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Difficulty: EasyClinical Preventive Services and Screening

A 65-year-old woman comes to the clinic for a routine preventive health visit. Her past medical history is significant for well-controlled hypertension and severe rheumatoid arthritis, for which she is currently receiving immunosuppressive therapy with rituximab. She has a 10-pack-year smoking history but quit 20 years ago. Family history is notable for osteoporosis in her mother. Current vitals show a temperature of 37.0°C (98.6°F), blood pressure of 128/80 mm Hg, heart rate of 76/min, and respiratory rate of 14/min. She reached menopause at age 51 and explicitly denies any episodes of vaginal bleeding since then. Her most recent colonoscopy and mammography were performed 2 years ago and were normal. She has had three consecutive negative Papanicolaou (Pap) tests in the past 10 years, with the most recent one being 3 years ago. She asks about her preventive health needs today. Which of the following is the most appropriate next step in the preventive care of this patient?

  1. Screening with dual-energy x-ray absorptiometryAnswer
  2. B
    Screening with low-dose computed tomography of the chest
  3. C
    Endometrial biopsy to screen for uterine malignancy
  4. D
    Administration of the measles, mumps, and rubella vaccine
  5. E
    Screening with a Papanicolaou test and human papillomavirus co-testing

Answer

Screening with dual-energy x-ray absorptiometry is the most appropriate preventive intervention.
Screening with dual-energy x-ray absorptiometry (DEXA) is the correct recommendation. The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women aged 65 years and older. This patient has reached the appropriate age milestone and has never had a DEXA scan, making it the most appropriate preventive step to order today.

Step-by-Step Solution

1
Evaluate the patient's age and demographic factors for routine screening eligibility.
The patient is a 65-year-old woman, which is the exact milestone age for initiating universal osteoporosis screening.
Age is the primary determinant for initiating USPSTF Grade A and B screening recommendations.
2
Review the patient's past screening history to determine if other routine tests are indicated.
She is up to date on colorectal and breast cancer screenings. She has adequate negative prior cervical cancer screening, meaning Pap tests can now be discontinued.
Avoiding redundant or unnecessary screening is a key component of clinical preventive services.
3
Assess the patient's specific risk factors and medications to rule out contraindicated interventions.
Her smoking history (10 pack-years) is insufficient for lung cancer screening. Her use of rituximab contraindicates the use of live vaccines.
Personalizing preventive care requires modifying recommendations based on comorbidities and iatrogenic immunosuppression.

Key Concept

Women aged 65 years and older should undergo routine screening for osteoporosis with dual-energy x-ray absorptiometry (DEXA), while cervical cancer screening can be safely discontinued if prior screening was adequate and negative.
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Topics

Clinical Preventive Services and Screening

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