1. Cancer screening in adults (USPSTF)

-Lung: screen people aged 55-80 with a >30 pack year smoking history who have smoked within last 15 years. Do not screen if they have been nicotine abstinent for >15 years, if they could not tolerate lung resection surgery, or if they are going to die of something else first (USPSTF grade B)
-Colon: screen people 50-74. Choice of high-sensitivity stool card every year, or sigmoidoscopy q5 years + stool card q3 years, or colonoscopy q10 years. (USPSTF grade A) You probably shouldn't screen people aged 75-85 (grade C), definitely for the love of jesus do not screen people older than 85 (grade D)
-Prostate: do not screen using PSA, and since we have no better test, that means don't screen at all. Screening doesn't change the rate of discovery of malignant prostate cancers, only increases discovery of benign cancers that wouldn't have killed anyone. The risk of the follow up biopsy (which requires 30 different samples) leading to incontinence or impotence are high. (USPSTF grade D)
-Breast: mammograms every 2 years for women aged 50-75 (USPSTF Grade B), younger 50 if the patient really wants it (grade C), unclear if there is benefit after age 75. Sidenote: In a young woman with a significant family history of breast cancer, don't do mammograms, just go straight to genetic testing. If she's BRCA+, she'll need to start tamoxifen for life.
2. Non-cancer screening tests:
-Bone density: Women should get a DEXA at 65. You only need to do it once if it's normal, as the data shows that if its normal at 65 it'll always be normal. Screen at 60 if the woman has risk factors (white or asian race, skinny, smoker)
-AAA: Men aged 65-75 who have ever smoked should get one abdominal u/s to look for AAA.
-Hyperlipidemia (men): Screen all men >35 (USPSTF grade A), screen men >20 if they have risk factors for CAD (USPSTF Grade A)
-Hyperlipidemia (women): Screen women >45 ONLY IF they have risk factors (USPSTF grade A), screen women >20 if they have risk factors (USPSTF grade B).
-Depression: all adolescents aged 12-18 and all adults should be screened for depression, if you have the ability to follow up with treatment. (USPSTF B) PHQ 9: 70-80% sens, 95%+ spec using 10 as cutoff score, compared to gold standard psych interview. ~10% prevalence
3. Vaccinations: 
-Zoster vaccine at 60

-Pneumovax: for healthy adults, one after 65 (if you got one before 65, then you'll need a booster 5 years later if you are over 65 at that point)
-Pneumovax: for adults who are immunocompromised or have diabetes, chronic lung dx, chronic kidney dx, chronic heart disease, no spleen, sickle cell, history of cancer, history of bone marrow/solid organ transplant, they should get their first pneumovax shot anytime, and a booster 5 years later.
-Prevnar: for adults that have no spleen, sickle cell, CSF leak, cochlear implant, or are immunocompromised should get prevnar first, then pneumovax 8 weeks later. If they already got pneumovax, wait 1 year to give prevnar. 

-Flu shot every year
-Meningitis vaccine first shot from age 11-13, second booster at 16.
4. Chemoprophylaxis: 

-All women should take baby aspirin and vitamin D from age 55 to age 80 to prevent strokes

-All men should take baby aspirin from age 45 on to prevent MI.

-Initiate aspirin at younger age if the person has risk factors for MI/CVA and no risks for GI bleed 

5. In an adult presenting with fatigue/insomnia/depressive like symptoms, do the following workup:

-Comprehensive metabolic panel: Screen for electrolyte, renal, and hepatic problems.
-TSH: Rule out hypothyroidism (affects 5% of the US population)
-CBC: Check for anemia and vitamin deficiencies.
-Erythrocyte sedimentation rate: Test for rheumatologic disease.
-EKG: Should be done if the patient is using drugs that might alter cardiac conductivity

-Testing to r/o parkinsons (depression can precede motor presentation)

-Testing to r/o dementia (mini-cog has sens 99%, spec 93%, better than MMSE; do 3 words, clockface to recall those 3 words) 

6. Ankle tendonitis: usually posterior tibial tendon. At first, it's just pain with aggravation, then it progresses to pain all the time, worse with exercise/during the day. It's a chronic disesae 

7. Tarsal tunnel syndrome: pain, tingling, numbness in bottom of feet or on medial side of ankle, pain is often shooting in quality, due to entrapment of tibial nerve. 

8. DDx of cough: 

-Post-nasal drip (now called upper airway cough syndrome)

-Asthma

-Acute/Chronic Bronchitis 

-Vocal cord dysfunction

-GERD

-ACE-I 

-Tobacco-related

-Post-infectious

-Non asthma eosinophilic bronchitis 

Rarer, more serious causes: structural lung findings (lung CA, sarcoid, TB), CHF 

9. DDx palpitations:

-Heart: arrhythmias, valve disease, congenital heart defects, coronary disease (atypical presentation)

-Things that make it more likely cardiac: lasting > 5 minutes, irregular rhythm, history of heart dx, accompanied by pleuritic/positional chest pain. 

-Endo: hyperthyroid, vasomotor (menopause)

-Psych: panic attack, anxiety

-Anemia

-Drugs: stimulants, alcohol, tobacco, caffeine, street drugs, sympathomimetics, vasodilators, anticholinergics, w/d from b-blockers

In a prospective cohort study of 190 patients at a university medical center who complained of palpitations:


31% was anxiety or panic 


43% was cardiac 
(40% dysrhythmias and 3% other cardiac causes)


6% due to drugs 

10. MIs in women are much more likely to be atypical--McSweeny et al noted that 95% of women reported prodromal symptoms, but only 29.7% reported chest discomfort.

Prodromal symptoms may include: fatigue, dyspnea, neck and jaw pain, palpitations, cough, nausea and vomiting, indigestion, back pain, dizziness, numbness

40% of initial cardiac events in women are fatal.