Adult Health Maintenance

Health care maintenance is the examination of asymptomatic individuals and screening for any occult disease. The process provides an opportunity for disease prevention and early diagnosis and the possibility of preventing progression and complications. During a health care maintenance examination, the primary physician conducts a thorough personal, social, and family history with a comprehensive systematic review to uncover any relevant risk factors. A physical examination is performed, and relevant screening exams are recommended. Screening tests cover malignancies (breast, prostate, colon, lung) and other conditions, including diabetes, cardiovascular diseases, and infections. Immunizations are administered if indicated. Different interventions are discussed to help reduce health risk factors, and health goals are set to determine future follow-up and monitoring.

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General Assessment

History

  • Obtain information on any patient concerns.
  • Past medical history: Include any conditions being treated currently or in the past. 
  • Past surgical history: Include inpatient and outpatient procedures.
  • Allergies: Note the allergy and reaction.
  • Current medications: 
    • Dose, frequency, and reason for taking
    • Ask about supplements and over-the-counter medications. 
  • Family history: 
    • Any known conditions in both 1st-degree (parent, child, sibling) and 2nd-degree relatives (grandparents, uncles/aunts, cousins)
    • If deceased, include cause of death if known.
  • Social history:
    • Marital status and number of children
    • Household/home environment (of everyone who lives in the home)
    • Use of alcohol, tobacco, and recreational drugs
    • Employment/occupation
    • Diet and physical activity 
    • Sexual activity: orientation, number of partners, use of protection
  • Review of systems: questions regarding possible symptoms (past or present) in every organ system

Physical exam

  • Vital signs: BP, heart rate, temperature, respiratory rate + oxygen saturation
  • General measurements:
    • Height
    • Weight
    • BMI (calculated as kg/m²):
      • Below normal: < 18.5
      • Normal: ≥ 18.5 to < 25
      • Overweight: ≥ 25 and < 30
      • Obese: ≥ 30
    • Waist circumference (in some instances)
  • Constitutional: 
    • Alertness
    • Appearance (e.g., well nourished, thin, ill appearing, unkempt)
  • Head, eyes, ears, nose, throat (HEENT): 
    • Head lesions
    • Conjunctiva, eye motility, and reactivity
    • External ear and otoscopic exam, including gross hearing
    • Oral mucosa, throat, dental features
    • Nasal appearance, presence of lesions or congestion
  • Neck: lymph nodes, thyromegaly, and ease of mobility 
  • Cardiovascular: any murmurs, abnormalities in heart rate or rhythm, extremity edema, and weakened or absent peripheral pulses
  • Respiratory: respiratory effort and any abnormalities on auscultation
  • Breasts: any lumps/masses, tenderness, abnormal coloration, or nipple discharge; include axillary findings
  • Gastrointestinal: bowel sounds, masses, tenderness, liver/spleen enlargement, swelling/distension, and hernias; include rectal exam
  • Genitourinary: bladder, pelvic exam
  • Musculoskeletal: Assess mobility of joints in upper and lower extremities as well as the spine.
  • Neurologic: Assess cranial nerve function, strength/weakness in extremities, and deep tendon reflexes.
  • Skin: Assess for any new or changing lesions or rash. 
  • Psychiatric: Assess orientation to place and time, mood, temperament, and judgment.

Screening for Metabolic Disorders

Hypertension

  • The United States Preventive Services Task Force (USPSTF) recommends BP measurement in all adults ≥ 18 years of age.
  • Ensure appropriate cuff size for accurate measurement.
  • Normal BP: < 120/80 mm Hg
  • Check BP at least every 2 years or with each visit.
  • Annual screening is recommended for the following individuals:
    • Age ≥ 40 years of age 
    • High-risk factors such as being African American or overweight/obese
    • BP of 120–139/80–89 mm Hg
  • Confirm measurements outside the clinical setting before initiating medication.
Table: Categories of high BP
CategorySystolic BPDiastolic BP
Elevated BP120–129 mm HgAND < 80 mm Hg
Hypertension stage 1130–139 mm HgOR80–89 mm Hg
Hypertension stage 2 ≥ 140 mm HgOR≥ 90 mm Hg
If there is a disparity between the stages of systolic and diastolic BP, the higher number determines the stage.
A healthcare professional performing blood pressure monitoring on a patient

