Adult Health Maintenance Screening

Aka: Adult Health Maintenance Screening, Health Maintenance in Adults, Well Woman Exam, Well Male Exam, Health Maintenance in Women, Health Maintenance in Men

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II. Epidemiology

  1. Preventive care visits for ages 15 to 65 years old (U.S.)
    1. Women: 44%
    2. Men: 15%
    3. Hsiao (2010) Natl Health Stat Report (27):1-32 [PubMed]
  2. Adults with primary care provider (U.S., 2000)
    1. Women: 80%
    2. Men: 66%
  3. Life Expectancy (U.S., 2015)
    1. Women: 82 years
    2. Men: 76 years

III. Risk Factors: Health Disparities

  1. Racial and ethnic minorities
  2. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) patients
  3. Uninsured
  4. Young adults
  5. Rural regions

IV. History

  1. Medical History
  2. Surgical History
  3. Medications
  4. Allergies

V. Prevention: Habitus and Lifestyle

  1. Precautions: High Risk Settings may direct additional screening
    1. STI Clinics
    2. Correctional facilities
    3. Homeless Shelters
    4. Tuberculosis Clinics
    5. Adolescent Health Clinics
  2. Obesity
    1. If BMI >30, refer to intensive behavioral counseling
    2. See Obesity Management
  3. Physical Activity
    1. See Exercise Prescription
  4. Dietary Intake
    1. See Nutrition Guidelines
  5. Substance Abuse
    1. Tobacco Abuse
      1. See Tobacco Cessation
    2. Alcohol Abuse
      1. See Alcohol Abuse Screening
    3. Drug Abuse
      1. See Substance Abuse Evaluation
      2. See Single-Question Drug Abuse Screening Test
  6. Sexually Transmitted Disease
    1. See STD Screening
    2. Prevention (Condom Use, limit sexual partners, Immunizations)
    3. Gonorrhea and Chlamydia screening in age <25 years who are sexually active
    4. HIV Risk Factors and HIV Screening for age 15 to 65 years old
    5. HSV screening is NOT indicated in asymptomatic adults (including asymptomatic in pregnancy)
    6. See Hepatitis C Screening as below
  7. Initimate Partner Violence
    1. See Intimate Partner Violence Screening
  8. Major Depression
    1. See Depression Screening Tools (e.g. PHQ2, PHQ9)
      1. Consider starting with PHQ2, and if positive, reflex to PHQ9
  9. Osteoporosis
    1. See Osteoporosis Screening

VI. Prevention: Cardiovascular

  1. Coronary Artery Disease
    1. See Cardiovascular Risk Management
    2. ASCVD Risk Estimator
      1. https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
  2. Hypertension
    1. See Hypertension Evaluation
  3. Hyperlipidemia
    1. See Hyperlipidemia Management
    2. Indications
      1. Cardiovascular Risk Factors
        1. Start screening for men and women at age 20 years old
      2. No risk factors
        1. Men: Over age 40 years old
        2. Women: Over age 45 years old
    3. Screen every 5 years
      1. Fasting lipid profile or
      2. Total Cholesterol and HDL Cholesterol
  4. Abdominal Aortic Aneurysm
    1. See Ultrasound in Abdominal Aortic Aneurysm
    2. Indications (per USPTF)
      1. Men aged 65 to 75 years with lifetime Tobacco use greater than 100 Cigarettes
      2. Women have no screening guidelines per USPTF
      3. See Abdominal Aortic Aneurysm for broader screening guidelines per Society Vascular Medicine
    3. References
      1. (2005) Am Fam Physician 71(11):2144-8 [PubMed]
  5. Carotid Artery Stenosis Guidelines
    1. See Carotid Artery Stenosis

VII. Prevention: Cancer in Men and Women

  1. Colorectal Cancer
    1. See Colorectal Cancer Screening
    2. Indications
      1. Start screening at age 50 years (and stop between 75 and 85 years old)
      2. See Colorectal Cancer Screening regarding indications to start screening earlier
    3. Options
      1. Colonoscopy: Every 10 years (preferred) or
      2. Flexible Sigmoidoscopy: Every 5 years or
      3. Occult Blood in stool: Annually
  2. Lung Cancer
    1. Screening
      1. Indicated in age 50 to 80 years old with 20 py Tobacco use (ongoing or quit in last 15 years)
      2. Screen with annual low dose CT chest
      3. Advantages
        1. Number Needed to Screen in 5 years to prevent one death: 320
        2. All cause mortality Relative Risk Reduction: 6.7%
      4. Disadvantages
        1. Cummulative radiation and cost with annual screening will be substantial
        2. High False Positive Rate with screening (96%) will require significant resources to evaluate
        3. Despite USPTF recommendation for screening, other organizations (e.g. AAFP) do not recommend
      5. Resources: USPTF Guidelines (updated 2021)
        1. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
      6. References
        1. Aberle (2011) N Engl J Med 365(5): 395-409 [PubMed]
        2. Gates (2014) Am Fam Physician 90(9): 625-31 [PubMed]
        3. Kovalchik (2013) N Engl J Med 369(3): 245-54 [PubMed]
    2. Prevention
      1. Tobacco Cessation
      2. Consider Radon Gas testing in the home
    3. USPTF Lung Cancer screening guidelines
      1. See Lung Cancer Screening CT Chest
  3. Skin Cancer
    1. See Self Skin Exam
    2. Counsel on reducing the risks of Sun Exposure (esp. in young, fair skinned patients)
    3. Insufficient evidence to recommend Skin Cancer screening (self screening, or that by a medical provider)

