# Clinical Cases: Preventive Care and Health Maintenance

## 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
![Mammogram screening](case_01_image.jpg)

*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
1. **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.

2. **Shared decision-making:** For lung cancer screening, the patient has the right to decline after informed discussion.

3. **Health maintenance visit structure:** Efficiently addressing multiple preventive needs in a single comprehensive visit.

4. **Risk factor modification:** Prevention extends beyond screening to lifestyle counseling and vaccination.

---

## Case 2: Cardiovascular Risk Assessment and Statin Decision

### Patient Demographics
- **Age:** 48 years old
- **Sex:** Male
- **Occupation:** Software engineer

### Chief Complaint
"My cholesterol came back high on a work screening. Do I need to be on medication?"

### History of Present Illness
Mr. David Park is a 48-year-old man who had a biometric screening at work that revealed total cholesterol of 248 mg/dL. He is concerned and wants to know if he needs medication. He has no chest pain, shortness of breath, or other cardiac symptoms. He exercises occasionally (walks 1-2 times weekly) and tries to "eat healthy" but admits to frequent fast food meals due to work demands.

### Past Medical History
- No known chronic conditions
- No prior cardiac events
- No diabetes

### Family History
- Father: MI at age 58, currently alive with CAD
- Mother: Hyperlipidemia, on statin
- No family history of diabetes

### Social History
- Never smoker
- Alcohol: 2-3 beers weekly
- Married with two children
- High-stress job with long hours
- Sedentary work

### Physical Examination
- **Vital Signs:** BP 128/84, HR 72, BMI 27
- **General:** Well-appearing, mildly overweight
- **Cardiovascular:** Regular rate and rhythm, no murmurs
- **Peripheral pulses:** Normal
- **No xanthomas or xanthelasma**

### Laboratory Results (fasting)
- Total cholesterol: 252 mg/dL
- LDL cholesterol: 168 mg/dL
- HDL cholesterol: 42 mg/dL
- Triglycerides: 210 mg/dL
- Fasting glucose: 102 mg/dL (impaired fasting glucose)
- HbA1c: 5.9%

### Cardiovascular Risk Calculation
**Using ASCVD Risk Calculator:**
- Age: 48
- Sex: Male
- Race: Asian
- Total cholesterol: 252
- HDL: 42
- Systolic BP: 128 (untreated)
- Diabetes: No
- Smoker: No

**10-year ASCVD Risk: 6.8%** (borderline risk: 5-7.5%)

**Risk-enhancing factors present:**
- Family history of premature ASCVD (father MI at 58)
- Metabolic syndrome features (low HDL, elevated TG, impaired fasting glucose)
- LDL > 160 mg/dL

### Assessment
1. **Hyperlipidemia** with LDL 168 mg/dL
2. **Borderline ASCVD risk** (6.8%) with multiple risk-enhancing factors
3. **Prediabetes** (IFG and HbA1c 5.9%)
4. **Metabolic syndrome** - meets criteria

### Management Plan

**Shared Decision-Making Discussion:**
Explained to patient:
- His 10-year risk of heart attack or stroke is approximately 7%
- Risk-enhancing factors (family history, metabolic syndrome) increase his true risk
- Options: lifestyle changes alone vs. lifestyle + statin therapy
- Statin benefits: Would reduce his risk by approximately 25-30%
- Statin risks: Muscle aches (5-10%), rare liver issues, small diabetes risk increase

**Patient Decision:** After discussion, patient elects to try intensive lifestyle modification for 3-6 months before starting medication.

**Lifestyle Prescription:**
- Diet: Mediterranean or DASH pattern, limit saturated fat <7% calories, increase fiber
- Exercise: Goal 150 min/week moderate intensity; start with 30 min walking 5x/week
- Weight: Target 5-7% weight loss (goal weight: 175 lbs from current 185 lbs)
- Referral to registered dietitian

**If Statin Indicated (follow-up):**
- Would recommend moderate-intensity statin (atorvastatin 20mg or rosuvastatin 10mg)
- Given risk-enhancing factors, may still recommend statin at follow-up

**Prediabetes Management:**
- Discussed progression risk
- Intensive lifestyle intervention (same as above)
- Consider Diabetes Prevention Program referral

### Follow-Up
- Repeat fasting lipid panel in 3 months
- Monitor weight and lifestyle adherence
- