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Difficulty: HardPreventive Care and Screening

A physician evaluates a 62-year-old female patient who presents for a scheduled health maintenance visit. Her past medical history is notable for hypertension, osteoarthritis, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed for symptomatic uterine fibroids at age 45. She has consumed half a pack of cigarettes per day continuously since she was 22 years old. She currently takes amlodipine and acetaminophen. She reports feeling well without any new symptoms. Physical examination shows a blood pressure of 126/78 mm Hg and a body mass index of 24 kg/m². A recently calculated 10-year major osteoporotic fracture risk using the FRAX assessment tool is 4.2%.

Review of her preventive care timeline demonstrates:
- A colonoscopy at age 54 with no abnormal findings.
- A screening mammogram completed 6 months ago that was interpreted as normal.
- A negative Hepatitis C virus antibody assay at age 58.
- Documentation of the 20-valent pneumococcal conjugate vaccine (PCV20) administered at age 60, alongside an up-to-date annual influenza vaccination.

Which of the following interventions is the most appropriate next step in this patient's preventive care?

  1. Annual low-dose computed tomography of the chestAnswer
  2. B
    Screening for abdominal aortic aneurysm with duplex ultrasonography
  3. C
    Repeat screening colonoscopy
  4. D
    Cervical cancer screening with high-risk human papillomavirus testing
  5. E
    Screening for osteoporosis with dual-energy x-ray absorptiometry

Answer

Annual low-dose computed tomography of the chest
The correct answer is annual low-dose computed tomography of the chest. The United States Preventive Services Task Force (USPSTF) recommends annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years who have at least a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. This patient has smoked 0.5 packs per day for 40 years (from age 22 to 62), which equates to exactly a 20 pack-year history. Because she meets the age criteria, meets the updated pack-year threshold, and is a current smoker, LDCT is strongly indicated to reduce lung cancer-specific mortality.

Step-by-Step Solution

1
Calculate the patient's smoking pack-year history.
The patient has smoked 0.5 packs per day for 40 years (from age 22 to 62). 0.5 x 40 = 20 pack-years.
Accurate pack-year calculation is essential to determine eligibility for lung cancer screening.
2
Evaluate the patient against USPSTF lung cancer screening criteria.
She is between 50 and 80 years old, has exactly a 20 pack-year history, and currently smokes. Therefore, she meets all indications for annual screening.
To identify if a high-value, mortality-reducing preventive intervention is currently due.
3
Assess the necessity of other preventive screenings based on her specific history.
Colonoscopy is deferred until age 64 (10 years after a normal result). Cervical screening is contraindicated due to prior total hysterectomy for benign disease. DEXA is deferred because she is under 65 and her FRAX score (4.2%) is below the 8.4% threshold. AAA screening is not routinely indicated in women.
To systematically eliminate distractors that represent mistimed or inappropriate care.

Key Concept

The USPSTF recommends annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years.

Alternative Method

Calculate pack-years by multiplying the total number of cigarettes smoked per day by the number of years smoked, then dividing by 20 (the standard number of cigarettes in a pack). (10 cigarettes/day * 40 years) / 20 = 20 pack-years.
Estimated Time:1m 30s
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Topics

Preventive Care and Screening

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