
Pulse: 72 beats/minute


Technique for proper blood pressure measurement

Use a properly-sized cuff, seat the patient with the arm at heart level, in a quiet room measure the blood pressure in
both arms.
Question
What is his BMI (body mass index) and what does this mean?
Non-evaluated freetext
31.6 kg/m2 A BMI over 30 categorizes Mr. Reynolds as obese.
Answer Comment
Calculating the BMI and Understanding Its Importance
BMI = weight in kg / height in m
2

Category BMI (kg/m
2
)
Underweight below 18.5
Normal 18.5 - 24.9
Overweight 25.0 - 29.9
Obese 30.0 and above
Some subcategorize obesity into obese 30-35; very obese 35-40; and extremely or morbidly obese 40+.
Incidence:
The population of overweight and obese patients has increased steadily over the past 20 years. In the United States,
the lifetime risk of becoming obese is 25%.
Use:
BMI is used clinically because actual measurement of percent body fat is difficult.
Importance:
BMI is important because high total body fat is a risk factor for type 2 diabetes, dyslipidemia, hypertension, and
cardiovascular disease.
Other measurements:
Body fat distribution may provide additional risk stratification for coronary artery disease beyond BMI. Waist
circumference and waist-hip ratio, as indicators of abdominal adiposity, are independent risk factors for coronary
artery disease. Consider measuring these in overweight patients to further determine risk and need for weight loss.
Mr. Reynolds is at risk for metabolic syndrome, characterized by abdominal obesity, dyslipidemia, hypertension,
and insulin resistance with or without impaired glucose tolerance.
Reference:
Vasan RS, Pencina MJ, Cobain M, et al. Estimated risks for developing obesity in the Framingham Heart Study. Ann
Intern Med. 2005;143:473.

Physical Exam
Changes associated with dyslipidemia:
Corneal arcus, xanthelasmas, acanthosis nigricans
Changes associated with atherosclerosis:
Decreased peripheral pulses, carotid bruit
The ABCDE of suspicious skin lesions:
Asymmetry
Border irregularity
Color non-uniform
Diameter >6 mm
Evolution or change over time

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Immunizations
Immunization resources:

CDC website and free PDA version of Shots

Relevant immunization recommendations:
Influenza is recommended annually.
Current recommendations recommend substituting a one-time dose of Tdap for Td booster (tetanus and
diphtheria) for ages 11-64 to provide additional pertussis protection, then boost with Td every 10 years.
One dose of zoster vaccine is recommended when patients turn 60.

Immunocompromising conditions:
Live vaccines, like zoster (also MMR, OPV, and Varicella), should not be administered to immunocompromised
patients, their close contacts, or to pregnant women.

Screening Tests
Question
Which of the following are characteristics of a good screening test? Choose all that apply.
Multiple Choice Answer:
A: X There should be a treatment for the condition being screened for.
B: X There should be a latent (asymptomatic) stage of the disease.
C: O The test should have low sensitivity and high specificity.
D: X The test should be acceptable to the population.
E: X The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
Answer Comment
Characteristics of a Good Screening Test
Medical screening should be considered for conditions that are important health problems which can be treated (A)
and have a latent phase of a disease (B) enabling early detection and more timely treatment, impacting the outcome
of the disease.

The screening test should be acceptable to patients (D) at reasonable cost (E).

Since patients without symptoms are being screened, the overall prevalence of the condition in the population will
be low. The goal is to identify cases at an early stage; thus, an effective screening test should have very good
sensitivity (identify most or all potential cases) and high specificity (label incorrectly as few as possible as potential
cases). Remember that even a test with a specificity of 95% will lead to many false positives when the prevalence of
the condition is very low.

