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Secondary amenorrhea, diagnostic aid ("progesterone challenge"):

Oral: 200 mg once daily for 10 days (Ref). Note: Withdrawal bleeding may be expected during therapy or within 7 days after cessation of therapy; absence of withdrawal bleeding suggests low endometrial estrogen exposure and/or uterine or outflow tract abnormality (Ref).

Manufacturer’s labeling: 400 mg once daily at bedtime for 10 days. Note: Higher oral doses (ie, >200 mg/day) are not preferred and infrequently used due to limited data.

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Routine lab testing is not universally required at every annual physical for healthy, asymptomatic adults. The frequency and type of screening labs depend on age, sex, and risk factors. The Society of General Internal Medicine's Choosing Wisely campaign specifically recommends against routinely performing annual comprehensive lab testing for asymptomatic adults without chronic conditions.[1] Here is a summary of evidence-based screening intervals:

Lipid Panel

- The 2026 ACC/AHA Dyslipidemia Guideline recommends screening with a lipid profile starting at age 19, then at least every 5 years in healthy adults, with more frequent screening for those with additional ASCVD risk factors. The USPSTF similarly supports lipid screening every 5 years beginning at age 40.[2][3][4]

Glucose / HbA1c

- The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35–70 with overweight or obesity (B recommendation). The American Diabetes Association recommends universal screening starting at age 45 regardless of weight, with repeat testing at minimum every 3 years if results are normal. For those with prediabetes, annual reassessment is recommended.[5][6][7]

Kidney Function (Creatinine/eGFR)

- The 2026 AHA/ACC/ADA/ASN CKM Guideline recommends eGFR assessment at least every 5 years in healthy adults (CKM stage 0), increasing to every 2–3 years in those with overweight/obesity (CKM stage 1), and annually in those with established metabolic risk factors (CKM stage 2+). UACR should be added for CKM stage 2 and above.[6]

CBC

- There is no USPSTF recommendation for routine CBC screening in asymptomatic adults. A CBC is recommended as part of the workup for specific conditions (e.g., hypertension evaluation per the 2025 AHA/ACC BP guideline) but is not an evidence-based annual screening test for healthy adults.[8]

Hepatitis C

- One-time screening for all adults aged 18–79 years (USPSTF B recommendation).[9]

Blood Pressure

- Screening annually for adults ≥40 years; every 3–5 years for adults aged 18–39 without risk factors.[4][10]

Summary by Risk Profile

TestHealthy Adult (No Risk Factors)Overweight/Obese or Risk FactorsReferencesLipid panelEvery 5 years (starting age 19–40)More frequently based on risk[1], [2]Glucose/HbA1cEvery 3 years (age 35–70 if overweight/obese; age 45+ per ADA)Every 1–3 years[3]Creatinine/eGFREvery 5 yearsEvery 2–3 years (overweight); annually (metabolic risk factors)[4]UACRNot routinely neededAnnually if CKM stage ≥2[4], [5]CBCNot routinely recommendedAs clinically indicated[6]Hepatitis COnce (ages 18–79)Once[7]

The key takeaway is that for a truly healthy, asymptomatic adult without risk factors, comprehensive annual lab panels are not supported by current evidence. Screening should be targeted based on age and risk profile, with most labs checked every 3–5 years rather than annually.[1] The annual visit itself remains valuable for blood pressure measurement, BMI assessment, counseling, immunization updates, and cancer screening discussions, even when labs are not indicated.

Would you like to explore how screening recommendations change for adults on chronic medications (e.g., statins, antihypertensives) who require more frequent lab monitoring?

References

General Health Checks in Adult Primary Care. Liss DT, Uchida T, Wilkes CL, Radakrishnan A, Linder JA. JAMA. 2021;325(22):2294-2306. doi:10.1001/jama.2021.6524.

2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Blumenthal RS, Morris PB, Gaudino M, et al. Journal of the American College of Cardiology. 2026;:S0735-1097(25)10254-4. doi:10.1016/j.jacc.2025.11.016.

Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. JAMA. 2016;316(19):1997-2007. doi:10.1001/jama.2016.15450.

Cardiovascular Risk and Statin Eligibility Of Young Adults After an MI: Partners YOUNG-MI Registry. Singh A, Collins BL, Gupta A, et al. Journal of the American College of Cardiology. 2018;71(3):292-302. doi:10.1016/j.jacc.2017.11.007.

Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement. US Preventive Services Task Force, Davidson KW, Barry MJ, et al. JAMA. 2021;326(8):736-743. doi:10.1001/jama.2021.12531.

2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Writing Committee Members, Ndumele CE, Rodriguez F, et al. Circulation. 2026;. doi:10.1161/CIR.0000000000001453.

2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Ndumele CE, Rodriguez F, Dixon DL, et al. Journal of the American College of Cardiology. 2026;87(22S):e1889-e2007. doi:10.1016/j.jacc.2026.03.056.

2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Jones DW, Ferdinand KC, Taler SJ, et al. Journal of the American College of Cardiology. 2025;86(18):1567-1678. doi:10.1016/j.jacc.2025.05.007.

Screening for Hepatitis C Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. US Preventive Services Task Force, Owens DK, Davidson KW, et al. JAMA. 2020;323(10):970-975. doi:10.1001/jama.2020.1123.

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association. Ndumele CE, Neeland IJ, Tuttle KR, et al. Circulation. 2023;148(20):1636-1664. doi:10.1161/CIR.0000000000001186.

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I have a pt who has lipedema. There are varying degrees of lipedema and it can actually be painful/disfiguring, but health insurance won't cover liposuction to treat it because liposuction is considered "cosmetic." I referred my pt to a plastic surgeon, who can hopefully write a letter of medical necessity so she can get lipo covered. She has tried conservative management including lymphatic drainage massage and compressive devices without much benefit. If a doctor is saying a certain treatment is needed, then the insurance company needs to just cover the damn treatment!

I just saw a video someone posted about it on tiktok. Someone in the comments mentioned pycnogenol, which is a European pine bark extract that is supposed to have anti-inflammatory effects and may help with lipedema.

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Hi folks- just an FYI that our current urine tox screen cups do not check for fentanyl .  Up to 95% of heroin now contains fentanyl and  about 15% of cocaine samples contain fentanyl.   The result template in Epic has contains a line for Fentanyl but even though some MAs were marking it negative it was not being tested.

Good news - our new urine test urine tox screen cups will now actually test for fentanyl, so the line in the tox screen report will be valid.  They should be in stock at both clinics by the end of this week. 

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https://www.aafp.org/assets/image/upload/v1777392265/nyme0soclvvfkutpwgvh.pdf

The AAFP has good vaccine guidelines. The stupid tRump administration has messed up vaccine guidelines.

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I have a female pt who is taking labetalol 100 mg bid. She used to take either HCTZ or chlorthalidone, but switched to labetalol when she was trying to become pregnant. She ended up not getting pregnant and then continued to take the labetalol since then. So I want to switch her to HCTZ. Beta blockers should not be abruptly discontinued because that can cause rebound HTN. So I will decrease her labetalol to 100 mg daily x1 week while at the same time taking HCTZ 12.5 mg a week. I never learned any specific way to taper off a beta blocker, but a quick search does say to decrease the dose by 25 to 50% 1 week at a time, so I think this is a good taper regimen.

