What labs, screenings, and preventive interventions should I order for a 74‑year‑old new patient?

Recommended Labs, Screenings, and Preventive Interventions for a 74-Year-Old New Patient

For a 74-year-old new patient, you should order: comprehensive metabolic panel, complete blood count, lipid profile, HbA1c or fasting glucose, TSH, urinalysis, blood pressure measurement, and initiate age-appropriate cancer screenings including colorectal cancer screening (if not up to date) and individualized lung cancer screening discussion if the patient has significant smoking history. 1

Core Laboratory Testing

Essential baseline labs for this age group include: 1

• Comprehensive metabolic panel (CMP) including electrolytes, creatinine with eGFR, and liver function tests (ALT, AST, total bilirubin, alkaline phosphatase) to monitor renal function, which deteriorates with age 1
• Complete blood count (CBC) with differential to screen for anemia, infection, and blood disorders 2
• Lipid profile (total cholesterol, LDL, HDL, triglycerides) for cardiovascular risk assessment 1, 2
• HbA1c or fasting glucose for diabetes screening 1, 2
• TSH for thyroid function assessment 1
• Urinalysis to screen for proteinuria, hematuria, or other renal abnormalities 1

Cardiovascular Risk Assessment

• Blood pressure measurement should be performed at this visit and at every subsequent clinical encounter 2
• Lipid profile results should guide statin therapy decisions based on cardiovascular risk 1
• If the patient is taking ACE inhibitors or ARBs, monitor renal function and serum potassium after 1-2 weeks of initiation, with each dosage increase, and at least yearly 1
• If prescribed thiazide or loop diuretics, check electrolytes after 1-2 weeks of initiation, with each dosage increase, and at least yearly 1

Cancer Screening

Colorectal Cancer Screening

Adults aged 74 should continue colorectal cancer screening if they are in good health with life expectancy greater than 10 years. 3 Options include: 3

• Annual fecal immunochemical test (FIT), or
• Colonoscopy every 10 years (if last colonoscopy was >10 years ago), or
• CT colonography every 5 years, or
• Flexible sigmoidoscopy every 5 years

For patients aged 76-85 years, screening decisions should be individualized based on patient preferences, life expectancy, health status, and prior screening history. 3 However, at age 74, if the patient is in good health, screening should continue. 3

Lung Cancer Screening

For current or former smokers aged 55-74 years in good health with at least a 30 pack-year smoking history who currently smoke or quit within the past 15 years, initiate a discussion about annual low-dose CT (LDCT) screening. 3, 2

This discussion must include: 3

• Benefits: LDCT substantially reduces the risk of dying from lung cancer 3
• Limitations: LDCT will not detect all lung cancers early, and not all detected cancers will be prevented from causing death 3
• Harms: Significant chance of false-positive results requiring additional testing; fewer than 1 in 1000 patients with false-positive results experience major complications from diagnostic workup 3
• Smoking cessation counseling remains a high priority and should not be replaced by screening 3

Screening should only be performed at high-volume, high-quality lung cancer screening and treatment centers with access to multidisciplinary teams. 3

Breast Cancer Screening (for Women)

Women aged 74 should continue biennial mammography screening as long as overall health is good and life expectancy is 10 years or longer. 3

Cervical Cancer Screening (for Women)

Women aged >65 years who have had ≥3 consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap tests within the last 10 years, with the most recent test in the last 5 years, should stop cervical cancer screening. 3 Women who have had a total hysterectomy should also stop screening. 3

Prostate Cancer Screening (for Men)

At age 74, prostate cancer screening with PSA should only be offered to men with at least a 10-year life expectancy after an informed decision-making process. 3 The discussion should include potential benefits, risks, and uncertainties associated with prostate cancer screening. 3

Immunizations

Pneumococcal Vaccination

Administer pneumococcal conjugate vaccine (Prevnar 20) if the patient has not received pneumococcal vaccination or needs updating based on current CDC guidelines. 4 Prevnar 20 is indicated for adults ≥60 years of age and covers 20 pneumococcal serotypes. 4

Herpes Zoster Vaccination

Administer recombinant zoster vaccine (Shingrix) as a 2-dose series (0 and 2-6 months apart) if not previously vaccinated. 5 This vaccine is recommended for adults aged 50 years and older. 5

Influenza Vaccination

Annual influenza vaccination should be administered. 6, 7

Tetanus-Diphtheria Vaccination

Ensure tetanus-diphtheria vaccination is up to date (booster every 10 years). 6

Additional Risk-Based Testing

• Hepatitis B and C serology if risk factors present (injection drug use, multiple sexual partners, occupational exposure) 1
• Syphilis serology (RPR or VDRL), gonorrhea, and chlamydia testing if risk factors for sexually transmitted diseases are present 1

Functional and Cognitive Assessment

Perform cognitive screening using validated tools such as the Montreal Cognitive Assessment (MoCA) and depression screening. 2 Brief geriatric assessment should include evaluation of functional, cognitive, affective status, hearing and visual impairments, nutritional status, fall risk, and social status. 8

Critical Pitfalls to Avoid

• Do not skip colorectal cancer screening if the patient is in good health with life expectancy >10 years, as this is critical for mortality reduction 3, 9
• Do not order routine comprehensive labs without clinical indication beyond the core panel listed above, as this leads to false positives and unnecessary follow-up 9
• Do not offer lung cancer screening to patients without significant smoking history (≥30 pack-years) or to those who quit >15 years ago 3
• Do not continue cancer screening in patients with life expectancy <5-10 years, as survival benefit is unlikely 6, 10
• Failing to assess family history significantly impacts screening recommendations for diabetes, cardiovascular disease, and cancer 1
• Do not perform PSA testing without shared decision-making and assessment of life expectancy 3

Lifestyle Counseling

Counsel on smoking cessation (if applicable), diet rich in healthy fats, aerobic exercise, and strength training. 6 These interventions remain important regardless of age and are among the most effective preventive measures. 6, 10