Family Medicine · Year 3 · from Family Medicine
Case 1: The Annual Wellness Visit
Patient Demographics
- Age: 52 years old
- Sex: Female
- Occupation: Accountant
Chief Complaint
"I'm here for my annual check-up. I want to make sure I'm doing everything I should be doing."
History of Present Illness
Mrs. Sandra Mitchell is a 52-year-old woman presenting for her annual wellness visit. She reports feeling generally well with no specific complaints. She had her last mammogram 2 years ago (normal) and has never had a colonoscopy. She is unsure when she last had a Pap smear. She received her last flu shot last year but is unsure about other vaccinations.
She mentions her mother was recently diagnosed with colon cancer at age 74, which has prompted her concern about her own screening.
Past Medical History
- Hypertension, controlled on lisinopril 10mg daily
- Hyperlipidemia, controlled on atorvastatin 20mg daily
- Obesity (BMI 32)
Family History
- Mother: Colon cancer (diagnosed at 74), hypertension
- Father: Type 2 diabetes, died of MI at age 65
- Brother: Hyperlipidemia
Social History
- Former smoker (quit 5 years ago, 10 pack-year history)
- Alcohol: 1-2 glasses of wine weekly
- Married, two adult children
- Sedentary lifestyle, office job
- No regular exercise program
Physical Examination
- Vital Signs: BP 132/82, HR 76, BMI 32
- General: Well-appearing, obese female
- Skin: No suspicious lesions
- Breast: No masses, no lymphadenopathy
- Heart: Regular rate and rhythm
- Lungs: Clear bilaterally
- Abdomen: Soft, non-tender, obese
Clinical Image
Image: A screening mammogram demonstrating normal breast tissue architecture. Mammography remains the primary screening modality for breast cancer in average-risk women.
Image Source: Wikimedia Commons Attribution: Public Domain URL: https://commons.wikimedia.org/wiki/Category:Mammography
Preventive Care Assessment
Cancer Screening Status:
| Screening | Last Done | Status | Recommendation |
|---|---|---|---|
| Mammography | 2 years ago | Due | Biennial screening (USPSTF Grade B) |
| Colorectal cancer | Never | Overdue | Begin screening at age 45 |
| Cervical cancer | Unknown | Needs assessment | Pap every 3 years or co-testing every 5 years |
| Lung cancer | N/A | Consider | LDCT screening (former smoker, 10 pack-years, quit <15 years) |
Cardiovascular Risk Assessment:
- 10-year ASCVD risk: 8.2% (intermediate risk)
- Already on statin therapy
- BP at goal (<130/80)
Immunization Status:
| Vaccine | Status | Recommendation |
|---|---|---|
| Influenza | Due | Annual vaccination |
| Tdap/Td | Unknown | Tdap if never received, then Td every 10 years |
| Shingrix | Not received | Two-dose series recommended age 50+ |
| Pneumococcal | Not due | Recommended at age 65 |
| COVID-19 | Up to date | Per current guidelines |
Outpatient Workup
- Order mammogram (routine screening)
- Order colonoscopy referral (colorectal cancer screening)
- Verify Pap smear history; if > 3 years, order cervical cytology
- Discuss lung cancer screening (LDCT) - qualifies based on smoking history
- Fasting lipid panel (monitoring)
- Fasting glucose or HbA1c (diabetes screening given obesity and family history)
Assessment and Plan
1. Cancer Screening:
- Schedule mammogram today
- Refer for colonoscopy given age 52 and new family history (mother with CRC at 74 does not change to high-risk protocol but reinforces importance)
- Order Pap smear with HPV co-testing
- Discussed lung cancer screening with LDCT; patient declines at this time but will reconsider
2. Cardiovascular Prevention:
- Continue lisinopril and atorvastatin
- BP well controlled
- Reinforce lifestyle modifications for weight management
3. Immunizations:
- Administer influenza vaccine today
- Administer Shingrix dose #1 today (schedule dose #2 in 2-6 months)
- Verify Tdap status from records
4. Lifestyle Counseling:
- Discussed importance of regular physical activity (goal: 150 min/week moderate activity)
- Brief dietary counseling; offered referral to registered dietitian
- Weight loss goal: 5-10% body weight
- Continue tobacco abstinence - congratulated on 5-year quit
5. Depression Screening:
- PHQ-2 negative (0/6)
Follow-Up
- Return for Shingrix dose #2 in 2-6 months
- Review screening results in 2-4 weeks
- Annual wellness visit in 1 year
Teaching Points
- Evidence-based screening: This case demonstrates application of USPSTF recommendations with appropriate grade consideration. Not all screening is beneficial - we must weigh benefits against harms.
- Shared decision-making: For lung cancer screening, the patient has the right to decline after informed discussion.
- Health maintenance visit structure: Efficiently addressing multiple preventive needs in a single comprehensive visit.
- Risk factor modification: Prevention extends beyond screening to lifestyle counseling and vaccination.