General Medical Examination in Adults

General Medical Examination in Adults

Synopsis

Pitfalls

• Periodic health examinations may lead to harms 
  • Potential harms include:
    • Overdiagnosis and resultant unnecessary treatments
    • Adverse psychological effects
    • Complications related to follow-up investigations
    • Negative behavioral effects (eg, failure to quit smoking after learning that screening CT findings were normal)

• General medical examination (well visit) in adults is a periodic patient encounter focused on risk assessment and primary and secondary prevention
  • Appropriate components of the visit will vary with patient age, sex, and individual risk factors
  • Objective is to deliver appropriate screening tests and prevention counseling
  • Patient encounter is general rather than focused
    • Typically includes consideration of screening for more than 1 disease or risk factor in more than 1 organ system
• Although systematic general health checks are commonly performed, a Cochrane review of 17 randomized trials (in more than 250,000 adults) found that they are unlikely to be beneficial 
  • Little or no effect on:
    • Total mortality (risk ratio, 1.00; 95% confidence interval, 0.97-1.03)
    • Cancer mortality (risk ratio, 1.01; 95% confidence interval, 0.92-1.12)
    • Cardiovascular mortality (risk ratio, 1.05; 95% confidence interval, 0.94-1.16)
    • Fatal and nonfatal ischemic heart disease (risk ratio, 0.98; 95% confidence interval, 0.94-1.03)
    • Fatal and nonfatal stroke (risk ratio, 1.05; 95% confidence interval, 0.95-1.17)
  • Study authors suggest that apparent lack of effect may be because primary care physicians at previous encounters have already identified and screened patients suspected to be at high risk for developing disease

Classification

• Terminology varies for these encounters; other descriptors include general health check, periodic health examination, annual physical, and wellness visit
  • May be part of systematic national or health insurance programs in some countries

Clinical Presentation

History

• History is reviewed to identify elements that increase individual’s risks for disease
  • Review may identify the need for additional screening and preventive measures beyond those recommended for the general adult population
• Risk assessment includes the following elements:
  • Health-related behaviors and lifestyle practices
    • Diet
    • Physical activity level
    • Unhealthy substance use
      • Tobacco products
      • Excessive alcohol
      • Recreational drugs
        • Brief screening tools/questions are most useful in a primary care setting 
          • Some tools screen for a variety of forms of substance use disorder in a single group of questions; for example, NIDA Modified-ASSIST (National Institute on Drug Abuse Quick Screen) asks 4 questions about use of alcohol, tobacco, nonmedical prescription drugs, and illegal drugs in the past year; available electronically 
    • Sexual behaviors that may increase risk of sexually transmitted infection
  • Mental and emotional health
    • Depression
      • PHQ-2 (Patient Health Questionnaire 2) is a 2-question screening tool that comprises the first 2 questions of the longer, diagnostic PHQ-9 questionnaire

Over the past 2 weeks, how often have you been bothered by:
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Points are assigned as follows (cut-off point for positive depression screening is 3 points):
Not at all: 0 points
Several days: 1 point
More than half of days: 2 points
Nearly every day: 3 points

Citation: Data from Mitchell AJ et al: Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies. BJPsych Open. 2(2):127-38, 2016; and Kroenke K et al: The patient health questionnaire-2: validity of a two-item depression screener. Med Care. 41(11):1284-92, 2003.

• Personal medical history
  • Chronic diseases
  • Known cardiovascular risk factors
  • Personal history of cancer
  • Birthplace and current and former countries/areas of residence
    • Residence in some areas may increase risk of certain infectious diseases (eg, tuberculosis, hepatitis B)
  • Immunization history to identify need for additional vaccines
• Family medical history
  • Cardiovascular diseases
  • Cancers
    • Especially important to obtain family history of the following:
      • Colorectal cancer
      • Breast, ovarian, tubal, and peritoneal cancer in females
      • Pancreatic cancer
      • Prostate cancer
    • Family history may place patient in a higher risk category and influence screening strategy and screening test interval
    • National Comprehensive Cancer Network has published both general and specific guidance for determining need for genetic counseling and/or genetic testing for some cancer susceptibility genes depending on family history 

