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Difficulty: HardPreventive Care and Screening

A 67-year-old biological male presents to the ambulatory clinic for a routine health maintenance evaluation. His medical history is notable for type 2 diabetes mellitus, essential hypertension, and mild osteoarthritis of the knees. His current medications include lisinopril, metformin, and atorvastatin.

He has a 45 pack-year smoking history but successfully quit smoking 17 years ago. He consumes one to two alcoholic beverages per week.

A comprehensive review of his preventive health record reveals the following:
- A screening colonoscopy performed at age 59, which revealed two 4-mm hyperplastic polyps in the sigmoid colon.
- A 2-dose series of the recombinant zoster vaccine completed at age 62.
- A single dose of the 20-valent pneumococcal conjugate vaccine (PCV20) administered at age 65.
- A seasonal inactivated influenza vaccine administered 2 weeks ago.
- A Tdap booster administered 5 years ago.

Vital signs show a blood pressure of 124/76 mmHg, heart rate of 70/min, respiratory rate of 14/min, and a body mass index of 28 kg/m². The physical examination is unremarkable.

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

  1. A
    Annual low-dose computed tomography of the chest
  2. B
    Screening colonoscopy
  3. C
    Carotid duplex ultrasonography
  4. One-time ultrasonography of the abdominal aortaAnswer
  5. E
    23-valent pneumococcal polysaccharide vaccination

Answer

The most appropriate next step is a one-time ultrasonography of the abdominal aorta.
The correct answer is a one-time ultrasonography of the abdominal aorta. According to the United States Preventive Services Task Force (USPSTF), a one-time screening for an abdominal aortic aneurysm (AAA) with ultrasonography is recommended for all men aged 65 to 75 years who have ever smoked (defined as a lifetime history of at least 100 cigarettes). This patient is a 67-year-old male with a significant smoking history who has not yet been screened, making this the most appropriate next step in his preventive care. The risk of AAA rupture is significantly elevated in this demographic, and early surgical or endovascular repair of large aneurysms improves mortality.

Step-by-Step Solution

1
Analyze the patient's demographics and social history.
The patient is a 67-year-old male with a 45 pack-year smoking history who quit 17 years ago.
Age, biological sex, and specific details of smoking history (pack-years and years since quitting) dictate several major screening guidelines.
2
Evaluate the indication for abdominal aortic aneurysm (AAA) screening.
The patient meets criteria for a one-time AAA screening ultrasound.
The USPSTF recommends a one-time screening for AAA in men aged 65 to 75 years who have ever smoked (Grade B).
3
Rule out the need for lung cancer screening.
Low-dose computed tomography (LDCT) is not indicated.
Although he has a >20 pack-year history, he quit 17 years ago. The USPSTF stops recommending LDCT once a patient has not smoked for 15 years.
4
Rule out the need for other tests and vaccines presented in the options.
Colonoscopy, carotid ultrasound, and PPSV23 are not indicated.
His next colonoscopy is due at age 69 (10-year interval for distal hyperplastic polyps). Asymptomatic carotid screening is Grade D. His PCV20 vaccine at age 65 completed his pneumococcal requirements.

Key Concept

The USPSTF criteria for abdominal aortic aneurysm (AAA) screening versus lung cancer screening based on smoking history.
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Topics

Preventive Care and Screening

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