NP Workshop Study Guide - Preventive Care
One visit, two patients. What is shared, what differs for a 65-year-old male and a 65-year-old female, which screenings start, continue, or stop, and exactly which vaccines are due. Built from the current CDC Adult Immunization Schedule (2025, with the April 2025 RSV update) and current USPSTF A and B recommendations.
The same skeleton applies to both patients. Sex-specific items layer on top in Sections 3 and 4.
Flag, do not just list. The AGS Beers Criteria identify medications whose risks often outweigh benefits in older adults.
There is no single mandatory panel for a healthy 65-year-old. Order for screening indications below, not by habit. Workshop cases penalize shotgun panels.
| Test | Why at 65 | Notes |
|---|---|---|
| Lipid panel | Cardiovascular risk and statin decision | USPSTF statin Grade B: age 40 to 75 with 1 or more CV risk factors and 10-year risk 10% or higher. Grade C at 7.5 to 10%. I statement over 76. |
| A1C or fasting glucose | Prediabetes and type 2 diabetes screening | USPSTF Grade B: age 35 to 70 with overweight or obesity, every 3 years. At 65 it applies if BMI criteria met. Continue on clinical judgment after 70. |
| CBC | Only if indicated | Fatigue, bleeding, pallor, before procedures. Not a USPSTF routine screen in asymptomatic adults. |
| CMP, kidney function, electrolytes | Med safety, hypertension, diabetes, diuretic or ACE inhibitor use | Needed for prescribing and Beers review, not as a stand-alone screen. |
| TSH | Only if indicated | Symptoms, atrial fibrillation, amiodarone or lithium use. USPSTF: I statement for asymptomatic thyroid dysfunction. |
| Vitamin D, B12 | Only if indicated | Deficiency risk, metformin use, anemia, neuropathy, malabsorption. USPSTF: I statement for routine vitamin D screening in asymptomatic adults. |
| Hepatitis C antibody (one time) | Universal adult screening | USPSTF Grade B: all adults 18 to 79, once. Confirm with HCV RNA if positive. |
| HIV test | At least once in a lifetime screening | USPSTF Grade A: age 15 to 65. At exactly 65, offer if never tested. Over 65, test if at increased risk. |
| Urinalysis | Only for symptoms | Do not screen for asymptomatic bacteriuria in nonpregnant adults. USPSTF Grade D. |
Everything in this table is different by sex. Everything not listed here is shared, and lives in Sections 1 and 5.
| Item | 65-year-old male | 65-year-old female |
|---|---|---|
| Abdominal aortic aneurysm | Order once One-time ultrasound, age 65 to 75, if he has EVER smoked. Grade B. | Do not order routinely Never smoked: Grade D. Ever smoked or family history: selective, Grade C. |
| Prostate / cervical | PSA only with shared decision making. Grade C was 55 to 69, so at 65 it is a conversation, not an order. Grade D at 70 and older. | Cervical screening STOPS at 65 if adequate prior screening and no high-risk history. See stopping rules in Section 4. |
| Breast screening | No routine mammography. Evaluate any lump, nipple discharge, or gynecomastia. | Biennial mammography, age 40 to 74, Grade B. At 65 she is squarely in the window. |
| Bone density | USPSTF I statement. Test if risk factors, fragility fracture, steroids, low body weight, or clinical concern. | Order at 65 DEXA for all women 65 and older, Grade B. Also younger postmenopausal women at increased risk. |
| Genital exam | Testicular and penile exam for symptoms, masses, lesions, discharge, or STI risk. No routine testicular cancer screening, Grade D. | Pelvic exam only for symptoms or procedures. No screening pelvic exam benefit in asymptomatic nonpregnant adults. Breast exam is not a substitute for mammography. |
| Sexual health flag | Erectile dysfunction: ask directly. Treat it as a cardiovascular risk marker, review meds, glucose, lipids, BP, and smoking. | Ask about libido, dyspareunia, vaginal dryness, postmenopausal bleeding. ANY postmenopausal bleeding needs prompt evaluation. |
| Osteoporosis risk meds | Review steroids, alcohol, smoking, falls. | Same, plus estrogen loss, prior fracture, parental hip fracture. Start calcium, vitamin D for deficiency, weight-bearing exercise, and pharmacotherapy if T-score -2.5 or lower or FRAX thresholds met. |
| Vaccines | Identical for a healthy male and female at 65. No sex difference in the Section 6 schedule. Differences only come from risk conditions, not sex. | |
Four items account for almost every male case question at this age.
