What is the recommended initial evaluation and management for a 20-year-old female with no past medical history, not taking any medications, presenting to establish care?

Initial Evaluation and Management for a 20-Year-Old Female Establishing Care

For a healthy 20-year-old female with no medical history establishing care, perform a focused history targeting sexual health, mental health, and cardiovascular risk factors, followed by a physical examination including blood pressure, BMI, and pelvic examination if sexually active, with screening for cervical cancer, sexually transmitted infections, and depression. 1, 2

Essential History Components

Sexual and Reproductive Health

• Document sexual activity status - this determines the need for STI screening, contraception counseling, and pelvic examination 1, 2
• Assess pregnancy intention - provide preconception counseling if planning pregnancy, or contraception counseling if not 2
• Screen for intimate partner violence using direct questions or validated screening tools 3, 2
• Obtain complete sexual history including number of partners, condom use, and history of STIs 3, 1

Mental Health and Substance Use

• Screen for depression using validated tools - depression is common in this age group and often presents with behavioral changes 3, 2
• Assess tobacco use, alcohol misuse, and drug use - all require screening and brief counseling 1, 2

Cardiovascular Risk Assessment

• Family history of premature coronary disease (first-degree relative with MI before age 50) - this determines need for lipid screening 4
• Personal history of hypertension or diabetes risk factors 1

Immunization History

• Document childhood immunizations and assess need for catch-up vaccines 3, 4

Physical Examination

Required Components

• Blood pressure measurement - screen for hypertension in all adults 1, 2
• Height, weight, and BMI calculation - screen for obesity 3, 1
• Breast examination - appropriate for women in their 20s 4
• Pelvic examination if sexually active - despite AAFP recommendations against routine pelvic exams in asymptomatic women, this is necessary for cervical cancer screening and STI testing 3, 2, 4

Laboratory and Screening Tests

Universal Screening (All Women Age 20)

• Cervical cancer screening with Pap smear - begin at age 21, but if she is 20 and sexually active, consider starting now 3, 1
• HIV screening - recommended for all women regardless of risk 1, 2
• Urinalysis and hematocrit - baseline screening 4

Risk-Based Screening (If Sexually Active)

• Chlamydia and gonorrhea screening - mandatory for all sexually active women under age 25 3, 1, 2
• Syphilis serology - if high-risk sexual behavior 3, 1, 4
• Hepatitis B and C screening - if risk factors present 3, 2
• Wet mount examination of vaginal secretions during pelvic exam 3

Cardiovascular Screening (If Risk Factors Present)

• Lipid panel - only if family history of premature coronary disease or other cardiovascular risk factors 1, 4
• Diabetes screening - only if blood pressure >135/80 mmHg or other risk factors 1

Counseling and Preventive Services

Mandatory Counseling

• Folic acid supplementation - 400-800 mcg daily for all women capable of pregnancy 1, 2
• Contraception counseling if sexually active and not planning pregnancy 2
• Safe sex practices - condom use and STI risk reduction if sexually active 3, 1
• Tobacco cessation if applicable 1, 2
• Weight management and physical activity if BMI elevated 1

Immunizations to Update

• HPV vaccine - critical for this age group if not previously completed 3, 2
• Tdap booster if not received in past 10 years 3, 2
• MMR and varicella - verify immunity 2
• Meningococcal vaccine - if not previously received 2
• Annual influenza vaccine 3, 2
• Hepatitis B vaccine series if not immune and at risk 3, 2

Common Pitfalls to Avoid

Do not perform unnecessary screening - avoid lipid panels, diabetes screening, or thyroid testing unless specific risk factors are present 1, 4. This differs from older adults where these are routine.

Do not skip STI screening in sexually active young women - chlamydia and gonorrhea screening is mandatory under age 25, not optional, as these infections are often asymptomatic and can cause infertility 3, 1, 2.

Do not forget preconception counseling - even if not currently planning pregnancy, all women of reproductive age should receive folic acid supplementation and counseling about optimizing health before pregnancy 1, 2.

Do not overlook mental health screening - depression and intimate partner violence are common in this age group and require active screening, not just waiting for patients to volunteer information 3, 2.