week 7 discussion

You are working at an outpatient family medicine clinic with Dr. Hill. He has asked you to interview and examine Savannah, a 16-year-old who has come in for a routine sports physical before the softball season begins. Her mother, Leslie, accompanies her.

Dr. Hill informs you, “This is one of the special aspects I love about family medicine: I have cared for Savannah and her entire family since I helped Leslie deliver Savannah 16 years ago!”

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He continues, “Today, in addition to performing a pre-participation physical examination, I would like to use this opportunity to perform prevention screening and counseling. Perhaps the most important ‘screening’ issue is the medical interview and developing a safe and trusting doctor-patient relationship. Since this can sometimes be challenging with adolescents, I have found it helpful to organize my interview around the adolescent interviewing mnemonic, HEEADSSS.”

Logistically, you both decide that it would probably be best to begin the history with Savannah’s mother present and then delve into more of the interview after she has been invited to the waiting room during the conclusion of the visit.

TEACHING POINT

HEEADSSS Adolescent Interview

Pre-participation exams are a great opportunity for prevention and counseling, as otherwise healthy adolescents may not come in for this routinely.

HEEADSSS covers the following issues:

· Home

· Education / Employment

· Eating

· Activities

· Drugs

· Sexuality

· Suicide / Depression

· Safety / Violence

Remember that in caring for adolescents, every effort should be made to encourage the patient to involve parents in their health care decisions. Nevertheless, teens have a right to be interviewed and examined without a parent or guardian in the room.

Dr. Hill reminds you, “Along with the psychosocial medical interview, we will want to consider prevention screening. First, you need to decide whether a screening test is worth ordering. The U.S. Preventive Services Task Force (USPSTF) has taken the qualities of a good screening test into account when they make recommendations of what screening tests we should do. Let’s take chlamydia for example and look online together and see what they have to say about chlamydia screening in a 16-year-old, such as Savannah.”

TEACHING POINT

Chlamydia: Epidemiology, Course of Disease, and Screening Recommendations

Epidemiology

Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In 2007, more than 1.1 million chlamydia cases were reported to the CDC. It is thought that another million cases of chlamydia remain unreported.

Course of disease

Chlamydia is often insidious and asymptomatic. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality.

Screening recommendations

The USPSTF found fair evidence that nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic men and women, including asymptomatic pregnant women, with high test specificity. In low prevalence populations, however, a positive test is more likely to be a false positive than a true positive, even with the most accurate tests available.

TEACHING POINT

Qualities of a Good Screening Test

1. The condition should be an important health problem and the condition screened for must have a high prevalence in the population.

2. There should be a latent stage of the disease.

3. There should also be effective treatment for the condition being screened.

4. Facilities for diagnosis and treatment should be available.

5. There should be a test or examination for the condition.

6. The test should be acceptable to the population and the total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. The potential benefits of early detection and treatment of a condition need to be weighed against many factors, including adverse side effects of the screening test, time and effort required (of both the patient and the health care system) to take the test, financial cost of the test, potential psychological and physical harm of false positive results (such as labeling and overtreatment), and adverse effects of the treatment.

7. The natural history of the disease should be adequately understood.

8. There should be an agreed policy on whom to treat.

9. Case-finding should be a continuous process, not just a “once and for all” project.

10. An effective screening test should have very good sensitivity (identify most or all potential cases) and specificity (label incorrectly as few as possible as potential cases). Even a test with a sensitivity of 95% will lead to many false positives when the prevalence of the condition is very low.

Question

According to USPSTF, of the groups listed below, who should be screened for chlamydia? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. All non-pregnant women

· B. All pregnant women

· C. All sexually active men

· D. All sexually active women under 25 years

· E. All sexually active women 25 years or older who are at high risk

SUBMIT

Answer Comment

The correct answers are D, E.

TEACHING POINT

United States Preventive Services Task Force Recommendations for Chlamydia Screening

The USPSTF recommends screening for chlamydia infection in the following:

Grade Recommendation

Rationale:

· All sexually active women age 24 and younger

· Sexually active women age 25 and older who are at increased risk

Grade B recommendation

There is direct evidence that screening reduces complications of chlamydial infection in women who are at increased risk, with a moderate magnitude of benefit. Such complications include pelvic inflammatory disease, infertility, and premature delivery (among pregnant women).

· The USPSTF advises against screening women age 25 and older if not at increased risk, regardless of pregnancy status.

· Only the above categories are found to have a high enough pretest probability to recommend screening. Women (pregnant or non-pregnant) in general are not recommended for chlamydial screening as the overall benefit of screening would be small, given the low prevalence of infection among women not at increased risk.

· Risk factors for chlamydial infection include a history of chlamydial or other sexually transmitted infection, new or multiple sexual partners, inconsistent condom use, and exchanging sex for money or drugs. Risk factors for pregnant women are the same as for nonpregnant women.

· The USPSTF states that there is “Insufficient” evidence for or against screening men.

· The CDC recommends consideration of screening for chlamydia in sexually active young men in settings with high prevalence or in men with high risk behaviors overall.

1. The CDC recommends consideration of screening for chlamydia in sexually active young men in settings with high prevalence or in men with high-risk behaviors overall.

2. The AAP recommends considering annual screening for chlamydia in sexually active males in settings with high prevalence rates, such as jail or juvenile correction facilities, national job training programs, STD clinics, high school clinics, and adolescent clinics (for patients who have a history of multiple partners), as well as routine annual screening for men who have sex with men.

There are several good sources for preventive screening recommendations. The Guidelines for Adolescent Preventive Services (GAPS) was developed by the AMA in 1993. Other recommendations include those from the American Academy of Pediatrics’ Bright Futures and the U.S. Preventive Services Task Force.

After discussing preventive screening, you and Dr. Hill review the sports pre-participation questionnaire that Savannah filled out in the waiting room.

Then, Dr. Hill tells you, “I think you are ready to go meet Savannah and her mother.”

You enter the room and see Savannah, a tall, athletic, 16-year-old, sitting with her mother.

You introduce yourself and explain, “Dr. Hill and I have been reviewing your sports pre-participation questionnaire together.

Would it be okay if I begin talking with you today, before Dr. Hill comes in?”

“Of course.”

“Also, after the three of us spend some time talking together, I am going to take some time to talk with Savannah alone. Is this okay?”

“Yes. Dr. Hill has always been very good about taking time to talk with Savannah without me, so I’ll just step out for a bit.”

After reviewing and confirming the questionnaire as well as completing a brief medical history, you find that Savannah has no health problems that would limit participation in softball this year. To help put Savannah at ease, you talk with her a bit and discuss her hopes of being selected for the pitching rotation and batting higher in the order.

You then turn to Leslie and ask, “Would you mind if I speak with Savannah alone for a few minutes?” Leslie excuses herself from the room. With the HEEADSSS mnemonic in mind, you continue your conversation with Savannah. week 7 discussion