Dear Dr. Lauro,
I am forty years old and healthy. My husband is fifty years old and is also healthy but does have diabetes in his family history. How often should we have check-ups and what tests should we have done?
The idea that physicians can detect certain diseases through routine health screening and check-ups is not new. However, with the extensive epidemiological research that has been done in the past thirty years, we have become much more skilled in knowing what to look for and thus are able to detect many diseases while they are yet in their earliest stages. So, by being good medical detectives we can be vigilant for very subtle clues in the medical history and the physical exam which then allow us to be in a position to pick up many serious and potentially life-threatening diseases while they are still in their earliest stages. Of course, discovering a disease when it is first getting started makes it much more treatable.
With these epidemiological studies in mind physicians have been able to put together certain screening schedules for the general population. In other words, we can suggest to the patient when it is best to have a physical exam, how often and how extensive these exams should be, and what lab tests and diagnostic studies should be performed. These routine health maintenance exams, as they are called, are scheduled according to one’s age, sex, family history, and lifestyle.
I will only be addressing adult medicine in this article. At a future date we will discuss pediatric screening, immunizations, etc.
Health Maintenance for the Young Woman:
For the average young woman who is eighteen years of age and not yet sexually active, a routine check-up with your family doctor (or gynecologist if you already have one) should occur about every three years. A pelvic exam and Pap smear is not indicated if one is not sexually active (one of the rewards of chastity!).
At this visit a brief medical history is obtained which assesses any current medical complaints. The diet and personal habits (such as smoking, drinking alcohol, drug use, sexual history, etc.) are then discussed. We also ask about past medical history (whether the patient has ever had an operation, a blood transfusion, or has ever been admitted to the hospital for a serious illness). We discuss which medications are being taken. We talk about whether the patient is participating in any athletics and whether they are getting enough exercise. We briefly discuss other lifestyle choices that could be risky such as scuba diving, parachuting, mountain climbing, and travel to foreign areas. The physician will also review immunization status. Usually most young adults have had a tetanus booster at the age of fifteen and most have had the hepatitis A and B immunizations.
The physician will inquire as to the patient’s social situation. For example, how many siblings does the patient have? Where is this child in the line-up of the other children? How is this young adult getting along at home, how is school going, and what are the plans after high school such as college, marriage, mission, or the armed forces? Next, the family history is obtained looking for genetically transmissible diseases, such as heart attack, stroke, diabetes, cancer, etc.
Finally the actual physical exam begins. The physician generally will measure the height and weight of the patient to assess the body mass index, which tells us whether the patient is medically obese or not. The physician will check the blood pressure and the pulse rate and then perform a limited hands-on exam checking the head, eyes, ears, nose, throat, neck, heart, lungs, breasts, abdomen and extremities. A simple urinalysis is done looking for sugar, protein, blood, mucus, and white cells (the latter can indicate infection in the urine.) I also recommend that the young woman have a simple blood test checking for cholesterol levels and a blood count looking for anemia, especially in those young women who have heavy and frequent periods.
At this point, if everything checks out normally, the young woman is done with her check-up for three years. However, should the young woman become sexually active, either through marriage or because of other “less fortunate choices,” then she would need to return for a Pap smear and pelvic exam. At that time we would also discuss the need for and different types of birth control that are available. After two consecutive annual Pap smears, if normal, the sexually active young woman may then have her exam every three years, until the age of forty.
The Eighteen-Year-Old Young Man:
The young man, when age eighteen, is also seen in the office for his first -up. The approach is very similar to the young woman in that a medical history is taken (current medical problems and complaints, medications, past medical history, family history, social history, personal habits, plans for the immediate future such as education, mission, etc.). A review of immunization status is obtained. A hands-on exam is performed. A genital exam is necessary because of the high risk of testicular cancer in young men. A rectal exam is not done at this time unless indicated by rectal complaints. A urinalysis is also obtained and a blood test for cholesterol is performed.
The young man is then finished with physical exams for three years. If the young man plans on a mission then this eighteen-year-old check-up usually satisfies the church’s requirement for pre-mission health evaluation. Most physicians will cut the prospective missionary some slack and not make them come back for another check-up. However, when the missionary returns home at age twenty-one an exam is usually recommended. If a young man goes away to college, the eighteen-year-old exam can also fulfill the school requirement for health evaluation. A young man is generally seen every three years until the age of forty, unless a new problem develops.