Blood pressure check by a health care professional

Image: “A healthcare professional performing blood pressure monitoring on a patient” by rawpixel.com. License: CC0

Dyslipidemia

Dyslipidemia is defined as lipid values associated with an increased risk of and/or presence of disease for which the initiation of lipid-lowering therapy will be of benefit.

  • USPSTF recommendations for lipid screening:
    • Screen individuals between 40 and 75 years of age.
    • No recommendations for or against screening for dyslipidemia in individuals < 35 years of age
  • Centers for Disease Control and Prevention (CDC) recommends cholesterol testing at age ≥ 20 years.
  • It is still recommended to obtain baseline lipid testing in young adults at initiation of care with an adult primary care provider. Repeat screening is guided by the patient’s cardiovascular disease risk:
    • In high-risk patients (history of diabetes, hypertension, smoker, obesity, family history of premature heart disease):
      • Follow-up lipid in men between the ages of 25 and 30 years
      • Follow-up lipid in women between the ages of 30 and 35 years
    • In low-risk patients:
      • Follow-up lipid in men at age 35 years
      • Follow-up lipid in women at age 45 years
  • Assessment of cardiovascular disease risk and lipid levels are recommended to be repeated:
    • Generally every 5 years 
    • Every 3 years if near the threshold for treatment

Cardiovascular disease risk

  • Statin for primary prevention:
    • Addition of statins for primary prevention is influenced by the atherosclerotic cardiovascular disease risk, which is calculated as a percentage based on:
      • Patient age
      • Systolic BP
      • Total cholesterol and high-density lipoprotein cholesterol
      • Hypertension on medications
      • Cigarette smoking
      • Diabetes
    • Low-to-moderate-dose statin is recommended by the USPSTF for the prevention of cardiovascular disease in adults aged 40 to 75 years with:
      • ≥ 1 cardiovascular disease risk factor (dyslipidemia, diabetes, hypertension, or smoking)
      • A 10-year atherosclerotic cardiovascular disease risk ≥ 10%
  • Aspirin for primary prevention:
    • Low-dose daily aspirin use is recommended by the USPSTF in adults 50–59 years of age to prevent cardiovascular disease in patients with:
      •  > 10% 10-year atherosclerotic cardiovascular disease risk
      • No increased risk for bleeding
      • Life expectancy ≥ 10 years
      • Willingness to take low-dose aspirin daily for ≥ 10 years
    • After age 59 years, discussion with the clinician is recommended to determine if low-dose aspirin is ideal way to begin preventing cardiovascular disease.

Diabetes

  • USPSTF recommends checking glucose levels in overweight or obese adults aged 40–70 years of age via 1 of the following tests:
    • Fasting glucose
    • HbA1c
    • Oral glucose tolerance test 
  • Normal values:
    • Fasting glucose < 100 mg/dL
    • HbA1c < 5.7%
    • Oral glucose tolerance test < 140 mg/dL
  • Impaired glucose tolerance (prediabetes):
    • Fasting glucose: 100–125 mg/dL
    • HbA1c: 5.7–6.4%
    • Oral glucose tolerance test: 140–199 mg/dL
  • Diabetes
    • Fasting glucose ≥ 126 mg/dL
    • HbA1c ≥ 6.5%
    • Oral glucose tolerance test ≥ 200 mg/dL
  • Optimal screening time is debatable, but suggested to re-screen at least every 3 years
  • Consider starting screening at an earlier age in persons with the following risk factors:
    • Family history of diabetes
    • History of gestational diabetes
    • History of other conditions associated with diabetes:
      • Hypertension
      • Acanthosis nigricans
      • Dyslipidemia
      • Polycystic ovarian syndrome
    • Member of certain groups: 
      • Native Americans
      • Asian Americans 
      • Native Hawaiians/South Pacific Islanders
      • Hispanics
      • African Americans

