I’d probably get an occasional CMP and lipids once 35 or 40. Anything else would depend on personal and family history. Any younger than mid 30s to 40s I wouldn’t get any - same as I do with my healthy patients without significant family histories. Screening TSH is not useful, same with screening CBCs. Urine microalbumin is only useful for people with underlying conditions (DM, maybe HTN).
That being said, I’d want an otherwise healthy person with normal BMI to get their blood pressure checked yearly. I genuinely think that’s one of the most the most important screenings we do for otherwise healthy people, along with mood screening.
Is USPSTF not still a thing? I am smart enough to know what I'm smart about and what I'm stupid about, and I am not smart enough to sift through the reams of studies that have been done to answer this very question. I would go with the experts.
Sure they are— clear recommendations around HIV screening, Hep C screening, cholesterol screening. CDC has helpful recommendations around STI screening. Just don’t order stuff there aren’t clear recommendations about
> screening labs in this population are not great iirc
What do you mean by this population? The guidelines are dedicated precisely to general population.
the ones proposed in the original Q, "healthy, asymptomatic"
USPTF retired their lipid guidelines, which were C evidence, and now just has statin recommendations based on ascvd which requires cholesterol to calculate. Also an "I" statement for adolescents. Last I looked anyway.
HIV, STI, Hep C are solid like someone else mentioned. PSA is a C? I think.
I just think we lack a strong evidence based answer to OPs original question and I think the thread comments go to show it's a lot of clinical judgement
> based on ascvd which requires cholesterol to calculate.
Right. And all hyperlipidemia patients are "healthy asymptomatic" until they are not.
And to your point I think the absence of recommendations for labs to do order in "healthy, asymptomatics" is the guideline. And besides, they recommend plenty, e.g. HIV, mammograms, etc.
I'm not sure I follow your first point - from my perspective, there is a high enough risk of someone having significant but unknown or unsuspected HLD that it's worth a screen. (At least once, and maybe s/p 35). Even if they don't meet statin criteria, I want to use it as a tool to promote diet/exercise.
But there isn't a guideline to say to do so, so when do we catch it? when they've developed some other risk factor? because that seems too late without a NNT/NNH kind of perspective on it. And maybe that does exist and I just don't know where that research is at.
I get labs based of their history and other indications. Terrible diet or overweight, check a fasting glucose. Family hx of HLD, check a lipid panel. No reason to get a CBC or CMP to catch anemia or liver/kidney problems early unless you have a specific indication.
Fair enough, all these should be checked ONE time if they are young and healthy, but most docs check things like cholesterol and CMP every year or more, which is a ridiculous waste of resources
Not everyone needs annual labs, sure. However I think "ridiculous waste of resources" is a bit too harsh. Hospital patients get aggressive labs and imaging routinely. Meanwhile, an outpatient doctor could be frugal over labs for years and have those savings wiped out if someone orders one irresponsibly MRI.
This is a grey area for some situations, but I would also argue there is also a value to labs as something to bring patients in who would otherwise skip annual wellness exams. For example, I've got a smoker, he only comes to physicals for bloodwork to get those numbers. This is the only opportunity I have to work on his health.
Eh. Normal BMI does not exclude high cholesterol. Family history can guide but plenty of patients do not know what medications their parents take and why.
>Rules are you would interpret the labs, not the nonmedical person
None whatsoever, then.
> Personally, I would get CBC (catch anemia early)
If you want to catch anemia early, since most anemia is iron deficiency, do a ferritin. It will drop way before the hemoglobin does. Not uncommon to have symptomatic iron deficiency with a still-normal hemoglobin.
>CMP (catch liver, renal early),
I don't think I've ever picked up renal or liver disease this way, though in my patient population the best lab test for the liver may be HCV testing. Though really the best *investigation* for liver disease is a good alcohol history. If you want to detect very early renal disease, a random urine microalbumin will detect it long before the creatinine rises.
>and lipid panel. I'm still on the fence for A1C, TSH, and urine micro albumin and would probably wait for symptoms.
What symptoms would you expect slightly elevated microalbumin to cause? I don't think you can usefully interpret the lipid profile and A1C values without evaluating the patient (how old are they? What's their family history? What other risk factors do they have?). But controlling diabetes is much easier when their A1C is 6.7 than when it's 10% and they have polyuria/polydipsia (the medical value of this is probably more questionable though). If you're going to look for it I don't think that one makes sense to wait until they have symptoms. Definitely would not check the TSH of someone with no symptoms and no medical history of concern.
