Case #1 Answers:
O.M. is eligible for many vaccines including influenza, pneumococcus, tetanus-diphtheria. October 15 to December 1 is considered by many experts to optimal time for influenza vaccination.
Prostate cancer screening by rectal examination and PSA determination is a topic of considerable controversy in the medical community. Few medical organizations now recommend that prostate cancer screening by rectal examination be done in normal risk individuals on a routine basis. The US Preventive Task Force does not recommend PSA screening for prostate cancer due to the lack of prospective trials which document its efficacy. There are organizations including The American Cancer Society and the American Urologic Association which do recommend yearly PSA testing in men over age 50. Many experts agree that no PSA screening should be performed on men with less than a ten year life expectancy. This is obviously a screening strategy which should be heavily discussed before implementation.
Other routine screening maneuvers include: hypertension, cholesterol, diabetes, colon cancer, and oral cancer. Colon cancer screening can be performed by doing yearly hemocult cards or flexible sigmoidoscopy/colonoscopy every five years. Oral exam should be considered yearly in longstanding smokers. In geriatric patients special attention to hearing loss and vision should also be considered. Longstanding
Should be carefully discussed.
Elderly patients with illnesses which involve the lower extremities require careful exercise counseling. Because of his age and Parkinson's disease, high impact and strenuous exercise should be discouraged. Low impact exercise will be important for the future of this patient in maintaining his musculoskeletal integrity and gait with his underlying Parkinson's disease.
C. Injury and fall prevention
Because of his Parkinson's disease and poor gait, the patient should have counseling about fall prevention. Older adults or their care givers should be counseled to 1) inspect their home for adequate lighting, 2) remove or repair floor structures which would expose to tripping, and 3) install handrails and traction-strips in hallways and bathtubs.
D. Aspirin use for primary prevention of MI
Prophylactic aspirin could be considered for this patient. The U.S Preventive task force recommends that physicians and patients discuss its potential benefits. In a large trial of American male physicians, 22,000 subjects were randomized to either 325 mg aspirin or placebo a day. Men older than age 50 had a significant reduction (44%) in the incidence of fatal and non-fatal MI. Total cardiovascular mortality was equal in both groups and not improved with aspirin. The risk of ulcer disease, GI bleeding, aspirin side effects, and coronary risk factors will all need to be considered in an individual man before prescribing aspirin for primary prophylaxis of MI.