Reunião 2 - Casos clínicos rastreamento COM RESPOSTAS

8/8/2019 Reunio 2 - Casos clnicos rastreamento COM RESPOSTAS

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Summary of Recommendations The USPSTF concludes that the current evidence is insufficient toassess the balance of benefits and harms of prostate cancerscreening in men younger than age 75 years.Grade: I Statement . The USPSTF recommends against screening for prostate cancer in

men age 75 years or older.Grade: D Recommendation.

03 . Uma paciente negra, 53 anos, procura atendimento mdico parasolicitar uma densitometria ssea por recomendao de uma vizinhaque j tinha feito o exame. Ela no informa nenhum problema desade relevante, exceto uma dor ocasional nos quadris, que acha quepode estar relacionada osteoporose. Na avaliao dessa senhora,verifica-se que ela teve menopausa h dois anos, no est usandonenhum medicamento e nunca foi fumante. A paciente teve trs

filhos e atualmente trabalha como vendedora autnoma decosmticos de casa em casa, percorrendo longos percursos pelomenos cinco vezes por semana. O exame fsico revela um IMC=32.

Em relao a esta paciente, considere as afirmaes abaixo.

I - Pela histria apresentada, alm da menopausa e do sexo feminino,o nico fator de risco identificado para osteoporose a obesidade.II - A densitometria ssea o exame ideal para diagnstico deosteoporose, devendo ser realizada em todas as mulheres dessa faixaetria.III - O uso de alendronato no est indicado para essa paciente nessemomento.

Quais esto corretas?(A) Apenas I.(B) Apenas II.(C) Apenas III.(D) Apenas I e II.(E) I, II e III.

http://www.uspreventiveservicestaskforce.org/3rduspstf/osteoporosis/osteorr.htm Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF)recommends that women aged 65 and older be screenedroutinely for osteoporosis. The USPSTF recommends that routinescreening begin at age 60 for women at increased risk forosteoporotic fractures (Go to Clinical Considerations fordiscussion of women at increased risk).Rating: B Recommendation .Rationale: The USPSTF found good evidence that the risk forosteoporosis and fracture increases with age and other factors, thatbone density measurements accurately predict the risk for fractures inthe short-term, and that treating asymptomatic women with
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osteoporosis reduces their risk for fracture. The USPSTF concludes thatthe benefits of screening and treatment are of at least moderatemagnitude for women at increased risk by virtue of age or presence of other risk factors. The USPSTF makes no recommendation for or against routineosteoporosis screening in postmenopausal women who areyounger than 60 or in women aged 60-64 who are not atincreased risk for osteoporotic fractures. Rating: C Recommendation .

Rationale: The USPSTF found fair evidence that screening women at lower risk forosteoporosis or fracture can identify additional women who may be eligible fortreatment for osteoporosis, but it would prevent a small number of fractures. TheUSPSTF concludes that the balance of benefits and harms of screening andtreatment is too close to make a general recommendation for this age group.

Clinical Considerations Modeling analysis suggests that the absolute benefits of screening forosteoporosis among women aged 60-64 who are at increased risk forosteoporosis and fracture are comparable to those of routine screening in olderwomen. The exact risk factors that should trigger screening in this age group aredifficult to specify based on evidence. Lower body weight (weight < 70 kg ) is thesingle best predictor of low bone mineral density. 4,5 Low weight and no currentuse of estrogen therapy are incorporated with age into the 3-item OsteoporosisRisk Assessment Instrument (ORAI). 4,5 There is less evidence to support the useof other individual risk factors (for example, smoking, weight loss, family history,decreased physical activity, alcohol or caffeine use, or low calcium and vitamin Dintake) as a basis for identifying high-risk women younger than 65. At any givenage, African-American women on average have higher bone mineral density(BMD) than white women and are thus less likely to benefit from screening.Additional characteristics of screening tools are discussed in the " Accuracy and Reliability of Screening Tests " section.