Screening for Malignancies

Cervical cancer screening

USPSTF recommendations:

  • Routine cytology screening every 3 years starting at age 21 years, regardless of sexual history 
  • For ages 21–29 years: cytology alone every 3 years
  • For ages 30–65 years, options are:
    • Cervical cytology alone every 3 years
    • High-risk HPV every 5 years
    • Cytology with high-risk HPV co-testing every 5 years 

Screening is not recommended in:

  •  Women < 21 years of age, regardless of sexual activity
  • Women > 65 years of age who have had adequate screening previously and are not high risk
Pap smear showing cervical cancer

Papanicolaou (Pap) smear showing cervical cancer: Pap staining in a patient with squamous carcinoma, exhibiting clusters of cohesive cells with marked nuclear enlargement, pleomorphisms, hyperchromatism, and keratinization (X40)

Image: “Pap smear showing cervical cancer” by Department of Pathology, Muhimbili University of Health and Allied Sciences (MUHAS), P,O, Box 65001, Dar es Salaam, Tanzania. License: CC BY 2.0

Breast cancer screening

USPSTF recommendations for average-risk individuals:

  • For women aged 50–74 years: Screening mammography is recommended every 1–2 years. 
  • For women aged 40–49 years, the decision to start biennial screening is individualized (made via shared decision-making between patient and provider).

USPSTF recommendations for high-risk individuals:

  • High-risk individuals include women with:
    • Personal history of breast, ovarian, tubal, or peritoneal cancer
    • Ancestry (associated with BRCA1 and BRCA2)
  • Familial risk assessment tool is recommended.
  • If positive, a referral for genetic counseling and possibly genetic testing should be provided.
  • Timing of screening modalities depend on the personal and family history of genetic mutations, high-risk syndromes, and history of chest radiotherapy.
  • Modalities include:
    • Clinical breast exam
    • Mammogram
    • Breast MRI
  • Risk reduction:
    • Chemoprevention: risk-reducing medications (tamoxifen or aromatase inhibitors) recommended for women ≥ 35 years of age
    • Prophylactic mastectomy: offered to those with high-risk genetic mutations (BRCA1 or BRCA2 carriers)
Woman receiving mammogram

Woman having a mammogram

Image: “Woman Receives Mammogram” by Rhoda Baer. License: Public Domain

Colorectal cancer screening

The USPSTF recommends screening for colorectal cancer (CRC) in adults to be initiated at age 45 years.

Screening methods include:

  • Annual high-sensitivity guaiac-based fecal occult blood test (HS-gFOBT)
  • Annual fecal immunochemical test (FIT)
  • Stool DNA-FIT test every 3 years
  • Flexible sigmoidoscopy every 5 years (limited to distal part of the colon)
  • Flexible sigmoidoscopy every 10 years plus annual FIT
  • Colonoscopy every 10 years
  • CT colonography every 5 years
  • A positive screening stool-based test, CT colonography, or sigmoidoscopy warrant a colonoscopy.

Individuals requiring more frequent screening and before 45 years of age (depending on the condition):

  • Individuals with a family history of colorectal cancer 
  • Individuals with hereditary colorectal cancer syndrome
  • Personal history of inflammatory bowel disease
  • History of radiation to the abdomen or pelvis

The USPSTF recommends daily low-dose aspirin for primary prevention of CRC (and cardiovascular disease) for individuals aged 50–59 years who have:

  • No bleeding risk 
  • At least 10 years of life expectancy
  • ≥ 10% risk of 10-year cardiovascular disease risk
Colonoscopy

Colonoscopy: This colon cancer screening procedure is generally recommended to start at the age of 50 years (45 years based on American Cancer Society recommendations) for average-risk individuals.