Physical examination

• Physical examination as performed as part of a periodic health examination will vary. Most parts of a complete physical lack supporting evidence for improved health outcomes
• Measure blood pressure in all adults; however, recommended repeat screening interval varies 
  • Adults aged 40 years or older and those at increased risk for high blood pressure: screen annually
  • Adults aged 18 to 39 years with a prior normal blood pressure reading who do not have other risk factors: screen every 3 to 5 years
• Measure weight and height; calculate BMI 
  • Screen annually (or more frequently)
  • Reasonable to measure waist circumference to identify those at higher cardiometabolic risk 
• Cognitive examination
  • US Preventive Services Task Force found insufficient evidence to recommend for or against cognitive testing in adults aged 65 years or older without recognized signs or symptoms of cognitive impairment
  • Medicare Annual Wellness Visit requires an assessment of patient’s cognition, which can be done by direct observation during the patient encounter 
    • Alternatively, a brief, structured, validated tool can be used; several are available from the National Institute on Aging website 
      • Mini-Cog is a 3-minute screening with 2 components: a 3-item recall test for memory and a clock-drawing test 
• Some aspects of a physical examination in the setting of a periodic health encounter are controversial; the patient may or may not expect that aspect of the examination to be performed
  • Breast examination for females
    • Recommendations for performing clinical breast examination vary
    • American Cancer Society does not recommend clinical breast examination for breast cancer screening among average-risk females at any age (qualified recommendation) 
    • National Comprehensive Cancer Network recommends a clinical encounter with a breast examination performed every 1 to 3 years for females aged 25 to 39 years and annually for females aged 40 years or older 
  • Pelvic examination for females
    • American College of Obstetricians and Gynecologists recommends that pelvic examinations be performed when indicated by medical history or symptoms; the decision to perform this examination should be based on shared decision making and may also be performed if a patient expresses a preference for the examination 
    • Data are inadequate to support a recommendation for or against performing a routine screening pelvic examination among asymptomatic, nonpregnant females who are not at increased risk for any specific gynecologic condition 
  • Digital rectal examination
    • For prostate cancer screening
      • Digital rectal examination is not sufficient as a stand-alone screening test, but consider it in addition to prostate-specific antigen testing because early malignancy occasionally presents as a palpable nodule before prostate-specific antigen level is elevated 
    • For obtaining fecal occult blood testing as a colorectal cancer screening
      • Not recommended to obtain such testing via a single guaiac-based test (very low sensitivity) 
        • Instead, guaiac-based testing requires 3 successive stool specimens or 1 fecal immunochemical test