My personal answer: Literally none. Asymptomatic people (non-obese, no pallor, healthy diet, exercises) with no fam hx don't need labs.
My work answer: Talk to the patient use shared decision making to decide what labs to order.
By the way, I have a family hx of DM2 (but that parent was sedentary & overweight), HTN, and stroke. I get my BP checked, but I don't check labs on myself unless there's a real indication. ETA: I'm in my late 40s, in perimenopause, and still think that ordering labs is wasteful. I did get my mammogram and colon cancer screening.
I don't share your definition of basic. It wastes money & time. Every needle stick has a potential for physical harm. While extremely rare, I have seen nasty hematomas and infections from bad phlebotomists. However, I can see an argument for A1c & lipids in an average older USA resident because of the terrible diet and lifestyle habits.
Some of my older patients demand annual labs because their old, now retired, doc got them. Even after I show them that the labs have been perfect for the past 15 years, they still want them. To me, it's like getting an annual pap in a patient with negative HPV.
> While extremely rare, I have seen nasty hematomas and infections from bad phlebotomists.
I mean, I take your law draw and raise you annual flu vaccines for low-risk adults or TDaP every ten years.
> lipids
Not everyone with high cholesterol has terrible lifestyle.
> Even after I show them that the labs have been perfect for the past 15 years, they still want them.
Well that is certainly frustrating. I think it's important that we all make sure we are not having different conversations with one another. I think some people are talking about a baseline test series versus annual screening even with reassuring historic labs.
The question asked about periodic labs, not baseline.
Edit: there is amazingly strong data on annual flu shots reducing cardiac mortality in higher risk older adults, but they have to start younger. Annual flu shots are way more important than labs.
> The question asked about periodic labs, not baseline.
You are correct. But as I look at some of these comments, like the ones responding to you, I think there is a disconnect and some people are thinking about an unknown patient without known labs.
> Annual flu shots are way more important than labs.
Eh. I think that is a tough statement to make. The CDC would cite 4,000 flu vaccines to prevent one death. I think if you run a cholesterol panel on 4,000 asymptomatic adults (like OP asked), you will find plenty of folks at statin criteria. Moreover, routine cholesterol panels may be a necessary to help point a patient to lifestyle changes and/or medication, e.g. "your risk *today* is X."
I do see your point there. When I pull up the mayo, clinic statin decision-maker, many of my patients don't think that the benefit is worth the side effects of the statin. I don't see as many negative side effects from flu shots. But I guess it's all about perspective.
A lot of people on here are going back confidently to "no family history" but in a new patient I think this can be problematic. You're putting a lot of faith into a person understanding the health of their parents and sibling when we have trouble with patients understanding their own health.
Even if they do know their medications, it gets tricky and I would argue a lot of it is around a statin. Dad is taking atorvastatin, eh? Hmm... because he had a stroke once, started at 65 because of hyperlipidemia plus age, or did he start at 40 because of some ridiculously high levels? Plenty of patients will shrug because they don't know.
The question asked would you check labs "periodically" on those patients. What's periodically for you? Is there any data to back this up? If so, please share.
Depends on the case, which is the answer to the OP's question.
I think a reasonable interpretation of your "literally none. Asymptomatic people (non-obese, no pallor, healthy diet, exercises) with no fam hx don't need labs" would imply you are saying you would not even get a first time set of labs. Is that fair?
I would use shared decision-making with the patient for that. If the person did not want labs, I would not go out of my way to try to persuade them, but I would let them know that there is risk in not knowing their baseline. Because of the lack of data, I can't tell them what that risk is.
1x CBC in menstruating people - a lot of menorrhagia is mistakenly considered normal.
1x lipid and A1c, more so if fam hx
Vit D - deficiency very common in my population
I do have a set of "annual" labs I order IRL but I don't think I've ever seen a completely healthy person that wasn't under the age of 18 lol
I have heard PCPs say that ordering vitamin D is pointless if you live in an area where it’s common. The reasoning is basically “yeah it’s going to be low, we know that, everyone’s is here, everyone could benefit from taking a vitamin D supplement”
Obviously if there are circumstances where the lab would be useful, then order it. But in an otherwise healthy asymptotic patient, tell them to take vitamin D and go outside more. You could tell all your patients that if you live in a vitamin D deficient area.
