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Difficulty: MediumPreventive Care and Screening

A physician evaluates a 68-year-old male patient who is visiting the clinic for a general check-up. The patient has a documented medical history of type 2 diabetes mellitus, essential hypertension, and hyperlipidemia, all of which are well-controlled with his current medications.

He is a former heavy smoker. He smoked 1.5 packs of cigarettes daily from age 18 until he successfully quit at age 52. He drinks alcohol occasionally and exercises three times a week. He has no personal history of cardiovascular disease.

A review of his health records shows that he underwent a screening colonoscopy at age 61, which was completely normal. His immunization records indicate he received the 20-valent pneumococcal conjugate vaccine at age 66, a Tdap booster at age 64, and an age-appropriate influenza vaccine two weeks ago. Recent laboratory studies, including a comprehensive metabolic panel, hemoglobin A1c, and a urine albumin-to-creatinine ratio, were performed last month and were all within target ranges.

The patient feels well and has no active complaints. His blood pressure is 126/78 mm Hg, heart rate is 72/min, and BMI is 28 kg/m228\text{ kg/m}^2. Physical examination reveals normal heart sounds, clear lungs bilaterally, and a soft, non-tender abdomen with no palpable masses or bruits.

Based on current guidelines, which of the following is the most appropriate next step in preventive care for this patient?

  1. A
    Carotid duplex ultrasonography
  2. B
    Dual-energy x-ray absorptiometry
  3. C
    Low-dose chest computed tomography
  4. One-time abdominal ultrasonographyAnswer
  5. E
    Repeat screening colonoscopy

Answer

One-time abdominal ultrasonography
The correct answer is one-time abdominal ultrasonography. According to the United States Preventive Services Task Force (USPSTF) guidelines, a one-time screening for an abdominal aortic aneurysm (AAA) with ultrasonography is recommended for men aged 65 to 75 years who have a history of smoking (defined as 100100 or more cigarettes in a lifetime). This 68-year-old male has an extensive smoking history and falls directly within the recommended age bracket, making this the most appropriate next step in his preventive care.

Step-by-Step Solution

1
Evaluate the patient's demographic and smoking history against abdominal aortic aneurysm screening guidelines.
The patient is a 68-year-old male who has a significant smoking history (greater than 100 lifetime cigarettes).
Current guidelines recommend a one-time screening ultrasound for men aged 65 to 75 who have ever smoked.
2
Calculate the patient's smoking pack-years and time since quitting to evaluate lung cancer screening indication.
The patient smoked 1.51.5 packs/day for 3434 years (1.5×34=511.5 \times 34 = 51 pack-years). He quit at age 5252, meaning it has been 1616 years since he last smoked (68−52=1668 - 52 = 16).
Lung cancer screening requires an annual low-dose chest CT for adults aged 50 to 80 with at least a 20 pack-year history, provided they currently smoke or quit within the past 15 years. Since he quit 16 years ago, he does not meet the criteria.
3
Review the timeline of previous preventive interventions.
His last colonoscopy was normal 7 years ago (due in 3 years). All required vaccinations for his age and comorbidities are up to date.
This confirms that other routine screenings or immunizations are not immediately indicated.

Key Concept

The USPSTF recommends a one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked. Conversely, lung cancer screening with low-dose CT should be discontinued once a patient has not smoked for 15 years.
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Topics

Preventive Care and Screening

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