Health
Information
Booklet
Presented by the Montana Chapter of the American College of Physicians
Jay Larson, MD, FACP
Governor Montana Chapter of the American College of Physicians
301 Saddle Drive
Helena, MT 59601
Phone (406) 442-2205 Fax (406) 442-2445
E mail: jaylarson@mt.net
INTRODUCTION
The following information is provided to you to complement the information your
clinician provides to you during your appointments. It is not meant to replace on going
follow up with your clinician. If you have any concerns or problems, be sure to see your
clinician.
ACTIVITY AND DIET
Today we eat more calories and are significantly less active than 50 years ago.
Most jobs now entail moving information and not anything else. We sit in front of
computer screens transferring data electronically. Even some of the more laborintensive occupations require less energy because of technology. Carpenters have air
hammers, electric saws, and electric drills. Farmers have machines to help move hay
bales and feed their stock.
As a result of an imbalance between increased calorie intake and less physical
activity, obesity has become a greater issue in our society. More than 2/3 of Americans
are overweight or obese. Obesity can lead to elevated lipids (blood fats), high blood
pressure, heart disease and diabetes. A pre-diabetes condition called Metabolic
Syndrome has recently been defined and affects about 20% of Americans.
Unfortunately, the approach to dealing with this imbalance between diet and
exercise has been focused only on our dietary intake. Most of the time when a person
tries a unique diet they are only able to stay with it for about 1-3 months and then they
go back to their old eating style.
It boils down to four simple words, “Move more, Eat less”. As you continue to
consume fewer calories and gradually increase your physical activity each day, you’ll
find that you feel better, sleep better, have less joint pain, and your risk of
cardiovascular disease and diabetes is decreased. Try to eat in a way that we are
genetically designed to eat. That is, frequent small meals, not one big meal a day.
A person’s weight is also affected by stress, sleep disturbance, and several
hormones and chemicals in the body. When a person is in “Fight or flight” mode, the
metabolism changes to hang on to as many calories as possible.
There are several ways to increase your physical activity. Don’t drive around the
parking lot for 10 minutes looking for the closest spot to the door. Park in the farthest
spot and walk a further distance. Use the stairs and not the elevator. At the end of the
day, instead of sitting in front of the home computer or TV, walk the dog or the kids.
Moderate physical activity (equivalent to walking 3-4 mph) should be started at 510 minutes per day and gradually increased as tolerated to as much as possible.
Starting physical activity should be discussed with a physician before starting if medical
illnesses such as lung disease, heart disease, kidney disease, arthritis, or diabetes is
present.
STRESS
Stress is a common term used in American society. Many do not understand
what stress truly is. Stress is overwhelming change. How many different things do you
have to do in a day? When there is something different in our environment, our body’s
“fight or flight” mechanism activates so that we can respond to the changing
environment more quickly. Unfortunately, with information technology, everyday is jam
2
packed with bits of different information that we need to process. We turn on our “fight
or flight” mechanism in the morning and we leave it on all day.
As a result of chronic hyper-alert state our immune system weakens, pain
becomes more noticeable, our brain neurochemistry changes and we start to develop
anxiety, depression, sleep difficulty, and fatigue. The inside of the arteries are attacked
by inflammation cells and arterial clogging (atherosclerosis) develops. Too much stress
has been shown to worsen many health problems.
RELAXATION
The opposite of stress is relaxation. These are two mutually exclusive states.
You cannot be stressed when you are relaxed and you cannot be relaxed when you are
stressed. There are several ways to achieve relaxation, but multi-tasking is not one of
them. American society is deficient in relaxation and recreation. Americans tend to
boast that they have worked long hours for many days without taking a break. This is
unfortunate because it only reduces productivity and adversely affects quality of life.
TOBACCO USE
Tobacco use is associated with increased risk of cancer, heart attack, stroke,
lung disease, dementia, thinning of the skin and bones, and early death.
Various forms of nicotine replacement (nicotine patches, gum, nasal spray,
lozenges, and inhalers), Zyban (bupropion), Chantix, support groups, Quit lines, and
smoking cessation classes are helpful to quit tobacco use.
Second-hand smoke has just as many health risks as smoking cigarettes directly.
Children, elderly, and those with lung disease are particularly susceptible to adverse
health effects of second-hand smoke.
IF YOU HAVE NOT HEARD IT YET, THEN YOU WILL HEAR IT NOW… STOP
THE USE OF ALL TOBACCO PRODUCTS!!!!
ALCOHOL ABUSE
Approximately 10 percent of Americans (10 million people) abuse alcohol. Excessive
alcohol consumption is the third leading preventable cause of death in the United
States.
