Well-patient care (adult): Clinical sciences

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Introduction 0:00–0:37

The well-patient care visit for adults ranging from 18 to 64 years old is a yearly check-up that promotes physical, mental, and social health while building trust between the healthcare provider and patient.
For all patients, each visit includes a comprehensive history and physical exam, followed by screening and counseling about a variety of topics such as substance use, mental health, interpersonal and domestic violence, and optimizing diet and physical activity.
Additional screening and counseling are provided based on the patient’s age, risk status, and biological sex. When an adult patient presents for well-patient care, begin with a comprehensive history and physical examination.

H&P 0:37–1:04

First, review your patient’s age; past medical history and surgical history; their family history and social history; sexual activity; medications; and diet and exercise habits.
Next, complete a physical examination including height, weight, body mass index, or BMI, and vital signs. Your next step is to provide screening and counseling for all adult patients, regardless of age or risk factors.

Screening and counseling: All patients 1:04–4:45

First, ask about alcohol, tobacco, and substance use through direct conversation with your patient or by using validated questionnaires like the CAGE questionnaire for alcohol misuse, Fagerstrom questionnaire for nicotine dependence, and the Substance Use Brief Screen or SUBS for substance use.
Because alcohol use, tobacco use, and substance use are significant preventable causes of disease, disability, and death, provide counseling and connect your patient to resources and referrals for further intervention and support, as needed.
Next, use a validated questionnaire such as the Generalized Anxiety Disorder 7 scale or GAD-7 to check for anxiety, and the Patient Health Questionnaire-9 or PHQ-9 for depression, both of which are highly common in the adult population.
A positive screening for either condition should prompt further evaluation. Along with medical management, your patient may benefit from counseling interventions, such as cognitive behavioral therapy and interpersonal therapy.
Now moving on, sensitively ask your patient about their relationships to screen for interpersonal and domestic violence, which is prevalent but often goes undetected.
Be alert for certain risk factors that can increase the risk of violence, such as economic hardships, social isolation, and substance use, and be sure to quickly provide resources and counseling referrals.
Next, discuss your patient’s diet and eating habits. Counsel them on a healthy diet to meet nutritional needs, maintain a healthy body weight, and reduce the risk of chronic diseases.
Your patients should focus on consuming nutrient-dense foods and beverages that have little or no added sugar, saturated fat, and sodium.
Okay, let’s move on to exercise. Remind your patient to get at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity aerobic activity and 2 days of muscle strengthening each week.
This will help with weight management, brain health, musculoskeletal health, and reduce the risk of developing chronic diseases including obesity and diabetes.
Also, assess for risk factors for high blood pressure, such as a diet high in sodium, excess weight, and lifestyle factors such as smoking, alcohol consumption, and lack of physical activity.
Provide counseling on how healthy blood pressure can reduce the incidence of cardiovascular and kidney disease. Next, screen for obesity, which is defined as a BMI of 30 or greater.
Because obesity increases the risk of chronic health conditions including cardiovascular disease, type 2 diabetes, liver disease, sleep apnea, and certain types of cancers, provide individualized counseling on weight reduction along with a healthy diet and physical activity.
Okay, now ask your patient about their medication use and screen for polypharmacy, which is defined as the regular use of at least five medications.
Screen patients for inappropriate medications using the Screening Tool of Older Persons’ Prescriptions, also known as STOPP, and the Screening Tool to Alert to Right Treatment, also known as START.
Monitor your patient’s active medication list and eliminate any unnecessary medications to mitigate the risk of adverse drug events.
Next, all patients should be screened for hepatitis C and HIV. Because these can present without symptoms in the early stages, patients are often unaware of their infection status; so, offer hepatitis C and HIV antibody testing, discuss preventative measures including safe sex and avoiding injection of illicit drugs, and talk about how early detection and treatment can prevent complications including cirrhosis, liver cancer, and AIDS.
Okay, now let’s review screening and counseling for high-risk patients. A patient is considered high-risk and in need of further work up and counseling if they have disease-specific risk factors.

