<p> SCREENING PROTOCOLS</p><p>1. MMG: Every year for all women after age forty. 2. Pap Smears: Start at age 18 or within 3 years of the onset of sexual activity. Can stop at age 65 if the last three screenings have been normal. Screen every year for sexually active people and every three years for virgins. No Pap smear needed for women with a TAH for benign reasons, although yearly bimanual exams must still be performed. 3. Colon Cancer: Screen every year w/ FOBT at age 40 combined with every 10 years with colonoscopy after age 50. 4. Prostate Cancer: DRE for all men yearly age 40 and above and add PSA starting at age 50. 5. AAA: Screen with abdominal ultrasound one time at age 65 for all men who have smoked at any time in their lives. 6. Cholesterol: Screen all people age 35 and older every two years. Start at age 20 and perform yearly if the following risk factors are present: a. Diabetes (yearly starting at diagnosis). b. A family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives. c. A family history suggestive of familial hyper-lipidemia. d. Tobacco use e. HTN f. Obesity 7. Pregnant women should be screened for asymptomatic bacteriuria at 12-16 wks gestation. 8. Screen all sexually active women aged 25 years and younger once a year, and other asymptomatic women at increased risk for chlamydial infection as defined below. Age is the most important risk marker. Other patient characteristics associated with a higher prevalence of infection include: a. Unmarried b. Prior history of sexually transmitted disease c. Having new or two or more sexual partners in the past six months d. Having cervical ectopy e. Using barrier contraceptives inconsistently. f. Work in the sex industry</p><p>9. Women and men under the age of 25—including sexually active adolescents— are at highest risk for genital gonorrhea infection. Risk factors for gonorrhea include a. Prior history of sexually transmitted disease b. Having new or two or more sexual partners in the past six months c. Using barrier contraceptives inconsistently d. Work in the sex industry e. Drug use f. Men who have sex with men 10. Screen for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. 11. Screen for human immunodeficiency virus (HIV) in all adolescents and adults at increased risk for HIV infection at least yearly: a. Men who have had sex with men b. Men and women having unprotected sex with two or more partners in the past six months c. Past or present injection drug users d. Men and women who work in the sex industry or have sex partners who do e. Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users f. Persons being treated for sexually transmitted diseases (STDs) g. Persons with a history of blood transfusion between 1978 and 1985 h. Persons who request an HIV test despite reporting no individual risk factors may also be considered at increased risk, since this group is likely to include individuals not willing to disclose high risk behaviors. 12. Influenza Immunizations: a. Annual vaccination with inactivated influenza vaccine is recommended for the following persons who are at increased risk for complications from influenza: i. persons aged >50 years ii. residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions iii. adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma (hypertension is not considered a high-risk condition) iv. adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]) v. adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration vi. children and adolescents (aged 6 months--18 years) who are receiving long-term aspirin therapy and, therefore, might be at risk for experiencing Reye syndrome after influenza infection vii. women who will be pregnant during the influenza season: Vaccination can occur in any trimester viii. children aged 6--23 months. ix. employees of assisted living and other residences for persons in groups at high risk x. persons who provide home care to persons in groups at high risk xi. household contacts (including children) of persons in groups at high risk. xii. Health-care and daycare workers b. CONTRAINDICATIONS TO VACCINATION: i. Inactivated influenza vaccine should not be administered to persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine ii. The following populations should not be vaccinated with Live Attenuated Influenza Vaccine: 1. persons aged <5 years or those aged >50 years 2. persons with asthma, reactive airways disease or other chronic disorders of the pulmonary or cardiovascular systems 3. persons with other underlying medical conditions, including such metabolic diseases as diabetes, renal dysfunction, and hemoglobinopathies 4. persons with known or suspected immunodeficiency diseases or who are receiving immunosuppressive therapies 5. children or adolescents receiving aspirin or other salicylates (because of the association of Reye syndrome with wild- type influenza infection) 6. history of Guillain-Barré syndrome 