EBM Levels of Evidence
The USPSTF grades each recommendation according to one of five classifications:
A: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net
benefit is substantial.
B: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net
benefit is fair or fair certainty that the net benefit is moderate - substantial.
C: The USPSTF recommends against routinely providing this service. There is moderate or high certainty that
health outcomes are not improved - net benefit is small. However there may be occasions that warrant provision of
this service in a patient.
D: The USPSTF recommends against providing this service. There is moderate or high certainty that the service
does not have any net benefits or harms outweigh benefits.
I: There is insufficient evidence to recommend for or against the service.
Question
Which of the following receive an A or B recommendation by the US Preventive Services Task Force for a 55-year-
old man who smokes and is asymptomatic?
Multiple Choice Answer:
A: O Lung cancer screening
B: X High blood pressure screening
C: O Pancreatic cancer screening
D: O Testicular cancer screening
E: X Alcohol misuse screening and counseling
F: X Hepatitis C screening
G: X Depression screening
Answer Comment
United States Preventive Services Task Force Screening Recommendations for a 55-year-
old asymptomatic man who smokes
"A" or "B" screening recommendations include:
Colorectal cancer
Obesity
Diabetes mellitus
Lipid disorders
Tobacco use
Lung cancer screening (A)
Lung cancer screening is only recommended under certain circumstances annual screening for lung
cancer with low-dose computed tomography is recommended in adults ages 55 to 80 years who have a 30
pack-year smoking history and currently smoke or have quit within the past 15 years. In this case, Mr.
Reynolds has a <30 pack-year smoking history, so lung cancer screening is not recommended at this time.
Hypertension (B)
Alcohol misuse (E)
Hepatitis C (F)
Screen for hepatitis C virus (HCV) infection in persons at high risk for infection. Offer one-time screening
for HCV infection to adults born between 1945 and 1965.

Depression (G)
Note: One of the USPSTF depression screening recommendations is Grade B, another is Grade C.
Grade B: S creen adults for depression when staff-assisted depression care supports are in place to assure
accurate diagnosis, effective treatment, and follow-up.
Grade C: Do not routinely screening adults for depression when staff-assisted depression care supports are
not in place. There may be considerations that support screening for depression in an individual patient.

Screen for depression with two questions:
1. Over the past 2 weeks, have you ever felt down, depressed, or hopeless?
2. Over the past 2 weeks, have you felt little interest or pleasure in doing things?
"D" (not recommended) screening recommendations include:
Bacteriuria, bladder cancer, pancreatic cancer (C), testicular cancer (D), spirometry for COPD, genital herpes,
gonorrhea, hemochromatosis, and hepatitis B.
Patients at higher risk for particular disorders may be candidates for some of these screening tests, so it is important
to consider other factors, including family history, travel history, sexual history, etc.

"I" screening recommendations include:
Prevention of motor vehicle injuries with seatbelt use and avoiding driving under the influence of alcohol; family
and intimate partner violence screening; illicit drug use; and skin cancer screening.
Depending upon the patient population, additional screening receiving an "I" recommendation are: screening for
glaucoma; lung cancer screening (A); oral cancer screening; and thyroid disease screening.

Reference:
Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: Two questions are as good as many. J Gen Intern
Med. 1997;12:439-45.
U.S. Preventive Services Task Force - Screening for Hepatitis C Virus Infection in
Adults: http://www.uspreventiveservicestaskforce.org/uspstf/uspshepc.htm

Prostate Cancer
Controversy Over Prostate Cancer Screening Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate
cancer (Grade D). Based on the data reviewed, they concluded that PSA based screening in average risk males
results in little or no reduction in prostate cancer related deaths and is associated with harms related to tests,
procedures and treatment of the condition, some of which may be unnecessary.

Other organizations, such as the American Cancer Society (ACS) recommended that physicians should have a
discussion of the potential benefits and harms of screening with a PSA test.
Question
Dr. Nayar asks, "Since Mr. Reynolds does not have a family history of prostate cancer, and is thus at average risk,
what is one potential benefit and one possible harm of PSA screening that we could discuss with him?"
Answer

The potential benefit of PSA screening is that it may lead to prolonged life from early detection and treatment of
prostate cancer. In addition to the potential benefit of early detection of malignant prostate cancer, some men may
receive psychological reassurance that they probably do not have prostate cancer or they have probably caught it
early so it can be treated. A potential harm of PSA screening is serious complication (such as erectile dysfunction,
urinary incontinence, bowel dysfunction) or even death from treatment of a prostate cancer that would not have
caused symptoms if left undetected during his lifetime. Another potential harm is pain and discomfort associated
with prostate biopsy and psychological effects of false-positive test results.
References:
American Cancer Society. Can Prostate Cancer Be Found Early? http://www.cancer.org/Cancer/ProstateCancer/DetailedGuide/prostate-cancer-
detection Accessed May 30, 2012.

