Step 3 · 1–3%

Human Development & Well Care

Normal growth and aging, screening schedules and vaccines across a lifetime.

Adult screening schedule & when to stop

Know who to screen, from what age, how often, and when to stop; for many patients the right answer is 'not yet' or 'no longer'.

Rules to know

Blood pressure screening → all adults: yearly from 40 or with risk factors, every 3–5 years at 18–39 if normal; confirm high office readings with home or ambulatory readings
Adults 40–75 → check lipids and estimate 10-year cardiovascular risk; statin if ≥1 risk factor (diabetes, hypertension, dyslipidemia, smoking) and risk ≥10%
Overweight or obese adult aged 35–70 → screen for prediabetes and diabetes with A1c or fasting glucose; repeat every 3 years if normal
Average-risk colorectal screening, ages 45–75 → colonoscopy every 10 years, yearly FIT, stool DNA-FIT every 1–3 years, or CT colonography or flexible sigmoidoscopy every 5 years
Positive stool test or abnormal CT colonography → follow-up colonoscopy; screening is not complete until it is done
First-degree relative with colorectal cancer before 60, or two affected → colonoscopy from 40 or 10 years before the youngest diagnosis, every 5 years
Colorectal screening at 76–85 → individual decision based on prior screening and health; over 85 → stop
Average-risk women 40–74 → mammogram every 2 years; at 75 or older, continue only if healthy with good life expectancy, after discussion
Family history of breast, ovarian, tubal or peritoneal cancer → familial risk tool (also for BRCA-linked ancestry); if positive, genetic counseling before BRCA testing
Known BRCA mutation or chest radiation in youth → yearly breast MRI plus mammography, starting earlier than average risk
Cervical screening at 21–29 → cytology every 3 years; under 21 → no screening, whatever the sexual history
Cervical screening at 30–65 → high-risk HPV test every 5 years, cotesting every 5 years, or cytology alone every 3 years
Over 65 with adequate negative screening and no recent precancer → stop cervical screening; also stop after total hysterectomy for benign disease
Lung screening → yearly low-dose CT at 50–80 with ≥20 pack-years who smoke or quit <15 years ago; stop once 15 years smoke-free or unfit for surgery
Men 65–75 who ever smoked → one-time abdominal ultrasound for aortic aneurysm; selective in men who never smoked; not in women who never smoked
Women 65 and older → bone density (DXA) screening; younger postmenopausal women when a risk tool shows raised fracture risk
Hepatitis C → antibody test with reflex RNA once for every adult 18–79; repeat periodically with ongoing risk such as injection drug use
Hepatitis B → test every adult at least once with surface antigen, surface antibody and core antibody; retest with ongoing risk
HIV → screen everyone 15–65 at least once, younger and older people at risk, and every pregnancy; test at least yearly with ongoing risk
Sexually active women 24 or younger, or older women at increased risk → yearly chlamydia and gonorrhea testing
Higher syphilis risk (men who have sex with men, HIV) → screen, repeating at intervals matched to risk
Depression → screen all adults, including pregnant and postpartum patients, when follow-up care is available; screen adults 64 and younger for anxiety too
Unhealthy alcohol and drug use → ask all adults with a brief validated screen; brief counseling for risky drinking
Tobacco use → ask every adult, advise quitting, offer counseling plus medication (varenicline or nicotine replacement); behavioral support alone in pregnancy
Aspirin for primary prevention → do not start at 60 or older; at 40–59 with ≥10% cardiovascular risk, individual decision only if bleeding risk is low
Asymptomatic low-risk adult → no screening ECG, carotid ultrasound, or screening for ovarian, pancreatic, testicular or thyroid cancer
Life expectancy under about 10 years → stop most cancer screening; the harms come now, the benefits years later
Transgender patient → screen by the organs present (cervix, breasts, prostate), not by gender identity