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Blood sugar goals for Type 2 diabetics

Point-of-Care Glucose Targets (ADA/AACE)

Fasting/preprandial glucose: 80–130 mg/dL (ADA); <110 mg/dL (AACE) [2][5]

2-hour postprandial glucose: <180 mg/dL (ADA); <140 mg/dL (AACE) 

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The American College of Cardiology (ACC) and American Heart Association (AHA) define hypertensive emergency as severe elevation in blood pressure (>180/120 mm Hg) associated with evidence of acute target organ damage. [1]

Forms of acute target organ damage that qualify include:

Brain: Hypertensive encephalopathy, posterior reversible encephalopathy syndrome (PRES), intracranial hemorrhage (ICH), acute ischemic stroke

Heart: Acute heart failure/pulmonary edema, acute coronary syndrome, acute decompensated heart failure

Large vessels: Acute aortic syndrome (aortic dissection, penetrating aortic ulcer)

Kidneys: Acute kidney injury

Microvasculature: Retinal hemorrhage, papilledema

The distinction from severe hypertension without target organ damage (previously termed "hypertensive urgency") is critical — patients with severe hypertension but no evidence of acute target organ damage should not receive aggressive BP lowering or parenteral antihypertensive therapy. Reinstitution or intensification of oral antihypertensive medications, preferably in the outpatient setting, is recommended for these patients. [1]

Management recommendations per the 2025 ACC/AHA guidelines: [1]

ICU admission is recommended for continuous BP monitoring and consideration of parenteral therapy.

For compelling conditions (e.g., acute aortic dissection), SBP should be reduced to <140 mm Hg for most conditions and <120 mm Hg in aortic dissection during the first hour.

For emergencies without a compelling condition, SBP should be reduced by no more than 25% within the first hour, then to <160/100 mm Hg within 2–6 hours, and cautiously to 130–140 mm Hg over the next 24–48 hours.

Overly rapid correction in patients with longstanding hypertension may cause vital organ hypoperfusion due to loss of autoregulation

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I have a 4 y/o whose venous lead level was minimally elevated to 4.3. The tx is increasing iron-rich foods. Iron block absorption of lead. You can prescribe iron supplements, but the pediatrician at my clinic doesn't unless the lead level is greater than 10. He recommends 3 mg/kg iron every other day. Can then re-assess blood lead level at 3 months. Counsel parents on cleaning floors with wet mop, as most lead exposure is environmental. You should also be able to request a lead certificate from the landlord, or if the property you live in hasn't been inspected for lead, you can request that.

The frequency of re-assessment of blood lead level depends on how high the level is.

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If someone has a positive hepatitis C screening test, they should be treated. There is no specific viral load that needs to be met in order for treatment to be initiated, but the viral load helps determine duration of treatment. Cure is when the viral load is less than 15 IU/mL. According to Open Evidence:

There is no viral load threshold required to initiate hepatitis C treatment — current guidelines recommend treating all patients with detectable HCV RNA, regardless of viral load level. [1-3] The decision to treat is based on the presence of chronic (or acute) HCV infection confirmed by a positive HCV RNA test, not on a specific viral load cutoff.

"Treat All" Approach

Both the AASLD-IDSA (2023) and the WHO/ACP guidelines endorse a universal treatment strategy for all individuals with chronic HCV infection. [1-3] The only exceptions are patients with a life expectancy of less than 1 year due to non-liver-related conditions or those whose liver disease is not remediable by DAA therapy or transplantation. [2] Treatment should be expedited in patients with significant fibrosis (METAVIR F2–F4), extrahepatic manifestations, or high-risk populations. [2]

Where Viral Load Does Matter: Treatment Duration

While viral load does not determine whether to treat, it can influence the duration of certain regimens:

Ledipasvir/sofosbuvir for genotype 1: treatment-naive, noncirrhotic patients with HCV RNA <6 million IU/mL may be eligible for a shortened 8-week course (vs. 12 weeks). [2][4]

Elbasvir/grazoprevir for genotype 1a or 4: this regimen is recommended only when HCV RNA is <800,000 IU/mL. [2]

However, the simplified treatment algorithms using glecaprevir/pibrentasvir (8 weeks) or sofosbuvir/velpatasvir (12 weeks) do not require pretreatment viral load for treatment duration decisions in treatment-naive patients.