American Urology Association. Prostate Cancer. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-
reports/proscan07/content.pdf. Accessed May 30, 2012.
American Urology Association. Early Detection of Prostate Cancer. http://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-
Cancer-Detection.pdf. Accessed Nov 15, 2013.
USPSTF. http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostateart.htm Release May 2012

U.S. Dept. of Health and Human Services. U.S. Preventive Services Task Force. Screening for Prostate
Cancer. http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm Accessed June 28, 2010.
Schrder FH, Hugosson J, Roobol MJ, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012 Mar 15;366(11):981-90.

Colon Cancer
Colon Cancer Screening Options
Screening colonoscopy every 10 years
Annual testing of three stools for blood and a flexible sigmoidoscopy test every 5 years
Double-contrast enemas every five years
CT colography (virtual colonoscopy) is still considered experimental
A rectal exam and test for occult blood are not adequate screening.

Lab Screening
Question
Which of the following do you want to order for Mr. Reynolds? Check only those that are strongly recommended by
evidence-based guidelines.
Multiple Choice Answer:
A: X Glucose
B: X Lipid panel
C: O TSH
D: O Ferritin
E: O Liver function panel
F: X Electrolyte panel: Na, K, Cl, CO2, BUN, Creatinine
Answer Comment
To assess risk for diabetes:
Glucose (A) is strongly recommended.
To assess risk for cardiovascular disease:
A lipid panel (B) is strongly recommended.
The ACC/AHA Cholesterol Guidelines recommend reassessing patients' ASCVD risk (including HDL and total
cholesterol) every 4-6 years. Given that they recommend treating with statins all patients over 21 with an LDL-c >
190 mg/dL, it is reasonable to check fasting lipids in all adults over 21 every 4-6 years. Ideally, these are drawn in
the fasting state at least 8 hours after the last food intake. Non-fasting triglycerides may be significantly higher than
fasting, but the total cholesterol, LDL-C, and HDL-C generally do not vary that much. LDL cholesterol can be
determined via calculation based on other components of the lipid panel, or it can be directly measured. A
"measured" LDL is often done when the patient's triglycerides are very high, invalidating LDL calculations. For
more required information about ASCVD risk assessment, read the MedU Cholesterol Guidelines Module.
To assess for chronic kidney disease:
Renal function and serum electrolytes (F) are indicated in this situation, since Mr. Reynolds has elevated blood
pressure.
Note -- the USPSTF has not reviewed liver function panels (E) or CBC, electrolyte, and chemistry panels -- and
repeated studies have failed to show benefit from routine biochemical screening tests in asymptomatic adults.
Because of his BMI, also consider screening Mr. Reynolds for obstructive sleep apnea.
USPSTF guidelines give an "I" recommendation for TSH (C).
USPSTF recommends against ferritin (D) as a screen for hemochromatosis.
References:
Cebul RD, Beck JR. Biochemical profiles. Applications in ambulatory screening and preadmission testing of adults. Ann Intern Med.
1987;106(3):403-13.

Chacko KM, Feinberg LE. Laboratory Screening at Preventive Health Exams: Trend of Testing, 1978-2004. Am J Prev Med. 2007;32(1):59-62.

Curry IP. An analysis of routine blood testing of British army pilots. Aviat Space Environ Med. 2003;74(4):332-6.

Takemura Y, Ishida H, Inoue Y, Beck JR. Common diagnostic test panels for clinical evaluation of new primary care outpatients in Japan: a cost-
effectiveness evaluation. Clin Chem. 1999;45(10):1752-61.
ECG
Approach to ECG Interpretation
1. Examine rate, PR interval, QRS, duration, and QT interval.
2. Look for abnormalities in P waves.
3. Assess axis, R wave progression, presence of Q waves, and level of voltage.
4. Look for ST depression or elevation and inverted T waves.

