Periodic Health Encounter & Preventive Health Advice

Introduction

The Periodic Health Encounter (PHE) has evolved significantly from the traditional “annual physical.” In the context of MCCQE1 preparation, it is crucial to understand that Canadian medical practice emphasizes an evidence-based, risk-stratified approach rather than a one-size-fits-all annual review.

This topic falls under the Population Health, Ethical, Legal, and Organizational Aspects of Medicine (PHELO) category. For the MCCQE1, you must demonstrate the CanMEDS Health Advocate and Scholar roles by applying current guidelines to individual patients.

Principles of Screening

Before memorizing the guidelines, understand the criteria for a valid screening test (Wilson and Jungner criteria), which is a frequent concept in Public Health questions on the MCCQE1.

1. The condition should be an important health problem.
2. There should be an accepted treatment for patients with recognized disease.
3. Facilities for diagnosis and treatment should be available.
4. There should be a recognizable latent or early symptomatic stage.
5. There should be a suitable test or examination.
6. The test should be acceptable to the population.

CTFPHC Grading System

Understanding the strength of recommendations is vital for clinical decision-making questions.

The Periodic Health Visit Structure

A systematic approach ensures no preventive opportunity is missed.

Canadian Clinical Guidelines for Screening

This section is high-yield for the MCCQE1. Guidelines change; ensure you are familiar with the most current CTFPHC recommendations.

Cancer Screening (Average Risk)

Cardiovascular & Metabolic Screening

• Hypertension: Screen all adults aged 18+ at all appropriate primary care visits.
• Diabetes (Type 2):
  • Screen using A1C or Fasting Glucose.
  • Start at age 40 for average risk.
  • Screen earlier/more frequently if risk factors exist (high risk populations include Indigenous peoples, South Asian, African, or Hispanic descent).
  • Use the CANRISK questionnaire.
• Dyslipidemia:
  • Men: Age >40.
  • Women: Age >40 or post-menopausal.
  • Earlier if risk factors (e.g., smoking, diabetes, hypertension, family history).
  • Calculate Framingham Risk Score (FRS) to determine statin eligibility.
• Abdominal Aortic Aneurysm (AAA):
  • Population: Men aged 65–80.
  • Intervention: One-time abdominal ultrasound.
  • Recommendation: Weak recommendation in favor. Women are generally not screened.

Other Specific Screening

• Osteoporosis: Women aged >65 (DEXA scan). Men/Women <65 only if risk factors (e.g., prolonged steroid use, fragility fracture). Use FRAX or CAROC tools.
• Hepatitis C: Screen adults born between 1945–1975 (Boomer cohort) or those with risk factors (IVDU).
• Chlamydia/Gonorrhea: Sexually active women <25 years and other high-risk groups.

Immunization (Adults)

Refer to the Canadian Immunization Guide.

• Tetanus/Diphtheria (Td): Every 10 years. (Substitute one dose with Tdap to cover Pertussis in adulthood, especially if expecting contact with infants).
• Influenza: Annually for all individuals >6 months.
• Pneumococcal:
  • Pneu-C-20 (Prevnar 20) is increasingly the standard for adults >65 or immunocompromised (replacing the Pneu-C-13 + Pneu-P-23 sequence in many guidelines).
• Herpes Zoster (Shingles):
  • Recombinant Zoster Vaccine (Shingrix).
  • Adults >50 years (2 doses, 2–6 months apart).
• HPV: Indicated for men and women up to age 45 (and potentially older based on risk).

Pediatric & Adolescent Preventive Care

For MCCQE1 Pediatrics, familiarize yourself with these specific tools:

1. Rourke Baby Record (RBR): Evidence-based guide for children 0–5 years. Covers growth, nutrition, development, and immunization.
2. Greig Health Record: For children and adolescents 6–17 years. Focuses on psychosocial health (HEEADSSS), screen time, and mental health.

Key Points to Remember for MCCQE1

• Choose Wisely Canada: Be aware of what not to do. Do not order ECGs, Chest X-rays, or Urinalysis for asymptomatic, low-risk adults.
• Cervical Cancer: Screening starts at age 25, regardless of age of sexual debut.
• Breast Cancer: No self-exams, no clinical breast exams for screening.
• Prostate Cancer: PSA is not a routine screen; it requires a discussion of risks/benefits.
• Indigenous Health: Be aware of higher risks for Diabetes (screen earlier), Tuberculosis, and specific social determinants of health.

Sample Question

Case Presentation

A 67-year-old man presents to your clinic for a periodic health review. He feels well and has no specific complaints. His past medical history is significant for hypertension, which is well-controlled on amlodipine. He smoked 1 pack of cigarettes daily for 25 years but quit 10 years ago. He drinks 1–2 beers on weekends. His father died of a myocardial infarction at age 72.

Physical examination reveals a blood pressure of 128/78 mmHg and a BMI of 27 kg/m². His heart and lung examinations are unremarkable. His last colonoscopy was 3 years ago and was normal.

Question

Which one of the following screening interventions is most appropriate for this patient at this visit?

• A. Prostate-specific antigen (PSA) testing
• B. Low-dose computed tomography (LDCT) of the chest
• C. Abdominal ultrasound
• D. Resting electrocardiogram (ECG)
• E. Carotid artery duplex ultrasonography

Explanation

The correct answer is:

• C. Abdominal ultrasound

Detailed Analysis:

• C is correct: The Canadian Task Force on Preventive Health Care (CTFPHC) recommends one-time screening for Abdominal Aortic Aneurysm (AAA) with abdominal ultrasound for men aged 65 to 80 years. This patient is 67, making him an ideal candidate. The benefit is the reduction of AAA-related mortality and rupture.
• A is incorrect: The CTFPHC recommends against PSA screening for prostate cancer in the general population. While some guidelines suggest shared decision-making, it is not the most appropriate clear-cut recommendation compared to AAA screening in this context.
• B is incorrect: While this patient has a significant smoking history, the criteria for lung cancer screening (LDCT) usually require a 30 pack-year history. This patient has a 25 pack-year history (1 pack/day × 25 years). Therefore, he does not strictly meet the criteria for LDCT screening.
• D is incorrect: The CTFPHC and Choosing Wisely Canada recommend against screening with resting ECG in asymptomatic adults with low/intermediate risk for coronary artery disease.
• E is incorrect: Screening for carotid artery stenosis in asymptomatic patients is recommended against by the CTFPHC (Grade D recommendation) due to the high rate of false positives and the risks associated with follow-up interventions.

References

1. Canadian Task Force on Preventive Health Care. (n.d.). Published Guidelines. Retrieved from canadiantaskforce.ca 
2. Public Health Agency of Canada. (2024). Canadian Immunization Guide. Retrieved from canada.ca 
3. Choosing Wisely Canada. (n.d.). Family Medicine Recommendations. Retrieved from choosingwiselycanada.org 
4. Rourke Baby Record. (2020). Evidence-based infant/child health maintenance guide.
5. Medical Council of Canada. (n.d.). MCCQE Part I Objectives: Population Health.