Case #1 Answers:
Answer 1
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.
Answer 2
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.
Answer 3
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
Answer 4
A. Diet
Should be carefully discussed.
B. Exercise
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.
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