Three of these are continuation or stopping decisions, not new starts. That is why they are tested so heavily.
Both patients, unless a sex-specific rule in Sections 3 or 4 overrides it.
| Screening | Who and when | Interval / stop | Grade |
|---|---|---|---|
| Blood pressure | All adults 18 and older | At every visit, at least annually. Confirm high readings out of office | A |
| Colorectal cancer | All adults 45 to 75 | Colonoscopy every 10 years, OR FIT annually, OR stool DNA-FIT every 1 to 3 years, OR CT colonography or flex sig every 5 years. Age 76 to 85: selective, Grade C. Over 85: do not screen, Grade D. | A for 50-75, B for 45-49 |
| Lung cancer - low-dose CT | Adults 50 to 80 with 20 pack-year or more history who smoke now OR quit within the last 15 years | Annual LDCT. Stop once quit for 15 years, or a health problem substantially limits life expectancy or ability to have lung surgery | B |
| Diabetes / prediabetes | Adults 35 to 70 with overweight or obesity | Every 3 years with A1C, fasting glucose, or OGTT | B |
| Lipids and statin | Statin for primary prevention: 40 to 75 with CV risk factor(s) and 10-year risk 10% or higher | Lipid panel as needed for risk calculation. 7.5 to 10% risk is Grade C | B / C |
| Hepatitis C | All adults 18 to 79 | Once. More often only with ongoing risk | B |
| HIV | All persons 15 to 65 at least once | Repeat by risk. Over 65, screen if at increased risk | A |
| Depression | All adults, including older adults | PHQ-2 / PHQ-9, periodically and when indicated | B |
| Unhealthy alcohol use | All adults in primary care | AUDIT-C or single-question screen, with brief counseling if positive | B |
| Tobacco use | All adults | Ask at every visit, advise, assess, assist, arrange. Pharmacotherapy plus counseling | A |
| Unhealthy diet, activity, obesity | Adults with high BMI or CV risk | Behavioral counseling interventions, Grade B in those groups | B |
| Falls prevention - exercise | Community-dwelling adults 65 and older at increased fall risk | Exercise or physical therapy intervention. Multifactorial assessment is Grade C, selective | B |
| Syphilis, STIs, Hep B | Persons at increased risk only at this age | Risk-based, not universal at 65. Hep B screening Grade B if at increased risk | A / B by infection |
| Latent TB | Persons at increased risk (born or lived in high-prevalence country, congregate settings) | Once if at risk and never tested | B |
Identical for male and female. Based on the CDC Adult Immunization Schedule 2025 and ACIP updates adopted through June 2025. Always confirm a prior record before ordering, and use the state immunization registry when history is unclear.
Annual, 1 dose
2 or more doses of 2024-2025 vaccine at 65+
Once, then every 10 years
2 doses, age 50 and older
1 dose of PCV at 65 if PCV-naive
Not routine for a healthy 65-year-old
Rule for unknown history: treat as unvaccinated for that antigen, document the attempt to obtain records, check the registry, and start. Extra doses of most vaccines are safer than leaving an older adult unprotected. Serology is only useful for selected antigens, such as hepatitis B in healthcare workers.
