"Best zetia 10mg, cholesterol ratio 5.1".

B. Harek, M.S., Ph.D.

Vice Chair, Keck School of Medicine of University of Southern California

On examination, she is found to have blood pressure 120/70 mm Hg, heart rate 70 bpm, and temperature 98°F. Pelvic examination shows a normal multiparous cervix, a normal-size uterus, and no adnexal masses. The patient states that she has regular Papanicolaou (Pap) smears, and that the last one performed 1 year ago was normal. Understand which health maintenance studies should be performed for a patient older than 65 years. Understand that preventive maintenance consists of immunizations, cancer screening, and screening for common diseases. Considerations the approach to health maintenance consists of three parts: (1) cancer screening, (2) immunizations, and (3) addressing common diseases for the particular patient group. For a 66-year-old woman, this includes annual mammography for breast cancer screening, colon cancer (annual stool for occult blood and either periodic colonoscopy or sigmoidoscopy), tetanus booster every 10 years, pneumococcal vaccine, and yearly influenza immunization. Screening for hypercholesterolemia every 5 years up to age 75 years and fasting blood glucose levels every 3 years also are recommended. Cervical cancer screening can be stopped at age 65 or 70 years if all previous Pap smears have been normal. An optimal screening test has high sensitivity and specificity, is inexpensive, and is easy to perform. For example, the most common cause of death in a 16-year-old is motor vehicle accidents; hence, the teenage patient is well served by the physician encouraging her to wear seat belts and to avoid alcohol intoxication when driving. In contrast, a 56-year-old woman is most likely to die of cardiovascular disease, so the physician might focus on exercise and weight loss, and screen for hyperlipidemia. Additionally, physicians should seek to identify high-risk behaviors in a nonjudgmental fashion and promote lifestyle modification: Patients should be screened for tobacco, alcohol, and illicit drug use. They should be advised to quit smoking and limit alcohol consumption to one drink per day for women and two drinks per day for men. Adjuvant pharmacologic agents are more successful in tobacco cessation, including bupropion and varenicline. Annual screening for gonorrhea and chlamydia is recommended for all sexually active women 25 years and younger. Obesity can lead to numerous complications including diabetes, hypertension, heart disease, menstrual irregularities, osteoarthritis, sleep apnea and respiratory difficulties, and hyperlipidemia. These are population-based guidelines, and it is important to consider family history and social history to identify individuals with special risks. There is always some degree of controversy surrounding population-based screening guidelines. For instance, annual mammography is no longer recommended for women aged 40 to 49 years, mainly based on the low incidence of cancer in this age group. In addition to these guidelines, there are other recommendations that can guide clinical practice. With advancing age and shorter life expectancy, it is reasonable to cease some screening activities, though there are limited data on when to discontinue screening. Depending on comorbidities and life expectancy, one can reassess the need for breast or colon cancer screening after age 75. The physician orders a fasting glucose level, lipid panel, mammogram, colonoscopy, and a Pap smear of the vaginal cuff. Which of the following statements is most accurate regarding the screening for this patient? In general, colon cancer screening should be initiated at age 60 but this patient has very sporadic care; therefore colonoscopy is reasonable. Which of the following statements is most accurate regarding health maintenance for this individual? Cervical cytology of the vaginal cuff is unnecessary when the hysterectomy was for benign indications (not cervical dysplasia or cervical cancer) and when there is no history of abnormal Pap smears. The varicella zoster vaccine is a live attenuated vaccine, recommended for individuals aged 60 and above, and has been shown to greatly reduce the incidence of herpes zoster (shingles) and the severity and likelihood of postherpetic neuralgia. Cervical cytology should be deferred until age 21 or 3 years after initiation of sexual intercourse. The most common cause of mortality for adolescent females is motor vehicle accidents. The hepatitis C vaccine is currently not available, but hopefully in several years, it may be developed.

Reliable statistical information on the extent of self-administration by the patient may not always be available. Absent evidence to the contrary, presume that drugs delivered intravenously are not usually self-administered by the patient. Absent evidence to the contrary, presume that drugs delivered by intramuscular injection are not usually self-administered by the patient. Absent evidence to the contrary, presume that drugs delivered by subcutaneous injection are self-administered by the patient. If the condition were longer term, it would be more likely that the patient would self-administer the drug. For example, if the drug is administered once per month, it is less likely to be selfadministered by the patient. However, if it is administered once or more per week, it is likely that the drug is self-administered by the patient. Definition of Acute Condition For the purposes of determining whether a drug is usually self-administered, an acute condition means a condition that begins over a short time period, is likely to be of short duration and/or the expected course of treatment is for a short, finite interval. A course of treatment consisting of scheduled injections lasting less than 2 weeks, regardless of frequency or route of administration, is considered acute. By the Patient the term "by the patient" means Medicare beneficiaries as a collective whole. The determination is based on whether the drug is self-administered by the patient a majority of the time that the drug is used on an outpatient basis by Medicare beneficiaries for medically necessary indications. In evaluating whether beneficiaries as a collective whole self-administer, individual beneficiaries who do not have the capacity to selfadminister any drug due to a condition other than the condition for which they are taking the drug in question are not considered. For example, an individual afflicted with paraplegia or advanced dementia would not have the capacity to self-administer any injectable drug, so such individuals would not be included in the population upon which the determination for self-administration by the patient was based. Note that some individuals afflicted with a less severe stage of an otherwise debilitating condition would be included in the population upon which the determination for "self-administered by the patient" was based; for example, an early onset of dementia. Therefore, physicians or providers may charge the beneficiary for an excluded drug. Provider and Physician Appeals A physician accepting assignment may appeal a denial under the provisions found in Pub. Drugs Treated as Hospital Outpatient Supplies In certain circumstances, Medicare pays for drugs that may be considered usually selfadministered by the patient when such drugs function as supplies. This is the case when the drugs provided are an integral component of a procedure or are directly related to it, i. Except for the applicable copayment, hospitals may not bill beneficiaries for these types of drugs because their costs, as supplies, are packaged into the payment for the procedure with which they are used. Listed below are examples of when drugs are treated as supplies and hospitals should bill Medicare for the drug as a supply and should not separately bill the beneficiary. Mydriatic drops instilled into the eye to dilate the pupils, anti-inflammatory drops, antibiotic drops/ointments, and ocular hypotensives that are administered to a patient immediately before, during, or immediately following an ophthalmic procedure. Barium or low osmolar contrast media provided integral to a diagnostic imaging procedure. Topical solution used with photodynamic therapy furnished at the hospital to treat nonhyperkeratotic actinic keratosis lesions of the face or scalp. Antibiotic ointments such as bacitracin, placed on a wound or surgical incision at the completion of a procedure. In many of these cases the drug itself is the treatment instead of being integral or directly related to the procedure, or facilitating the performance of or recovery from a particular procedure. Oral pain medication given to an outpatient who develops a headache while receiving chemotherapy administration treatment. Daily routine insulin or hypertension medication given preoperatively to a patient. A fentanyl patch or oral pain medication such as hydrocodone, given to an outpatient presenting with pain. These two lists of examples may serve to guide hospitals in deciding which drugs are supplies packaged as a part of a procedure, and thus may be billed under Part B. Drugs and biologicals furnished by other health professionals may also meet these requirements. Payment may also be made for blood fractions if all coverage requirements are satisfied and the blood deductible has been met.

