Adult Health Maintenance

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.

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

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)

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

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.

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

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)

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