Among different bone measurement tests performed at various anatomicalsites, bone density measured at the femoral neck by dual-energy x-rayabsorptiometry (DXA) is the best predictor of hip fracture and is comparable toforearm measurements for predicting fractures at other sites. Other technologiesfor measuring peripheral sites include quantitative ultrasonography (QUS),radiographic absorptiometry, single energy x-ray absorptiometry, peripheraldual-energy x-ray absorptiometry, and peripheral quantitative computedtomography. Recent data suggest that peripheral bone density testing in theprimary care setting can also identify postmenopausal women who have a higherrisk for fracture over the short term (1 year). Further research is needed todetermine the accuracy of peripheral bone density testing in comparison withdual-energy x-ray absorptiometry (DXA). The likelihood of being diagnosed withosteoporosis varies greatly depending on the site and type of bone measurementtest, the number of sites tested, the brand of densitometer used, and therelevance of the reference range. Estimates of the benefits of detecting and treating osteoporosis are basedlargely on studies of bisphosphonates. Some women, however, may prefer othertreatment options (for example, hormone replacement therapy, selectiveestrogen receptor modulators, or calcitonin) based on personal preferences orrisk factors. Clinicians should review with patients the relative benefits andharms of available treatment options, and uncertainties about their efficacy andsafety, to facilitate an informed choice. No studies have evaluated the optimal intervals for repeated screening.Because of limitations in the precision of testing, a minimum of 2 years may beneeded to reliably measure a change in bone mineral density; however, longerintervals may be adequate for repeated screening to identify new cases of osteoporosis. Yield of repeated screening will be higher in older women, thosewith lower BMD at baseline, and those with other risk factors for fracture. There are no data to determine the appropriate age to stop screening andfew data on osteoporosis treatment in women older than 85. Patients who
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receive a diagnosis of osteoporosis fall outside the context of screening but mayrequire additional testing for diagnostic purposes or to monitor response totreatment.

UK NSC - http://www.screening.nhs.uk/osteoporosis

Osteoporosis (policy currently under review)The UK NSC policy on Osteoporosis screening in women after the

menopause

More InformationOsteoporosis is a condition that affects the bones, causing them to become thin andweak. Approximately three million people in the UK have osteoporosis, and there areover 230,000 fractures every year as a result. Osteoporosis happens more commonly inold age when the body becomes less able to replace worn-out bone. Special cells withinthe bones, called living bone cells, are no longer able to break down old bone and renew

it with healthy, dense new bone. Read more about osteoporosis on NHS Choices

Policy PositionScreening should not be offered.

This policy is currently being reviewed as part of the UK NSC's regular review cycle of allpolicies.

The review process began in Jan 2010 and is estimated to be completed by Mar 2011.

Evidence Supporting the Policy The UK NSC reviewed the evidence about the benefits of screening for osteoporosis, andconcluded that this should not be introduced at present. NICE is currently carrying out areview of osteoporosis screening: see Osteoporosis: assessment of fracture risk and theprevention of osteoporotic fractures in individuals at high risk

04 . Me com filho em idade escolar:A Sra. Jussara, 47 anos, no era uma freqentadora rotineira daUnidade de Sade, mas nos ltimos 3 anos aparecera umas 5 ou 6vezes tanto para consultas de rotina sua como consultas deintercorrncia de seu nico filho Luciano, 8 anos. Neste dia ela veiodevido a uma urgncia do filho ( um quadro de resfriado) e ela fez aseguinte pergunta: Doutor Paulo, acho que faz uns 5 anos que o

Luciano no faz um exame. Acho que seria bom que ele viesse parafazer uns exames de sangue, urina e fezes.

a) conduza a situaob) elencar os exames necessrios de rotina para o Luciano

http://www.uspreventiveservicestaskforce.org/uspstf/uspschlip.htm Summary of Recommendation

The USPSTF concludes that the evidence is insufficient torecommend for or against routine screening for lipid disorders ininfants, children, adolescents, or young adults (up to age 20).Grade: I Statement .