The following categories of alcohol use are designated by National Institute on Alcohol
Abuse and Alcoholism:
Moderate drinking: low risk for alcohol problems
- Women: <2 drinks per day
- Men: <3 drinks per day
- People age ≥ 65: < 2 drinks per day
Heavy drinking: at risk for alcohol problems
- Women: >7 drinks per week or 3 drinks per occasion
- Men: >14 drinks per week or 4 drinks per occasion
3
Binge drinking:
- Women: 4 or more drinks in a row
- Men: 5 or more drinks in a row
A simple screening test for excessive alcohol use is the CAGE questionnaire:
1.
Have you ever felt you should cut down on drinking?
2.
Have people annoyed you by criticizing your drinking?
3.
Have you ever felt guilty about your drinking?
4.
Have you ever taken a drink in the morning as an eye opener to steady your
nerves or get rid of a hangover?
A positive response to two or more questions may mean an alcohol drinking
problem.
Potential adverse health problems associated with excessive alcohol use include:
accidents, memory problems, sleep disturbance, anxiety, depression, suicide risk, nerve
damage, hallucinations, paranoia, intestinal bleeding, liver damage, increased risk of
cancer, blood abnormalities, heart failure, stroke, high blood pressure, seizures,
impotence, muscle damage, malnutrition, driving difficulties, legal difficulties, social and
interpersonal difficulties, fetal malformation, and early death.
If concerned about excess alcohol use, contact Alcoholic Anonymous or see a
counselor who specializes in alcohol abuse (found in the yellow pages under
Alcoholism).
CHEMICAL DEPENDENCY
In addition to alcohol and tobacco, there are other substances that can be used
to temporarily improve how a person feels and to cope with the trials and tribulations of
life. These substances include cocaine, amphetamines, narcotics, marijuana, and
inappropriate use of prescription medications used to treat anxiety, insomnia, and pain.
If these substances are overused they can cause early death as well as driving, legal,
social, and interpersonal difficulties. There are chemical dependency counselors
available. Seek help if concerned about chemical dependency.
SAFE SEX
It is important for a person to use safe sex practices. Sexually transmitted
diseases include the human papilloma virus (HPV) which increases a woman’s risk of
cervical cancer, chlamydia and gonorrhea which may lead to sterility, syphilis which
may lead to neurologic damage, genital herpes which may cause recurrent painful
sores, and HIV which may lead to chronic illness and increased risk of infection.
Symptoms of a sexually transmitted disease include: Burning in the genital area
when urinating, abnormal discharge from the vagina or penis, pain in the pelvis or
abdomen, irritation or burning with intercourse, and redness, sores, bumps, rashes, or
blisters in the genital area.
Many people with sexually transmitted diseases may not experience symptoms. If
sexually active and unsure if partner is infected with a sexually transmitted disease it is
recommended to:
4
 Correctly use a new latex condom from beginning throughout the duration of the sex
act every time with vaginal, anal, or oral sex.
 Avoid contact with body fluids and tissues, such as vaginal fluids, semen, and open
sores.
THINGS TO DO CHECKLIST
 OBTAIN MEDICAL ID
If chronic medical problems or medication allergies are present, it is important to
carry medical ID stating medical problems in the event of unconsciousness. Medical ID
is recommended for those with diabetes, heart disease, seizure disorder, kidney failure,
asthma, an artificial heart valve or joint, pacemaker, ICD (implanted defibrillator), latex
allergies, warfarin (Coumadin) use, and dementia. Listing allergies can reduce the
chance of receiving that medication or similar medications. A MedicAlert medical ID
can be obtained by calling 1-800-432-5378.
 FILL OUT LIVING WILL AND ADVANCED DIRECTIVES
A Living Will is a document stating that if a terminal illness is present and death is
expected despite treatment, that resuscitation and other treatments to extend life are
not be used. The Living Will, however, only applies to terminal illnesses and not to other
disabling conditions such as advanced dementia or severe head injury.
An Advanced Directive is a document stating what treatments desired for medical
conditions other than a terminal illness. The shortcoming of an Advanced Directive,
however, is that medical treatment is very complex and unexpected events happen. A
person can be designated Durable Power of Attorney for Healthcare to make decisions
if incapacity develops.
It’s very important to have an open discussion with friends and family about what
is desired in the event of a terminal or a significantly disabling condition.
Discuss what is important in regards to self-values.
 Is quality of life important or quantity of life important?
 What treatment is desired if a terminal condition develops and further treatment
would not extend life?
 What treatment is desired if a significant brain injury due to trauma, stroke, or
Alzheimer’s disease occurs but is not considered terminal?
What treatments would be desired to above conditions:
 Antibiotics to treat infection?
 Surgery to treat surgical conditions?
 IV hydration in the event of dehydration?
 Tube feeding if unable to swallow?
 A respirator or breathing machine to assist breathing?
 CPR and resuscitation if heart or breathing stops?
Advanced Directives are important to discuss at a time that does not involve a
crisis. Living Wills, Advanced Directives, and Durable Power of Attorney only apply to
5
situations of incapacity. A Living Will and Advanced Directive can be revoked at any
time.
