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Difficulty: HardPreventive Care and Screening

A 67-year-old man comes to the clinic for a routine health maintenance examination. His past medical history is significant for essential hypertension and mild osteoarthritis of the right knee. His current medications include lisinopril and as-needed acetaminophen. He reports feeling well, walking two miles daily, and having no chest pain, shortness of breath, changes in bowel habits, or weight loss.

The patient has a 40 pack-year smoking history but successfully quit smoking at age 51. He had a normal screening colonoscopy at age 62. Review of his medical record indicates he has received the recombinant zoster vaccine series, an updated 20-valent pneumococcal conjugate vaccine, a Tetanus-diphtheria-acellular pertussis (Tdap) booster 4 years ago, and completed one-time screening for hepatitis C and HIV at age 60. He has no family history of cancer, cardiovascular disease, or aortic aneurysms.

Vital signs show a blood pressure of 122/78 mmHg, heart rate of 72/min, and respiratory rate of 14/min. His body mass index is 26 kg/m². Physical examination reveals a normal cardiovascular exam with no murmurs, normal lung sounds, and a non-tender abdomen without pulsatile masses.

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

  1. A
    Low-dose computed tomography of the chest
  2. Ultrasonography of the abdomenAnswer
  3. C
    Fecal immunochemical testing
  4. D
    Prostate-specific antigen testing
  5. E
    Exercise electrocardiography

Answer

The most appropriate next step is ultrasonography of the abdomen to screen for an abdominal aortic aneurysm.
Ultrasonography of the abdomen is the correct choice because the US Preventive Services Task Force (USPSTF) recommends one-time screening for an abdominal aortic aneurysm (AAA) in men aged 65 to 75 years who have ever smoked. This patient is 67 years old and has a significant smoking history, making him a prime candidate for this Grade B recommendation. He has no record of having this one-time screening completed yet.

Step-by-Step Solution

1
Evaluate the patient's demographic risk factors and smoking history.
The patient is a 67-year-old male with a 40 pack-year smoking history who quit 16 years ago.
Age and smoking history are the primary determinants for several major screening guidelines, including abdominal aortic aneurysm (AAA) and lung cancer.
2
Determine eligibility for lung cancer screening.
The patient does not qualify for low-dose computed tomography (LDCT) of the chest.
Although he meets the age (50-80) and pack-year (>=20) criteria, he quit smoking 16 years ago. Guidelines state screening should stop once a person has not smoked for 15 years.
3
Determine eligibility for abdominal aortic aneurysm (AAA) screening.
The patient qualifies for one-time abdominal ultrasonography.
The USPSTF recommends one-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked (>=100 cigarettes in a lifetime).
4
Review the status of other routine screenings (colorectal, prostate, cardiac).
Colorectal screening is up to date (next due at 72). Cardiac screening is not indicated. Prostate screening is preference-sensitive.
Ruling out other options ensures that AAA screening is the single most appropriate, guideline-mandated next step.

Key Concept

USPSTF guidelines mandate one-time abdominal aortic aneurysm screening for men 65-75 who have ever smoked, while lung cancer screening is strictly limited to those who currently smoke or quit within the past 15 years.
Estimated Time:1m 30s
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Topics

Preventive Care and Screening

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