| Vaccine | If history is unknown |
|---|---|
| Influenza | Give this season's dose now, prefer HD-IIV3, RIV3, or aIIV3 |
| COVID-19 | Treat as unvaccinated for the current formulation and follow the CDC notes for unvaccinated adults 65 and older, including the additional dose 6 months later |
| Tdap / Td | Give Tdap now, then Td or Tdap in 10 years. For a completely unknown tetanus history, use the 3-dose primary series: Tdap, then Td at least 4 weeks later, then Td 6 to 12 months after that |
| RZV (Shingrix) | Give dose 1 now, dose 2 in 2 to 6 months |
| Pneumococcal | Give 1 dose PCV20 or PCV21 now and be done, or PCV15 now plus PPSV23 in at least 1 year |
| RSV | Give 1 dose ONLY if age 75 or older, or age 50 to 74 with a CDC risk factor. Unknown history alone does not make a healthy 65-year-old eligible |
| Hepatitis B | Assess risk, offer or recommend by risk and shared decision at this age, start the product-specific series if accepted |
Workshop cases love this distinction because patients call all three a physical, and only two are Medicare benefits.
| Welcome to Medicare Visit (IPPE) | Annual Wellness Visit (AWV) | Routine annual physical | |
|---|---|---|---|
| When | Once only, within the first 12 months of Part B enrollment. Miss the window and it is gone. | Once every 12 months, after Part B for more than 12 months. First AWV cannot be within 12 months of the IPPE or of Part B start. | Any time, but it is not a Medicare benefit. |
| Cost to patient | $0 for the visit itself if the provider accepts assignment, Part B deductible does not apply. | $0 for the visit itself if the provider accepts assignment. | Patient pays, unless a Medicare Advantage plan adds it as a supplemental benefit. |
| What it is | Review of medical and social history, BP, vision screen, BMI, depression and safety screening, a screening ECG only if referred from this visit and only under its own rules, end-of-life planning on request, and a written screening and vaccine plan. | Health Risk Assessment, updated history and provider list, cognitive impairment check, updated screening schedule, risk factor review, and a personalized prevention plan. Subsequent visits update the plan. | Head-to-toe examination and routine labs as the clinician chooses. |
| What it is NOT | Neither Medicare visit is a comprehensive head-to-toe physical exam. Neither includes routine labs or treatment of new or chronic problems for free. If problem-focused care or extra tests happen at the same appointment, those are billed separately and Part B deductible and 20 percent coinsurance can apply. Tell the patient that in advance. | Not covered by Original Medicare. | |
| Exam pearl | At exactly 65, a newly enrolled patient is usually in the Welcome window. The correct answer is often IPPE now, first AWV at least 12 months later, with vaccines and USPSTF screenings ordered under their own preventive benefits, not because the wellness visit itself covers the test. | Do not document an AWV as a physical. | |
Questions test the stops as hard as the starts. If a vignette patient is 65, check this list before ordering anything.
Tap a flashcard to flip it. Work the cases before opening the answers. Then take the quiz.
Mr. D, 65, presents for his first visit after enrolling in Medicare 3 months ago. He smoked 1.5 packs a day for 30 years and still smokes. He quit for 2 months last year, then restarted. BP 148/86, BMI 29. No prior colonoscopy, no pneumococcal or zoster vaccine on record, last tetanus shot unknown, last flu shot 3 years ago. He asks for a PSA because his brother had prostate cancer at 68. No urinary symptoms. He reports trouble getting an erection for the past year.
Work it: What visit type, what screenings, what vaccines, what conversations?
Answer: This is a Welcome to Medicare visit (IPPE), he is within 12 months of Part B. Screenings due: colorectal screening (any USPSTF option, colonoscopy is reasonable given never screened), annual lung LDCT (age 50 to 80, pack-years are 1.5 x 30 = 45, well over 20, currently smoking), one-time AAA ultrasound (man 65 to 75, ever smoked), BP management and lipids with a statin risk calculation, A1C (age 35 to 70 with overweight), one-time hepatitis C, HIV if never tested, depression screening, alcohol and tobacco counseling with pharmacotherapy offered. PSA: shared decision making, Grade C at 65, discuss family history as a risk factor, benefits and harms, and document his informed choice, do not just order it. ED: evaluate as a cardiovascular flag, check A1C, lipids, BP, meds, and counsel that smoking contributes. Vaccines: influenza with a preferred 65 and older formulation, COVID-19 per the 65 and older schedule, Tdap now (history unknown) then Td or Tdap every 10 years, RZV dose 1 now and dose 2 in 2 to 6 months, pneumococcal with 1 dose PCV20 or PCV21 (or PCV15 plus PPSV23 in 1 year). RSV: he has a risk argument only if a CDC risk factor is present, smoking alone with chronic lung disease would count through that lung disease, but age 65 alone does not. Document a falls, cognition, function, and Beers review, and set the first Annual Wellness Visit at least 12 months after this visit.
