Periodic Health Examination

The purpose of the periodic health examination is to evaluate health status, screen for risk factors and disease, and provide preventive counseling interventions in an age-appropriate manner. The goal of screening and evaluation is to prevent the onset of disease or the worsening of an existing disease. For example, measurement of blood pressure is intended to detect hypertension so as to initiate treatment and prevent subsequent morbidity (e.g., stroke or renal failure) or mortality. A further goal of the periodic health examination is to educate patients about behavioral patterns or environmental exposures that pose risks for future diseases. Examples include counseling about smoking prevention and cessation to prevent lung cancer and emphysema, seat belt use to prevent motor-vehicle injuries, or modifying sexual practices to prevent the spread of sexually transmitted disease.

In the 1920s the American Medical Association first proposed a yearly, routine physical examination (check-up) for healthy patients. However, there have always been questions about exactly what to include in routine check-ups, and whether they are beneficial. An important principle of clinical medicine is to "do no harm." This is a particular concern when considering testing and counseling in well persons. In 1976, the Canadian Task Force on the Periodic Health Examination was formed to provide a systematic evaluation and recommendations about periodic health exams. The United States Preventive Services Task Force (USPSTF) was formed in 1984 to provide similar guidelines in the United States. The most recent recommendations of the USPSTF for evaluation, screening, and counseling interventions were published in 1996. Input was provided by primary-care medical societies, the U.S. Public Health Service, and the Canadian Task Force on the Periodic Health Examination. These recommendations are based on available evidence of safety and efficacy, and are tailored for patients based upon their individual age, gender, and risk-factor characteristics. Key summary findings of the USPSTF include:

1. Effective interventions that address the patient's individual health behaviors are most important for preventing the leading causes of death and disability (e.g., interventions to prevent smoking, alcohol, and other drug use; encourage use of seat belts; and encourage increased physical activity and appropriate nutrition).
2. The patient and clinician should share responsibility for weighing risks and benefits when deciding about screening and diagnostic testing and preventive interventions.
3. To maximize benefits and avoid doing harm, clinicians should be selective in choosing screening tests and other preventive services for their patients.
4. Special efforts should be taken to provide preventive services to people with less access to care.
5. Community-level public health and public-policy interventions may be more effective for some health problems than interventions delivered in the clinical setting (e.g., community educational interventions to prevent the initial onset of cigarette smoking by children, and seat belt use legislation).

Tables 1, 2, and 3 show the recommended components of the periodic health examination for children, women, and men. The clinical preventive services addressed in these tables are in the areas of immunizations, screening, and counseling. The following are some examples of preventive services offered in these categories, for specific groups.

Immunizations

Immunizations play an important role in the periodic health examination of young children. Haemophilus influenzae type B vaccine is an example of the importance of immunization for children. Haemophilus influenzae type B (Hib) is a bacterial organism that can cause invasive infections (such as meningitis, blood and soft tissue infections, and pneumonia) with a high risk of morbidity or mortality, particularly in infants in the first year of life, with 85 percent of disease occurring in children under five years of age. Prior

Table 1

to the development of effective vaccines, Hib was the leading cause of bacterial meningitis in children under five years of age, and about 500 out of every 100,000 children developed invasive Hib infections. Since the introduction of the Hib vaccine, in 1987, the incidence of invasive Hib disease has decreased by more than 95 percent, to about two per 100,000 children. Currently, immunization recommendations for children include administration of Hib vaccine at two, four, six, and fifteen months of age. Administration is clustered in the age group at highest risk for getting Hib disease, and at the youngest ages that the vaccines produce an effective immune response.