Traps that cost points

Waiting until 50 to start colorectal screening in an average-risk 46-year-old→ Average-risk screening now starts at 45; offer colonoscopy or a stool-based test.
Ordering yearly mammograms from 40 by default in average-risk women→ The national task force advises every 2 years from 40 to 74; yearly imaging adds false positives without clear extra benefit at average risk.
Doing a Pap test on a sexually active 19-year-old→ No cervical screening before 21; test her for chlamydia and gonorrhea and offer HPV vaccine instead.
Continuing cervical screening after hysterectomy for fibroids→ No cervix and no prior high-grade lesion means no further screening.
Ordering low-dose CT for a 62-year-old who quit 20 years ago→ Eligibility ends 15 years after quitting; lung screening is no longer indicated.
Ordering an aneurysm ultrasound for a 70-year-old woman who never smoked→ Screening benefit is shown in men who ever smoked; never-smoking women are not screened.
Screening a healthy 45-year-old with an ECG before exercise→ Resting ECG in low-risk adults finds false positives that lead to harmful testing; do not order it.
Testing hepatitis C only in patients with risk factors→ Every adult 18–79 gets a one-time test, because many infected people report no risk.
Continuing routine screening colonoscopy in a frail 88-year-old→ Beyond 85, or with limited life expectancy, procedure risks outweigh any benefit; stop.

Immunization schedules, catch-up & contraindications

In the Brain

Give what is due today, never restart a series, know the few true contraindications, and keep live vaccines away from pregnancy and severe immunosuppression. The federal childhood schedule was reorganized in 2026, so child rules here stick to the parts that have not changed.

Rules to know

Adult influenza vaccine → one dose every season for all adults; at 65 or older, high-dose, adjuvanted or recombinant vaccine is preferred
Adult Tdap → one dose as an adult, then Td or Tdap every 10 years; Tdap in every pregnancy at 27–36 weeks
Adults 50 and older, or 19 and older with immune compromise → recombinant zoster vaccine, 2 doses 2–6 months apart, even after shingles or old live zoster vaccine
Adult 50+ or 19–49 with risk condition, no prior conjugate vaccine → one PCV20 or PCV21 dose, or PCV15 followed by PPSV23 at least a year later
Risk conditions for earlier pneumococcal vaccine → chronic heart, lung, liver or kidney disease, diabetes, smoking, alcohol use disorder, asplenia, immunocompromise, CSF leak, cochlear implant
RSV vaccine in older adults → one dose for all 75+ and for 50–74 at increased risk (heart, lung or kidney disease, complicated diabetes, immunocompromise, nursing home); not yearly
HPV vaccine → routine at 11–12 (may start at 9), catch-up through age 26; 27–45 only by shared decision
Adults 19–59 not known to be immune → hepatitis B vaccine series; adults 60 and older if they have risk factors or ask for it
Infant of a mother positive for hepatitis B surface antigen → hepatitis B vaccine plus hepatitis B immune globulin within 12 hours of birth, then serology after the series
Adult born in 1957 or later without proof of measles immunity → one MMR dose; two doses for health workers, college students and international travelers
Adult without varicella immunity (no vaccine record, history or serology) → two doses of varicella vaccine 4–8 weeks apart, unless pregnant or immunosuppressed
Childhood MMR and varicella → first doses at 12–15 months, second doses at 4–6 years
First MMR and varicella doses before age 4 → give them as separate shots; the combined MMRV vaccine raises febrile seizure risk
Infant 6–11 months traveling abroad → one early MMR dose; it does not count, so give the routine two doses after the first birthday
Oral rotavirus vaccine → first dose before 15 weeks of age, series finished by 8 months; contraindicated after intussusception or with SCID
Infant RSV protection → maternal RSV vaccine at 32–36 weeks in season, or a long-acting RSV monoclonal antibody for the infant if the mother was not vaccinated
Child or adult behind on vaccines → continue the series where it stopped; never restart, however long the gap
Several vaccines due at one visit → give all of them the same day at separate sites; two live injected vaccines not given together need ≥4 weeks between them
True contraindication → severe allergic reaction to a prior dose or component; encephalopathy within 7 days of a pertussis vaccine (for further pertussis doses)
Precautions (weigh, often defer) → moderate or severe acute illness, Guillain-Barré within 6 weeks of a prior flu or tetanus vaccine, recent antibody-containing blood products before live vaccines
Not reasons to delay → mild illness or low fever, antibiotics, breastfeeding, prematurity, egg allergy, a pregnant or immunocompromised household contact, local reaction to a prior dose
Pregnancy → no live vaccines (MMR, varicella, live intranasal flu); give inactivated flu in any trimester and Tdap; postpone HPV until after delivery
MMR or varicella vaccine given to a woman → advise avoiding pregnancy for 4 weeks; inadvertent vaccination in pregnancy is not a reason to end it
Severe immunosuppression (chemotherapy, biologics, high-dose steroids, HIV with CD4 <200) → no live vaccines; inactivated vaccines are safe; high-dose means prednisone ≥20 mg daily for ≥14 days
Asplenia or planned splenectomy → pneumococcal, meningococcal (ACWY and B) and Hib vaccines, ideally ≥2 weeks before elective surgery
Travel to tropical Africa or South America → live yellow fever vaccine ≥10 days before; avoid with severe immunosuppression, thymus disease or age under 6 months
Travel to low- or middle-income countries → hepatitis A vaccine once travel is planned; typhoid for South Asia or rural food risks; meningococcal for the Hajj or meningitis belt
Long stays with animal exposure where rabies care is scarce → pre-exposure rabies vaccine; long rural stays in parts of Asia → consider Japanese encephalitis vaccine