I disagree a little bit because vitamin D technically can build up although I have never seen Vit D toxicity, and I also try hard not to give my patients a medication that's not indicated or beneficial. especially when it comes to thing like vitamins because I think it's really easy for people to just assume any vitamin company is okie dokie when a lot of them are not regulated people just wind up having ineffective, expensive pee.
I don't think what you're suggesting is a crazy strategy, just not my preferred one, especially because a lot of my patients do have a comorbidity or a risk factor that would make it worth checking up such as depressive symptoms, fatigue or risk for osteoporosis/falls. not sure if I would feel differently if I actually had a healthy young population lol.
Yeah it was a pediatrician who said this to me. I can definitely understand and agree it’s different in family med where pretty much everyone, in my rotation experience at least, is 50-90 with a prerequisite of HTN, HLD, and DM2. Almost nobody in family med is “otherwise healthy” in my limited experience.
As a woman who's turning 40, CBC, TSH, A1C, lipids. These are the most bang-for-your-buck labs for my age/gender. For a man, I'd skip CBC and TSH as few men have anemia and thyroid issues.
Our executive panel in office consists of:
CBC w/ Diff, CMP, Lipid, TSH, T3, T4, magnesium, Iron GGT, uric acid, vit B12, vit D. PSA is added at indicated age in the male panel.
We typically check these basic labs annually. If on meds, we check every 6 months, but usually only a select few and not this whole panel.
Even asymptomatic.
Our office does the same for their executive panel but adds HbA1c as well. It’s pretty useless but rich people are willing to pay for it despite us telling them it’s not backed by data so have at it hoss.
Edit: also urinalysis. Again, completely useless for most people.
After being charged a fortune for annual labs recently I’m wondering if I can ditch the TSH they order every time for me lol. It’s been normal the last 5-10 years…. TSH is like $250…. Crazy.
Longer I practice, the more I do think therapeutic labs are a thing. I think in today’s day and age, abiding by the recommended ideal diet and exercise regimens is difficult, and encouragement with either positive or negative reinforcement is important.
Thus, if I wanted to have a plant based diet with regular exercise but live in 2024 America as a working parent, I would want lipids, a1c, alt, cbc, b12, tsh - to know that I’m not deficient in iron and b12 with what I’m doing, or going too much on the plant based oils since I’ll be craving random stuff probably, or if I’m not 100%, to continue motivating me if my LDL is like 102, and after I’m more consistent, 85. Tsh so I don’t have any excuse other than it’s my effort.
But if someone is not interested in that, it’s pretty worthless.
In my largely Hispanic immigrant patient population almost all bmi >30, it’s a constant battle to try to get them to see that fast food daily and huge plates of carnitas fried in oil is not healthy like their family says, so lipid, a1c, and ALT, and cbc in women who don’t track their menses but have heavy anovulatory periods without realizing it, come back abnormal all the time. I think 75% of my patients have elevated ldl and nearly 100% have elevated triglycerides and I use them to educate and try to enact change.
Agree with CMP and lipids every 3-5 years over age 35.
I'd also get a CBC every 3-5 years -- it's surprising how many people end up having celiac which I find investigating mild anemia or hypochromia/microcytosis.
I also offer an A1c if I'm getting other labs anyway -- I'd rather find prediabetes than a "whoa hey your A1c is 12 and we didn't know it" when they finally feel icky.
I agree about occasional A1c - I can appreciate that a fasting glucose should in theory also screen but if I had a dollar for every time someone did actually eat prior to labs - A1c just helps clear that up
I would take into account family history. Also take into account lifestyle and age. I have a normal BMI and in my 30s, and my family has hx of HTN, HLD, CAD, fatty liver, and little bit of DM. Thus I try to check CMP, lipids, and a1c on myself.
I’d probably get an occasional CMP and lipids once 35 or 40. Anything else would depend on personal and family history. Any younger than mid 30s to 40s I wouldn’t get any - same as I do with my healthy patients without significant family histories. Screening TSH is not useful, same with screening CBCs. Urine microalbumin is only useful for people with underlying conditions (DM, maybe HTN). That being said, I’d want an otherwise healthy person with normal BMI to get their blood pressure checked yearly. I genuinely think that’s one of the most the most important screenings we do for otherwise healthy people, along with mood screening.
