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Difficulty: Very hardPreventive Care and Screening

A 62-year-old man comes to the clinic for a routine health maintenance evaluation. He recently went through a divorce and reports being sexually active with multiple new male partners over the past 6 months. He admits to inconsistent condom use. His medical history is significant for essential hypertension, for which he takes amlodipine. He smoked 1.5 packs of cigarettes daily for 20 years but quit 8 years ago. His most recent cancer screening was a colonoscopy at age 54, which was normal. His vaccination history includes the complete hepatitis B series, a tetanus-diphtheria-acellular pertussis (Tdap) booster at age 58, and an influenza vaccine 2 weeks ago. He has never received pneumococcal or zoster vaccines. Vital signs and physical examination are unremarkable. Basic metabolic panel and hepatic function panel are within normal limits. Point-of-care HIV testing is negative, and comprehensive sexually transmitted infection testing is sent to the laboratory. Assuming the pending tests are negative, which of the following is the most appropriate next step in comprehensive preventive care?

  1. Initiate emtricitabine-tenofovir, order low-dose computed tomography of the chest, and administer recombinant zoster vaccineAnswer
  2. B
    Initiate emtricitabine-tenofovir, order low-dose computed tomography of the chest, and administer 20-valent pneumococcal conjugate vaccine
  3. C
    Initiate emtricitabine-tenofovir, order abdominal aortic aneurysm ultrasound, and administer recombinant zoster vaccine
  4. D
    Order low-dose computed tomography of the chest, order a screening colonoscopy, and administer 20-valent pneumococcal conjugate vaccine
  5. E
    Order low-dose computed tomography of the chest, order fecal immunochemical testing, and administer recombinant zoster vaccine

Answer

Initiate emtricitabine-tenofovir, order low-dose computed tomography of the chest, and administer recombinant zoster vaccine.
The correct comprehensive preventive care plan for this patient addresses his unique risks across three domains. First, his high-risk sexual behavior warrants the initiation of HIV pre-exposure prophylaxis (PrEP). Second, his smoking history (30 pack-years, quit 8 years ago) and age (62) perfectly align with the USPSTF guidelines for annual lung cancer screening with low-dose computed tomography (LDCT). Finally, all adults aged 50 and older should receive the recombinant zoster vaccine (RZV), making him due for this immunization.

Step-by-Step Solution

1
Evaluate the patient's sexual history and risk for HIV acquisition.
The patient is a man who has sex with men with multiple recent partners and inconsistent condom use.
High-risk sexual behavior is a Grade A USPSTF indication for pre-exposure prophylaxis (PrEP) with emtricitabine-tenofovir.
2
Assess the patient's smoking history against lung and vascular screening guidelines.
The patient has a 30 pack-year history and quit 8 years ago. He is 62 years old.
Patients aged 50-80 with ≥\ge 20 pack-years who currently smoke or quit ≤\le 15 years ago require annual low-dose CT of the chest. He is too young (62) for the AAA ultrasound, which starts at age 65.
3
Determine the appropriate adult immunizations based on age and comorbidities.
The patient is 62 years old and has not received zoster or pneumococcal vaccines.
Recombinant zoster vaccine (RZV) is indicated universally starting at age 50. PCV20 is not indicated for average-risk adults until age 65.
4
Review the colorectal cancer screening history.
Normal colonoscopy at age 54. The patient is now 62.
The standard interval after a normal colonoscopy is 10 years, meaning his next screening is due at age 64. Interval testing with FIT is not indicated.

Key Concept

Simultaneous application of age-appropriate and risk-based preventive care guidelines including HIV PrEP, cancer screening, and adult immunizations.
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Topics

Preventive Care and Screening

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