Image: “Colonoscopy procedure” by United States Navy. License: Public Domain

Lung cancer screening

  • Screening recommendation: annual low-dose CT of the lung
  • Patient selection based on organization recommendations:
    • USPSTF 2020 recommends lung cancer screening for (must meet all criteria):
      • Adults aged 50–80 years
      • 20 pack-year smoking history
      • Current smoker or has quit within the past 15 years
    • The American Cancer Society recommends screening for (must meet all criteria):
      • Adults aged 55–74 years
      • 30 pack-year smoking history
      • Current smoker or has quit within the past 15 years
    • Other organizations have similar recommendations, although there is variability in the age range.
Low-dose CT for lung cancer screening adenocarcinoma

Low-dose CT screening image (left) and follow-up diagnostic CT image (right) for a patient diagnosed with adenocarcinoma

Image: “Low-dose CT scan screening for lung cancer: comparison of images and radiation doses between low-dose CT and follow-up standard diagnostic CT” by Ono K, Hiraoka T, Ono A, Komatsu E, Shigenaga T, Takaki H, Maeda T, Ogusu H, Yoshida S, Fukushima K, Kai M. License: CC BY 2.0

Prostate cancer screening

  • USPSTF recommendations:
    • Men aged 55–69 years should: 
      • Discuss potential benefits and harms with their clinician
      • Consider age, family history, race/ethnicity, comorbid conditions, and life expectancy
      • Make an individual decision about screening
    • Men ≥ 70 years: 
      • Benefits do not outweigh the expected harms.
      • Should not be routinely screened for prostate cancer
    • Men who do not express a preference for screening should not be screened.
  • PSA blood test alone recommended for screening, if elected, every 1–2 years
  • Digital rectal examination (DRE) is not recommended as a screening tool with or without PSA test.

Screening for Sexually Transmitted and Blood-borne Diseases

HIV screening and prevention

The USPSTF recommends screening for HIV in:

  • All individuals aged 15–65 years
  • Patients < 15 years of age or > 65 years of age who are high risk 
  • Men who have sex with men (screened annually or even more frequently depending on risks)
  • All pregnant women

An HIV pre-exposure prophylaxis (PrEP) with antiretrovirals is recommended for high-risk individuals.

Chlamydia and gonorrhea screening

  • Recommended for all sexually active women ≤ 24 years of age
  • Recommended for older women who are considered higher risk (new sexual partner, multiple sex partners, unprotected sex in non-monogamous relationship)

Other diseases

  • Syphilis: recommended for persons in high-risk groups (history of previous sexually transmitted disease, multiple sex partners, men who have sex with men)
  • Hepatitis B screening: recommended for those in high-risk groups (injection drug users, engagement in high-risk sexual activities)
  • Hepatitis C screening: all adults age 18–79 years

Miscellaneous Screenings

Alcohol and tobacco use

  • Tobacco/cigarette use:
    • Inquire about tobacco use in any form.
    • Discuss health risks, determine readiness for cessation, and offer interventions to aid in cessation.
  • Alcohol abuse/misuse:
    • Inquire about amounts and frequency of alcohol use in ≥ 18 years of age.
    • Further screening can be done via the CAGE questionnaire or similar screening tool:
      • Ever feel the need to Cut down on drinking?
      • Ever feel Annoyed by others criticizing your drinking?
      • Ever feel Guilty about your drinking?
      • Have you ever needed a drink first thing in the morning (Eye-opener) to steady yourself or combat a hangover?
    • If screen is positive, behavioral counseling interventions are recommended.

Obesity

  • BMI should be a part of health maintenance examination.
  • Individuals with BMI > 30 should be offered behavior interventions (e.g., nutrition consult) and counseling to promote weight loss.

Domestic violence and depression

  • Intimate partner violence:
    • Screen all women of child-bearing age.
    • If screen is positive, referral to interventional services should be provided. 
  • Depression:
    • USPSTF recommends screening all adults (including pregnant and postpartum women) for depression using a validated tool.
    • If positive, assess for suicidality and provide further evaluation and management.

