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Difficulty: HardPreventive Care and Screening

A 54-year-old man presents to the clinic for a routine health maintenance visit. His past medical history is significant for type 2 diabetes mellitus, well-controlled on metformin, and primary hypertension treated with lisinopril. He has a 25-pack-year smoking history but successfully quit smoking 2 years ago. He drinks alcohol socially and denies illicit drug use.

His last primary care visit was 5 years ago, during which he received a tetanus, diphtheria, and acellular pertussis (Tdap) booster. He receives an annual influenza vaccine at his local pharmacy. At age 51, he completed a two-dose series of the recombinant zoster vaccine. He has no history of pneumococcal vaccination.

A screening colonoscopy performed at age 46 revealed two diminutive hyperplastic polyps in the distal rectum, which were completely excised. He had a one-time screening test for Hepatitis C and HIV at age 48, both of which were negative.

His vital signs today are temperature 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), blood pressure 128/78 mmHg128/78\text{ mmHg}, heart rate 72/min72/\text{min}, and respiratory rate 14/min14/\text{min}. BMI is 31 kg/m231\text{ kg/m}^2. Physical examination is unremarkable.

Which of the following interventions are indicated for this patient during today's visit? (Select all that apply)

  1. Low-dose computed tomography (LDCT) of the chestAnswer
  2. Pneumococcal conjugate vaccinationAnswer
  3. C
    Surveillance colonoscopy
  4. D
    Tetanus and diphtheria (Td) booster
  5. E
    Ultrasonography of the abdominal aorta

Answer

The indicated interventions for this patient are low-dose computed tomography (LDCT) of the chest and pneumococcal conjugate vaccination.
The interventions that are indicated for this patient today are lung cancer screening with LDCT and pneumococcal conjugate vaccination. The USPSTF recommends annual LDCT screening for adults aged 50 to 80 years who have a ≥20\geq 20 pack-year smoking history and currently smoke or have quit within the past 15 years. This 54-year-old patient fulfills these criteria. Furthermore, the CDC recommends pneumococcal vaccination (e.g., PCV20) for adults aged 19 to 64 years who have underlying medical conditions that increase the risk of invasive pneumococcal disease. This patient's type 2 diabetes mellitus and history of cigarette smoking are both qualifying indications.

Step-by-Step Solution

1
Evaluate the patient's eligibility for lung cancer screening.
The patient is 54 years old with a 25-pack-year smoking history and quit 2 years ago. This meets the criteria for annual LDCT screening.
USPSTF guidelines require annual LDCT for adults aged 50 to 80 with at least a 20-pack-year history who currently smoke or have quit within 15 years.
2
Assess the patient's immunization needs, particularly for pneumococcal disease.
The patient has type 2 diabetes mellitus and a smoking history, making him eligible for pneumococcal vaccination prior to age 65.
Adults aged 19 to 64 with high-risk comorbidities (e.g., diabetes, chronic heart/lung/liver disease, smoking, alcoholism) require pneumococcal vaccination.
3
Determine the appropriate interval for the patient's next surveillance colonoscopy.
The previous colonoscopy showed only distal hyperplastic polyps, which means the screening interval remains 10 years.
Diminutive (<10 mm<10\text{ mm}) hyperplastic polyps in the rectum or sigmoid colon are considered non-neoplastic and do not warrant a shortened surveillance interval.
4
Review other age- and risk-based screening guidelines for AAA and tetanus boosters.
Neither AAA screening nor a Td/Tdap booster is indicated at this time.
AAA screening is recommended for men starting at age 65 who have ever smoked. A Td/Tdap booster is required every 10 years, and his last dose was 5 years ago.

Key Concept

Application of age- and risk-based preventive screening and immunization guidelines in the primary care setting.
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Topics

Preventive Care and Screening

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