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Difficulty: MediumPreventive Care and Screening

A 62-year-old woman presents to her primary care physician for a routine health maintenance evaluation. She has no acute medical complaints today and feels well. Her past medical history is notable for hypertension, which is well-controlled on amlodipine, and obesity. Her body mass index is 32 kg/m². Social history reveals she is a former smoker who smoked 1 pack of cigarettes daily for 30 years before quitting 16 years ago. She currently drinks one glass of wine occasionally.

Review of her preventive screening records shows she underwent a screening colonoscopy at age 55 that revealed no polyps or abnormalities. She had a normal screening mammogram 6 months ago. Her last Pap smear with high-risk human papillomavirus (HPV) co-testing was performed at age 59 and was negative for both. Her hepatitis C antibody test was negative 3 years ago. Regarding immunizations, she received an annual influenza vaccine last month and a Tdap booster 4 years ago. She has no history of receiving the recombinant zoster vaccine or any pneumococcal vaccines.

Which of the following is the most appropriate next step in preventive care for this patient?

  1. Administer recombinant zoster vaccineAnswer
  2. B
    Order a low-dose CT scan of the chest
  3. C
    Order a dual-energy x-ray absorptiometry scan
  4. D
    Schedule a screening colonoscopy
  5. E
    Administer 20-valent pneumococcal conjugate vaccine

Answer

Administer recombinant zoster vaccine
The recombinant zoster vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP) as a two-dose series for all immunocompetent adults aged 50 years and older to prevent herpes zoster (shingles) and its complications, such as postherpetic neuralgia. Since this 62-year-old patient has no history of receiving it, administering the first dose is an essential and strongly indicated step in her preventive care today.

Step-by-Step Solution

1
Analyze the patient's demographic and social risk factors
The patient is a 62-year-old female, obese, with a 30 pack-year smoking history who quit 16 years ago.
Age and smoking history strictly dictate the timing of specific cancer screenings and immunizations.
2
Evaluate prior screening intervals for cancer and chronic disease
Colonoscopy at 55 was normal (due in 10 years at age 65). Mammogram at 61.5 is normal (due biennially or annually). Pap/HPV co-test at 59 is negative (due in 5 years at age 64).
Determining current screening needs requires calculating the next due date based on the results of the most recent tests.
3
Apply lung cancer screening criteria
Although she has a >= 20 pack-year history, she quit 16 years ago. USPSTF guidelines state screening should stop once a person has not smoked for 15 years.
Lung cancer screening with low-dose CT is heavily age- and cessation-time dependent.
4
Evaluate immunization status according to ACIP schedules
She lacks the recombinant zoster vaccine, which is universally recommended starting at age 50. She does not meet the criteria for early pneumococcal vaccination.
Identifying missing indicated vaccines is a core component of adult preventive health maintenance.

Key Concept

Evidence-based preventive screening and immunization intervals for older adults
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Topics

Preventive Care and Screening

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