Screening

Screening tests

• Adults (excludes recommendations related to pregnancy planning, pregnancy, and breastfeeding)
  • Cancer screening
    • Breast cancer
      • Screening guidelines for females at average risk vary with respect to when to initiate screening, how to determine screening interval, and when to stop screening
      • American Cancer Society does not recommend clinical breast examination for breast cancer screening among average-risk females at any age (qualified recommendation) 
      • National Comprehensive Cancer Network recommends a clinical encounter with a breast examination performed every 1 to 3 years for females aged 25 to 39 years and annually for females aged 40 years or older 
      • US Preventive Services Task Force recommends biennial screening mammography for females aged 50 to 74 years (US Preventive Services Task Force grade B); the decision to start screening mammography in females before age 50 years should be an individual one 
      • American College of Physicians recommendations are similar to the US Preventive Services Task Force and state that clinicians should discuss risks and benefits of earlier screening mammography (ages 40-49 years) with the patient and should discontinue screening at age 75 years or when life expectancy is 10 years or less 
      • American Cancer Society and the National Comprehensive Cancer Care Network recommend earlier and more frequent screening mammograms for females at average risk 
        • American Cancer Society 
          • Screening mammography starting at age 45 years (strong recommendation), with a qualified recommendation to offer the opportunity for screening at age 40 to 44 years. Continue annual screening to age 54 years, and then transition to biennial screening as long as overall health is good and life expectancy is 10 years or more (qualified recommendation)
        • National Comprehensive Cancer Care Network 
          • Screening mammography beginning at age 40 years and continued annually without a specific upper age limit; consider life expectancy (and whether therapeutic breast cancer interventions would be undertaken) when determining whether to screen
    • Cervical cancer
      • Screening for cervical cancer is not recommended in females younger than 21 years or older than 65 years (unless prior screening was inadequate or patient is at high risk) 
      • For females aged 21 to 29 years, screen every 3 years with cervical cytology (Papanicolaou test) alone (US Preventive Services Task Force grade A) 
      • For females aged 30 to 65 years, several screening schedules can be followed depending on test modality chosen (US Preventive Services Task Force grade A); can use 1 of the following: 
        • Test every 3 years with cervical cytology alone
        • Test every 5 years with high-risk HPV testing alone
        • Test every 5 years with high-risk HPV testing in combination with cytology (cotesting)
    • Colorectal cancer
      • Screening recommendations apply to people of average risk who do not have any of the following: 
        • Personal history of colorectal cancer or adenomatous polyps
        • Family history of colorectal cancer
        • Personal history of inflammatory bowel disease (ie, ulcerative colitis or Crohn disease)
        • Confirmed or suspected hereditary colorectal cancer syndrome (eg, familial adenomatous polyposis, Lynch syndrome [hereditary nonpolyposis colon cancer])
        • Personal history of radiation to abdomen or pelvic area to treat a prior cancer
      • For patients at average risk, screen for colorectal cancer starting at age 45 years and continue until age 75 years (US Preventive Services Task Force, American Cancer Society) 
      • Limited evidence supports screening Black patients starting at age 45 years 
      • Decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account patient’s overall health and previous screening history (US Preventive Services Task Force grade C; American Cancer Society) 
      • Screening tests
        • Stool-based tests include:
          • Guaiac-based fecal occult blood test
          • Fecal immunochemical test
          • Fecal immunochemical test with DNA test
        • Direct visualization tests include:
          • Colonoscopy
          • CT colonography (virtual colonoscopy)
          • Flexible sigmoidoscopy
          • Flexible sigmoidoscopy combined with fecal immunochemical test
        • US Multi-Society Task Force of Colorectal Cancer recommends colonoscopy as a first-tier test, with fecal immunochemical test offered as an alternative to patients who refuse colonoscopy 
          • Other tests are considered second-tier owing to various disadvantages relative to first-tier tests
        • Patients with positive results on any noncolonoscopic colorectal cancer screening require referral for colonoscopy
      • Screening interval
        • Fecal immunochemical test annually or every 2 years 
        • Highly sensitive guaiac-based fecal occult blood test annually or every 2 years 
        • Fecal immunochemical test with DNA test every 3 years 
        • CT colonography every 5 years 
        • Flexible sigmoidoscopy recommended intervals vary:
          • Every 5 years (American Cancer Society) or every 5 to 10 years (US Multi-Society Task Force of Colorectal Cancer) 
          • Every 10 years when combined with fecal immunochemical test every 2 years 
        • Colonoscopy every 10 years 
    • Lung cancer
      • Screening test: low-dose CT
      • Screening interval: annually
        • Discontinue once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (US Preventive Services Task Force grade B) 
      • US Preventive Services Task Force recommends annual screening for lung cancer with low-dose CT in adults aged 50 to 80 years who have a 20-pack-year smoking history (or more) and currently smoke or have quit within the past 15 years 
      • National Comprehensive Cancer Network and American College of Chest Physicians have also published lung cancer screening recommendations
    • Prostate cancer
      • Prostate cancer screening is controversial and recommendations vary. If screening is elected, it should be prostate-specific antigen–based
        • Digital rectal examination alone is insufficient
      • The most recent US Preventive Services Task Force recommendation is for individualized decision making for males aged 55 to 69 years, based on discussion of harms and benefits (US Preventive Services Task Force grade C). No screening is recommended for males aged 70 years or older 
        • US Preventive Services Task Force does not make separate, specific recommendation about prostate-specific antigen–based screening in Black patients or in those with a family history of prostate cancer. It is possible that screening may offer greater benefits to both groups
      • American Urological Association also recommends individualized decision making and makes the following specific age-based recommendations regarding prostate-specific antigen screening: 
        • Younger than 40 years: do not routinely screen
        • Aged 40 to 54 years and at average risk: do not routinely screen
        • Aged 40 to 54 years and at higher risk (eg, positive family history or Black race): explain harms and benefits to patient and individualize screening decision based on discussion
        • Aged 55 to 69 years: explain harms and benefits to patient and individualize screening decision based on discussion. Screening every 2 years may be preferred over annual screening because it preserves most benefits of screening and reduces overdiagnosis and false-positive results
        • Aged 70 years or older, and any patient with less than 10- to 15-year life expectancy: no routine screening
      • National Comprehensive Cancer Network recommends earlier baseline testing, with subsequent frequency determined by risk estimated on the basis of the initial test result 
        • Begin informed testing at age 45 years (age 40 for Black patients) and continue to age 75 years unless current life expectancy is less than 10 years; testing may be continued in very healthy patients after age 75 years

