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Difficulty: HardPreventive Care and Screening

A 66-year-old man visits his physician to review his cardiovascular risk and update his preventive health plan. He has not seen a doctor since his previous provider retired a year ago. He reports feeling well and has no specific complaints. His medical history includes essential hypertension treated with amlodipine and hyperlipidemia treated with atorvastatin. The patient has a 15-pack-year smoking history but quit completely at age 35. He consumes one or two glasses of wine per week. His father died of a myocardial infarction at age 75, and his mother died of breast cancer at age 80. Current vital signs show a blood pressure of 126/78 mm Hg, heart rate of 70/min, and a BMI of 27 kg/m².

A review of his transferred medical records reveals the following:
- A screening colonoscopy at age 62 revealed no polyps or masses.
- A fasting lipid panel and hemoglobin A1c performed 6 months ago were within target ranges.
- He received the 20-valent pneumococcal conjugate vaccine (PCV20) and the recombinant zoster vaccine series at age 65.
- He received an updated seasonal high-dose influenza vaccine and an annual COVID-19 vaccine two weeks ago at a local pharmacy.

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

  1. A
    Annual low-dose chest computed tomography
  2. B
    Administration of 23-valent pneumococcal polysaccharide vaccine
  3. C
    Dual-energy x-ray absorptiometry
  4. D
    Fecal immunochemical testing
  5. One-time duplex ultrasonography of the abdomenAnswer

Answer

One-time duplex ultrasonography of the abdomen is the correct next step, as the patient meets the criteria of being a man between 65 and 75 years old who has a history of smoking.
The correct action is one-time duplex ultrasonography of the abdomen. The United States Preventive Services Task Force (USPSTF) recommends a one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked. 'Ever smoked' is defined as having smoked at least 100 cigarettes in a lifetime. This 66-year-old patient has a 15-pack-year smoking history, clearly meeting the threshold for this Grade B recommendation.

Step-by-Step Solution

1
Evaluate the patient's demographics and smoking history against abdominal aortic aneurysm (AAA) screening criteria.
The patient is a 66-year-old male who has a history of smoking (15 pack-years).
The USPSTF recommends a one-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked (defined as at least 100 cigarettes in a lifetime).
2
Assess eligibility for lung cancer screening with low-dose computed tomography (LDCT).
The patient does not meet the criteria for LDCT.
Lung cancer screening is indicated for adults aged 50 to 80 with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years. This patient has only 15 pack-years and quit 31 years ago.
3
Review the patient's immunization record for age-appropriate vaccines.
The patient is up to date on pneumococcal, zoster, influenza, and COVID-19 vaccines.
For adults 65 and older, a single dose of PCV20 completes the pneumococcal vaccination series. PPSV23 is only required if PCV15 was administered instead.
4
Verify current status for colorectal cancer and osteoporosis screening.
Colorectal screening is up to date; osteoporosis screening is not indicated.
A normal colonoscopy provides a 10-year screening interval (due at age 72). Routine DEXA screening is indicated for women 65 and older, but not for average-risk men.

Key Concept

Application of age- and risk-stratified preventive screening and vaccination guidelines in older adults.
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Topics

Preventive Care and Screening

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