Exercise Stress Test
Asymptomatic male patients over 45 years of age with one or more risk factors (hypercholesterolemia, hypertension,
smoking, or family history of premature coronary artery disease) may obtain useful prognostic information from
exercise testing.
Question
Dr. Nayar asks you, "What ECG changes would suggest that Mr. Reynolds has existing coronary artery disease?"
Multiple Choice Answer:
A: X ST segment depression or downsloping ST segment
B: X Q waves
C: O U waves
D: X Convex ST segment elevation
E: O Short PR interval
Answer Comment
ECG changes suggesting coronary artery disease:
Horizontal ST segment depression or downsloping ST segment (A) Suggests cardiac ischemia
Convex ST segment elevation (D)
Suggests acute myocardial
injury
Q waves (B) that are greater than 25% of succeeding R wave and greater than 0.04
seconds
Indicate infarction

Other ECG changes:
U waves (C) are abnormal when greater than 1.5 mm in any lead, and are associated with bradycardia,
electrolyte imbalance such as hypokalemia, hypercalcemia or hypomagnesemia, drug effect (digitalis,
quinidine, procainamide), CNS disease, hyperthyroidism, left ventricular hypertrophy or mitral valve
prolapse.
A short PR interval (E) is seen in arrhythmias such as Wolff-Parkinson-White, AV junctional rhythm with
retrograde P wave conduction, or Lown-Ganong-Levine.
Lifestyle Changes
When a patient is ready to quit smoking
1. Set a quit date
2. Give instructions for taking bupropion
Start one week before the quit date with one pill a day for the first 3 days, then increase to one pill twice a
day, morning and evening.
After another 4 days, stop smoking and continue on the pills twice a day.
Add nicotine gum for bad cravings, if needed.
After about two months on the pills, gradually stop.
3. Provide other smoking cessation resources
1-800-QUIT NOW
www.smokefree.gov
Tips for weight loss
1. Target a realistic weight goal.
2. Reduce calories consumed and increase calories burned.
3. Eliminate soft drinks; drink water instead.
4. Five servings of fruits and vegetables.
5. Meet with a dietician.
Lifestyle Recommendations to lower hypertension and ASCVD risk
For more required information about lifestyle recommendations to lower hypertension and ASCVD risk, read the
MedU Hypertension Module and the MedU Cholesterol Module.

By the way...
As you say goodbye to Mr. Reynolds, he says to you, "Oh, by the way, do you have any samples of Viagra?"
Question
Based upon your own experience, how would you respond to this request?
Answer
Here is how Dr. Nayar handles it: Dr. Nayar responds to Mr. Reynolds' Viagra request matter of factly, "Are you
having problems attaining erections?" Mr. Reynolds answers, "Sometimes they are not as hard as they used to be."
Dr. Nayar replies, "I am glad you mentioned this and very sorry we do not have any time right now to talk about it
more. I will make a note of your concern, and we will be sure to address it when you come back for follow-up."
Answer Comment
Managing "door handle" issues
Patients often bring up a question or issue at the end of a visit that can take more than a minute to discuss. There are
conflicting priorities: service to this patient versus keeping on schedule as much as possible for the remaining
patients on the schedule.
Sometimes the "door handle" issue is more important than the original reason for visit. A quick assessment of
whether the issue is life-threatening or requires an early return visit should be made. Usually the patient will
understand if the issue is not completely dealt with at that visit but can be discussed at a future visit.
It is not always possible to avoid this situation, but allowing the patient to state an agenda at the start of the
interview has been shown to correlate with fewer late concerns. Studies of clinicians show that the average patient is
allowed to talk uninterrupted by the physician for only 18-23 seconds.
References:
Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have we improved? JAMA 1999;281:283-7. http://jama.ama-
assn.org/cgi/content/full/281/3/283

Exercise
Exercise Prescriptions
The American Academy of Family Physicians has a program called Americans in Motion-Healthy Interventions
(AIM-HI). Their website includes excellent links for resources to provide patients to encourage exercise and healthy
eating. Generally, exercise prescriptions include the following specific recommendations:
Type of exercise or activity: Patient preference should guide the choice of type of exercise. Swimming or
water jogging is beneficial for those with musculoskeletal problems, such as arthritis. Varying the activity
can increase compliance by providing variety.
Precautions: Issues such as orthopedic concerns should be regarded.
Specific workloads: E.g. watts, walking speed, etc.
Duration and frequency: Depends on the activity or exercise session. For cardiovascular fitness, sessions
should be 40 minutes three times a week. For weight loss, patients should try to do 20-40 minutes every
day.
Intensity guidelines: Target heart rate (THR) range and estimated rate of perceived exertion (RPE).
o If you can talk and walk at the same time, you aren't working too hard.
o Target heart rate calculation: THR = (220 - age) * 0.7-0.8
o Perceived exertion:
! There is a fairly good correlation between THR and perceived exertion, so after
measuring for THR with exercise several times, patients can rely on perceived exertion to
gauge their level of exercise.
! Using the Borg perceived level of exertion scale, patients should exercise to a level of 12-
14.
The U.S. Department of Health and Human Services
Recommends that men participate in at least 150 minutes of moderate-intensity aerobic exercise per week,
as well as muscle strengthening at least twice per week.