Recommended screening	Sex	Age group	Screen all those at average risk OR screen only those with risk factors?	Risk factor	Recommended screening interval
Mental health, substance misuse, and safety
Depression	Males and females	Adult, senior	All (grade B)	N/A	Optimal interval unknown; use clinical judgment
Unhealthy drug use	Males and females	Adult, senior	All (grade B)	N/A	Optimal interval unknown; use clinical judgment
Unhealthy alcohol use	Males and females	Adult, senior	All (grade B)	N/A	Optimal interval unknown; use clinical judgment
Intimate partner violence	Females	Reproductive age	All (grade B)	N/A	Optimal interval unknown; use clinical judgment
Cancer
Breast  cancer*	Females	50 to 74 years	All (grade B)	N/A	Biennial
BRCA1/BRCA2 familial risk assessment (refer to genetic counselor if positive) (grade B)	Females	Adult, senior	With risk factor (grade B)	Personal or family history of breast, ovarian, tubal, or peritoneal cancer or an ancestry associated with BRCA1/BRCA2 gene mutations	N/A
Cervical  cancer	Females	21 to 65 years	All (grade A)	N/A	Aged 21 to 29 years: cytology every 3 years; aged 30 to 65 years: cytology alone every 3 years, hrHPV alone every 5 years, OR hrHPV in combination with cytology every 5 years
Colorectal cancer*	Males and females	45 to 75 years	All (aged 50-75 years: grade A, aged 45-49 years: grade B)	N/A	Varies depending on screening test
Lung cancer*	Males and females	50 to 80 years	With risk factor (grade B)	Tobacco smoking history (20 pack-years or more) and currently smoke or have quit within the past 15 years	Annual
Cardiovascular and Metabolic
High blood pressure	Males and females	18 years and older	All (grade A)	N/A	Annual for those aged 40 years or older or at higher risk; every 3 to 5 years for those aged 18 to 39 years
Abnormal blood glucose levels/type 2 diabetes*	Males and females	40 to 70 years	With risk factor (grade B)	Overweight or obese	Optimal screening interval is uncertain if initial screening findings normal; consider every 3 years
Abdominal aortic aneurysm (grade B)	Males	65 to 74 years	With risk factor (grade B)	Ever smoker	Screen once
Osteoporosis*	Females	65 years and older	All (grade B)	N/A	No specific interval recommended
Osteoporosis*	Females	Younger than 65 years	With risk factor (grade B)	Increased risk based on formal clinical risk assessment tool	No specific interval recommended
Infectious disease
Hepatitis B	Males and females	Adolescent, adult	With risk factor (grade B)	In general, risk is related to residence in an area of high prevalence, injecting drug use, coinfection with HIV, and sexual practices (males who have sex with males)	Periodic screening in patients with ongoing risk
Hepatitis C	Males and females	18 to 79 years	All (grade B)	N/A	Screen once unless continued risk for infection
HIV	Males and females	15 to 65 years	All (grade A)	N/A	Repeated screening is reasonable for persons at increased risk; optimal strategies/intervals are uncertain
HIV	Males and females	Older than 65 years	With risk factor (grade A)	Males who have sex with males; anal intercourse without a condom; vaginal intercourse without a condom and with more than 1 partner whose HIV status is unknown; exchanging sex for drugs or money; injecting drug use; sex with individual who is HIV positive or who uses injecting drugs	Repeated screening is reasonable for persons at increased risk; optimal strategies/intervals are uncertain
Gonorrhea and chlamydia	Females	Younger than 25 years	All sexually active (grade B)	N/A	Repeat screening if sexual history reveals new risk factor since the last negative test result
Gonorrhea and chlamydia	Females	25 years and older	Sexually active with additional risk factor (grade B)	Previous STI; new sex partner; more than 1 sex partner; sex partner with concurrent partners; sex partner who has an STI; inconsistent condom use among persons who are not in mutually monogamous relationships; and exchanging sex for money or drugs	Repeat screening if new or persistent risk factors are present since last negative test result
Syphilis	Males and females	Adolescent, adult	With risk factor (grade A)	Males who have sex with males; males and females with HIV infection; persons presenting to STI clinics; persons with current or past exposure to communities with increased prevalence (eg, prisons, sex workers)	Optimal screening frequency for persons at increased risk for syphilis infection is not well established. Males who have sex with males or persons living with HIV may benefit from more frequent screening (eg, every 3 months)
Latent tuberculosis	Males and females	All ages	With risk factor (grade B)	Foreign-born individuals from (or individuals residing in) areas of high disease prevalence; those at risk for progression to active disease if latent tuberculosis is present (eg, immunosuppressed patients including all those with HIV infection)	Depending on specific risk factors, screening frequency could range from 1-time-only screening among persons who are at low risk for future tuberculosis exposure to annual screening among those who are at continued risk of exposure