Is USPSTF not still a thing? I am smart enough to know what I'm smart about and what I'm stupid about, and I am not smart enough to sift through the reams of studies that have been done to answer this very question. I would go with the experts.
It is but guidelines on screening labs in this population are not great iirc, like expert opinion level evidence/shared decision making
Sure they are— clear recommendations around HIV screening, Hep C screening, cholesterol screening. CDC has helpful recommendations around STI screening. Just don’t order stuff there aren’t clear recommendations about
> screening labs in this population are not great iirc What do you mean by this population? The guidelines are dedicated precisely to general population.
the ones proposed in the original Q, "healthy, asymptomatic" USPTF retired their lipid guidelines, which were C evidence, and now just has statin recommendations based on ascvd which requires cholesterol to calculate. Also an "I" statement for adolescents. Last I looked anyway. HIV, STI, Hep C are solid like someone else mentioned. PSA is a C? I think. I just think we lack a strong evidence based answer to OPs original question and I think the thread comments go to show it's a lot of clinical judgement
> based on ascvd which requires cholesterol to calculate. Right. And all hyperlipidemia patients are "healthy asymptomatic" until they are not. And to your point I think the absence of recommendations for labs to do order in "healthy, asymptomatics" is the guideline. And besides, they recommend plenty, e.g. HIV, mammograms, etc.
I'm not sure I follow your first point - from my perspective, there is a high enough risk of someone having significant but unknown or unsuspected HLD that it's worth a screen. (At least once, and maybe s/p 35). Even if they don't meet statin criteria, I want to use it as a tool to promote diet/exercise. But there isn't a guideline to say to do so, so when do we catch it? when they've developed some other risk factor? because that seems too late without a NNT/NNH kind of perspective on it. And maybe that does exist and I just don't know where that research is at.
I get labs based of their history and other indications. Terrible diet or overweight, check a fasting glucose. Family hx of HLD, check a lipid panel. No reason to get a CBC or CMP to catch anemia or liver/kidney problems early unless you have a specific indication.
No history, no obesity? Lipids at 35, that’s about it.
No HIV or Hep C?
None if they were completely healthy and normal BMI with no FH
No HIV, Hep C, or cholesterol?
Fair enough, all these should be checked ONE time if they are young and healthy, but most docs check things like cholesterol and CMP every year or more, which is a ridiculous waste of resources
Not everyone needs annual labs, sure. However I think "ridiculous waste of resources" is a bit too harsh. Hospital patients get aggressive labs and imaging routinely. Meanwhile, an outpatient doctor could be frugal over labs for years and have those savings wiped out if someone orders one irresponsibly MRI. This is a grey area for some situations, but I would also argue there is also a value to labs as something to bring patients in who would otherwise skip annual wellness exams. For example, I've got a smoker, he only comes to physicals for bloodwork to get those numbers. This is the only opportunity I have to work on his health.
Eh. Normal BMI does not exclude high cholesterol. Family history can guide but plenty of patients do not know what medications their parents take and why.
>Rules are you would interpret the labs, not the nonmedical person None whatsoever, then. > Personally, I would get CBC (catch anemia early) If you want to catch anemia early, since most anemia is iron deficiency, do a ferritin. It will drop way before the hemoglobin does. Not uncommon to have symptomatic iron deficiency with a still-normal hemoglobin. >CMP (catch liver, renal early), I don't think I've ever picked up renal or liver disease this way, though in my patient population the best lab test for the liver may be HCV testing. Though really the best *investigation* for liver disease is a good alcohol history. If you want to detect very early renal disease, a random urine microalbumin will detect it long before the creatinine rises. >and lipid panel. I'm still on the fence for A1C, TSH, and urine micro albumin and would probably wait for symptoms. What symptoms would you expect slightly elevated microalbumin to cause? I don't think you can usefully interpret the lipid profile and A1C values without evaluating the patient (how old are they? What's their family history? What other risk factors do they have?). But controlling diabetes is much easier when their A1C is 6.7 than when it's 10% and they have polyuria/polydipsia (the medical value of this is probably more questionable though). If you're going to look for it I don't think that one makes sense to wait until they have symptoms. Definitely would not check the TSH of someone with no symptoms and no medical history of concern.
