Periodic Health Examination

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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 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

Clinical Preventive Services for Normal Risk Children
Intervention Birth 2m 4m 6m 12m 15m 18m 2y 4-6y 11-18y
source: Guide to Clinical Preventive Services, 2nd ed. (1996). Alexandria, VA: Report of the U.S. Preventive Services Task Force, International Medical Publishing Inc.
Hepatitis B x x x
Polio x x x x
Haemophilus influenza type B x x x x
Diphtheria, Tetanus, Pertussis x x x x x
Measles, mumps, rubella x x x
Varicella x
Newborn screening (e.g.Hypothyroidism) x
Hearing x
Head circumference x x x x x x x x
Height and weight x x x x x x x x x x
Lead x x
Vision x x x
Blood pressure x x x x x
Dental health x x
Alcohol/Drug use x
Development, nutrition, & safety x x x x x x x x x x
Sexually transmitted diseases x
Tobacco, alcohol, and drug use x

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.


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

Clinical Preventive Services for Normal-Risk Women
Intervention 18-35 years 40-50 years 60+ years
source: Guide to Clinical Preventive Services, 2nd ed. (1996). Alexandria, VA: Report of the U.S. Preventive Services Task Force, International Medical Publishing Inc.
Tetanus-diphtheria (every 10 years) x x x
Varicella (2 doses if none as a child) x x x
Measles, mumps, rubella (1 dose) x x
Pneumococcal (one dose) x
Influenza (yearly) x
Blood pressure, height, weight, dental x x x
Alcohol use x x x
Pap smear (every 1-3years) x x x
Cholesterol (every 5 years) x x
Mammography (every 1-2 years) x x
Sigmoidoscopy (every 5-10 years) x
Fecal occult blood (every year) x
Vision and hearing (periodically) x
Calcium intake x x x
Folic acid x x
Hormone replacement therapy x x
Mammography screening x x
Tobacco, drugs, alcohol, sexually transmitted diseases & safety x x x

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

Clinical Preventive Services for Normal-Risk Men
Intervention 18-35 years 40-50 years 60+ years
source: Guide to Clinical Preventive Services, 2nd ed. (1996). Alexandria, VA: Report of the U.S. Preventive Services Task Force, International Medical Publishing Inc.
Tetanus-diphtheria (every 10 years) x x x
Varicella (2 doses if none as a child) x x x
Pneumococcal (one dose) x
Influenza (yearly) x
Blood pressure, height, weight, dental x x x
Alcohol use x x x
Cholesterol (every 5 years) x x
Sigmoidoscopy (every 5-10 years) x
Fecal occult blood (every year) x
Vision and hearing (periodically) x
Prostate cancer screening x
Tobacco, drugs, alcohol, sexually transmitted diseases & safety x x x

pharmacologic therapy according to clinical standards of care.


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.

Lee Rachel Atkinson

Thomas N. Robinson

(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] )


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.

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Two parallel cultures of health have existed since ancient times: healing (the traditional role of physicians), and staying healthy. Other than public health procedures (e.g., provision of a clean water supply, reduction of overcrowding), serious attempts to prevent illness by interventions on an individual level began only in the twentieth century. The annual physical examination was established as an attempt to detect and treat illnesses before they caused serious harm. The annual physical examination became increasingly complex and comprehensive, including the use of laboratory tests, X rays, and various procedures; culminating, in the 1960s and 1970s, with the executive check-up. Such procedures discovered numerous abnormalities (which occur more frequently, by chance, as the number of tests increases), yet failed to produce overall better health. With this realization, the concept of targeted preventive health care procedures emerged in the 1970s and evolved into the periodic health examination (PHE).

Epidemiologic studies have revealed the most common causes of death among older people to be cardiovascular diseases (especially heart attacks and heart failure), strokes, and malignant diseases (cancers). Disability is produced by a wide range of conditions, including complications of cardiovascular diseases, musculoskeletal disorders (arthritis, fractures), strokes, and problems with the special senses (i.e., hearing and eyesight). Risk factors are phenomena that are associated with disease. For example, tobacco smoking is strongly associated with lung cancer and heart disease. Risk factors may be modifiable (e.g., lowering blood pressure reduces the risk of stroke), or nonmodifiable (e.g., age, family history of certain diseases, genetic disorders). Knowledge of the epidemiology of diseases, their risk factors, and specific treatments has laid the foundation for the study of preventive health care.