Advanced Directives do not mean that physicians do not continue to strive
toward keeping a person as comfortable as possible if they are suffering.
When a person is in the hospital and they stop breathing or their heart stops,
resuscitation efforts are initiated unless a “do not resuscitate” or “DNR” order is written
in the chart by the attending physician. If a person does not want to be resuscitated they
should make sure that the physician knows this.
A good Living Will is “Five Wishes” designed by the Aging with Dignity
organization. A copy can be obtained by calling 1-888-5-wishes.
Montana Provider Orders For Life-Sustaining Treatment (POLST) is an advanced
directive form. The form can be found on the mt.gov website at:
http://www.dphhs.mt.gov/sltc/services/vethome/MVHForms/POLST.pdf
 CONSIDER ORGAN DONATION
There are over 100,000 persons in need of an organ transplant every year. If
you decide to be an organ donor, it is important to discuss with your family.
 LEARN CPR
CPR is the technique used to help someone who has collapsed. Learn CPR.
This is especially important if family or friends have heart disease.
 HAVE ANNUAL EYE AND DENTAL EXAMS
Have eyes and teeth checked by a qualified professional on a regular basis.
Brush teeth and floss regularly.
 INSTALL CARBON MONOXIDE AND SMOKE DETECTORS AND KEEP
BATTERIES CHARGED
Carbon monoxide is an odorless gas that pushes oxygen off red blood cells so
that less oxygen is carried to tissues. Carbon monoxide is produced by combustion. It is
very important to have a carbon monoxide monitor in the household to detect elevated
levels of carbon monoxide.
Smoke detectors should be installed in several household locations. Periodically
replace batteries in battery operated detectors.
 USE SAFETY BELTS AND HELMETS
Always wear safety belts when in a motor vehicle and wear a helmet if downhill
skiing or riding a horse, motorcycle, bike, or four-wheeler.
 KEEP FIREARMS SAFE
Make sure firearms are in a safe place, unloaded, and away from ammunition
and children.
6
 DRIVE SAFELY
The driver should be able determine if they are safe to operate a motor vehicle.
Several medications or health problems can impair the ability to drive safely and impair
the driver’s ability to determine that they are a safe driver. Aging may slow reflexes,
diminish vision, and reduce hearing. Never drive while intoxicated or sedated. Always
be well rested when driving. Do not drive if sleepy. Always follow posted speed limits.
Do not rush. Do not be distracted by using a cell phone nor text messaging.
 OBTAIN SAFETY IF EXPOSED TO DOMESTIC ABUSE
If physically hurt or threatened, feel unsafe, or controlled by partner, domestic
abuse is a potential risk. Leave the situation before harm occurs. Shelter phone
numbers can be found in the Community Service Numbers at the front of the
phonebook.
 PREVENT FALLS
Falls may lead to significant injury, especially with aging. To prevent falls, make
sure there is adequate lighting at nighttime. Remove loose rugs and cords from walking
paths. Use banisters when going up and down stairways. Use a walker or cane if
walking or balance problems. Avoid wet or freshly waxed floors. Avoid ice and slippery
pathways. Wear shoes with good traction.
 USE HEARING AND EYE PROTECTION
Noise pollution is common. Use adequate hearing protection if using firearms,
power tools, machinery, or small gas engines such as lawnmowers. Hearing loss may
not develop for 10-20 years. Use eye protection if around equipment that might flick
particles into the eyes.
 ASSUME RESPONSIBILITY FOR YOUR HEALTH AND EMPOWER
YOURSELF TO MAKE HEALTHY CHOICES
You are responsible for your health. A clinician is only a guide that can help
direct you toward a healthier lifestyle. You choose your own path. Often, clinicians
recommend treatments that are not followed through by individuals. That’s an
individual’s choice. You choose what information you wish to believe and not believe.
You choose your lifestyle.
 You are responsible for knowing your health insurance coverage. There
are dozens of different insurance plans, each with their own nuances. It is
impossible for a physician to know what services are covered by the
different health insurance plans. If an insurance company does not cover
a service, address it with the insurance company. If a clinician orders a
test or medication, but your insurance does not cover the test or
medication, it is still your choice to follow your clinician’s
recommendations.
 You are responsible for keeping track of your medications and taking them
as directed. Do not allow the medication to run out and call the office in a
panic. Make sure you have your medications renewed before the
7
prescription has run out. If you choose to wait until there are no more
refills, you may not be able to have the prescription renewed promptly.
 You are also responsible for your happiness or unhappiness. You can
choose to blame someone if something bad happens, or you can choose
to move on the best way you can looking for the good in life. If you
choose to blame someone or something else for your unhappiness, you
will never be happy.
 USE ANTIBIOTICS PRIOR TO DENTAL WORK, GASTROINTESTINAL, AND
URINARY PROCEDURES IF ARTIFICIAL HEART VALVE OR ARTIFICIAL
JOINTS
Artificial heart valves and artificial joints are at risk of becoming infected with
dental, gastrointestinal, and urinary procedures. Antibiotics given before certain
procedures may reduce the risk of infection.