Abdominal aortic aneurysm

  • Only in men aged 65–75 years who have any history of smoking tobacco 
  • 1-time ultrasonography
Ultrasonography of abdominal aortic aneurysm

Abdominal aortic aneurysm screening: abdominal ultrasonography in the sagittal plane showing an abdominal aortic aneurysm with axial plane diameter (red dashed line), and maximal diameter in the sagittal plane (dotted yellow line)

Image: “Ultrasonography of abdominal aortic aneurysm” by Mikael Häggström, M.D. License: CC0

Osteoporosis

  • Recommended for women aged ≥ 65 years for prevention of osteoporotic fractures
  • Consider screening in postmenopausal women < 65 years of age if considered high risk (smoker, alcohol abuse).
  • Bone mineral density screening using DEXA scan
  • There are conflicting data regarding recommendations for men:
    • USPSTF states that there is not enough evidence to support screening in men.
    • Other organizations (such as the Endocrine Society) recommend screening:
      •  All men > 70 years of age
      • Men 50–70 years of age with risk factors (glucocorticoid therapy, androgen deprivation treatment for prostate cancer, hypogonadism, primary hyperparathyroidism)
Morbus Fabry DEXA

Dual-energy X-ray absorptiometry assessment of bone mineral density of the femoral neck (A) and the lumbar spine (B):
T scores of –4.2 and –4.3 (consistent with osteoporosis) were found at the hip (A) and lumbar spine (B), respectively, in a 53-year-old man affected with Fabry disease.

Image: “DEXA” by Dr Caroline LEBRETON, CHU Raymond Poincaré, Garches, France. License: CC BY 2.0

Vaccinations

Influenza vaccine

Vaccines:

  • Inactivated vaccine
  • Live attenuated vaccine (intranasal): 
    • Only approved for use in individuals 2–49 years of age
    • Should not be given to individuals who are pregnant, immunocompromised, have functional or anatomic asplenia, or have cochlear implants

Influenza vaccine is recommended to be given annually to all adults ≥ 18 years of age unless they have a history of allergic reactions to components.

Tetanus, diphtheria, and pertussis vaccination

Vaccines:

  • Tdap
  • Td

In the United States:

  • Tdap or Td is given intramuscularly every 10 years to all adults with complete prior immunization to tetanus and diphtheria.
  • If the adult has not been vaccinated against tetanus and diphtheria, a 3-vaccine series is initiated with Tdap as the preferred 1st dose, followed by Td or Tdap.

Older adults:

  • Likely to have decreased antibodies either from not having the initial vaccine or from not receiving the subsequent booster doses
  • Thus, Tdap is important for all older adults, especially those in contact with children under 1 year of age: 
    • Tdap may be given 1 time, to replace the Td booster.
    • Tdap can be administered regardless of the interval since the last Td booster.

Special indications:

  • 1-dose Tdap is also given with each pregnancy.
  • 1-dose Td or Tdap is also given in the setting of severe wound or burn, if it has been at least 5 years since the last booster.

Measles, mumps, and rubella vaccination

Vaccines:

  • Live virus vaccines against measles, mumps, and rubella
  • 2 formulations:
    • Measles, mumps, rubella (MMR)
    • Measles, mumps, rubella, varicella (MMRV)

General principles:

  • Measles and mumps component:
    • If born before 1957, individuals are generally considered immune to measles and mumps. 
    • This does not apply to health care personnel, who need documentation of immunity.
  • Rubella component:  
    • Immunity in adulthood is not guaranteed.
    • Women of childbearing age should have lab testing for immunity.

Recommendations:

  • 1 dose is recommended for most adults if with no evidence of immunity and/or born after 1957.
  • 2 doses recommended for certain populations if with no evidence of immunity:
    • Health care personnel
    • Students in postsecondary educational institutions
    • International travellers
    • Patients with HIV (without severe immunocompromise)
    • Hematopoietic cell transplant patients 2 years after transplant and without immunosuppressive therapy or active graft-versus-host disease
  • Women of childbearing age:
    • Those with no evidence of immunity should get vaccinated while not pregnant.
    • Those who are pregnant and with no evidence of immunity should be vaccinated upon completion of pregnancy.