Traps that cost points

Restarting a hepatitis B series after a two-year gap→ Doses already given still count; continue from where the series stopped.
Withholding flu vaccine because of egg allergy→ Any age-appropriate flu vaccine is fine with egg allergy of any severity, with routine observation only.
Postponing vaccines for a cold with low-grade fever→ Mild illness is not a reason to defer; missed chances are the main cause of under-vaccination.
Holding a child's MMR because the mother is pregnant→ Household contacts of pregnant or immunocompromised people should be vaccinated; MMR virus is not spread to contacts.
Giving MMR or varicella vaccine to a patient on a TNF inhibitor→ Live vaccines are contraindicated with significant immunosuppression; give them before therapy starts when possible.
Checking varicella antibodies before recombinant zoster vaccine→ Not needed for adults 50 and older; vaccinate directly.
Skipping zoster vaccine because the patient already had shingles→ Prior shingles does not prevent recurrence; give recombinant vaccine once the rash has healed.
Starting rotavirus vaccine in a 5-month-old who missed it→ The first dose must be given before 15 weeks of age; older infants do not start the series.
Delaying a preterm infant's vaccines until corrected age→ Vaccinate by chronological age with full doses.
Repeating RSV vaccine every autumn in older adults→ Adult RSV vaccine is a single dose; no booster is currently recommended.

Infancy & childhood: growth, milestones & safety

In the Brain

Separate normal variants from red flags, screen at the right visits, and give the safety advice that prevents the commonest childhood deaths.

