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Difficulty: HardPreventive Care and Screening

A 65-year-old man presents to the primary care clinic for an annual health maintenance examination. His past medical history is significant for type 2 diabetes mellitus, hypertension, and obesity. He is a former smoker, having smoked 1 pack per day for 40 years before quitting 2 years ago. He feels well and reports no acute symptoms. His vital signs and physical examination are unremarkable.

Review of his preventive health record reveals the following:
- A screening colonoscopy 6 years ago was completely normal, with no polyps identified.
- He received a Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine 12 years ago.
- He received two doses of the recombinant zoster vaccine at age 50.
- He received the seasonal influenza vaccine one month ago.
- He has never undergone abdominal imaging, chest imaging, or bone density screening.
- He has not received any pneumococcal vaccines.

Based on current guidelines, which of the following interventions are indicated for this patient at today's visit? (Select all that apply)

  1. One-time screening for abdominal aortic aneurysm with ultrasonographyAnswer
  2. Annual screening for lung cancer with low-dose computed tomographyAnswer
  3. Administration of a tetanus and diphtheria toxoids (Td) or Tdap booster vaccineAnswer
  4. D
    Screening for colorectal cancer with colonoscopy
  5. E
    Screening for osteoporosis with dual-energy x-ray absorptiometry (DXA)
  6. F
    Administration of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) alone

Answer

The indicated interventions are one-time screening for abdominal aortic aneurysm with ultrasonography, annual screening for lung cancer with low-dose computed tomography, and administration of a tetanus and diphtheria (Td) or Tdap booster vaccine.
The indicated interventions are based on age, sex, and smoking history. The patient requires a one-time abdominal ultrasound to screen for an abdominal aortic aneurysm because he is a man aged 65-75 with a smoking history. He requires annual low-dose computed tomography (LDCT) for lung cancer screening because he is between 50-80 years old, has at least a 20 pack-year smoking history, and quit within the last 15 years. Finally, he requires a Td or Tdap booster because it has been over 10 years since his last dose.

Step-by-Step Solution

1
Evaluate the patient's age and smoking history for cancer and vascular screening guidelines.
The patient is a 65-year-old man with a 40 pack-year smoking history who quit 2 years ago.
Age and smoking history are primary determinants for AAA and lung cancer screening.
2
Apply AAA screening guidelines.
He meets criteria for a one-time AAA screening with abdominal ultrasonography.
The USPSTF recommends a one-time AAA screening for men aged 65 to 75 who have ever smoked (100 or more cigarettes in a lifetime).
3
Apply lung cancer screening guidelines.
He meets criteria for annual lung cancer screening with low-dose CT.
The USPSTF recommends annual LDCT for adults aged 50 to 80 with a 20 or more pack-year smoking history who currently smoke or quit within the last 15 years.
4
Review the immunization record.
His last Tdap was 12 years ago, which is past the 10-year booster interval. He needs a Td or Tdap booster.
Adults require a tetanus toxoid-containing booster every 10 years to maintain immunity against tetanus and diphtheria.
5
Evaluate the remaining options for appropriateness based on his history.
Colonoscopy is not due (normal 6 years ago, 10-year interval). DXA is not routinely indicated for men. PPSV23 alone is incorrect for initial pneumococcal vaccination.
Preventing unnecessary testing and adhering to current vaccine sequencing guidelines is critical for appropriate patient management.

Key Concept

Application of age- and risk-factor specific preventive screening and immunization guidelines for older adults.
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Topics

Preventive Care and Screening

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