Screening Children and Pregnant Women for Iron Deficiency Anemia The U.S. Preventive Services Task Force (USPSTF) concludes thatevidence is insufficient to recommend for or against routine screening
http://www.screening.nhs.uk/osteoporosishttp://www.nhs.uk/conditions/osteoporosishttp://www.nice.org.uk/page.aspx?o=33923http://www.nice.org.uk/page.aspx?o=33923http://www.uspreventiveservicestaskforce.org/uspstf/uspschlip.htmhttp://www.uspreventiveservicestaskforce.org/uspstf/gradespre.htm#irechttp://www.screening.nhs.uk/osteoporosishttp://www.nhs.uk/conditions/osteoporosishttp://www.nice.org.uk/page.aspx?o=33923http://www.nice.org.uk/page.aspx?o=33923http://www.uspreventiveservicestaskforce.org/uspstf/uspschlip.htmhttp://www.uspreventiveservicestaskforce.org/uspstf/gradespre.htm#irec


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for iron deficiency anemia in asymptomatic children aged 6 to 12months. Grade: I Statement .

Iron Supplementation for Children and Pregnant Women The U.S. Preventive Services Task Force (USPSTF) recommendsroutine iron supplementation for asymptomatic children aged 6 to 12months who are at increased risk for iron deficiency anemia (go toClinical Considerations for a discussion of increased risk).Grade: B Recommendation . The USPSTF concludes that evidence is insufficient to recommendfor or against routine iron supplementation for asymptomatic childrenaged 6 to 12 months who are at average risk for iron deficiency anemia.Grade: I Statement .

05 .- A Sra. Marisa, 33 anos entrou no consultrio vindo a frente doseu esposo o Sr. Luis Incio, 32 anos, tabagista e motoboy. A pessoaque estava agendada para esta consulta era o Sr. Luis. Ao entrar noconsultrio ela inicia falando da dificuldade em trazer o marido paraconsultar-se: Doutor Renato, ele no vem ao mdico nemamarrado! Parece que tem medo... Embora parea vontadedurante a consulta o paciente evita muitas vezes olhar para esposa esempre fica observando a porta do consultrio. Respondemonossilabicamente s perguntas do mdico. Em poucos minutos aesposa toma a conduo da consulta e pergunta: Doutor, ele temque fazer um check up, ver o colesterol e se tem diabete! Todomundo l na empresa dele faz. E se acontecer algo?

***Framingham - http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof

http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm This topic page summarizes the U.S. Preventive Services Task Force (USPSTF)recommendations on screening for lipid disorders in adults.

Summary of Recommendations

Screening Men

The U.S. Preventive Services Task Force (USPSTF) stronglyrecommends screening men aged 35 and older for lipid disorders.Grade: A Recommendation . The USPSTF recommends screening men aged 20 to 35 for lipiddisorders if they are at increased risk for coronary heart disease. Grade: B Recommendation .

Screening Women at Increased Risk

The USPSTF strongly recommends screening women aged 45 andolder for lipid disorders if they are at increased risk for coronary heartdisease.Grade: A Recommendation . The USPSTF recommends screening women aged 20 to 45 for lipiddisorders if they are at increased risk for coronary heart disease. Grade: B Recommendation .

Screening Young Men and All Women Not at Increased Risk

The USPSTF makes no recommendation for or against routinescreening for lipid disorders in men aged 20 to 35, or in women aged 20
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and older who are not at increased risk for coronary heart disease.Grade: C Recommendation .

06 . Milene, 22 anos, com sobrepeso (IMC: 29) acompanhada pelamesma profissional, Dra. Aline, h cerca de 4 anos. Apresenta uma

boa relao com sua mdica e veio nesta consulta acompanhada deuma revista. Aps as saudaes e outras conversas ela diz mdica:Dra. Aline, nesta revista diz que toda mulher tem que fazer algunsexames e ir ao mdico periodicamente. Aqui h opinio deespecialistas famosos. Eu queria fazer esta bateria de exames queso citados aqui. Doutora eu queria saber se eu tenho tireide?

nico exame: colo de tero e checar presso (a cada 2 anosse normal)http://www.uspreventiveservicestaskforce.org/uspstf/uspsthyr.htm Summary of Recommendations

The USPSTF concludes the evidence is insufficient to recommendfor or against routine screening for thyroid disease in adults. Grade: I Statement .

