Patient is a 70-year-old man with a history of diabetes mellitus and cirrhosis secondary to hemochromatosis. He comes in for a 6-month follow-up and has no complaints. He takes only metformin for his diabetes. His history and examination are unchanged from previous visits. His immunization record shows a pneumococcal vaccine 7 years ago and a tetanus booster 3 years ago.
1. Based on his age and comorbidities, which immunizations are indicated for him?
He is a candidate for several different vaccines, given his age, diabetes, and chronic liver disease. He should receive a 1-time booster of pneumococcal vaccine as more than 5 years have passed since he turned 65. He should receive a dose of Tdap that is recommended for all adults, even those older than 65. Given his chronic liver disease/cirrhosis, he should be immunized against hepatitis A and B if he has not been exposed or does not have protective immunity. He should also receive the zoster vaccine indicated for all adults older than 60 years of age and without contraindications. He should receive an annual influenza vaccine as recommended for all adults regardless of comorbidities or risk factors.
Immunizations and Preventive Medicine
Preventive medicine includes the routine care of the healthy patient, assessment of lifestyle risk factors, need for immunizations, and screening for prevalent diseases such as hypertension, diabetes, or cancer, among many others.
In regards to lifestyle risk factors, there is evidence that brief primary care–based interventions to modify risk behaviors are effective. This is particularly important in tobacco and alcohol misuse and includes the “5 A's” model for brief counseling: assess (the behavior), advise (clear behavior change advice), agree (mutual collaboration to set goals), assist (aid patient to reach goals), and arrange (schedule follow-up to provide ongoing support). The “5 R's” model can be used for smokers unwilling to quit and includes: relevance (for the smoker to quit), risks (negative consequences of smoking), rewards (benefits of cessation), roadblocks (barriers to quit), and repetition (repeat motivational counseling at future visits).
Screening is defined as an evaluation to detect a disease at an asymptomatic stage. It is appropriate when the population to be screened is accessible and willing to undergo testing, the disease causes burden to patients or society, and the test used is sensitive and specific enough to detect disease without undue false-positives or -negatives. Screening should result in a decrease in mortality. However, screening can also result in significant morbidity to the patient. False-positives tests can generate anxiety, and unnecessary tests and procedures. They can also lead to false-negatives, which gives a false sense of reassurance.
The U.S. Preventive Services Task Force follows rigorous methodology to assess available evidence from clinical trials and issues recommendations for multiple preventive services.