Recommended antibiotics for dental procedures (especially tooth extraction, gum
surgery, implant placement)
Amoxicillin 2,000 mg 1 hour before procedure
Clindamycin 600 mg 1 hour before procedure
Cephalexin 2,000 mg 1 hour before procedure
Zithromax 500 mg 1 hour before procedure
Biaxin 500 mg 1 hour before procedure
Recommended antibiotics for gastrointestinal or urinary procedures are
intravenous and depends on the procedure.
 PARTICIPATE IN BREAST CANCER SCREENING
Risk factors for breast cancer include age greater than 50 years old, a family
history of breast cancer, onset of menstrual periods less than 12 years old, menopause
after 55 years old, age of first live birth older than 30, history of breast biopsies, history
of atypical hyperplasia on breast biopsies, and hormone replacement therapy. A Breast
Cancer Risk Assessment Tool to calculate five year and lifetime risk of breast cancer
can be accessed at http://bcra.nci.nih.gov/brc/. This program uses information about
risk factors to calculate risk of breast cancer. If a woman’s risk of breast cancer is
substantially increased, options include bilateral mastectomy (breast removal) and
tamoxifen. There are potential risks associated with both of these treatments and they
should be discussed with a physician.
Breast cancer is a cancer that if found early has a greater chance of cure. To
detect breast cancer earlier, mammograms every 1-2 years are performed starting at 50
years old. Obtaining mammograms under the age of 50 should be individualized.
Mammograms may miss 15% of cancers and therefore it’s important to have a breast
exam by a healthcare provider. Self breast exams should be done monthly.
8
 PARTICIPATE IN CERVICAL CANCER SCREENING AND PREVENTION
Cervical cancer is a potentially preventable cancer. Human Papilloma Virus
(HPV) causes genital warts. Certain strains of HPV can cause chronic inflammation of
the cervix, which can lead to abnormal cells, which can lead to cancer. To detect
abnormal cells at an earlier stage Pap smears are done every 3 years (after 3 annual
negative PAPs) starting at 21 years old or sooner if sexually active. The pap smear is a
screening test and not a diagnostic test. Women can have cervical cancer and have a
normal pap smear. Safe sex is an important part of cervical cancer prevention, as the
risk of cervical cancer increases with more than one male sexual partner. A women and
her healthcare provider may consider discontinuing pap smears at age 65 if regular pap
smears have been normal over the previous 10 years and no vaginal symptoms are
present. “Gardasil” vaccine is for males and females 9-26 years old. This vaccine helps
the body fight HPV strains 6,11, 16, and 18, which are known to increase cervical
cancer risk.
 PARTICIPATE IN COLON CANCER SCREENING
Risk factors for colon cancer include high dietary intake of fat, ulcerative colitis,
Crohns’s disease, obesity, history of colon polyps, family history of colon cancer, and
increased age. If colon cancer is detected early, there is a greater likelihood of cure with
appropriate surgical treatment. Symptoms of colon cancer can include rectal bleeding,
blood in the stool, change in bowel habits, unexplained weight loss, and abdominal
pain.
Screening tests are used to detect polyps and early cancers before symptoms
develop. Screening usually starts at the age of 50 in persons without symptoms of colon
cancer or significant risk factors. Screening starts in the 40’s in persons with symptoms
of colon cancer or significant risk factors. Currently, the recommended screening test for
colorectal cancer is a colonoscopy (a fiberoptic instrument used to visualize the entire
colon) every 5-10 years. Most insurance companies are now covering screening
colonoscopies.
 PARTICIPATE IN SKIN CANCER SCREENING AND PREVENTION
The main risk factor for skin cancer is sun exposure and sunburns, especially at
a young age. Protect from sunburn by reducing sun exposure. It is unclear how much
protection sun screens have against skin cancer. Actinic keratoses are red scaly lesions
that occur on the face and arms in sun exposed areas. These are precancerous lesions
that can be treated by a physician with liquid Nitrogen. If a mole has changed in size,
has an irregular border, or has irregular coloration, have this looked at by a medical
clinician to determine if it may be a melanoma. Melanomas are curable if they are found
early and have not invaded deep into the skin tissue. Squamous cell carcinoma is a
thickened, scaly area in a sun-exposed area that does not go away and should also be
seen by a physician. A basal cell carcinoma is usually a pink growing lesion. Any skin
lesion concerning for cancer should be evaluated by a medical clinician.
9
 PARTICIPATE IN TESTICULAR CANCER EARLY DETECTION
Testicular cancer is an uncommon cancer of young men. It can be cured if found
and treated early. A testicular exam should be done monthly and if an abnormal firm
lump is found, physician assessment of the lump should be pursued.