07. O Sr. Waldemiro, 89 anos, ex-tabagista (fumou 20 cigarros ao diadurante 20 anos, cessou h 20 anos) , asmtico e DPOC, ainda andade bicicleta, utiliza apenas uma medicao para controle de seusnveis pressricos. Eventualmente queixa de prurido quando atemperatura esfria e tem que mexer com roupas guardadas noarmrio. Ultimamente tem freqentado mais o consultrio comqueixas diversas que sempre se alteram (dor , vazio na cabea,preocupao..). Pergunta o que ele deveria fazer de rotina pois halgum tempo no faz nenhum exame.

a) que exames de rastreamento voc solicitaria para o Sr. Waldemiro?b) como voc trabalharia a preveno neste caso?c) levante hipteses para este aumento na freqncia de consultas dopaciente com queixas inespecficas

08 . Voc foi convidado a ser secretrio de sade do municpio deOrizontinpolis, uma cidade com cerca de 15 mil habitantes no sul doestado. O prefeito do municpio expe que voc ter toda a liberdade

no trabalho com a ateno sade do municpio. No primeiro diavoc descobre que no h nenhum servio de rastreio implementadono,para qualquer neoplasia. No segundo dia voc descobre que no tem

uma verba para implementar todos os servios que voc julganecessrio. Quais os servios abaixo voc optaria?

a) rastreio de cncer de mama e clonb)rastreio de cncer de colo de tero e clonc)rastreio de cncer de mama e prstatad) rastreio de cncer de colo de tero e mamae)rastreio de prstata e colo de tero
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As duas respostas, b e d, seriam as mais razoveis, mas o objetivomaior dessa questo passar a ideia de que qualquer deciso sobrerastreio precisa levar em conta no apenas as melhores evidnciascientficas, mas tambm a custo-efetividade e a deciso poltica sobreonde aplicar os recursos pblicos.

CONSTRUO DE UM PROGRAMA ORGANIZADOProgramas Organizados XRastreamento oportunstico

Deteco precoce

Acesso/Equidade Custo-efetividadecereja do bolo Construo da redeCertificao de laboratrios Avaliao

09 . O Sr. Alcides, 80 anos, catador de berbigo, j vem sendoacompanhado pelo Dr. Germano h cerca de 8 anos. O paciente temuma seqela de Acidente Vascular Cerebral com uma discretadiminuio de fora em dimdio esquerdo. Tem diagnosticado h 20anos Diabete Melitus e Hipertenso Arterial Sistmica controlados.Durante a ausncia do Dr. Germano um outro colega solicitou umexame de PSA de rotina para o seu Alcides e ele vem trazer agoranesta consulta. PSA: 10,00 ng/dl

a) qual seria sua conduta frente a este exame?b)o que orientar para o paciente?

http://www.uspreventiveservicestaskforce.org/uspstf/uspsprca.htm Summary of Recommendations

The USPSTF recommends against screening for prostate cancer inmen age 75 years or older.Grade: D Recommendation.

10 . A Sra. Madalena, 46 anos , dona de casa, moradora de uma regiode classe mdia, tem 2 filhos, sendo que um deles tem paralisiacerebral com seqela importante, vem trazer seu exame demamografia. Demonstra grande preocupao com sua sade e umcerto medo acima da mdia com doenas e de vir a adoecer. Oexame no apresenta nenhuma alterao significativa ( Idade de inciode mamografia).

- Como voc informaria a paciente?- Qual seu significado do exame normal?http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

This topic page summarizes the U.S. Preventive Services Task Force (USPSTF)recommendations on breast cancer screening.

Summary of Recommendations
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The USPSTF recommends biennial screening mammography forwomen aged 50 to 74 years. Grade: B recommendation . The decision to start regular, biennial screening mammographybefore the age of 50 years should be an individual one and takepatient context into account, including the patient's values regarding

specific benefits and harms.Grade: C recommendation . The USPSTF concludes that the current evidence is insufficient toassess the additional benefits and harms of screening mammographyin women 75 years or older. Grade: I Statement . The USPSTF recommends against teaching breast self-examination(BSE).Grade: D recommendation . The USPSTF concludes that the current evidence is insufficient toassess the additional benefits and harms of clinical breastexamination (CBE) beyond screening mammography in women 40years or older.