Human papillomavirus vaccination

  • In the United States, only Gardasil 9 (9-valent vaccine) is available.
  • Indicated for adults up to age 26 years: 
    • If received a single dose between ages 9–14 years and/or a 2nd dose was given less than 5 months apart, 1 more dose is needed.
    • If no previous vaccinations given before 15 years of age, 3 doses should be given at 0, 1–2, and 6 months of age. 
  • Shared decision-making recommended regarding vaccinating adults aged 27–45 years
  • Not approved for use in individuals > 45 years of age

Pneumococcal vaccine

Vaccines:

  • Pneumococcal polysaccharide vaccine (PPSV) 23: contains 23 pneumococcal polysaccharides
  • Pneumococcal conjugate vaccine (PCV): made of pneumococcal capsular polysaccharides
    • PCV13: 13 capsular types
    • PCV7 (Prevnar7): 7 capsular types

In adults aged 19–64 years with an increased risk of pneumococcal infection and complications, a dose of PPSV 23 is indicated for those with:

  • Heart disease (not including hypertension)
  • Chronic liver disease
  • Chronic lung disease
  • Alcoholism
  • Cigarette smoker

In adults aged 19–64 years of age, both PCV13 and PPSV23 are recommended for individuals:

  • Who have increased risk for meningitis:
    • CSF leak
    • Cochlear implant
    • History of pneumococcal meningitis
  • Schedule: PCV13 then 1 dose of PPSV23 ≥ 8 weeks after

In adults aged 19–64 years of age, PCV13 and 2 doses of PPSV23 are recommended in individuals with:

  • Impaired splenic function (asplenia, splenectomy, sick cell disease, hyposplenism)
  • Other immunocompromising diseases:
    • HIV
    • Chronic kidney disease
    • Hematologic malignancy (leukemia, lymphoma)
    • Solid tumor malignancies with or without metastasis
    • Solid organ and hematopoietic cell transplantation
    • Immunosuppressive medications
    • Congenital or acquired immunodeficiency
  • Schedule: PCV13, then 1st PPSV23 ≥ 8 weeks after; 2nd PPSV23 5 years after 1st PPSV23 dose

In all immunocompetent adults ≥ 65 years of age:

  • 1 dose of PPSV23 is recommended.
  • If PPSV23 was given before age 65 years, give due dose at least 5 years after the prior administration.

PCV13 in adults ≥ 65 years of age:

  • Recommended for those who have not received the vaccine previously and if with immunocompromising diseases and impaired splenic function
  • PCV13-type of disease has declined significantly in the ≥ 65-year-old age group because of pediatric vaccinations.
  • Thus, for immunocompetent patients, shared decision-making is recommended regarding PCV13 vaccination.
  • If it is decided that PCV13 is to be administered, PCV13 is given 1st followed by PPSV23 after ≥ 1 year.

Varicella and herpes zoster vaccine

Varicella vaccine:

  • Formulations:
    • Single-antigen varicella vaccine (live)
    • MMRV
  • Indicated for adults with no history of chickenpox or evidence of immunity
  • Single-antigen vaccine: 2 doses given, 1 to 2 months apart

Herpes zoster vaccine:

  • Vaccine: 
    • Shingrix (recombinant zoster vaccine)
    • 2 doses, given 2 to 6 months apart
  • Indicated for adults ≥ 50 years of age to decrease risk of developing herpes zoster (shingles) and postherpetic neuralgia
  • Vaccine should be given irrespective of previous vaccination or disease history.