Caption: *1 or more specialty organizations have published screening recommendations which may differ from US Preventive Services Task Force recommendations. hrHPV, high-risk human papillomavirus; N/A, not applicable; STI, sexually transmitted infection.

Citation: Data from US Preventive Services Task Force: A and B Recommendations. USPSTF website. Updated May 18, 2021. Accessed May 25, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations

• Cardiovascular and metabolic disease screening
  • Overall cardiovascular risk
    • Routinely assess cardiovascular risk for adults aged 40 to 75 years by calculating 10-year atherosclerotic cardiovascular disease risk; a calculator is available from the American Heart Association. It is also reasonable to periodically assess in younger adults 
      • Blood pressure, weight, and total and HDL cholesterol levels are required to estimate risk
      • 10-year risk is used to guide lifestyle modifications and management of elevated cholesterol
  • Hypertension
    • Screen for high blood pressure in adults aged 18 years or older (US Preventive Services Task Force grade A) 
    • Screening test: office-based pressure measurement with manual or automated sphygmomanometer (ambulatory blood pressure measurement is not recommended for screening but can be helpful with confirming diagnosis)
    • Screening interval: 
      • Adults aged 40 years or older and people at increased risk for high blood pressure: screen annually
      • Adults aged 18 to 39 years with a prior normal blood pressure reading who do not have other risk factors: screen every 3 to 5 years
  • Diabetes
    • Screen adults with overweight or obesity and aged 35 to 70 years for abnormal blood glucose level as part of cardiovascular risk assessment (US Preventive Services Task Force grade B) 
    • Several professional society guidelines recommend screening all adults beginning at age 45 years 
    • Regardless of age, consider screening any overweight adult when additional risk factors are present, such as: 
      • Physical inactivity
      • First-degree relative with diabetes
      • High-risk race or ethnicity (eg, Black, Latino, Native American, Pacific Islander, Asian American)
      • Other cardiovascular risk factors (or history of cardiovascular disease), including hypertension or dyslipidemia
      • Polycystic ovary syndrome
    • Screening tests: hemoglobin A1C, fasting plasma glucose level, or oral glucose tolerance test
    • Screening interval:
      • US Preventive Services Task Force, American Diabetes Association, and American Association of Clinical Endocrinology suggest screening adults with normal blood glucose levels every 3 years 
  • Abdominal aortic aneurysm
    • Screen once for abdominal aortic aneurysm in males aged 65 to 75 years who have ever smoked (US Preventive Services Task Force grade B) 
      • Screening of males in this age group who have never smoked can be considered based on personal and family medical history and other risk factors (US Preventive Services Task Force grade C)
      • Screening of females who have never smoked (and have no family history) is not recommended (US Preventive Services Task Force grade D). Evidence is insufficient to make a recommendation for females who have smoked or who have a family history of abdominal aortic aneurysm
    • Society for Vascular Surgery recommendations differ from those of US Preventive Services Task Force 
      • 1-time screening for abdominal aortic aneurysms in males or females aged 65 to 75 years with history of tobacco use; screen older males or females with history of tobacco use (and in otherwise good health) who have not previously received a screening ultrasonographic examination
      • Screen first-degree relatives who are aged 65 to 75 years, and screen persons older than 75 years who are in good health
    • Screening test: ultrasonography
    • Screening interval: 1 time
  • Osteoporosis screening
    • Multiple specialty societies and the US Preventive Services Task Force have published recommendations regarding screening 
    • Females
      • All postmenopausal females aged 50 years or older: perform a comprehensive assessment for osteoporosis and fracture risk, using detailed history, examination, and (foremost) FRAX assessment (Fracture Risk Assessment Tool) ⁴²
      • Postmenopausal females younger than 65 years who are at increased risk based on additional risk factors: assess 10-year risk of major osteoporotic fracture using FRAX questionnaire and calculator; this includes questions about previous DXA results but does not require this information to estimate fracture risk ³⁸
      • Females aged 65 years or older: measure bone mineral density (US Preventive Services Task Force grade B) ³⁸
    • Males
      • US Preventive Services Task Force does not recommend screening in males, given the insufficient evidence ^38 43
        • Recommendations from other groups vary
        • Consider screening if other risk factors are present