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I have a pt who was taking oral Wegovy and wanted to try Zepbound, which she was on previously. They did not approve the prior authorization for Zepbound. This is their reason why:

They need documentation that patient has used phentermine or Contrave or phentermine/topiramate (Qsymia). As well as documentation of continued diet and exercise, of 150 minutes exercise weekly and 1200-1800 calories daily. If patient has not lost 5% of body weight after these measures have been taken, then they will be approved for an injectable GLP-1.

Phentermine is contraindicated because the pt has a hx of substance use disorder. So we applied to get a PA for Zepbound again and they approved it:

"PA was approved, however her copay is $885.00 for 1 month. Because she has a deductible. I applied a copay card and it came down to $499. I spoke with the insurance and they said after this month, it should be covered with a normal monthly co-pay of approximately $40.

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When you choose an ABMS board certified doctor, you can count on quality care for yourself and those you love. Certification Matters is a fr

This is a website you can use to check your surgeon's certification. It's important to ensure that your surgeon is certified in plastic surgery if you are going for plastic surgery because at some commercial cosmetic procedure places like Sono Bello, they have doctors who are not certified in that specialty who are doing procedures like liposuction. A doctor who trained in orthopedic surgery for example could learn how to do liposuction and do it well, but the best results are likelier with someone who has completed a plastic surgery fellowship and is certified by the American Board of Medical Specialties. I'm planning on going for liposuction and my doctor is board certified with more than a decade of experience. So it's reassuring, but I still worry about it a bit.

Even if you have the best and a board certified surgeon, complications or unsatisfactory results are always possible. So it's important to do your due diligence and research before electing to go through with a procedure.

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Vitamin D

1 mcg = 40 IU

The recommended daily allowance (RDA) of vitamin D for most adults aged 1 to 70 is 600 IU (15 mcg), increasing to 800 IU (20 mcg) for adults over 70. The safe upper limit for daily intake is 4,000 IU.

Osteopenia:

For adults with osteopenia, the general recommendation is 600 to 2,000 IU of Vitamin D daily, often paired with 1,000–1,200 mg of calcium, to maintain bone health and prevent further density loss. Those over 70, with limited sun exposure, or with a diagnosed deficiency may require higher doses, typically in the range of 800–2,000 IU.

Osteoporosis treatment:

Check calcium, vitamin D, and Cr. Correct low calcium and vitamin D before starting alendronate.

Prior to starting pharmacotherapy for osteoporosis, confirm the diagnosis and review the following serum tests usually performed as part of the evaluation of osteoporosis:

●Calcium

●Creatinine

●25-hydroxyvitamin D

Correct underlying vitamin D deficit, if needed, with repeat measurement of 25-hydroxyvitamin D in approximately eight weeks

Refer patients with eGFR <30 to 35 mL/min per 1.73 m2 to a clinician with experience in treating chronic kidney disease-mineral bone disorder.

Most women – For the initial treatment of osteoporosis in most postmenopausal women, we suggest oral bisphosphonates. We prefer these agents based on efficacy, cost, and long-term safety data. Oral bisphosphonates are contraindicated in those with esophageal disorders (eg, esophageal stricture) or known malabsorption (eg, Roux-en-Y gastric bypass).

We typically prefer alendronate, although risedronate is a reasonable alternative.

Very high fracture risk – Examples of very high fracture risk may include:

●T-score of ≤-3.0 even in the absence of fractures

●T-score of ≤-2.5 plus a fragility fracture

●Severe or multiple fragility fractures

For postmenopausal women with very high fracture risk, we suggest initial treatment with an anabolic agent (eg, teriparatide, abaloparatide, romosozumab). Anabolic therapy is most effective when given as initial therapy and should always be followed by an antiresorptive agent. Refer to a clinician with expertise in treating severe osteoporosis to facilitate shared clinical decision-making.

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ABA, or Applied Behavior Analysis, is considered by many to be the gold standard intervention for teaching individuals with Autism Spectrum

Resources for autistic patients

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IEP = Individualized Education Plan