The PHE evolved from the annual check-up. It consists of a list of procedures that target specific conditions or their risk factors, and it aims to reduce subsequent illness, disability, and premature death. While the PHE is offered to individuals who visit their personal physicians for the purposes of prevention, components of the PHE may be offered on other, opportunistic, occasions, such as counseling against smoking when an individual consults a physician for cough.

Components of the PHE

A wide range of tests and procedures may be offered as part of a PHE. Physicians and other health care workers have a responsibility to promote only those elements for which there is evidence of more benefit than harm. In North America, two parallel organizations, The Canadian Task Force on Preventive Health Care and the U.S. Preventive Services Task Force, use a rigorous process to weigh the scientific evidence, and they then recommend to physicians whether specific procedures should be included or excluded from the PHE. Other authoritative bodies and societies also issue recommendations, but conflicting recommendations can cause confusion among physicians and consumers of health care. The following elements are commonly included in the PHE.

Counseling. Counseling involves a discussion with an individual to provide advice and encouragement towards a particular behavior. Tobacco use is regarded as one of the most important modifiable risk factors for a wide variety of diseases, including lung cancer, chronic bronchitis, heart disease, strokes, and peripheral vascular disease. Counseling individuals about their smoking practices is effective for reducing the risk of subsequent illness. This advice may be supplemented by additional antismoking aids, such as the use of nicotine patches or gum.

Many individuals in North America, and in the Western world, have unhealthy diets. An excess of saturated fat and inadequate amounts of fibre and calcium are frequent. Counseling to take up a more prudent diet (total fat less than 30 percent of daily intake), increased consumption of fibre (more than 20 grams per day), and 12001500 grams of calcium per day is frequently part of the PHE. Advice may also be offered concerning the use of supplemental vitamins and minerals.

Many older individuals have an inactive lifestyle. There is ample evidence that even modest amounts of exercise improve well-being, muscle strength, bone integrity, and cardiovascular fitness. Individuals are therefore often advised to take up some form of aerobic exercise, such as walking, bicycling, or swimming. Counseling about safety in driving a motor vehicle usually stresses the importance of wearing seat belts and avoidance of alcohol. While small amounts of alcohol have been shown to benefit cardiovascular health, excessive consumption of alcohol is injurious to health. Advice concerning judicious use of alcohol is usually offered together with questions to detect excessive drinking. The risk of injury in the home may also be discussed. Such risks can be minimized by eliminating objects on the floor (e.g., scatter rugs), ensuring correct hot water temperature (49°C, or 120°F) and adequate lighting on stairs and other hazardous areas.

Inoculations. Annual strain-specific influenza inoculations reduce the risk of influenza and reduce mortality and disability from this condition. Influenza inoculations are recommended for all older individuals. Pneumococcal inoculations reduce the risk of pneumonia and other infections caused by the pneumococcus bacteria. This inoculation is usually given every ten years. Although tetanus is very rare in older people, some physicians recommend maintaining immunity with periodic inoculations.

Risk factors for cardiovascular disease. Modifiable risk factors for cardiovascular disease include high blood pressure (hypertension), elevated levels of cholesterol and other lipids (fats), tobacco smoking, and elevated blood-sugar levels (diabetes mellitus). All older individuals should have their blood pressure measured regularly. Treatment for hypertension is usually initiated when the systolic (higher reading) is above 160 (and sometimes 140) or the diastolic (lower reading) is above 90. Older individuals who are at increased risk of heart disease (smokers, diabetics, and those with high blood pressure, strong family history, or symptoms of heart disease) should have blood tests to measure blood cholesterol and lipid levels. Individuals at high risk of diabetes (e.g., overweight, family history) will usually be offered a test for blood-sugar level. Not all of these tests will be required for every older person, and there is some disagreement among authorities about which tests are advisable.