 CONSIDER PROSTATE CANCER SCREENING
The prostate is a gland at the base of the bladder in men. The risk of prostate
cancer increases with age, family history, and non-Caucasian race. Eating tomato
products and/or taking a medication to block DHT (Dihydrotestosterone) such as
finasteride may decrease prostate cancer risk. To detect prostate cancer earlier, a
prostate specific antigen (PSA) may performed in men 50 years and older. Screening
for prostate cancer may be started at age 40 if risk factors for prostate cancer are
present. There is considerable controversy whether screening for prostate cancer is of
any benefit. It is not clear whether screening for prostate cancer can extend a man’s life
or help him avoid any symptoms or problems.
The treatment for prostate cancer can include surgery to remove the prostate
and lymph glands or radiation. There are risks and benefits with each treatment option.
Treatment of prostate cancer may cause trouble with obtaining and maintaining
erections and leakage of urine.
 PARTICIPATE IN ENDOMETRIAL CANCER EARLY DETECTION
The endometrium is the inside lining of the uterus. After menopause, a woman
should not have further vaginal spotting or periods. If spotting or periods develops after
menopause, a physician should assess this; it may be an early indication of endometrial
cancer. Endometrial cancer can be cured if found early.
 AWAIT LUNG/OVARIAN/LIVER CANCER SCREENING
RECOMMENDATIONS
Currently, there are no good screening tests for these types of malignancies,
though studies are ongoing. All tobacco production should be avoided to reduce the
risk of cancer. There is some information that suggests that low dose chest CT may be
an effective in persons with a 30 pack year (number of packs per day smoked times the
number of years smoked) who continue to smoke or have quit in the past 15 years.
 CONSIDER SCREENING FOR HEPATITIS C IF BORN BETWEEN 1945-1965
Hepatitis C is an increasing cause of death from liver failure or cancer and liver
cirrhosis. Most people with the virus do not realize that they are infected. There are
treatments that can lead to halting the disease and can lead to sustained viral clearance
from the blood stream.
 OBTAIN APPROPRIATE IMMUNIZATIONS/VACCINES
Immunizations are an effective means of preventing excessive illness and death
in adults, especially those in "high-risk" categories due to age, lifestyle, weak immune
system, or chronic illness. Vaccine coverage is variable depending on insurance plan.
Vaccines can be obtained at the county health department and possibly your pharmacy.
10
HEPATITIS A
Hepatitis A is one of the most common causes of acute viral inflammation of the
liver. Adults especially those planning to travel outside the United States or with chronic
liver disease should receive the vaccine. Persons traveling to highly endemic areas
should receive the first dose of vaccine at least 2 weeks before departure. A second
dose is given 6 months after the first.
HEPATITIS B
Hepatitis B infection can cause chronic liver inflammation. Adults, especially
persons with household or sexual contact with a person infected with Hepatitis B,
persons with several sexual partners, and persons with occupational exposure to
human blood, should receive the vaccine. Persons with diabetes (both type 1 and type
2) age 19-59 should receive the vaccine series of 3 doses.
INFLUENZA
Influenza A and B viruses are responsible for the epidemics of serious respiratory
illness that occur every winter. Adults, especially health care professionals, persons
with chronic medical problems (diabetes, lung disease, kidney disease, liver disease,
and heart disease) and persons in contact with those with chronic medical problems,
should receive the vaccine. All influenza vaccines contain two type A strains and one
type B strain of the viruses that are likely to circulate for that influenza season. The
vaccine is available in late September and should be administered once a year, ideally
between October and December.
MEASLES-MUMPS-RUBELLA (MMR)
Measles-Mumps-Rubella are three different viruses that can cause a viral
syndrome, rash, or swelling of the salivary glands. Rubella during pregnancy is
associated with serious fetal problems. All adults born after 1956, health care workers,
college students, and international travelers may need a second dose. The MMR
vaccine should not be given to pregnant women, anyone with a malignant disease
affecting the bone marrow or lymphatic system, or those with a weak immune system.
In addition, persons who have received blood products in the past 11 months should not
receive the vaccine because of the presence of passive immunity, which prevents the
development of protective antibody.
PNEUMOVAX
The bacteria Streptococcus pneumoniae can cause pneumonia, bacteremia
(bacteria in the blood stream), and meningitis. Persons older than 65 years and in
those younger than 65 years who have certain underlying medical conditions (asthma,
chronic liver, heart, spleen or lung problems, diabetes, or excess alcohol use) should
receive the vaccine. A booster Pneumovax after 65 years old may be recommended. At
most 2 vaccinations with pneumovax in a lifetime are recommended. This vaccine does
not prevent pneumonia. It improves the chance of surviving pneumococcal pneumonia
by an aggressive strain of pneumococcus.
