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Difficulty: Very hardPreventive Care and Screening

A 63-year-old man presents to the clinic for a routine wellness evaluation. His medical history includes type 2 diabetes mellitus, hyperlipidemia, and mild osteoarthritis. He smoked one pack of cigarettes daily for 25 years but successfully quit at age 45. His family history is non-contributory.

Review of his preventive care records reveals the following:
- A screening colonoscopy performed at age 58 showed three 6-mm tubular adenomas, which were completely excised.
- He received the 20-valent pneumococcal conjugate vaccine (PCV20) at age 58 shortly after his diabetes diagnosis.
- He received a 2-dose series of recombinant zoster vaccine at age 50.
- He received a tetanus-diphtheria-acellular pertussis (Tdap) booster 4 years ago.
- He has never undergone abdominal imaging.

He currently has no symptoms, and his diabetes is well-controlled. Which of the following is the most appropriate next step in this patient's preventive care?

  1. A
    Low-dose computed tomography of the chest
  2. B
    Ultrasound of the abdomen
  3. C
    Fecal immunochemical testing
  4. D
    Administration of 23-valent pneumococcal polysaccharide vaccine
  5. Repeat colonoscopyAnswer

Answer

Repeat colonoscopy
The patient requires a surveillance colonoscopy. According to the US Multi-Society Task Force (USMSTF) on Colorectal Cancer, a baseline finding of 3 to 4 small (<10 mm) tubular adenomas warrants a repeat surveillance colonoscopy in 3 to 5 years. Because his last procedure was 5 years ago, he has reached the end of this interval and is currently due for a repeat procedure.

Step-by-Step Solution

1
Analyze the patient's colorectal cancer surveillance requirements based on prior colonoscopy findings.
The patient had three small (<10 mm) tubular adenomas at age 58. Per the US Multi-Society Task Force (USMSTF), the recommended interval is 3 to 5 years.
Different baseline polyp burdens mandate different direct visualization intervals to prevent colorectal cancer.
2
Evaluate the patient's eligibility for lung cancer screening.
The patient is 63 with a 25 pack-year history, but he quit 18 years ago (at age 45). He exceeds the 15-year cessation limit, so screening is no longer indicated.
USPSTF LDCT guidelines (age 50-80, ≥20 pack-years) strictly require the patient to be a current smoker or have quit within the past 15 years.
3
Assess the need for abdominal aortic aneurysm (AAA) screening.
The patient is 63 years old. AAA screening is not indicated until age 65.
USPSTF recommends one-time AAA screening with ultrasound for men aged 65 to 75 who have ever smoked.
4
Review the patient's immunization status.
He received Tdap 4 years ago (not due for 6 years). He received a complete RZV series. He received PCV20 at age 58 and therefore requires no further pneumococcal doses (PPSV23 is unnecessary).
Recent ACIP guidelines simplified pneumococcal schedules; a single dose of PCV20 is considered a complete series for adults.

Key Concept

Evidence-based application of multiple concurrent preventive screening and immunization guidelines (USPSTF, USMSTF, ACIP) with a focus on specific interval cutoffs and contraindications.
Estimated Time:2m 0s
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Topics

Preventive Care and Screening

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