Rules to know

Newborn weight loss in the first days → up to about 7–10% is normal, with birth weight regained by 10–14 days; more loss → assess feeding
Healthy infant growth → weight roughly doubles by 4–6 months and triples by 12 months; length increases about 50% in the first year
Short child, delayed bone age, normal growth velocity, parent a late bloomer → constitutional delay; reassure, expect late puberty and normal adult height
Short child, bone age equal to age, short parents, normal velocity → familial short stature; reassure, adult height in line with parents
Head circumference crossing percentiles up or down → evaluate for hydrocephalus or poor brain growth; measure at each visit through the first 2 years
Gross motor milestones → head steady by 4 months, sits alone by 9, walks alone by 15–18 months, runs at 2, pedals a tricycle at 3, hops at 4–5
Language milestones → coos by 2 months, babbles by 6–9 months, first words by 12 months, two-word phrases by 24 months, mostly understood by strangers by 3–4 years
Social milestones → social smile by 2 months, stranger anxiety around 6–9 months, parallel play at 2 years, cooperative play by 4
Loss of skills a child already had, at any age → red flag; prompt developmental and neurologic evaluation
Language red flag: no words by 16 months or phrases by 24 → formal hearing test plus developmental and autism evaluation; same for no babbling or pointing by 12 months
Clear hand preference before about 18 months → suspect weakness of the other side, such as cerebral palsy
Well-child visits at 9, 18 and 30 months → standardized developmental screen; autism-specific screen at 18 and 24 months
Newborn with pustular red rash, milia, or bluish sacral patches → normal findings; reassure, and document blue patches so they are not mistaken for bruises
Newborn scalp swelling crossing suture lines → caput succedaneum, gone in days; swelling bounded by sutures → cephalohematoma, resolves over weeks, watch bilirubin
Safe infant sleep → on the back, firm flat surface, in the parents' room but not their bed, no pillows, bumpers or soft bedding; avoid inclined sleepers
Flat occiput with the same-side ear pushed forward → positional plagiocephaly; awake tummy time and repositioning; helmet only if severe
Car seats → rear-facing to the seat's limit, then forward-facing harness, then booster until the belt fits (about 4 feet 9 inches); back seat until 13
Firearms in a home with children → stored unloaded and locked, with ammunition locked separately
Drowning prevention → constant close supervision of toddlers near water, four-sided pool fencing, swim lessons from about age 1
Nighttime bedwetting under age 5 with no daytime symptoms → normal; reassure
Primary nocturnal enuresis at 5 or older → urinalysis, treat constipation, behavioral steps; bedwetting alarm for lasting cure; desmopressin for quick or short-term control
Bedwetting returns after 6 or more dry months → look for UTI, diabetes, constipation, sleep apnea, stress or abuse
Teething → drooling and fussiness only; fever or diarrhea needs another explanation; avoid benzocaine gels and amber necklaces
Well infant crying >3 hours a day, >3 days a week → colic; teach soothing, ask how caregivers are coping, warn never to shake the baby
Child screams early in the night, cannot be comforted, recalls nothing → night terrors; reassure, do not wake; nightmares come later in the night and are remembered
Screen time in young children → avoid screens other than video chat before 18–24 months; about 1 hour a day of quality programs at 2–5 years
Lead screening → blood lead at 12 and 24 months for children on Medicaid or at high risk
Infant eyes → red reflex at every visit (absent or white reflex → urgent eye referral); amblyopia screening at least once at 3–5 years

Traps that cost points

Ordering growth hormone testing for a short boy with delayed bone age and normal velocity→ That pattern is constitutional delay; reassure and follow growth, since he will grow late and reach a normal adult height.
Blaming a toddler's speech delay on being a boy or bilingual→ Get a formal hearing test and developmental evaluation; delay is never explained away by sex or bilingual exposure.
Reassuring parents whose child has stopped using words→ Regression at any age needs prompt evaluation, including for autism and neurologic disease.
Reporting bluish sacral patches in a newborn as abuse→ Congenital dermal melanocytosis is normal; document it at birth so it is not mistaken later.
Turning a car seat forward at the second birthday→ Keep children rear-facing until they outgrow the seat's rear-facing limits.
Suggesting bed-sharing or a wedge for a spitting-up infant→ Back to sleep on a flat, firm surface in the parents' room; inclined or shared sleep raises sudden death risk.
Starting desmopressin for a 4-year-old who wets the bed→ Bedwetting is normal before 5; reassure and avoid blame or punishment.
Attributing a fever of 39°C to teething→ Teething does not cause high fever; look for a real source.
Using imipramine first for enuresis→ Alarm and behavioral steps come first; desmopressin for short-term needs; tricyclics carry overdose and cardiac risk.

Older adults: normal aging, falls, medications & function

In the Brain

Tell normal aging from disease, prevent falls, prune the medication list, and keep the patient functional, safe on the road and supported at home.