    • Screening test: most guidelines recommend central (hip and lumbar spine) DXA to measure bone mineral density ³⁸
    • Screening interval: no specific testing interval is recommended; consider age and baseline bone mineral density
• Infectious disease screening
  • Gonorrhea and chlamydia
    • Screen: ⁴⁴
      • Sexually active females aged 24 years or younger (US Preventive Services Task Force grade B)
      • Older females who are at increased risk for infection (US Preventive Services Task Force grade B), including those with:
        • Previous sexually transmitted infection
        • New sex partner
        • More than 1 sex partner
        • Sex partner with concurrent partners
        • Sex partner with a sexually transmitted infection
        • Inconsistent condom use who are not in mutually monogamous relationship
        • History of exchanging sex for money or drugs
      • Evidence is insufficient to recommend routine screening in men
    • Screening test: nucleic acid amplification test
    • Screening interval: screen patients whose sexual history presents new or persistent risk factors since the last negative test result
  • Syphilis
    • Screen for syphilis in people considered high risk (US Preventive Services Task Force grade A), including: 
      • Males who have sex with males
      • Males and females with HIV infection
      • People presenting to sexually transmitted infection clinics
      • People with current or past exposure to communities with increased prevalence (eg, prisons, sex work)
    • Screening test: VDRL or rapid plasma reagin test 
      • A positive VDRL or rapid plasma reagin test result must be confirmed with a test for treponemal antigens (Treponema pallidum particle agglutination test or fluorescent treponemal antibody absorption)
    • Screening interval: not established 
      • Males who have sex with males and people with HIV infection may benefit from more frequent screening (ie, every 3 months rather than annually)
  • HIV
    • Screen for HIV infection in adolescents and adults aged 15 to 65 years. Also screen younger adolescents and older adults who are at increased risk of infection (US Preventive Services Task Force grade A). CDC recommends that screening begin at age 13 years 
      • People outside the 15- to 65-year age range who are at increased risk include:
        • Males who have sex with males
        • People who:
          • Have anal intercourse without a condom
          • Have vaginal intercourse without a condom and with more than 1 partner whose HIV status is unknown
          • Exchange sex for drugs or money
          • Inject drugs
      • Encourage patients and their prospective sex partners to be tested before initiating a new sexual relationship 
    • Screening test: fourth generation HIV-1 and HIV-2 antigen/antibody combination immunoassay 
      • Patients with nonreactive status (ie, negative results for HIV antibodies and p24 antigen) are considered to be HIV-negative unless patient has had exposure within the previous 3 weeks
    • Screening interval: patients considered to be at high risk should be tested at least annually 
  • Hepatitis B
    • Screen for hepatitis B infection in people at high risk for infection (US Preventive Services Task Force grade B) 
      • CDC has published guidance on identifying those at high risk 
        • In general, risk is related to residence in high-prevalence region, injection drug use, coinfection with HIV, and some sexual practices (males who have sex with males)
    • Screening test: HBsAg and related tests 
    • Screening interval: varies based on risk status
  • Hepatitis C
    • Screen adults aged 18 to 79 years for hepatitis C infection (US Preventive Services Task Force grade B) 
      • Also screen other patients at high risk, including those younger than 18 years. Specialty organizations have published joint guidance to identify those considered at high risk 
    • Screening test: anti-HCV with reflex HCV-RNA polymerase chain reaction testing 
    • Screening interval: 1 time 
      • Periodically repeat screening in adults who are at continued risk for hepatitis C infection; annual testing is recommended for those who inject drugs and for HIV-infected males who have unprotected sex with males 
  • Latent tuberculosis
    • Screen for latent tuberculosis infection in populations at increased risk (US Preventive Services Task Force grade B) 
      • Generally includes foreign-born persons from or residing in areas of high disease prevalence as well as those at risk for progression to active disease if latent tuberculosis is present (eg, immunosuppressed patients, including all those with HIV infection). Specific guidance is available from the CDC
    • Screening test: either a tuberculin skin test or an interferon-γ release assay (but not both) 
    • Screening interval: depends on specific risk factors. 1-time screening is likely sufficient for those at low risk for continued exposure to tuberculosis. Annual screening may be reasonable for those with continued exposure risk 