Screening

A careful history and a physical examination are important parts of the periodic health examination. The patient history elicits recent and current symptoms or complaints; medications being taken (and any allergies to medications); an accounting of the past medical history of the patient; the social factors that may impact on the health of the patient (e.g., marital status, household makeup, employment); a family history of illnesses affecting family members; and a review of signs and symptoms for each of the organ systems in the body. The physical examination consists of three modalities to gather information: inspection, auscultation, and palpation. These methods are applied in a systematic way to the major systems of the body. Inspection involves observation of the body part being examined. The general appearance, color, and any other visual characteristics are noted. Auscultation involves listening, often with the aid of a stethoscope. The quality of any sound is noted, including loudness, musical tones, and effect of change in position. Palpation involves feeling both the size and texture of organs under examination. The major areas of the body to be examined are the head and neck, chest, abdomen, extremities, skin, musculoskeletal system, and nervous system. Using the three modalities in conjunction with the patient's medical history and screening tests allows an assessment of the overall health of a patient.

Table 2

Screening involves the utilization of a diagnostic procedure to check for the presence of a disease prior to the manifestation of clinical symptoms. Hypertension is a risk factor for coronary heart disease, stroke, and renal disease. Hypertension in adults is defined as having a systolic blood pressure greater than 140 mmHg (millimeters of mercury) and/or a diastolic blood pressure of greater than 90 mmHg on at least three separate occasions. It is well established that decreases in elevated blood pressure, particularly an average 5 to 6 mmHg reduction in diastolic blood pressure reduces the incidence of coronary heart disease and stroke. By measuring the blood pressure at routine health examinations for adult men and women, as shown in Tables 2 and 3, the presence of hypertension can be detected and treatment can be instituted, prior to the development of further complications of the disease. Treatments include weight and diet modification, increased physical activity, assessment for other risk factors or concomitant disease, and prescription of

Table 3

pharmacologic therapy according to clinical standards of care.

Counseling

Counseling during the periodic health examination is also very important, for this is where physicians recommend changes in lifestyle that can affect future morbidity and mortality. One example is the recommendation that folic acid be taken by women of childbearing age (see Table 2). Folic acid supplementation has been shown to decrease the risk of neural tube defects in newborn infants, especially among women who have had a prior pregnancy with a child with a neural tube defect. The current recommendations of the United States Public Health Service, the American Academy of Pediatrics, and the Canadian Task Force on the Periodic Health Examination is that all women of childbearing age who are capable of becoming pregnant take 0.4 mg of folic acid daily. It is also recommended that women who have had a previous pregnancy affected by a neural tube defect and who are planning to become pregnant again be offered treatment with four mg of folic acid daily, beginning one to three months prior to planned conception and continuing through the first three months of pregnancy.

The periodic health examination is a vital part of health care in the United States. As new information reveals improved methods of detecting and preventing disease and risk factors for disease, and of reducing the morbidity and mortality from illness, clinicians will be able to continue to improve the effectiveness of the periodic health examination.

(SEE ALSO: Assessment of Health Status; Blood Pressure; Canadian Task Force on Preventive Health Care; Child Health Services; Folic Acid; Haemophilus Influenzae Type B Vaccine; Immunizations; Influenza; Personal Health Services; Prevention; Preventive Medicine; Primary Care; United States Preventive Services Task Force [USPSTF])

Bibliography

Canadian Task Force on the Periodic Health Examination (1994). Canadian Guide to Clinical Preventive Health Care. Ottawa: Canada Communication Group.

Committee on Infectious Diseases American Academy of Pediatrics (2000). 2000 Red Book: Report of the Committee of Infectious Diseases, 25th edition. Elk Grove Village, IL: American Academy of Pediatrics.

Green, M., ed. (1994). Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. Arlington, VA: National Center for Education in Maternal and Child Health.

U.S. Preventive Services Task Force (1996). Clinician's Handbook of Preventive Services, 2nd edition. Washington, DC: U.S. Department of Health and Human Services.

—— (1996). Guide to Clinical Preventive Services, 2nd edition. Washington, DC: U.S. Department of Health and Human Services.

— LEE RACHEL ATKINSON; THOMAS N. ROBINSON