MKSAP: Healthy 68-year-old man with a cigarette smoking history

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

MKSAP: Healthy 68 year old man with a cigarette smoking history A 68-year-old man is evaluated during a routine examination. He has a 5 pack-year cigarette smoking history but stopped 12 years ago. He has no history of hypertension, diabetes mellitus, stroke, or transient ischemic attack. He has no claudication. He is being treated for hyperlipidemia. There is no family history of premature coronary artery disease. He has noted no change in his bowel movements, and his most recent screening colonoscopy, performed at age 60 years, was normal. His only current medication is lovastatin.

Blood pressure is 130/82 mm Hg. BMI is 24. Physical examination reveals no abnormalities. Total cholesterol level on his most recent lipid profile was 213 mg/dL (5.52 mmol/L), and his HDL cholesterol level was 48 mg/dL (1.24 mmol/L).

Which of the following is the most appropriate screening test for this patient?

A) Abdominal ultrasonography
B) Colonoscopy
C) Low-dose CT of the chest
D) Office spirometry

Answer and Critique

The correct answer is A) Abdominal ultrasonography. This item is available to MKSAP 15 subscribers as item 28 in the General Internal Medicine section.

An abdominal ultrasonography is the most appropriate test for this patient. In a large randomized trial, abdominal duplex ultrasound screening in men aged 65 to 75 years who had ever smoked reduced mortality from abdominal aortic aneurysm (AAA) rupture. AAA repair prevents rupture, and the benefits of repair appear to outweigh its risks for large AAAs (>5.5 cm) in good-operative-risk patients. The U.S. Preventive Services Task Force (USPSTF) recommends a one-time screening by ultrasonography for AAA in men aged 65 to 75 years who have ever smoked, makes no recommendation for men who have never smoked, and recommends against screening in women.

The USPSTF recommends using one of the following protocols to screen for colorectal cancer in average-risk persons: annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years, and screening colonoscopy at intervals of 10 years. This patient’s last colonoscopy was 8 years ago; therefore, a colonoscopy at this time is not indicated.

Although low-dose CT is more sensitive than chest radiograph for the detection of lung cancer, there is insufficient evidence to recommend for or against this test to screen for lung cancer. In this former smoker, the fact that his risk of lung cancer is significantly less than that of a current smoker would further diminish screening test performance.

The USPSTF recommends against using spirometry to screen for chronic obstructive pulmonary disease. This recommendation is based on the findings that harms (time and effort required by patients and the health care system, false-positive results, and adverse effects of subsequent unnecessary therapy) exceed benefits (improvement in respiratory-related health status).

Key Point

  • Abdominal duplex ultrasound screening in men aged 65 to 75 years who have ever smoked reduces mortality related to abdominal aortic aneurysm rupture.

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  • Dorothy Green

    5 pack year – as I know it means 1 pkg/day for 5 years. That’s not a long or intense smoking history for a 68 yr old man.

    A more common smoking history might be 25 pack years – 1 pkg for 25 years or it could be 50 pack years – 2 pkg for 25 years.

  • John

    Oh and can you tag all these MKSAP questions with a MKSAP tag to make them easier to find. I’m a medical student and I love the review and having a specific tag would be great to find them