7. pregnant women 8. persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs. 13. Pneumococcal vaccine (PPV) is recommended for all immunocompetent individuals who are age 65 years and older. High risk categories include: a. Children >/= 2yrs w/ SSD, anatomic or functional asplenia, immunocompromising conditions, and HIV should receive 2 doses of PPV separated by 3-5 years if </=10yrs old and by 6 or more years if >10yrs old. First dose is given at least 2 months after completing the PCV series. b. Children >/=2yrs old with chronic diseases such as DM, cerebrospinal fluid leaks, cochlear implants, chronic lung disease (including asthma only if on steroids), immunocompromised states, chronic renal failure, and chronic cardiac disease—should receive one dose of PPV at least 2 months after completing the PCV series. c. Medical indications in older children and adults before age 65 include COPD, asthma (on chronic steroids), cardiovascular diseases, DM, chronic liver disease, chronic renal failure, CSF leak, cochlear implants, functional or anatomic asplenia (SSD), and immunosuppressive conditions. Also any institutionalized adult should be offered the vaccine. d. Revaccination: i. One time after five years for persons with CKD, asplenia, immunosuppressive conditions. ii. Adults vaccinated before age 65 if >/=5 yrs have passed 14. Hepatitis B vaccine is recommended for all adults age 25 and below not previously immunized and for all persons at high risk for infection (healthcare and daycare workers, hemodialysis patients, household contacts of people with HBV, and those at risk for STDs as above under gonorrhea). 15. For patients under age 50, notation of the date that a patient received a tetanus/diphtheria booster within the last ten years should be included in the medical record. There should be documentation in the medical record that patients over the age of 50 were offered a tetanus/diphtheria booster after their 50th birthday. Patients receiving medical attention for any wound should receive Td injection under either of the following conditions: a. For clean minor wounds, if the last Td booster was greater than 10 years; b. For other/dirty wounds, if the last Td booster was greater than 5 years 16. Varicella vaccine is recommended for susceptible adults (that either have not been immunized or have not had the disease). 17. Routine screening for rubella susceptibility by history of vaccination or by serology is recommended for all women of childbearing age at their first clinical encounter. Susceptible non-pregnant women should be offered rubella vaccination; susceptible pregnant women should be vaccinated immediately after delivery. 18. Patients otherwise presenting for care should receive counseling regarding the use of seat belts on at least one occasion. 19. Patients should be asked about current or past use of intravenous drugs at least once. 20. Patients should be asked if they have ever been sexually active. Patients under the age of 50, who have ever been sexually active, should be asked the following questions: a. if they currently have a single sexual partner; b. if they have had more than 2 sexual partners in the past 6 months; c. if they have a history of any STDs 21. Patients who are sexually active and not in a monogamous relationship, have had more than 2 sexual partners in the past six months, have a history of STDs or have used intravenous drugs should be counseled regarding the prevention and transmission of HIV and other STDs. 22. Screen persons at increased risk for syphilis infection: a. men who have sex with men and engage in high-risk sexual behavior b. commercial sex workers, persons who exchange sex for drugs c. persons in adult correctional facilities d. persons diagnosed with other STDs e. All pregnant women should be tested at their first prenatal visit 23. Screen adults yearly for alcohol misuse with the CAGE questionnaire (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning). 24. Screen adults yearly for depression: Asking two simple questions about mood and anhedonia ("Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?") may be as effective as using longer instruments. 25. Screening for iron deficiency anemia using hemoglobin or hematocrit is recommended for: a. Pregnant women. b. Infants at one and two years of age 26. Screen for type 2 diabetes in adults with obesity, hypertension or hyperlipidemia. Screen all patients age 45 and older for DM every year with a fasting blood glucose. 27. Screen all adult patients for obesity with the BMI yearly and offer counseling. 28. Screen for osteoporosis in all women age 65 and older and those age 60 -65 who are not on estrogen or who weigh less than 154lbs (70kg). 29. Offer structured breastfeeding education and behavioral counseling programs to promote breastfeeding in pregnant women. 30. Screening for elevated lead levels by measuring blood lead at least once at age 12 months</p>