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Zorluk: OrtaPreventive Care and Screening

During a scheduled annual wellness examination, a 60-year-old woman is evaluated in the primary care clinic. She feels well and has no acute complaints. Her medical history is notable for seropositive rheumatoid arthritis, which has been well-controlled on a stable regimen of adalimumab and methotrexate for the past four years. She has a 10 pack-year smoking history, currently smoking half a pack of cigarettes daily. Her family history is significant for her mother being diagnosed with breast cancer at age 72 and her father having a stroke at age 80.

Review of her preventive health record reveals the following:
- Screening colonoscopy at age 52 was normal.
- Screening mammography 6 months ago was normal.
- Pap smear with human papillomavirus (HPV) co-testing 2 years ago was normal.
- Hepatitis C virus antibody test 1 year ago was negative.

Her immunizations are up to date, including a 20-valent pneumococcal conjugate vaccine (PCV20) at age 58, two doses of the recombinant zoster vaccine at age 50, and an inactivated influenza vaccine 3 weeks ago.

Her body mass index is 21 kg/m². Physical examination shows no joint effusions, tenderness, or deformities.

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

  1. Dual-energy x-ray absorptiometryCevap
  2. B
    Low-dose computed tomography of the chest
  3. C
    Fecal immunochemical testing
  4. D
    Administration of live-attenuated influenza vaccine
  5. E
    Abdominal aortic aneurysm screening with ultrasonography

Cevap

The most appropriate next step is performing dual-energy x-ray absorptiometry (DEXA) to screen for osteoporosis.
The correct answer is dual-energy x-ray absorptiometry (DEXA). The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with bone measurement testing (e.g., DEXA scan) in women 65 years and older, as well as in postmenopausal women younger than 65 years who are at increased risk of osteoporosis. Increased risk is defined as having a 10-year risk of a major osteoporotic fracture equal to or greater than that of a 65-year-old white woman with no additional risk factors (which is approximately 8.4% using the FRAX tool). This patient has multiple significant clinical risk factors for osteoporosis, including a diagnosis of rheumatoid arthritis, current tobacco use, and a low-normal body mass index (21 kg/m²). These factors place her well above the risk threshold, making a DEXA scan the most appropriate and indicated next step in her preventive care.

Adım Adım Çözüm

1
Analyze the patient's demographics, past medical history, and social history.
The patient is a 60-year-old postmenopausal woman with rheumatoid arthritis, active tobacco use (10 pack-years), and a BMI of 21 kg/m².
Identifying these clinical factors is necessary to calculate patient-specific risks for various diseases targeted by screening guidelines.
2
Evaluate the status of her routine cancer and infectious disease screenings based on the provided dates.
Colorectal cancer (colonoscopy 8 years ago), breast cancer (mammogram 6 months ago), cervical cancer (Pap/HPV 2 years ago), and HCV screenings are all up to date. She is also fully vaccinated for her age and risk profile.
This eliminates several options by confirming that these specific screenings and vaccines are not currently due.
3
Assess her eligibility for specialized screenings based on her unique risk factors.
While she does not meet the 20 pack-year requirement for lung cancer screening (LDCT) and AAA screening is not routinely indicated for women, her rheumatoid arthritis and smoking status significantly increase her osteoporosis risk.
The USPSTF recommends bone density screening for women under 65 if their 10-year fracture risk meets or exceeds 8.4%. Her secondary causes of osteoporosis (RA) and lifestyle factors exceed this threshold.

Anahtar Kavram

The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with bone measurement testing in postmenopausal women younger than 65 years who are at increased risk of osteoporosis (10-year fracture risk ≥8.4%).
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Preventive Care and Screening

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