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Difficulty: MediumPreventive Care and Screening

A 71-year-old man comes to his primary care physician for an annual health maintenance examination. His medical history includes hypertension, hyperlipidemia, and osteoarthritis. His current medications are lisinopril, atorvastatin, and acetaminophen as needed. He smoked one pack of cigarettes daily from age 18 until quitting completely at age 48. He drinks one or two alcoholic beverages weekly. The patient received a 20-valent pneumococcal conjugate vaccine at age 66 and completed the 2-dose recombinant zoster vaccine series at age 68. A screening colonoscopy performed at age 63 was entirely normal. He has never undergone any imaging of his chest or abdomen. Vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in preventive care for this patient?

  1. One-time ultrasonography of the abdomenAnswer
  2. B
    Low-dose computed tomography of the chest
  3. C
    Prostate-specific antigen testing
  4. D
    Fecal immunochemical testing
  5. E
    Administration of the 23-valent pneumococcal polysaccharide vaccine

Answer

One-time ultrasonography of the abdomen
The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked (defined as 100 or more cigarettes in a lifetime). This 71-year-old patient has a substantial smoking history and has never undergone abdominal imaging. Therefore, ordering a one-time ultrasonography of the abdomen is the most appropriate, guideline-concordant next step in his preventive care.

Step-by-Step Solution

1
Evaluate the patient's demographic risk factors for abdominal aortic aneurysm (AAA).
The patient is a 71-year-old male with a significant smoking history (30 pack-years).
The USPSTF recommends one-time screening for AAA by ultrasonography in men aged 65 to 75 years who have ever smoked (defined as 100 or more cigarettes in a lifetime).
2
Assess eligibility for lung cancer screening.
The patient smoked 1 pack per day for 30 years but quit 23 years ago at age 48.
Annual screening for lung cancer with low-dose computed tomography (LDCT) is indicated for adults aged 50 to 80 years with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years. Because this patient quit more than 15 years ago, he is no longer eligible.
3
Determine current colorectal cancer screening needs.
The patient had a normal screening colonoscopy at age 63.
After a normal screening colonoscopy in an average-risk individual, the recommended interval before the next screening is 10 years. He does not need screening until age 73.
4
Review adult immunization status and prostate cancer screening indications.
The patient is fully vaccinated against pneumococcus (received PCV20) and zoster. He is 71 years old, which places him outside the recommended age for prostate-specific antigen (PSA) screening.
The USPSTF recommends against PSA screening in men aged 70 and older. Furthermore, ACIP guidelines state a single dose of PCV20 is complete coverage for adults aged 65 and older.

Key Concept

Guideline-concordant preventive care in older adults requires integrating age, smoking history, prior screening results, and updated immunization schedules while actively avoiding outdated tests.
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Topics

Preventive Care and Screening

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