Early detection of malignant diseases. Mammography (breast X rays) and physical examination of the breasts at regular intervals (usually two years) have been shown to reduce deaths from breast cancer. Screening for colorectal (bowel) cancer with stool testing for blood or endoscopy (examining the bowel with a flexible instrument) can reduce the risk of deaths from cancer. Papanicolaou (Pap) test screening of the cervix (neck of the womb) can detect changes that may lead to subsequent cancer. Regular screening for these three cancers is recommended by almost all authorities. Examination of the skin is usually performed to detect changes that may develop into cancer. Tests to detect cancer of the prostate gland are also available, though it is not yet clear whether these tests should be regularly performed on older men.

Screening of special senses. Approximately one-third of older people have difficulty hearing, though they may not be aware of it. A hearing test is recommended as part of the PHE, as is a test of eyesight using a Sight Card (letters of diminishing size) viewed at a fixed distance.

Counseling about hormone replacement. There is mounting evidence that estrogen hormone replacement for women after menopause reduces the risk of osteoporosis, menopausal symptoms, and possibly Alzheimer's disease. Balanced against these benefits is a very slight increased risk of breast cancer with prolonged use of estrogens. There is conflicting evidence on the effects of estrogen replacement on the risk of heart disease. The PHE should therefore include a discussion of hormone replacement therapy and assessment of individual risk prior to a shared decision being made by a woman and her physician.

Miscellaneous conditions. Early detection of physical disabilities (e.g., difficulties walking, climbing stairs, dressing) may be beneficial, as appropriate therapy and additional supports may reduce subsequent disability. Simple tests to detect physical disability are available. Memory tests and inquiry of caregivers about memory problems may be included in the PHE, although the value of such screening remains debatable. For individuals at high risk of osteoporosis (e.g., family history, small frame, female gender, previous fractures), tests for bone density may be offered. Screening for abdominal aortic aneurysm (a swelling of the large artery in the abdomen) may be offered to older men and women with a family history of this condition or risk factor such as hypertension and smoking. Inquiry is sometimes made concerning symptoms of depression, and questions to detect any abuse or neglect by family or other caregivers may also be asked.

Requesting a periodic health examination

The PHE is offered by most primary care physicians. Individuals should feel free to discuss their request for a PHE with their physicians. Some components of the PHE may be offered at times other than during a special visit for prevention. For example, blood pressure will usually be taken during any visit to an emergency ward, and an inquiry will be made about immunization status at these times. Physicians should be willing to provide a PHE and be knowledgeable about the appropriate components as determined by the age and gender of the recipient.

Role of PHE in maintaining health

The PHE is only one component of maintaining good health. It does not replace episodic care (e.g., the usual treatments for acute or chronic conditions). Neither does it replace the responsibility of the individual to maintain a healthy lifestyle, although advice and counseling may reinforce health behaviors. While it is tempting to believe that preventive health care reduces health care costs by preventing illness, this does not appear to be the case, at least not in the short term. With increasing acceptance, and increasing demand by older individuals for preventive health care, benefits of improved health may eventually be followed by reduced health care expenditures.

Christopher J. Patterson

See also Breast; Cholesterol; Eye; Hearing; Heart Disease; High Blood Pressure; Influenza; Osteoporosis; Prostate; Skin.


Canadian Task Force on the Periodic Health Examination. Guide to Clinical Preventive Health Services. Edited by R. B. Goldbloom. Ottawa: Canada Communication Group, 1994.

Lavizzo-Mourey, R.; Day, S. C.; Diserens, D.; and Grisso, J. A. Practicing Prevention for the Elderly. Philadelphia. Hanley & Belfus, 1989.

Patterson, C. "Health Promotion, Screening and Surveillance." In Oxford Textbook of Geriatric Medicine, 2d ed. Edited by J. G. Evans, T. F. Williams, B. L. Beattie, J.-P. Michel, and G. K. Wilcock. Oxford, U.K.: Oxford University Press, 2000. Pages 11261135.

U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2d ed. Alexandria, Va.: International Medical Publishing, 1996.

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