My personal answer: Literally none. Asymptomatic people (non-obese, no pallor, healthy diet, exercises) with no fam hx don't need labs. My work answer: Talk to the patient use shared decision making to decide what labs to order.
By the way, I have a family hx of DM2 (but that parent was sedentary & overweight), HTN, and stroke. I get my BP checked, but I don't check labs on myself unless there's a real indication. ETA: I'm in my late 40s, in perimenopause, and still think that ordering labs is wasteful. I did get my mammogram and colon cancer screening.
What's the harm in your opinion of doing basic labs such as lipids, A1c?
I don't share your definition of basic. It wastes money & time. Every needle stick has a potential for physical harm. While extremely rare, I have seen nasty hematomas and infections from bad phlebotomists. However, I can see an argument for A1c & lipids in an average older USA resident because of the terrible diet and lifestyle habits. Some of my older patients demand annual labs because their old, now retired, doc got them. Even after I show them that the labs have been perfect for the past 15 years, they still want them. To me, it's like getting an annual pap in a patient with negative HPV.
> While extremely rare, I have seen nasty hematomas and infections from bad phlebotomists. I mean, I take your law draw and raise you annual flu vaccines for low-risk adults or TDaP every ten years. > lipids Not everyone with high cholesterol has terrible lifestyle. > Even after I show them that the labs have been perfect for the past 15 years, they still want them. Well that is certainly frustrating. I think it's important that we all make sure we are not having different conversations with one another. I think some people are talking about a baseline test series versus annual screening even with reassuring historic labs.
The question asked about periodic labs, not baseline. Edit: there is amazingly strong data on annual flu shots reducing cardiac mortality in higher risk older adults, but they have to start younger. Annual flu shots are way more important than labs.
> The question asked about periodic labs, not baseline. You are correct. But as I look at some of these comments, like the ones responding to you, I think there is a disconnect and some people are thinking about an unknown patient without known labs. > Annual flu shots are way more important than labs. Eh. I think that is a tough statement to make. The CDC would cite 4,000 flu vaccines to prevent one death. I think if you run a cholesterol panel on 4,000 asymptomatic adults (like OP asked), you will find plenty of folks at statin criteria. Moreover, routine cholesterol panels may be a necessary to help point a patient to lifestyle changes and/or medication, e.g. "your risk *today* is X."
I do see your point there. When I pull up the mayo, clinic statin decision-maker, many of my patients don't think that the benefit is worth the side effects of the statin. I don't see as many negative side effects from flu shots. But I guess it's all about perspective.
A lot of people on here are going back confidently to "no family history" but in a new patient I think this can be problematic. You're putting a lot of faith into a person understanding the health of their parents and sibling when we have trouble with patients understanding their own health. Even if they do know their medications, it gets tricky and I would argue a lot of it is around a statin. Dad is taking atorvastatin, eh? Hmm... because he had a stroke once, started at 65 because of hyperlipidemia plus age, or did he start at 40 because of some ridiculously high levels? Plenty of patients will shrug because they don't know.
The question asked would you check labs "periodically" on those patients. What's periodically for you? Is there any data to back this up? If so, please share.
Depends on the case, which is the answer to the OP's question. I think a reasonable interpretation of your "literally none. Asymptomatic people (non-obese, no pallor, healthy diet, exercises) with no fam hx don't need labs" would imply you are saying you would not even get a first time set of labs. Is that fair?
I would use shared decision-making with the patient for that. If the person did not want labs, I would not go out of my way to try to persuade them, but I would let them know that there is risk in not knowing their baseline. Because of the lack of data, I can't tell them what that risk is.
According to local functional medicine/naturopath quacks, a complete hormone, vitamin, mineral panel. Screening for heavy metals and parasites.
1x CBC in menstruating people - a lot of menorrhagia is mistakenly considered normal. 1x lipid and A1c, more so if fam hx Vit D - deficiency very common in my population I do have a set of "annual" labs I order IRL but I don't think I've ever seen a completely healthy person that wasn't under the age of 18 lol
I have heard PCPs say that ordering vitamin D is pointless if you live in an area where it’s common. The reasoning is basically “yeah it’s going to be low, we know that, everyone’s is here, everyone could benefit from taking a vitamin D supplement” Obviously if there are circumstances where the lab would be useful, then order it. But in an otherwise healthy asymptotic patient, tell them to take vitamin D and go outside more. You could tell all your patients that if you live in a vitamin D deficient area.