Grade	Definition	Suggestions for Practice
A	The USPSTF recommends the service. There is high certainty that the net benefit is substantial	Offer or provide this service
B	The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial	Offer or provide this service
C	The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small	Offer or provide this service for selected patients depending on individual circumstances
D	The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits	Discourage the use of this service
I Statement	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined	Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms

Caption: USPSTF, US Preventive Services Task Force.

Citation: From US Preventive Services Task Force: Grade Definitions. USPSTF website. Reaffirmed June 2018. Accessed September 2, 2020. https://www.uspreventiveservicestaskforce.org/uspstf/grade-definitions

Prevention

• Counseling and other preventive interventions for adults
  • Healthful diet and physical activity for cardiovascular disease prevention
    • Emphasize a diet primarily of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish 
    • Emphasize minimal intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages
    • Recommend at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity 
    • For patients with risk factors, offer to refer to intensive behavioral counseling interventions (US Preventive Services Task Force grade B)
      • If patient has overweight or obesity, counseling and caloric restriction are recommended to help patient achieve and maintain weight loss 
  • Tobacco smoking cessation
    • Behavioral and pharmacotherapy interventions
      • Advise smoking cessation, providing (or referring for) behavioral interventions and FDA-approved pharmacotherapy 
  • Pharmacologic therapy for primary prevention of atherosclerotic cardiovascular disease
    • Low-dose aspirin (75-100 mg daily) should be used infrequently in the routine primary prevention of arteriosclerotic cardiovascular disease owing to lack of net benefit. Can be considered for some adults aged 40 to 70 years who are at higher cardiovascular risk but not at increased bleeding risk 
  • Sexually transmitted infections prevention
    • Counsel all sexually active adults who are at increased risk for sexually transmitted infections 
  • Skin cancer prevention
    • Counsel young adults (younger than 25 years) with light skin about minimizing exposure to UV light to decrease risk of skin cancer. Offer counseling to older adults selectively because net benefit is small in this group 
  • Falls prevention counseling and intervention for community-dwelling older adults
    • Recommend exercise (eg, supervised individual or group classes, physical therapy) for older adults (65 years or older), especially when there is a history of previous falls, altered gait, or limited mobility 
  • Administer vaccines, if needed, according to published immunization schedules