Rules to know

Normal creatinine in an older adult → GFR may still be reduced because muscle mass is lower; estimate clearance before dosing renally cleared drugs
Older body composition (more fat, less water and muscle) → fat-soluble drugs such as benzodiazepines last longer; water-soluble drugs reach higher levels
Normal aging findings → presbyopia, high-frequency hearing loss, slower processing, small height loss, thin skin with forearm purpura, higher systolic pressure
Mild forgetfulness with intact daily function → normal aging; new trouble with finances, medicines or getting lost → evaluate for dementia
Anemia, incontinence, confusion or depression in an older adult → disease, not normal aging; work it up
Sleep changes with age → earlier bedtime and waking, lighter sleep, more awakenings, less deep sleep; treat insomnia with behavioral therapy first, not sedatives
Blunted fever and thirst in older adults → serious infection may show only as confusion or a fall; dehydration and heat or cold injury occur easily
Aging bladder (smaller capacity, more nocturia, larger residual) → incontinence is still never normal; look for reversible causes such as infection, drugs, glucose, stool impaction
Yearly visit at 65 or older → ask about falls; if a fall in the past year or unsteadiness, test gait and balance (timed up-and-go)
Older adult at increased fall risk → strength and balance exercise (tai chi, physical therapy); review drugs, check orthostatic pressure, vision, feet and home hazards
Vitamin D to prevent falls in community-dwelling older adults → not recommended
Drugs that most raise fall and delirium risk → benzodiazepines, sedative hypnotics, first-generation antihistamines, tricyclics, antipsychotics, opioids, antihypertensives causing orthostasis
Medication review → patient brings every bottle, including over-the-counter drugs and supplements; stop anything without a current indication
New symptom after a new drug, treated with yet another drug → prescribing cascade (cholinesterase inhibitor, then a bladder antimuscarinic); stop or change the first drug
Long-term benzodiazepine or sleeping pill in an older adult → taper slowly over weeks with insomnia-focused behavioral therapy; abrupt stopping risks withdrawal
Diphenhydramine, oxybutynin or tricyclics in older adults → strong anticholinergic effects (confusion, constipation, urinary retention); choose alternatives
Frail older adult with diabetes → relax the A1c goal (around 8%) and avoid sulfonylureas and sliding-scale insulin alone to prevent hypoglycemia
Limited life expectancy → reconsider statins, bisphosphonates, tight blood pressure goals and other drugs whose benefit takes years
Activities of daily living → bathing, dressing, toileting, transferring, continence, feeding; losses point to in-home help or a higher level of care
Instrumental activities (finances, medications, shopping, cooking, transport, phone) → these decline first in early dementia
Medicare annual wellness visit → health risk review, cognitive check, function and safety review, advance care planning; a planning visit, not a physical exam
Family worried about an older driver → assess vision, cognition and motor function; refer for a formal driving evaluation when in doubt
Moderate or worse dementia → advise stopping driving; mild dementia → individual assessment with periodic recheck
Hearing loss in an older adult → audiology and hearing aids (over-the-counter devices for mild to moderate loss); untreated loss is linked to isolation and cognitive decline
Exhausted caregiver of a person with dementia → ask about caregiver strain; offer respite care, adult day programs, support groups and social work
Caregiver burnout with a dependent older adult → higher risk of elder abuse; watch for warning signs
Older adult reviewing life with acceptance → integrity rather than despair; reminiscence is healthy, not a symptom
Sexual activity in later life → often continues; vaginal dryness responds to lubricants or vaginal estrogen; ask about it

Traps that cost points

Attributing new confusion or incontinence to old age→ These are signs of disease, often infection, drugs or metabolic change; look for a cause.
Prescribing diphenhydramine or a benzodiazepine for sleep in an 80-year-old→ Both raise falls, fractures and delirium; use behavioral therapy for insomnia first.
Adding oxybutynin for incontinence that began after donepezil→ That is a prescribing cascade; adjust the cholinesterase inhibitor instead of treating its side effect.
Giving vitamin D to prevent falls in a community-dwelling older adult→ It does not prevent falls; prescribe strength and balance exercise and review medications.
Taking a normal creatinine as proof of normal kidney function→ Low muscle mass hides reduced GFR; estimate clearance before dosing.
Telling a family that any dementia diagnosis means no driving→ Mild dementia needs individual assessment and regular review; moderate dementia means stopping.
Targeting A1c below 7% in a frail nursing home resident→ Hypoglycemia is the bigger danger; relax the target and simplify the regimen.
Stopping a long-term benzodiazepine abruptly→ Taper gradually to avoid withdrawal seizures and rebound insomnia.
Focusing only on the patient with dementia and ignoring the caregiver→ Caregiver strain predicts institutional placement and abuse risk; assess it and connect them with support.

Adolescence: puberty, confidential care & risk

In the Brain

Know normal puberty timing, interview the teen alone, and counsel on the injuries, substances and sexual risks that drive teen illness and death.