VIII. Prevention: Women

  1. Precautions
    1. Routine pelvic exam is not indicated in asymptomatic non-pregnant women of child bearing age
      1. Exception: Cervical Cancer Screening protocols or other specific risk factors may indicate exam
      2. Oral Contraception does not require a pelvic exam
  2. Sexually Transmitted Infection
    1. See Sexually Transmitted Infection
    2. Sexually Transmitted Infection screening and prevention as above
    3. Screen women with HIV annually for Trichomonas
  3. Family Planning ("Would you like to become pregnant in the next year?")
    1. Contraception Counseling
      1. Unplanned Pregnancy accounted for 45% of pregnancies in 2011
        1. Finer (2016) N Engl J Med 374(9): 843-52 [PubMed]
    2. Preconception Counseling
      1. Folic Acid 400-800 mcg orally daily
  4. Cervical Cancer
    1. See Cervical Cancer Screening
    2. Pap Smears are not indicated under age 21 years old or after Hysterectomy for benign causes
    3. Pap Smear Intervals are typically at every 3 years for under age 30 in immunocompetent patients
      1. HPV Testing may be considered after age 25 years
      2. Cervical Dysplasia and HPV results directs further testing
  5. Breast Cancer
    1. See Breast Cancer Screening
    2. Offer Mammograms every 1-2 years ages 40-50 years, and recommend routinely after age 50 years
    3. Consider BRCA testing in those with Family History of Breast Cancer or Ovarian Cancer
  6. Ovarian Cancer
    1. Routine screening not recommended (USPTF)

IX. Prevention: Men

  1. Sexually Transmitted Infection
    1. See Sexually Transmitted Infection
    2. Sexually Transmitted Infection screening and prevention as above
  2. Prostate Cancer
    1. See Prostate Cancer Screening
    2. Prostate Specific Antigen (PSA)
      1. See Prostate Cancer Prevention for an Informed Consent outline for PSA testing
      2. Discuss risks and benefits of test
        1. Not recommended by most organizations other than ACS and AUA
      3. Offer test annually between ages 55 to 69 years after discussion of test poor efficacy
        1. Previously indicated for ages 50 to 75 years
  3. Testicular Cancer
    1. See Testicular Self-Exam
    2. No routine screening recommended by USPTF or NCI

X. Prevention: Eye

  1. Glaucoma
    1. See Intraocular Pressure
    2. Medicare will cover an annual dilated Eye Exam and Glaucoma screening
    3. Consider baseline exam indications
      1. Age over 40 years
        1. USPTF does not recommend routine screening for asymptomatic patients (2012, 2022)
      2. Family History of Glaucoma related Vision Loss
      3. High risk groups (e.g. Black, hispanic and latino)
  2. Vision
    1. See Vision Screening

XI. Prevention: Miscellaneous

  1. Diabetes Mellitus
    1. See Diabetes Screening
    2. Diabetes Screening indications
      1. Treated or untreated Hypertension (BP >135/80)
      2. Overweight or obses adults 40 to 70 years old
  2. COPD
    1. See COPD
    2. Routine screening with Spirometry not recommended (USPTF)
  3. Hepatitis C
    1. See Hepatitis C
    2. Hepatitis C Screening indications
      1. All patients born between 1945 and 1965
      2. Patients at high risk of Hepatitis C (e.g. IV Drug Abuse)
    3. CDC Hepatitis C Screening Guidelines
      1. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm
  4. Hepatitis B
    1. See Hepatitis B Screening
    2. Universal screening for U.S. Adults is recommended as of 2023
      1. Triple Screen (HBsAg, HBsAb, HBcAb) at least once in all adults regardless of risk factors
      2. Conners (2023) MMWR Recomm Rep 72(1):1-25 +PMID: 36893044 [PubMed]

XII. Prevention: Immunizations

  1. Tetanus Vaccine
    1. Tetanus Vaccine given every 10 years
    2. Age under 65 years: Give Tdap (e.g. Adacel) once at next opportunity
    3. Age over 65 years: Give Tdap (e.g. Adacel) once if in contact with infants under age 1 year old
  2. Influenza Vaccine
    1. Annual Vaccine recommended in all patients
    2. See Influenza Vaccine for indications
  3. Pneumococcus Vaccine
    1. One dose over age 65 years or Asplenic
  4. Measles Vaccine
    1. Booster for 1 dose if born after 1956
  5. Rubella Vaccine
    1. Fertile woman without proof of Immunity
  6. Tuberculin Skin Test (Purified Protein Derivative)
    1. Recommended for high risk patients for Tuberculosis
  7. Hepatitis B Screening and Immunization
    1. See Hepatitis B Vaccine for Immunization indications
    2. See Hepatitis B Serology for screening indications
    3. Universal Hepatitis BVaccination is recommended for all unimmunized adults age <59 years
  8. HPV Vaccine
    1. Included in Primary Series and indicated to age 26 (age 45 if high risk) in men and women
  9. Meningococcal Vaccine
    1. Included in Primary Series (at ages 11-12, and booster at age 16-18)
    2. Consider in unvaccinated adults with risk factors (e.g. military barracks, HIV Infection, travel to high risk areas)
  10. Shingles Vaccine (Herpes Zoster Vaccine)
    1. Two doses for over age 50 years
  11. Varicella Vaccine
    1. Adults born after 1980 without confirmed Immunity
  12. CDC Immunization Schedules
    1. http://www.cdc.gov/vaccines/recs/schedules/default.htm

XIII. References

  1. Heidelbaugh (2018) Am Fam Physician 98(12): 729-37 [PubMed]
  2. Heidelbaugh (2012) Am Fam Physician 85(10): 964-71 [PubMed]
  3. Paladine (2021) Am Fam Physician 103(4): 209-17 [PubMed]
  4. Riley (2012) Am Fam Physician 87(1): 30-7 [PubMed]

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