Screening and counseling: High-risk patients 4:45–7:38

Let’s start with latent tuberculosis screening for those who have immigrated from countries with increased prevalence of tuberculosis, and those living in high-risk congregate settings such as homeless shelters, prisons, or long-term care facilities.
Counsel these patients to obtain a screening tuberculin skin test or interferon-gamma release assay also known as IGRA. Next up is risk assessment for breast cancer genes BRCA 1 and 2.
Screen patients with a known family history of breast or ovarian cancer; those who previously had breast or ovarian cancer and are now considered cancer-free; as well as patients with high-risk ancestry such as Ashkenazi Jewish ethnicity.
Patients with a positive result on risk assessment should receive genetic counseling and genetic testing. For patients at increased risk of breast cancer based on a breast cancer risk tool, including early menarche, nulliparity, or a history of atypical hyperplasia on breast biopsy, and are at low risk for adverse medication effects, discuss chemoprevention.
Counsel them on medications including tamoxifen, raloxifene, and aromatase inhibitors to reduce the risk of breast cancer for high-risk patients.
Okay, let’s move on to sexually transmitted infections, also known as STIs, for those with risk factors such as having unprotected sex, or multiple or anonymous sex partners.
Because many STIs, like gonorrhea, chlamydia, hepatitis B, hepatitis C, HIV, and syphilis can be asymptomatic, especially in the early stages, screening is key, as these conditions can cause serious conditions including pelvic inflammatory disease, infertility, and cervical cancer.
Counsel these patients on safe sexual practices to prevent STIs and prescribe treatment, as needed. Regarding the hepatitis B virus screening, check a hepatitis B surface antigen in those who have household contacts or sexual partners with hepatitis B infection, and those who are HIV positive, IV drug users, and men who have sex with men.
Again, early detection allows prompt initiation of antiviral therapy to prevent cirrhosis and its complications. Now, those that are at greatest risk of acquiring HIV may benefit from preexposure prophylaxis, also known as PrEP.
High-risk sexually active individuals include those having anal or vaginal sex in the past 6 months with an HIV positive partner, or those who have bacterial STIs including gonorrhea and syphilis, unprotected sex with partners of unknown HIV status, or a history of intravenous drug use.
Okay, next let’s initiate individualized well-patient care based on age. For patients ages 18 to 20, start by reviewing age-appropriate immunizations.

Ages 18 to 20 7:38–8:06

These include COVID-19, influenza, hepatitis B, and HPV. Encourage skin cancer screening for high-risk patients, which includes those with fair skin, light hair and eye color, freckles, and those who sunburn easily.
Counsel patients on behavioral modification for sun protection including moderating sun exposure, using sunscreen, and performing skin self-exams.
On the other hand, if your patient is 21 to 39 years old, review immunization recommendations including COVID-19, influenza, hepatitis B, and HPV.

Age 21 to 8:06–9:07

Again, recommend skin cancer screening for high-risk patients until age 24. Next, recommend a Pap test in biological females for cervical cancer screening, starting at age 21.
Screen these individuals using cytology from age 21 to 29, every 3 years. Here’s a clinical pearl to keep in mind!
Although cytology alone is the most common approach, starting at age 30 you can offer primary HPV testing every 5 years alone or combined with cytology, also known as co-testing.
Alright, now let’s move on to screening for prediabetes and diabetes. If your patient is overweight or obese, check a fasting glucose, hemoglobin A1c, or an oral glucose tolerance test every 3 years, and counsel them on lifestyle interventions to optimize their diet and exercise.
Last up are patients ages 40 to 64. Confirm that your patient is up to date on immunizations per the CDC, including the herpes zoster vaccine, starting at age 50 and respiratory syncytial virus or RSV at age 60.

Age 40 to 64 9:07–11:22

You should also discuss an annual influenza and updated COVID-19 vaccines! Next up is cancer screenings.
First, for biological females, recommend cervical cancer screening using primary HPV testing every 5 years alone or combined with cytology, and breast cancer screening starting at age 40 with biennial mammograms.
Now, for all patients, start screening for colorectal cancer at age 45 using stool-based tests every 1 to 3 years. Alternatively, your patient may opt for direct visualization with a colonoscopy every 10 years, sigmoidoscopy every 5 years, or CT colonography every 5 years.
Recommend lung cancer screening starting at age 50 for individuals with a 20-pack-year smoking history that currently smoke or have quit smoking in the last 15 years via an annual low-dose CT scan of the lungs.
Lastly, for biological males, screen for prostate cancer starting at age 55 with a PSA but keep in mind this should be individualized using shared decision making weighing the benefits and harms.
Again, check for prediabetes and diabetes if overweight or obese by obtaining a fasting glucose, hemoglobin A1c, or oral glucose tolerance test every 3 years and counsel your patient on lifestyle interventions.
For primary prevention of cardiovascular disease, start a moderate intensity statin at age 40 in patients who have one or more cardiovascular risk factors and an estimated 10-year cardiovascular disease risk of 10 percent or greater.
Use the ACC/AHA estimator to calculate their 10-year cardiovascular risk. Finally, discuss bone mineral density testing including DEXA scanning and quantitative ultrasound to prevent osteoporotic fractures in postmenopausal patients younger than 65 who are at increased risk for osteoporosis.
Assess your patient’s clinical risk using the FRAX tool or the Osteoporosis Self-Assessment Tool. Alright, as a quick recap...

Review 11:22–11:56

The well-patient care visit for adults ranging from 18 to 64 years old is a yearly check-up that promotes physical, mental, and social health while building trust between the healthcare provider and patient.
For all patients, each visit includes a comprehensive history and physical exam, followed by screening and counseling about a variety of topics such as substance use, mental health, interpersonal and domestic violence, and optimizing diet and physical activity.
Additional screening and counseling are provided based on the patient’s age, risk status, and biological sex.