Master Preventive Medicine
for USMLE Step 2 CK

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.