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Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnos

CPT4 code

Name of the Procedure:

Initial Comprehensive Preventive Medicine Evaluation and Management (Common names: Annual Physical, Preventive Health Check-Up)

Summary

An initial comprehensive preventive medicine evaluation and management involve a thorough health assessment tailored to age and gender. It includes detailed medical history, physical examination, and counseling on preventive measures. The evaluation may also involve ordering laboratory tests for a complete health profile.

Purpose

This procedure aims to detect early signs of diseases, prevent health problems, and promote a healthy lifestyle. It addresses overall well-being, assesses risk factors, and provides guidance on maintaining or improving health.

Indications

  • No previous comprehensive health evaluation.
  • Routine health maintenance for detecting potential health issues early.
  • Presence of risk factors (e.g., family history of chronic diseases).
  • Age-specific exams (e.g., mammograms, prostate screenings).

Preparation

  • Fasting may be required if blood tests are involved.
  • A list of current medications, allergies, and past medical history should be prepared.
  • No specific physical preparation is typically needed.

Procedure Description

  1. History Taking: Review of patient's medical, family, and social history.
  2. Physical Examination:
    • Vital signs (blood pressure, heart rate, respiratory rate).
    • General appearance and neurological exams.
    • Age/gender-specific exams (e.g., breast exam for females, testicular exam for males).
  3. Counseling/Anticipatory Guidance:
    • Lifestyle advice (diet, exercise).
    • Risk factor reduction (smoking cessation, alcohol use).
  4. Ordering Laboratory Tests:
    • Blood tests (e.g., cholesterol, blood glucose).
    • Depending on age/gender, additional tests (e.g., Pap smear, PSA test).

Duration

Typically 30 minutes to 1 hour.

Setting

Outpatient clinic or primary care physician's office.

Personnel

  • Primary Care Physician (PCP) or General Practitioner (GP)
  • Nurses or Medical Assistants for preliminary measurements and documentation.

Risks and Complications

  • Minimal risk associated.
  • Possible discomfort during certain examinations (e.g., pelvic exam).
  • Rare risk of false-positive or false-negative test results leading to further unnecessary tests or missed diagnosis.

Benefits

  • Early detection of potential health issues.
  • Personalized health advice and preventive measures.
  • Establishment of a baseline for future health monitoring.
  • Overall enhancement of physical and mental well-being.

Recovery

  • No recovery period as it is non-invasive.
  • Immediate return to normal activities.
  • Follow-up appointments if any issues or abnormalities are detected.

Alternatives

  • Targeted health screenings based on specific concerns.
  • Walk-in health clinics, though they may not offer as comprehensive evaluation.
  • Home health kits for specific tests but lack professional guidance and counseling.

Patient Experience

  • Generally well-tolerated.
  • Mild discomfort during certain physical exams or blood draw.
  • Patients typically find it reassuring and informative.
  • Pain management not usually required; comfort measures include a relaxed environment and clear communication from healthcare providers.

Medical Policies and Guidelines for Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnos

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