The Forty Year Old:
At the age of forty the pace of routine health screening picks up. Both men and women are now seen every two years in the office for check-ups (until the age of fifty). Once again, patients are administered a medical history questionnaire in which the physician specifically enquires about changes in their health, new complaints or problems, medications taken, and changes in their recent medical history such as new operations, accidents, admissions to the hospital for serious illnesses, etc. We really begin emphasizing cardiovascular risk at this age and discuss in detail the risk factors for heart attack, stroke, etc. Cancer warning signs are discussed and evaluated (change in a mole or a new skin lesion; a new lump in the skin, breast, or elsewhere; a new unexplained cough, especially if it brings up blood; change in bowel habits or type or size of stool; rectal bleeding; urinary bleeding; l bleeding; unexplained weight loss; or profound fatigue). The social history is updated. The patient is asked about habits once again (smoking, drinking, drug use, family relations, marital situation, employment). We also focus on the amount of exercise the patient is getting. We pay close attention to the diet and the patient’s weight. Immunization status is again addressed, as the patient should be having tetanus shots every ten years.
The routine physical exam at age forty also includes a rectal exam for the first time and checking the stool for microscopic (occult) blood; in men a prostate exam is also done at this time. If there is a strong family history of colon cancer, a colonoscopy is ordered as well.
Otherwise, this is not done until age fifty.
Once again, lab tests are done including a simple urinalysis looking for sugar, protein, red blood cells, and white blood cells. Blood is obtained to check cholesterol levels and blood sugar (for diabetes). Women at age forty are encouraged to have their first mammogram. This is done earlier if there is strong family history of breast cancer or if any abnormalities have been found in the breast through patient self-examination or during the routine physicals that have occurred every three years in the past. Remember, a Pap smear was also supposed to be performed every three years from age twenty on. In the forties, patients should also be seeing their eye doctors periodically for glaucoma screening.
Fifty and Older:
At age fifty every patient should have a colonoscopy, which screens for colon cancer. Women should be getting mammograms every year at this point and Pap smears every three years. The physician also discusses menopause and hormone replacement therapy with the women (both the pros and cons). We again urge the patient to do self-examinations for breast cancer.
Patients are encouraged to maintain a healthy weight and to also exercise. We again discuss in detail the patient’s cardiovascular risk factors (high blood pressure; elevated blood fats, especially LDL cholesterol; diabetes; smoking; sedentary life style; family history); In men, the rectal exam again includes a prostate exam–this began at age forty and occurs at every visit hereafter. At age fifty men are given their first prostate antigen test for prostate cancer. This should be done every year thereafter. At age fifty the physician should also start checking the carotid arteries with his stethoscope, listening for early occlusions of the carotids in the neck. These are the main arteries that supply the brain, and narrowing or occlusion of these arteries puts one at higher risk for embolic stroke. In the fifties and thereafter the physician should also be paying close attention to the patient’s extremities by palpating the arteries in the groin area, behind the knees, and in the feet. We are looking for obstructions in arterial flow. The physician pays close attention to the heart rate and blood pressure, looking for elevated blood pressure (hypertension) and cardiac abnormalities such as new murmurs or irregular heart rhythm. The lungs are listened to very closely to see if the patient has any narrowing of the airways which would indicate emphysema, asthma, etc. The breasts are palpated carefully looking for masses or lumps. The abdomen is palpated very closely looking for liver enlargement, spleen enlargement, and any abdominal masses or lumps (both in the abdomen or on the other organs, such as the kidneys). And as I mentioned above, a rectal exam and stool testing for occult blood is mandatory, as well as prostate exam for men. In the fifties the patient is also given the opportunity to start having pneumonia vaccines (every five years) and influenza shots (yearly). Don’t forget to have a tetanus shot every ten years.
If you have your routine check-ups with a qualified physician according to the above schedule you will vastly improve your odds of finding diseases while they are yet in their earliest stages and thus quite treatable. The value of routine health screening reminds me of that commercial where the mechanic is holding a $10 oil filter in his hand and says, “You can pay me now,” (camera focused on the inexpensive oil filter) “or you can pay me later!” (the camera shifts to an engine receiving a major overhaul). Our bodies really are quite similar: you can take care of yourself now by having your routine check-ups, with relatively little expense and hassle, or you can just go along your merry way and wait for the “big one” to hit you, at which time you will pay a lot and also be greatly inconvenienced and potentially very sick (or dead!). Best wishes.
