What should be included in the annual exam of a 75-year-old male with a history of hypertension, hyperlipidemia, and diabetes?

Annual Examination for a 75-Year-Old Male with Hypertension, Hyperlipidemia, and Diabetes

Core Laboratory Testing

All of the following laboratory tests should be obtained annually for this patient 1:

• Complete blood count (CBC) with differential to screen for anemia, infection, and blood disorders 1
• Comprehensive metabolic panel (CMP) to assess kidney function (serum creatinine and eGFR), liver function, and electrolyte balance 2, 1
• Hemoglobin A1C for diabetes monitoring 2, 1
• Fasting lipid profile (total cholesterol, LDL, HDL, triglycerides) every 6-12 months 2, 1
• Urinalysis with albumin-to-creatinine ratio to screen for diabetic nephropathy 2, 1
• Thyroid-stimulating hormone (TSH) particularly important in older adults 1

Medication-Specific Monitoring

Given this patient's likely medication regimen:

• Serum potassium levels are essential for patients on ACE inhibitors, ARBs, or diuretics (for hypertension management) 2, 1
• Vitamin B12 levels if the patient is on metformin for diabetes 1

Cardiovascular Risk Assessment

Blood pressure measurement should be performed at every visit 2, 1. For this patient with established hypertension:

• Measure blood pressure in both arms to identify potential subclavian artery stenosis 3
• Assess orthostatic blood pressure changes, particularly important in older adults with diabetes who may have autonomic dysfunction 3
• Target blood pressure should be <140/90 mmHg, with goals individualized based on comorbidities 2

Lipid management monitoring should occur 4-12 weeks after any statin dose change, then annually 2. The patient should be on maximum tolerated statin therapy given his age and multiple cardiovascular risk factors 2.

Physical Examination Components

Vital Signs and Anthropometrics

• Height, weight, and BMI calculation 1, 3
• Waist circumference (target <94 cm for men) 2
• Blood pressure in both arms 3

Cardiovascular Examination

• Comprehensive cardiopulmonary examination including auscultation in all four valve areas for murmurs, gallops, or rubs 3
• Peripheral pulse assessment: femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally 3
• Ankle-brachial index should be considered given his cardiovascular risk factors 2, 3

Diabetic Foot Examination

This is critical and often overlooked 3:

• Inspect skin integrity for ulcers, fissures, calluses, or corns 3
• Assess for foot deformities 3
• Perform 10-gram monofilament testing on plantar surfaces of both feet to assess for peripheral neuropathy 3
• Teach daily foot inspection and proper footwear selection 3

Neurological Assessment

• Evaluate orientation to person, place, time, and situation 3
• Screen for cognitive impairment using a validated tool, as older adults with diabetes and hypertension are at increased risk 1, 3
• Assess memory, attention, and executive function 3

Ophthalmologic Considerations

• Fundoscopy or referral to ophthalmology is recommended for hypertensive patients with diabetes 2
• Visual acuity testing using Snellen chart 3

Comprehensive Skin Examination

• Systematic inspection of entire skin surface for lesions, ulcerations, or suspicious changes 3

Age-Specific Screening

Abdominal Aortic Aneurysm

One-time abdominal ultrasonography is recommended for men aged 65-75 years who have ever smoked 1, 4. If this patient has a smoking history and hasn't been screened, this should be done.

Bone Health

Bone densitometry is recommended for men age ≥50 years, particularly those with diabetes who are at increased risk for fractures 1.

Functional Assessment

Functional performance assessment is recommended for adults ≥65 years 1:

• Assess gait and mobility 3
• Evaluate activities of daily living and instrumental activities of daily living 2

Preventive Health Counseling

The following counseling should be provided at each annual visit 1:

• Diet and nutrition guidance: Emphasize Mediterranean or DASH diet, sodium restriction to approximately 2g/day (5g salt/day), and restriction of free sugar to <10% of energy intake 2
• Physical activity recommendations: Moderate-intensity aerobic exercise ≥150 minutes/week plus resistance training 2-3 times/week 2
• Tobacco cessation counseling if applicable 2
• Alcohol counseling: Recommend <100g/week of pure alcohol, preferably avoiding alcohol entirely 2
• Depression and anxiety screening using validated tools 1

Immunizations

Update immunizations according to CDC Advisory Committee on Immunization Practices guidelines 4:

• Annual influenza vaccine
• Pneumococcal vaccines (PPSV23 and PCV series)
• Zoster vaccine (Shingrix)
• Tetanus-diphtheria-pertussis booster if not up to date
• COVID-19 vaccination per current recommendations

Common Pitfalls to Avoid

• Do not skip the comprehensive foot examination in diabetic patients—this is where preventable complications are often missed 3
• Do not forget to monitor serum creatinine, eGFR, and urine ACR at least annually in patients with hypertension and diabetes, as these patients are at high risk for chronic kidney disease 2
• Do not overlook cognitive screening in older adults with multiple cardiovascular risk factors, as vascular cognitive impairment is common and treatable 2, 1
• Ensure electrolyte monitoring is performed after any changes to antihypertensive medications, particularly ACE inhibitors, ARBs, or diuretics, to detect hyperkalemia or AKI early 2