11
TETANUS-DIPHTHERIA-PERTUSSIS
Tetanus (lockjaw) is a potentially fatal disease associated with severe muscle
spasms due to a toxin caused by a certain bacteria contaminating a wound. Diphtheria
is a serious infection of the throat that produces a toxin that may be associated with
heart and nerve problems. For a primary series (first time receiving the vaccine), the
second dose should be administered 1 to 2 months after the first has been given; the
third dose should be given 6 to 12 months later. Routine booster doses are
administered at 10-year intervals. Tetanus prophylaxis should be given with dirty
wounds or burns if the last tetanus vaccine is more than 5 years.
Adacel (tetanus-diphtheria-acellular pertussis) or Tdap should substitute for a
tetanus-diphtheria vaccine once. Pertussis is “whooping cough”, which is a serious
infection in children. Adults with pertussis have a severe, persistent cough that can last
for weeks. The incidence of pertussis is increasing, especially in adults because a
person does not maintain lifelong immunity after infection or immunization. Adults
affected by pertussis can then be a source to infect children with whooping cough.
VARICELLA (CHICKEN POX AND SHINGLES)
Approximately 5% of adults in the United States are susceptible to varicella
(Chicken pox). Adult Chicken pox is serious and can be associated with pneumonia,
hepatitis, and brain inflammation. Chicken pox also tends to be severe during
pregnancy and can cause problems with the fetus. All adults who have not had Chicken
pox should receive this vaccine.
The varicella vaccine schedule for adults consists of two doses of 0.5 mL each,
administered under the skin 4 to 8 weeks apart. If a person is uncertain about a
previous varicella (Chicken pox) infection, testing for varicella antibodies is reasonable
to assess for the need of vaccination. The varicella vaccine should not be given to
pregnant women, anyone with a malignant disease affecting the bone marrow or
lymphatic system, those with a weak immune system, or those with active tuberculosis.
In addition, persons who have received blood products in the past 5 to 6 months should
not receive the vaccine because of the presence of passive immunity, which prevents
the development of protective antibody.
Zostavax became available in 2006. This vaccine reduces the risk of shingles
(reactivation of varicella virus) by about 50%. The vaccine is recommended for all
adults 60 years old and older, even in those who have had zoster/shingles in the past.
GARDASIL (HPV 6, 11, 16, 18)
Certain strains of human papilloma virus increases a woman’s risk of cervical
cancer. Gardasil is recommended for males and females 9-26 years old. The
vaccination series is one dose followed by 2 additional doses 2 and 6 months later.
12
 LIMIT CARDIOVASCULAR DISEASE BY HAVING RISK FACTORS
MANAGED
Atherosclerosis is the term used to describe arteries clogged with cholesterol.
Clogged arteries can limit blood flow to tissues resulting in ischemia (lack of oxygen). If
ischemia lasts too long, the tissue can be permanently injured. Different problems may
occur depending where the arteries are plugged. Clogged heart arteries may cause a
heart attack, angina (chest pressure), heart failure, and death. Clogged carotid arteries
may cause a stroke. Clogged leg arteries may cause muscle pain with walking and if
severe – amputation.
Risk factors for atherosclerosis include cigarette smoking; hypertension (BP
140/90 mmHg or if taking an antihypertensive medication); low HDL-cholesterol (<40
mg/dL); family history of premature CHD (CHD in male first degree relative <55 years or
CHD in female first degree relative <65 years); and age (men 45 years; women 55
years).
LIPID DISORDER MANAGEMENT
Lipids (triglycerides and cholesterol) are fat or fat-like substances. Triglycerides
are stored as fat and are used for fuel. Cholesterol is a building block for cells and
hormones. LDL-cholesterol is considered “bad cholesterol” or “lousy cholesterol”. LDL
transports most of the body’s cholesterol from the liver to tissues. LDL may be oxidized
and can lead to cholesterol clogging of arteries. HDL-cholesterol is considered “good
cholesterol” or “helpful cholesterol” and helps to protect against artery clogging. Usually
lipid disorders are inherited, but can worsen by kidney disease, improper diet, lack of
physical activity, tobacco use, excessive alcohol ingestion, diabetes, birth control pills or
estrogen, steroids, certain blood pressure medications, excessive stress, and under
active thyroid (hypothyroidism). Treatment includes therapeutic lifestyle changes (diet
and activity) and medications if target lipid levels are not achieved.
 Therapeutic Lifestyle Changes diet:
Cholesterol under 200 mg per day
Saturated fat under 7% of total calories
Polyunsaturated fat under 10% of total calories
Monounsaturated fat under 20% of total calories
Total fat 25-35% of total calories
Carbohydrate 50-60% of total calories
Fiber 20-30 grams per day
Protein 15% of total calories
Total calories to maintain ideal body weight and prevent weight gain.
Moderate physical activity (equivalent to walking 3-4 mph) should be started at 510 minutes per day and gradually increased as tolerated to at least 30 minutes per day.
Physical activity should be discussed with a physician before starting if medical
illnesses such as lung, heart, or kidney disease, arthritis, or diabetes are present.
