Master Preventive Medicine
for USMLE Step 2 CK
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Core Concepts
Preventive medicine focuses on protecting, promoting, and maintaining health by preventing disease, disability, and death. It employs strategies at individual and population levels, guided by evidence-based recommendations.
- Levels of Prevention:
- Primary: Prevents disease onset. Examples: Vaccinations, healthy lifestyle counseling, PrEP, seatbelts.
- Secondary: Early detection and prompt treatment to reduce disease impact. Examples: Cancer screenings (mammography, colonoscopy), blood pressure screening.
- Tertiary: Minimizes impact of established disease/injury, improves quality of life, prevents complications. Examples: Cardiac rehab, diabetes management.
- Key Principles: Evidence-based guidelines (USPSTF, ACIP), risk assessment, patient education, shared decision-making, population health focus.
Clinical Presentation
Preventive care "presentations" involve identifying opportunities for intervention in various settings, focusing on risk factors rather than symptoms:
- Routine Visits: Well-child visits, annual physicals, wellness visits, pre-operative evaluations.
- Risk Factor Identification:
- Modifiable: Smoking, unhealthy diet, physical inactivity, obesity, excessive alcohol, uncontrolled HTN/DM/dyslipidemia.
- Non-modifiable: Age, sex, family history.
- Social/Environmental: Occupational exposures, low socioeconomic status, lack of access.
- Often, the "presentation" is an asymptomatic patient seeking routine care or health maintenance.
Diagnosis (Gold Standard)
In preventive medicine, "diagnosis" refers to accurate risk assessment and adherence to evidence-based guidelines.
- USPSTF (U.S. Preventive Services Task Force) Recommendations:
- A/B Grades: Strong recommendation for service (e.g., colonoscopy, HTN screening).
- C Grade: Selective recommendation based on individual patient circumstances (e.g., PSA screening).
- D Grade: Recommendation against the service (e.g., screening for asymptomatic carotid stenosis).
- I Statement: Insufficient evidence.
- ACIP (Advisory Committee on Immunization Practices) Recommendations: Schedules for children, adolescents, adults, and specific populations.
- Clinical Risk Calculators:
- ASCVD Risk Calculator: Estimates 10-year CVD risk, guides statin/aspirin therapy.
- FRAX Tool: Estimates 10-year fracture risk, guides osteoporosis management.
- Breast Cancer Risk Assessment (e.g., Gail model): Guides screening and chemoprophylaxis discussions.
- Comprehensive History & Physical Exam: Essential for personalized risk assessment.
Management (First Line)
Management involves implementing recommended interventions based on risk and guidelines.
- Primary Prevention:
- Immunizations: Routine childhood (DTaP, MMR, Polio, Varicella, HepB, Hib, PCV, Rotavirus), adolescent (Tdap, HPV, Meningococcal), adult (Influenza, Tdap, Zoster, Pneumococcal, HepA/B, COVID-19).
- Lifestyle Counseling: Healthy diet (DASH, Mediterranean), regular physical activity, smoking cessation (pharmacotherapy, counseling), moderate alcohol, stress management.
- Chemoprophylaxis: Aspirin (select high-risk CVD), statins (primary prevention for high ASCVD risk), PrEP (HIV), folic acid (childbearing age), fluoride.
- Injury Prevention: Seatbelts, helmets, fall prevention, poison control.
- Secondary Prevention (Screenings):
- Cancer: Mammography (breast), Pap smear (cervical), Colonoscopy/FIT (colorectal), Low-dose CT (lung for high-risk smokers).
- Cardiovascular/Metabolic: Blood pressure, Lipid panel, A1c/fasting glucose (diabetes), AAA for men 65-75 with smoking history.
- Infectious: HIV, Hep C, Syphilis, Chlamydia/Gonorrhea.
- Bone Health: DEXA (osteoporosis).
- Mental Health: Depression, anxiety, substance use.
- Tertiary Prevention: Rehabilitation, chronic disease management programs, palliative care.
Exam Red Flags
- Ignoring USPSTF A/B Grades: Failing to recommend or order strongly supported screenings/interventions.
- Missing Age-Appropriate Vaccinations: Especially routine adult vaccines (Influenza, Tdap, Zoster, Pneumococcal).
- Failure to Address Modifiable Risk Factors: Not counseling on smoking, diet, exercise.
- Over- or Under-screening: Recommending tests outside guidelines or missing indicated ones.
- Neglecting Social Determinants of Health: Ignoring how socioeconomic status, access, or cultural factors impact care.
- Disregarding Patient Preferences: Not engaging in shared decision-making for C-grade recommendations (e.g., PSA).
- Misinterpreting Risk Calculators: Incorrectly applying risk scores for therapy decisions.
- Not Considering Contraindications: Administering interventions despite known contraindications.
Sample Practice Questions
A 45-year-old male presents to his physician, stating he is ready to quit smoking. He reports smoking one pack of cigarettes per day for 20 years. He has attempted to quit multiple times in the past using nicotine patches and 'cold turkey' methods, but relapsed each time. He is motivated to try pharmacotherapy in conjunction with counseling. Which of the following is considered the most effective single pharmacologic agent for smoking cessation?
A 62-year-old healthy man presents for a routine physical exam. He has no significant past medical history, takes no medications, and has no known allergies. He reports he has never received a shingles vaccine. His physical exam is normal. What is the most appropriate recommendation regarding shingles vaccination for this patient?
A 35-year-old male construction worker presents to his primary care physician reporting persistent cough and shortness of breath that has worsened over the past year. He denies smoking. He has been working on demolition projects for the last 10 years, often without consistent use of personal protective equipment (PPE). His chest X-ray shows diffuse interstitial infiltrates and bilateral pleural plaques. Which of the following is the most appropriate initial preventive measure or recommendation for this patient?
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