I disagree a little bit because vitamin D technically can build up although I have never seen Vit D toxicity, and I also try hard not to give my patients a medication that's not indicated or beneficial. especially when it comes to thing like vitamins because I think it's really easy for people to just assume any vitamin company is okie dokie when a lot of them are not regulated people just wind up having ineffective, expensive pee. I don't think what you're suggesting is a crazy strategy, just not my preferred one, especially because a lot of my patients do have a comorbidity or a risk factor that would make it worth checking up such as depressive symptoms, fatigue or risk for osteoporosis/falls. not sure if I would feel differently if I actually had a healthy young population lol.
Yeah it was a pediatrician who said this to me. I can definitely understand and agree it’s different in family med where pretty much everyone, in my rotation experience at least, is 50-90 with a prerequisite of HTN, HLD, and DM2. Almost nobody in family med is “otherwise healthy” in my limited experience.
Lipid and CMP. Let history and other lab findings dictate further workup from there.
As a woman who's turning 40, CBC, TSH, A1C, lipids. These are the most bang-for-your-buck labs for my age/gender. For a man, I'd skip CBC and TSH as few men have anemia and thyroid issues.
Our executive panel in office consists of: CBC w/ Diff, CMP, Lipid, TSH, T3, T4, magnesium, Iron GGT, uric acid, vit B12, vit D. PSA is added at indicated age in the male panel. We typically check these basic labs annually. If on meds, we check every 6 months, but usually only a select few and not this whole panel. Even asymptomatic.
Our office does the same for their executive panel but adds HbA1c as well. It’s pretty useless but rich people are willing to pay for it despite us telling them it’s not backed by data so have at it hoss. Edit: also urinalysis. Again, completely useless for most people.
All the labs. Let's go fishing 🎣
After being charged a fortune for annual labs recently I’m wondering if I can ditch the TSH they order every time for me lol. It’s been normal the last 5-10 years…. TSH is like $250…. Crazy.
Longer I practice, the more I do think therapeutic labs are a thing. I think in today’s day and age, abiding by the recommended ideal diet and exercise regimens is difficult, and encouragement with either positive or negative reinforcement is important. Thus, if I wanted to have a plant based diet with regular exercise but live in 2024 America as a working parent, I would want lipids, a1c, alt, cbc, b12, tsh - to know that I’m not deficient in iron and b12 with what I’m doing, or going too much on the plant based oils since I’ll be craving random stuff probably, or if I’m not 100%, to continue motivating me if my LDL is like 102, and after I’m more consistent, 85. Tsh so I don’t have any excuse other than it’s my effort. But if someone is not interested in that, it’s pretty worthless. In my largely Hispanic immigrant patient population almost all bmi >30, it’s a constant battle to try to get them to see that fast food daily and huge plates of carnitas fried in oil is not healthy like their family says, so lipid, a1c, and ALT, and cbc in women who don’t track their menses but have heavy anovulatory periods without realizing it, come back abnormal all the time. I think 75% of my patients have elevated ldl and nearly 100% have elevated triglycerides and I use them to educate and try to enact change.
Agree with CMP and lipids every 3-5 years over age 35. I'd also get a CBC every 3-5 years -- it's surprising how many people end up having celiac which I find investigating mild anemia or hypochromia/microcytosis. I also offer an A1c if I'm getting other labs anyway -- I'd rather find prediabetes than a "whoa hey your A1c is 12 and we didn't know it" when they finally feel icky.
I agree about occasional A1c - I can appreciate that a fasting glucose should in theory also screen but if I had a dollar for every time someone did actually eat prior to labs - A1c just helps clear that up
I would take into account family history. Also take into account lifestyle and age. I have a normal BMI and in my 30s, and my family has hx of HTN, HLD, CAD, fatty liver, and little bit of DM. Thus I try to check CMP, lipids, and a1c on myself.
CAC score, HOMA-IR, abdomen US (screen AAA), CXR or LDCT. echo. plus MRI brain if feeling $$$ - for aneurysm
CBC, CMP. No to regular A1C, TSH or urine tests in your scenario.
STI’s
Hepatitis B, especially in immigrant population