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
- History Taking: Review of patient's medical, family, and social history.
- 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).
- Counseling/Anticipatory Guidance:
- Lifestyle advice (diet, exercise).
- Risk factor reduction (smoking cessation, alcohol use).
- 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.