13


 Target lipid levels for those with 0-1 risk factors for coronary arterial
disease:
LDL cholesterol under 130-160 mg/dl
HDL over 40 mg/dl in men, HDL over 50 mg/dl in women


 Target lipid levels for those with 2 or more risk factors for coronary arterial
disease:
LDL cholesterol under 100-130 mg/dl
HDL over 40 mg/dl in men, HDL over 50 mg/dl in women


 Target lipid levels for those with coronary arterial disease, diabetes, or
presence of atherosclerosis affecting other arteries:
LDL cholesterol under 70-100 mg/dl
HDL over 40 mg/dl in men, HDL over 50 mg/dl in women
Aspirin use should be discussed with a physician. Tobacco products should never
be used, even infrequently, and alcoholic beverages should be limited to 1 drink per day
(12 oz of beer, 4 oz of wine, or 1 oz of hard alcohol). Using psyllium (Metamucil) and
food products such as Take Control and Benecol can also help lower cholesterol.
“Phytosterols” may also be of benefit.
HYPERTENSION MANAGEMENT
Blood pressure consists of systolic blood pressure (SBP) and diastolic blood
pressure (DBP). Systolic blood pressure is the artery pressure when the heart is
squeezing. Diastolic blood pressure is the artery pressure when the heart is relaxing.
Blood pressure is reported as SBP/DBP. Hypertension is a persistent blood pressure of
 140/90 mmHg at rest, based on an average of 2 readings taken at 2 or more office
visits. Acute illness should not be present. Caffeine and tobacco use should not be
used for 30 minutes before blood pressure reading.
Classification of blood pressure
BP classification
Normal
Pre-hypertension
Stage 1 hypertension
Stage 2 hypertension
Systolic BP mmHg Diastolic BP mmHg
under 120
and under 80
120-139
or 80-89
140-159
or 90-99
over 159
or over 99
Usually the cause of hypertension is unknown, but may be due to inherited
factors, narrowing of the arteries to the kidneys, low thyroid (hypothyroidism), chronic
kidney disease, sleep disorders, alcohol use, stress, and disorders of endocrine glands.
Contraceptive pills, steroids, appetite suppressants, tobacco use, and decongestants
can also elevate blood pressure.
Possible complications of long-standing hypertension include heart enlargement,
stroke, heart attack, angina, heart failure, eye disease, peripheral vascular disease,
impotency, and kidney failure. Usually hypertension has no symptoms unless the blood
14
pressure is severely elevated. When blood pressure is severely elevated, headache,
drowsiness, confusion, nosebleeds, and severe shortness of breath may occur. This
medical emergency requires prompt treatment to prevent complications.
Hypertension treatment reduces the risk of complications. Adequate treatment of
hypertension can reduce heart failure risk by >50%, stroke risk by 35-40%, and
myocardial infarction risk by 20-25%.
In persons older than 50 years, systolic blood pressure greater than 140 mmHg
is a much more important cardiovascular disease (CVD) risk factor than diastolic blood
pressure.
The risk of CVD beginning at 115/75 mmHg, doubles with each increment
increase of 20/10 mmHg; individuals who have normal blood pressure at age 55 have a
90% lifetime risk for developing hypertension.
Individuals with a systolic blood pressure of 120–139 mmHg or a diastolic blood
pressure of 80–89 mmHg should be considered as pre-hypertensive and require healthpromoting lifestyle modifications to prevent CVD.
Treatment is individualized and may involve weight loss, reduction of salt intake,
increase of fruits and vegetables in the diet, tobacco cessation, an exercise program,
reduction in alcohol consumption, lifestyle changes to reduce stress, and medications.
To control hypertension adequately, medications are often prescribed. More than one
medication is often required to control hypertension.
Lifestyle modifications recommended for all persons with BP over 120/80 mmHg
Modification
Weight reduction
weight loss
Recommendation
Approximate SBP Reduction
Maintain normal body weight.
5 –20 mmHg/10 kg
DASH eating plan
Consume a diet rich in fruits,
vegetables, and low fat dairy
products with a reduced content
of saturated and total fat.
8 –14 mmHg
Dietary sodium reduction Reduce dietary sodium intake
to no more than 2.4 g sodium
per day.
2 –8 mmHg
Physical activity
Engage in regular aerobic
physical activity such as
brisk walking (at least 30 min
per day, most days of the week).
4 –9 mmHg
Moderation of alcohol
Limit consumption to no more
than 1 drink per day
(1 oz hard liquor, 12 oz beer,
4 oz wine)
2 –4 mmHg
15
Avoiding over-the-counter medications that may raise blood pressure is very
important. Cold/sinus and anti-inflammatory medications should not be taken without
discussing with a physician. Many appetite suppressants (including herbal) can raise
blood pressure and should be avoided. Tobacco products should never be used, even
infrequently.