Reference:
Lauer M, Froelicher ES, Williams M, Kligfield P. Exercise testing in asymptomatic adults: a statement for professionals from the American Heart
Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2005;112:771-6.

McMullen SA, May M, Staton EW, Pace WD, Theobald ML, McAndrews JA. AIM-HI Practice Manual. American Academy of Family
Physicians. 2009.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub_health/aim/practicemanual.Par.0001.File.tmp/AIMPracticeManual.pdf.
Accessed June 28, 2010.
The U.S. Department of Health and Human Services. How much exercise do adults
need? http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html. Accessed November 15 2013

Results follow up
Measurements:
Weight: down 2 pounds. Blood pressure: 139/86 mmHg.
Studies:
Fasting lipids: Total Cholesterol 230 mg/dL; HDL-C 38 mg/dL; LDL-C 142 mg/dL; triglycerides 130 mg/dL
Fasting glucose: 122 mg/dL
HIV: Negative
Colonoscopy report: Diverticulosis; 1 small polyp descending colon - tubular adenoma with low-grade dysplasia (<1
cm)
Question
Dr. Nayar asks you which of the following you recommend for Mr. Reynolds now?
Multiple Choice Answer:
A: X Low dose aspirin (81 mg daily)
B: X Moderate-to high-intensity statin
C: O High sensitivity C-reactive protein (HS CRP)
D: O Electron-beam computerized tomography scan for coronary calcium (EBCT)
E: O Carotid ultrasound
F: O Abdominal ultrasound of aorta
Answer Comment
Management of CHD Risk
An ASCVD risk of 17.4% places Mr. Reynolds at high risk for an ASCVD event in the next ten years. Appropriate
steps are to start Mr. Reynolds on aspirin (A) and begin a moderate-to high-intensity statin (B). An exercise stress
test can be considered to further evaluate for the presence of coronary atherosclerosis in a high risk man,
particularly if he were planning to begin a vigorous exercise program. If he had symptoms of coronary artery
disease, further evaluation with stress testing would be indicated.

HS CRP (C) is a minor risk factor for ASCVD, which might be helpful if there was clinical uncertainty after
assessing risk using the Pooled Cohort Equations. Similarly, EBCT (D) may help stratify those at intermediate risk.
Mr. Reynolds is already at high risk and warrants aggressive therapy to lower his lipids, so HS CRP or EBCT results
would not change his management.
USPSTF review in 2007 gave a D recommendation for carotid ultrasound in asymptomatic individuals (E).
USPSTF review in 2005 gave a B recommendation for one-time abdominal ultrasound of the aorta (F) in males aged
65-75 who have smoked. Mr. Reynolds is only in his 50s, so it is not recommended now for Mr. Reynolds.
For more required information about risk factors for ASCVD and cholesterol management, read the MedU
Cholesterol Guidelines Module.
References:
Budoff MJ, Achenbach S, Blumenthal RS, et al. Assessment of Coronary Artery Disease by Cardiac Computed Tomography; AHA
Scientific Statement. Circulation. 2006;114:1761-1791.

Guidelines for colonoscopy surveillance after polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal
Cancer: http://www.guideline.gov/content.aspx?id=38454 . Accessed Mar 15, 2013.

Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR; United States Multi-Society Task Force on Colorectal
Cancer. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the USMulti-Society Task
Force on Colorectal Cancer. Gastroenterology. 2012Sep;143(3):844-57.
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation 2013 Nov 12. [Epub ahead of print]

Results follow up 2
Diet recommendations to lower heart disease risk
The American Heart Association recommends eating fish twice a week. Eating more fatty fish like mackerel, lake
trout, sardines, albacore tuna, and salmon, which are high in omega-3 fatty acids, can lower heart disease risk.
Eating the oils contained in tofu or other forms of soybeans, canola, walnuts, and flaxseeds may also help lower
heart disease risk.
Unfortunately, studies are showing that vitamins C, E, and folic acid do not reduce heart attacks or strokes.