Associated Symptoms Weight loss, fatigue, and fever are common especially in chronic cases. If there is a significant effusion, heart sounds may be decreased and a paradoxical pulse may be elicited. Laboratory signs include a "water bottle" configuration on chest X-ray if there is an effusion, as well as changes in fluoroscopy, echocardiography, or angiography. Usual Course the course varies depending on the etiology and may range from being acute to chronic. Main Features Deep, diffuse, aching central chest pain is associated with large aneurysms. Page 140 Signs and Laboratory Findings A discrepancy may develop between pulses or blood pressures in the two arms. Usual Course If there is a large aortic aneurysm, there can be chronic dull, central chest aching. Acute complications include acute aortic valvular incompetence, occlusion of major vessels, hypotension, and death. Social and Physical Disability the main problems with aortic aneurysms are life and death considerations. Pathology "True" aneurysms involve all three layers-intima, media, and adventitia. Summary of Essential Features and Diagnostic Criteria A rare cause of chronic chest pain with a wide superior mediastinum on chest X-ray. A dramatic cause of excruciating acute pain with importance because of medical and surgical therapies available. Noxious stimulation may affect phrenic nerve sensory fibers C3, C4, and C5 and therefore is often felt at the shoulder tips and along the upper border of the trapezius muscle, or it may affect the intercostal nerves T6, T7, T8, and T9 with radiation of pain into the anterior chest, the upper abdomen, and the corresponding region of the back. System the system is musculoskeletal, cardiac, pulmonary, or intestinal depending upon the disease. Main Features the pain is deep, dull, poorly localized, and non-specific if it involves only the central chest and upper abdomen and upper back, but becomes better identified if there is shoulder tip radiation as well. Associated Symptoms these symptoms depend most on the underlying pathology, so that if there is pulmonary pathology, respiratory symptoms may be prominent. Likewise, if the basic disease is gastrointestinal or subphrenic, gastrointestinal complaints are most likely associated. Signs and Laboratory Findings Frequently there are no physical findings, but if there are, the most classic would be elevation of a hemidiaphragm. Usual Course There is usually a specific therapy once the etiology is determined, but a considerable time may elapse before a conclusive diagnosis is reached. Social and Physical Disability these relate partly to the underlying disease process and partly to the vagueness of understanding of the cause of pain. Etiology Although a wide range of causes can cause disease affecting the diaphragm, the most important are infections and neoplasms. Chronic aneurysm If the pain assumes a thoracic spinal pattern (although of visceral origin), code according to X-7. Page 141 Summary of Essential Features and Diagnostic Criteria Abdominal pain in epigastrium with radiation to central chest, posterior midthorax and shoulder tip(s), with evidence of space-occupying lesions above or below the diaphragm. Differential Diagnosis Involves a wide range of cardiac, pulmonary, musculoskeletal, and gastrointestinal uses. X6 Infection: chest or pulmonary source Neoplasm: chest or pulmonary source Musculoskeletal Infection: gastrointestinal source Neoplasm: gastrointestinal source Cholelithiasis Complications Esophageal obstruction, erosion into a bronchus, bronchoesophageal stricture, erosion into aorta with catastrophic hemorrhage. Social and Physical Disability If the tumor is inoperable and the patient cannot eat, a plastic tube can be passed through the tumor or a feeding jejunostomy performed. Summary of Essential Features and Diagnostic Criteria Presents with dysphagia with pain as a late feature. Main Features this is a relatively uncommon tumor in the Western World but has localized areas of high incidence, especially in Iraq and Iran among the Kurds. The presenting symptom is usually dysphagia without pain, which usually occurs only when the cancer extends beyond the esophagus. At that point dysphagia and retrosternal pain may become continuous and radiate through the back. Associated Symptoms Dysphagia is the major symptom; others include regurgitation and recurrent pneumonia. Signs and Laboratory Findings Evidence of weight loss and cervical lymphadenopathy, particularly deep to the sternomastoid.