If possible, moderate physical activity should be performed daily. Moderate
physical activity (equivalent to walking 3-4 mph) should be started at 5-10 minutes per
day and gradually increased as tolerated to at least 30 minutes per day. More daily
physical activity than 30 minutes per day is even better. Physical activity should be
discussed with a physician before starting if medical illnesses such as lung, heart, or
kidney disease, arthritis, or diabetes are present. A physician should be seen at least 24 times a year to assess blood pressure control and monitor medications used for
treatment.
A target of achieving and maintaining a blood pressure of under140/90 is desired
for persons without other health problems. For those with diabetes, heart disease, or
kidney disease, a blood pressure of under130/80 is the target.
Daily aspirin, even in low doses, can increase the risk of a bleeding-type stroke in
persons with hypertension that is not controlled. Blood pressure should be controlled before
using daily aspirin. Daily aspirin should be discussed with your physician.
 PARTICIPATE IN ABOMINAL AORTIC ANEURYSM SCREENING (MALES)
An aneurysm is a focal dilation of a blood vessel. An abdominal aortic aneurysm
(AAA) is defined as a dilated aorta with a diameter at least 1.5 times the diameter
measured at the level of the kidney arteries. In most individuals, the diameter of the
normal abdominal aorta is approximately 2.0 cm. An undetected large (above 5 cm in
diameter) abdominal aortic aneurysm (AAA) can present catastrophically with fatal
rupture. The highest risk persons for an abdominal aortic aneurysm (AAA) are men
ages 65 to 75 who have ever smoked. It is recommended that a one-time screening for
AAA with abdominal ultrasonography in men ages 65 to 75 who have ever smoked be
performed.
 KNOW RISKS AND BENEFITS OF POSTMENOPAUSAL HORMONES
Taking hormones after menopause is an individual choice. As with any choice,
there are potential risks and potential benefits. The information about postmenopausal
hormones continues to evolve and become more controversial, making the choice even
more difficult.
Potential risks of postmenopausal hormones:
 Hormones may increase the risk of a heart attack or stroke in women
 Increased risk of breast cancer with long term use (12-15 years)
 Increased risk of uterine cancer if estrogen is taken without progesterone
 Breast soreness
 Increased risk of blood clots
 Increased risk of gallstones
 Vaginal spotting*
16
*If postmenopausal bleeding occurs, notify physician.
Potential benefits of postmenopausal hormones:
 Prevention and treatment of postmenopausal osteoporosis (but other medications
are available that do not have the same potential risks of hormones)
 Mood stabilization
 Hot flash relief
 Improvement of the vaginal lining reducing vaginal irritation
 PREVENT AND ASSESS FOR OSTEOPOROSIS
Osteoporosis is bone weakening, which increases the risk of fracture.
Osteoporosis is more common after menopause, when estrogen levels decline. Risk
factors for osteoporosis include Caucasian or Asian race, advanced age, female sex,
poor health, estrogen deficiency, low calcium intake, alcohol abuse, tobacco use, low
body weight, over active thyroid, inactivity, glucocorticoid steroid use, and family history
of osteoporosis.
Osteoporosis usually develops over many years without symptoms. The first
signs of osteoporosis include loss of height, developing a curved upper back (dowager’s
hump), back pain, or broken bones.
The test for osteoporosis is the DEXA scan (bone density test). This is a special xray of the lower spine and hip. DEXA results are compared to a healthy 30-year old
woman’s bone density to obtain a “T-score”. A negative T-score indicates bone loss. Tscores -1 to -2.5 indicate osteopenia; mild bone loss. T-scores less than 2.5 indicate
osteoporosis. All women 65 and older and younger women with more than one risk
factor for osteoporosis should consider having a DEXA scan.
Medical treatment options for osteoporosis include medication and adequate
calcium and vitamin D intake.
In addition to improving bone strength, it is important to reduce the risk of falling
and injury. Stay off icy streets and wet or waxed floors. Hold banisters when using
stairs. Use a walker or cane if balance is unsteady. Remove loose rugs and loose
wires from walking paths in the house. Use lights when walking in house at night. Install
bathtub floor mats.
It is recommended to:
 Do daily weight-bearing exercise, such as walking, climbing stairs, or weight lifting.
 Avoid tobacco products
 Avoid excessive caffeine and alcohol
 AVOID ANTIBIOTICS IN VIRAL UPPER RESPIRATORY TRACT INFECTIONS
Most upper respiratory tract infections (sinusitis and bronchitis) are viral and do not
respond to antibiotics. Typically symptoms resolve by 7-10 days without specific
treatment. Antibiotics may be considered if symptoms persist beyond 7-10 days.
Because of excessive antibiotic use, bacteria are developing resistance to commonly
prescribed antibiotics. Bacterial resistance leads to ineffective treatment when
antibiotics are truly necessary, such as with pneumonia.
17