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Difficulty: Very hardPreventive Care and Screening

A 53-year-old woman comes to the clinic for a routine health maintenance visit.

Past medical history: Crohn disease (currently maintained on infliximab), mild persistent asthma (on fluticasone-salmeterol).
Surgical history: Total abdominal hysterectomy and bilateral salpingo-oophorectomy at age 45 due to symptomatic uterine leiomyomata.
Social history: She smoked 1.5 packs of cigarettes daily from age 20 until she quit 8 years ago. She consumes 1-2 glasses of wine on weekends.
Family history: Father died of a ruptured abdominal aortic aneurysm at age 75. Mother has osteoporosis.

Vaccinations:
- Annual influenza vaccine received 2 weeks ago.
- Received 15-valent pneumococcal conjugate vaccine (PCV15) 2 years ago, followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) 1 year ago.
- Tdap booster received 4 years ago.

Previous screenings:
- Screening colonoscopy at age 48 was normal.
- Hepatitis C and HIV screening tests at age 50 were negative.
- Prior to her surgery at age 45, she had normal cervical cytology every 3 years for two decades.
- She has never received the recombinant zoster vaccine.

Which of the following preventive care interventions are currently indicated for this patient? (Select all that apply)

  1. Low-dose computed tomography of the chestAnswer
  2. Recombinant zoster vaccineAnswer
  3. C
    Cervical cytology and high-risk human papillomavirus co-testing
  4. D
    23-valent pneumococcal polysaccharide vaccine
  5. E
    Abdominal ultrasound
  6. F
    Screening colonoscopy

Answer

The indicated interventions are low-dose computed tomography of the chest and the recombinant zoster vaccine.
Low-dose computed tomography (LDCT) of the chest is recommended annually for adults aged 50 to 80 years who have a 20 pack-year or greater smoking history and currently smoke or have quit within the past 15 years. This 53-year-old patient has a 37.5 pack-year history and quit 8 years ago, perfectly fulfilling the criteria.

The recombinant zoster vaccine (RZV) is recommended as a 2-dose series for all adults aged 50 years and older, as well as for adults aged 19 years and older who are immunocompromised. Because she is 53, is taking an immunosuppressive medication (infliximab for Crohn disease), and has never received the vaccine, it is strongly indicated today.

Step-by-Step Solution

1
Analyze the patient's demographic and social risk factors for cancer screening.
The patient is 53 years old with a 37.5 pack-year smoking history, having quit 8 years ago.
Determines eligibility for lung cancer screening with LDCT, which requires age 50-80, >=20 pack-years, and current smoking or quitting within 15 years.
2
Evaluate the impact of her surgical history on cervical cancer screening.
She had a total hysterectomy for benign fibroids.
Cervical screening must be discontinued after total hysterectomy for benign indications without a history of high-grade dysplasia.
3
Assess her age and immune status to determine vaccine indications.
She is 53, taking an immunosuppressive biologic (infliximab), and has never received the zoster vaccine.
The non-live recombinant zoster vaccine is indicated for adults over 50 and for immunosuppressed adults over 19, making it highly indicated here.
4
Review the intervals for her previous preventive care measures.
PPSV23 was given 1 year ago; colonoscopy was normal 5 years ago.
Prevents over-screening. PPSV23 revaccination for immunocompromised patients is at 5 years. Normal colonoscopy interval is 10 years.

Key Concept

Preventive care guidelines require synthesizing age, smoking history, surgical alterations, and medication-induced immunosuppression to determine appropriate screening and vaccination intervals.
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Topics

Preventive Care and Screening

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