A 42-year-old pediatric nurse practitioner seeks your advice regarding his immunization needs. He is healthy and takes no regular medications. He had well-documented chickenpox as a child. He received a tetanus-diphtheria booster 5 years ago and influenza vaccine 4 months ago. Influenza A activity has been reported in your community in the last 2 weeks.
Which of the following immunizations would you recommend for this patient at this time?
The Advisory Committee on Immunization Practices (ACIP) is an independent panel of experts and makes evidencebased immunization recommendations for children and adults. Tetanus-diphtheria-acellular pertussis (Tdap) should replace a single dose of tetanus-diphtheria (Td) for all adults who have not previously received this vaccine. Health care workers should be vaccinated with the tet-anus-diphtheria-acellular pertussis vaccine (Tdap), especially those health care workers who have direct patient contact with infants. Yearly influenza immunization is recommended for all health care workers. A single dose of trivalent influenza vaccine is recommended each year beginning in October. Booster doses for influenza are not recommended. The ACIP recommends pneumococcal vaccination for all adults aged 65 and older, and for younger adults with certain medical illnesses such as chronic obstructive pulmonary disease, diabetes mellitus, HIV infection, or asplenia. Herpes zoster vaccine is recommended for adults 60 years of age or older. Meningococcal vaccine is recommended for adults with anatomic or functional asplenia, complement deficiencies, and first-year college students who live in dormitories. Up-to-date ACIP recommendations can be found on the website of the Immunization Action Coalition (http://www.immunize.org/).
You see a debilitated 80-year-old woman who requires nursing home placement in the early summer. She had had no immunizations for many years except for a pneumococcal vaccine 3 years ago when discharged from the hospital after a stay for pneumonia.
Which of the following do appropriate admission orders to the nursing home include?
A Td (adult tetanus-diphtheria booster) should be given every 10 years. The tetanus-diphtheria-acellular pertussis (Tdap) vaccination is not FDA approved for persons 65 years of age or older. A flu shot should be given in this age group, but at the appropriate time in the fall. There is no recommendation to give the Haemophilus immunization in adults. This patient is not in one of the high-risk categories for hepatitis B (including health care workers, hemodialysis patients, routine recipients of clotting factors, travelers to endemic areas, persons at elevated risk for sexually transmitted diseases, injection drug users, those in institutions for the mentally retarded, and household contacts of hepatitis B carriers) and therefore has no specific indication to receive this series. The pneumococcal vaccine may be given again to higher-risk individuals at least 5 years after the original, and to older adults who received the initial pneumococcal vaccine before age 65.
A 52-year-old Hispanic woman with a history of hypertension and diabetes comes to the office for an annual physical examination. She had a mammogram at age 50 but has had no other preventive medicine tests or advice that she can recall. She does not smoke cigarettes, does not drink alcohol, and is overweight by evidence of a BMI of 30. Her mother developed breast cancer at age 75 and her father had colon cancer detected at age 65. According to the U.S. Preventive Services Task Force,
which combination of screening tests should you recommend?
A woman aged 52 years should have a mammogram every 2 years and a Pap smear at least every 3 years. She should also have had colorectal cancer (CRC) screening (colonoscopy is preferred) starting at age 50 if there is no family history of CRC in a first-degree relative or at 10 years younger than the age at which a first degree relative was diagnosed with colon cancer. Chest x-rays are not recommended as a screening tool for lung cancer in smokers. While CT scans may detect lung cancer earlier in smokers, a reduction in all-cause mortality has not yet been demonstrated and hence is not recommended. A bone density scan is recommended for women at age 65 unless they have risk factors for osteoporosis (hyperthyroidism, chronic steroid use, low BMI, smoking, white race, excessive alcohol, among others), which this patient does not have. A screening aortic sonogram is recommended for male smokers (or prior smokers) once between the ages of 65 and 75 but is not recommended at all for women. While a CA-125 has been shown to detect ovarian cancer somewhat earlier than without screening, no mortality benefit has been demonstrated; hence it is not recommended.
A 26-year-old medical student plans a 3-week mission trip to Mexico. She will be staying with local villagers and working indoors in a rural area 30 minutes from Mexico City. She has previously been vaccinated for hepatitis B.
Of the following choices, which vaccination is most important?
Travel to developing countries is becoming more common and exposes the traveler to uncommon infectious diseases. The physician can obtain up-to-date professional advice for travelers at the CDC Travel Medicine website (http://www.cdc.gov/travel/default.aspx). For travel to most countries outside of North America and Europe, hepatitis A vaccine and typhoid vaccine are recommended. Polio vaccine is recommended for travel to areas where polio is endemic, including a few countries in Africa, Asia, and Southeast Asia. Rabies vaccination is recommended for travelers who will be spending time in rural areas and outdoors where they might encounter rabid animals, especially if it will be several days journey to a major metropolitan area where rabies biologicals would be available. Malaria prophylaxis is recommended for most of Africa, Southeast Asia, the Middle East, and Central and South America. If traveling to an area reporting chloroquineresistant malaria, mefloquine, atovaquone/proguanil, or doxycycline are usually the drugs of choice. Meningococcal vaccine is recommended before travel to sub-Saharan Africa and for pilgrims to Mecca. There is no vaccine against dengue.
A 28-year-old laborer sees you because of low back pain. Ten days ago he strained his back while moving a refrigerator. Despite taking acetaminophen, his pain has worsened. He has difficulty sleeping because of the pain and for the past 3 days he has spent most of the day in bed. He has not had fever, leg numbness or weakness, or bladder or bowel problems. He takes no regular prescription medications. On examination he has difficulty getting on and off the examination table because of back pain. He has normal vital signs including a normal temperature. There is evidence of bilateral paraspinous muscle spasm. The patient is able to walk on his heels and toes and has negative straight leg raising test bilaterally.
What is the best next step in the management of this patient?
This patient has acute low back pain. This is a very common complaint seen by primary care physicians and is the most common cause of occupational disability in young persons. In the absence of certain “red flags,” patients with acute low back pain can be treated without imaging studies. Clinical “red flags” that would suggest the need for early imaging include recent trauma, age greater than 50 years, fever, weight loss, corticosteroid or illicit drug use, bladder or bowel symptoms, progressive radicular symptoms, and a history of cancer. Evidence-based studies demonstrate that nonsteroidal anti-inflammatories, chiropractic manipulation, massage, cognitive behavioral therapy, and muscle relaxants shorten the duration of symptoms. Bed rest delays recovery. Lumbosacral spine series can identify fractures, but CT scanning and MRI scanning are much more sensitive for detecting herniated discs, if evaluation becomes indicated. Epidural corticosteroids may be used for radicular pain that does not respond to initial modalities but is less effective for pain localized to the low back and paraspinous muscles.