Rules to know

First sign of puberty in girls → breast budding (8–13 years); menarche about 2–3 years later; height spurt peaks before menarche
First sign of puberty in boys → testicular enlargement (≥4 mL) at about 9–14 years; height spurt comes later than in girls
Puberty before 8 in girls or 9 in boys → precocious; evaluate
No breast budding by 13 or testicular growth by 14 → delayed puberty; evaluate (constitutional delay is most common); no menses by 15 also needs evaluation
Irregular cycles in the first 1–2 years after menarche → usual anovulation; reassure if cycles are 21–45 days and bleeding is not heavy
Midpubertal boy with a tender, rubbery disk under one or both nipples → physiologic gynecomastia; reassure and recheck; most resolve within 1–2 years
Gynecomastia that is large, hard, eccentric, prepubertal, or with abnormal testes → evaluate: testicular exam, hormones, drug and anabolic steroid history
Mild breast asymmetry in a developing girl → normal; reassure and re-examine later
Interviewing a teen → spend part of every visit alone with the teen; explain confidentiality and its limits to teen and parent at the start
Psychosocial history → home, education, activities, drugs, sexuality, suicide and mood, safety; start with less sensitive topics
Leading causes of death in teens → unintentional injury (mostly crashes), suicide, homicide; aim counseling at these
New teen driver → seat belt every trip, no phone use, no alcohol or drugs, limit teen passengers and night driving through graduated licensing
Bicycle, skateboard or motorcycle → helmet every ride
Firearms where a teen lives, especially with depression → counsel locked, unloaded storage or removal from the home
Adolescent depression → screen yearly from age 12 with a validated questionnaire and act on positive screens
Sexually active teen → discuss consent and coercion, condoms every time; long-acting reversible contraception is a first-line option
Teen falls asleep late, struggles to wake for school, fine on weekends → normal pubertal sleep-phase delay; fixed wake time, morning light, screens off at night
Teen vaping or using alcohol or cannabis → ask privately, brief counseling, involve parents when safety requires
Sports preparticipation exam → history finds most risk: exertional chest pain or syncope, family sudden death before 50, known heart disease, Marfan features
Athlete's murmur louder with standing or Valsalva → suspect hypertrophic cardiomyopathy; no sports until echocardiography and cardiology review
Routine ECG before sports in a healthy US teen → not required; reserve for abnormal history or exam
Athlete with one kidney or one testis → not automatically excluded; counsel on risk and protective gear
Recent infectious mononucleosis → no contact sports for at least 3–4 weeks after onset and until the spleen is no longer enlarged
Female athlete with missed periods, low weight or stress fractures → low energy availability (athlete triad); assess intake and bone density, increase calories
Muscular teen with acne, small testes and gynecomastia → suspect anabolic steroid use; ask confidentially, counsel, check hematocrit and lipids
Teen exploring sexual or gender identity → part of normal development; offer a supportive, confidential space and screen for depression, bullying and suicide risk
Early adolescent thinking → mostly concrete, abstract reasoning comes later; explain risks with concrete, near-term consequences
Growing independence and search for identity → normal adolescent psychosocial development (identity versus role confusion)

Traps that cost points

Interviewing the teen only with a parent in the room→ Teens disclose risk behaviors far more often when seen alone; make private time a routine part of every visit.
Ordering hormone tests for a 14-year-old boy with a tender breast bud→ Midpubertal gynecomastia is physiologic; examine the testes, reassure and recheck.
Doing a Pap test on a sexually active 17-year-old→ Cervical cytology starts at 21; test for chlamydia and gonorrhea and offer HPV vaccine.
Requiring a parent's signature to prescribe contraception to a 16-year-old→ Many states let minors consent to contraception; know your state's rule, and encourage, but do not require, parental involvement.
Clearing an athlete with exertional syncope after a normal ECG→ Exertional syncope needs full cardiac evaluation, including echocardiography, before any return to play.
Requiring a routine ECG for every high school athlete→ US practice relies on a careful history and exam; ECG is reserved for abnormal findings.
Letting a teen with mononucleosis return to football once fever settles→ Splenic rupture risk lasts weeks; no contact sports for at least 3–4 weeks and until the spleen is normal.
Starting hormones for irregular periods in the first year after menarche→ Anovulatory cycles are normal early on; evaluate only for very short or long cycles, heavy bleeding or absent periods.