Grade: I Statement . The USPSTF concludes that the current evidence is insufficient toassess the additional benefits and harms of either digitalmammography or magnetic resonance imaging (MRI) instead of filmmammography as screening modalities for breast cancer. Grade: I Statement .

UK NSChttp://www.screening.nhs.uk/breastcancer-compare Breast cancer screening across the UK

This table summarises the state of breast cancer screening across the home nations.

England All women aged 50 to 70 invited forscreening every three years. Read more

Northern Ireland Universal offer to women aged 50 to 70years. Read more

Scotland All women aged between 50 and 70routinely invited for breast screening. Read more

WalesBreast Test Wales offers mammographicscreening to women aged 50 and overevery three years, and annual screeningto women at increased risk from age 35 or40 depending on risk level. Read more

11 . O Sr. Sebastio, tem 54 anos, pescador, nativo do sul da ilha deFlorianpolis. No fuma, bebe sua cervejinha nos finais de semanacom os amigos. Vem pouco a Unidade de Sade da Tapera,geralmente a cada 2 anos para ver a presso arterial que estsempre dentro da normalidade. Vem ao consultrio dizendo: Estoucom muito medo e no tenho dormido direito pois a gordura do

sangue est alta e pode afetar o corao n? Li que o normal para ocolesterol at 200 n?
http://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#brechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#crechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#irechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#drechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#irechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#irechttp://www.screening.nhs.uk/breastcancer-comparehttp://www.screening.nhs.uk/breastcancer-englandhttp://www.screening.nhs.uk/breastcancer-northernirelandhttp://www.screening.nhs.uk/breastcancer-scotlandhttp://www.screening.nhs.uk/breastcancer-waleshttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#brechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#crechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#irechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#drechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#irechttp://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#irechttp://www.screening.nhs.uk/breastcancer-comparehttp://www.screening.nhs.uk/breastcancer-englandhttp://www.screening.nhs.uk/breastcancer-northernirelandhttp://www.screening.nhs.uk/breastcancer-scotlandhttp://www.screening.nhs.uk/breastcancer-wales


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Foi sugerido iniciar medicao sinvastina devido a um colesterol totalde 260 mg/dl; HDL: 60 mg/dl Triglicerdeo: 100 mg/dl ;

a) qual a sua conduta frente ao caso?

Risk Assessment Tool for Estimating 10-year Risk of Developing HardCHD (Myocardial Infarction and Coronary Death) Framinghamhttp://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof

12 . A Sra. Matilde, 50 anos vem ao consultrio dizendo: Doutor euno tenho mais plano de sade. Todo ano eu fazia no meu plano desade o meu check up: mamografia e Ultrasonografia (US)transvaginal. Dr. Tenho medo de ter cncer de ovrio, minha vizinhamorreu de cncer de ovrio .

O que fazer?

http://www.uspreventiveservicestaskforce.org/uspstf/uspsovar.htmSummary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommendsagainst routine screening for ovarian cancer. Grade: D Recommendation.

UK NSC -http://www.screening.nhs.uk/ovariancancer

The UK NSC organised a workshop on the use of family history or genetic markers to

identify a high risk group and made recommendations to the UK National ScreeningCommittee at its meeting on 13 June 2001, based on a report of the workshop. Theyconcluded that there is no evidence to support the introduction of a population-screening programme designed to identify people at high risk of breast or ovariancancer, either based on asking people if they have a family history of breast or ovariancancer or by offering a blood test for genetic mutations.
http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=profhttp://www.uspreventiveservicestaskforce.org/uspstf/uspsovar.htmhttp://www.uspreventiveservicestaskforce.org/uspstf/gradespre.htm#drechttp://www.screening.nhs.uk/ovariancancerhttp://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=profhttp://www.uspreventiveservicestaskforce.org/uspstf/uspsovar.htmhttp://www.uspreventiveservicestaskforce.org/uspstf/gradespre.htm#drechttp://www.screening.nhs.uk/ovariancancer

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