Other vaccines

  • Hepatitis A vaccine:
    • 2-dose series recommended for high-risk individuals
    • Indications: chronic liver disease, IV drug user, travel to endemic areas
  • Hepatitis B vaccine: 
    • 2 or 3 doses, depending on vaccine, are recommended for high-risk individuals.
    • Indications: chronic liver disease such as hepatitis C infection, HIV infection, IV drug use, high-risk sexual behavior, health care personnel
  • Haemophilus influenzae type b vaccine: 
    • 1 dose (inactivated vaccine)
    • Indications: anatomic or functional asplenia or recipient of hematopoietic stem cell transplant
  • Meningococcal vaccine:
    • In the United States: quadrivalent meningococcal conjugate vaccines (inactivated)
    • Indicated for college students and military recruits living in residential housing if not previously vaccinated at age 16 years or older
  • Also indicated for those with anatomic or functional asplenia

Additional Preventative Counseling

Lifestyle

  • Healthy diet and physical activity encouraged to decrease risk of cardiovascular disease and associated risk factors:
    • At least 150 minutes of moderate-intensity exercise per week, or 75 minutes of vigorous activity per week
    • Participation in strengthening exercises recommended at least twice per week
  • Ultraviolet (UV) radiation exposure: Counsel adults, especially fair-skinned individuals, to minimize sun exposure to decrease risk of skin cancer.
  • Sleep hygiene:
    • Recommendation is to obtain at least 7–8 hours sleep per night
    • Maintain a regular sleep schedule.
    • Avoid stimulants (e.g., caffeine) and electronic screens (e.g., phones, laptops) before bed.

Sexual health and contraception

  • Counseling on safe sex practices
  • If patient is interested in contraception, discuss contraceptive options, methods, effectiveness, risks/benefits, and possible side effects.
  • Folic acid supplementation recommended in women of child-bearing age to prevent neural tube defects in offspring

References

  1. American Cancer Society (2020). Guideline for colorectal cancer risk. American Cancer Society. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html
  2. American Academy of Family Physicians (2019). Adult preventative health care schedule: Recommendations from the USPSTF. Am Fam Physician. https://www.aafp.org/dam/AAFP/documents/journals/afp/USPSTFHealthCareSchedule2019.pdf
  3. Centers for Disease Control and Prevention. (2021). Immunization schedules. CDC. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
  4. Cox, J., Palefsky, J. (2020). Human papillomavirus vaccination. UpToDate. Retrieved March 14, 2021, from https://www.uptodate.com/contents/human-papillomavirus-vaccination
  5. Heidelbaugh, J. J. (2018). The adult well-male examination. Am Fam Physician. 98(12): 729-737. Retrieved March 1,  2021, from  https://www.aafp.org/afp/2018/1215/p729.html
  6. Hibberd, P. (2020). Measles, mumps, and rubella immunization in adults. UpToDate. Retrieved March 14, 2021, from https://www.uptodate.com/contents/measles-mumps-and-rubella-immunization-in-adults
  7. Hibberd, P. (2021). Seasonal influenza vaccination in adults. UpToDate. Retrieved March 14, 2021, from https://www.uptodate.com/contents/seasonal-influenza-vaccination-in-adults
  8. Musher, D. (2020). Pneumococcal vaccination in adults. UpToDate. Retrieved March 14, 2021, from https://www.uptodate.com/contents/pneumococcal-vaccination-in-adults
  9. Pignone, M. (2021). Management of elevated low density lipoprotein-cholesterol (LDL-C) in the primary prevention of cardiovascular disease. UpToDate. Retrieved March 14, 2021, from https://www.uptodate.com/contents/management-of-elevated-low-density-lipoprotein-cholesterol-ldl-c-in-primary-prevention-of-cardiovascular-disease
  10. Riley, M., Dobson, M., Jones, E., & Kirst, N. (2013). Health maintenance in women. Am Fam Physician. 87(1):30-37. https://www.aafp.org/afp/2013/0101/p30.html
  11. USPSTF(NA) A and B recommendations. USPSTF. Retrieved March 1, 2021, from https://uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations
  12. Vijan, S. (2020). Screening for lipid disorders in adults. UpToDate. Retrieved March 1, 2021, from  https://www.uptodate.com/contents/screening-for-lipid-disorders-in-adults

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