Mrs. L, 65, is due for a comprehensive exam. Last mammogram was 3 years ago. Pap history: HPV co-tests negative at age 57 and 62, no history of CIN 2 or higher, cervix intact. She has never had a DEXA. BMI 24, never smoked, walks daily, no falls. Vaccine record shows Tdap 8 years ago, Shingrix dose 1 given 8 months ago, no pneumococcal vaccine, flu shot last fall.
Work it: What is due, what is finished, and what is the one vaccine catch-up error to avoid?
Answer: Due now: mammography (biennial 40 to 74, she is 3 years out, so overdue), DEXA (all women at 65), colorectal screening if not current (routine to 75), BP, lipids and statin risk review, depression screening, hepatitis C once if never done. Diabetes screening Grade B does not automatically apply because BMI is 24 and she is not in the overweight or obesity group, use clinical judgment. Cervical screening: STOP. She has adequate prior screening (2 negative co-tests within 10 years, most recent within 5 years, ages 57 and 62 at presentation age 65 fits the look-back as documented in the vignette history, no CIN 2 or higher), so no Pap today, and that stop should be explained and documented. Vaccines: pneumococcal now (PCV20 or PCV21 alone, or PCV15 plus PPSV23 in 1 year), influenza this fall with a preferred formulation, COVID-19 up to date for 65 and older, Td or Tdap booster in 2 years (10 years after her Tdap). Shingrix: give dose 2 NOW. It is late, at 8 months, but the rule is do not restart the series, just give the missing dose. RSV: healthy, never smoked, no CDC risk factor, so not recommended at 65, revisit at 75 or if a risk factor develops. No AAA ultrasound, no ovarian screening, no screening pelvic exam without symptoms.
At 65, BOTH: BP every visit - Colorectal 45 to 75 - LDCT if 50 to 80, 20+ pack-years, quit under 15 years, annually - A1C if 35 to 70 and overweight or obese, every 3 years - Lipids and statin risk - Hep C once, 18 to 79 - HIV once, 15 to 65 - Depression screen - Alcohol and tobacco counseling - Falls: exercise if at risk.
MALE only: AAA ultrasound once, 65 to 75, ever smoked - PSA is a conversation at 55 to 69, never screen 70 and older - ED equals CV risk check.
FEMALE only: Mammogram every 2 years, 40 to 74 - DEXA at 65 - Cervical STOPS at 65 if adequate prior screening and no CIN 2+ in 20 years - No ovarian screening, no routine pelvic screening exam.
VACCINES at 65: Flu yearly, prefer high-dose, recombinant, or adjuvanted - COVID up to date, 65 and older get an additional dose 6 months after the prior 2024-2025 dose - Tdap once, then Td or Tdap every 10 years - Shingrix 2 doses, 2 to 6 months apart, age 50 and older - Pneumococcal at 50 and older now: PCV20 or PCV21 x 1, OR PCV15 then PPSV23 in 1 year - RSV: all 75 and older, plus 50 to 74 with risk only, 1 dose, not annual, not shared decision making anymore.
VISIT CHECKLIST: Med rec + Beers review - Vitals + BMI - Cognition - PHQ-2/9 - Falls + gait - ADLs / IADLs - Vision + hearing - Social drivers - Advance directive - Vaccine record from registry - Screening dates verified - Written prevention plan with next due dates - Medicare visit type documented correctly (IPPE vs AWV, neither is a physical).
NEVER / STOP: No Pap after 65 if adequate - No PSA at 70+ - No colorectal over 85 - No aspirin started for primary prevention at 60+ - No CA-125, no testicular screening, no asymptomatic bacteriuria screening, no vitamin D for fall prevention.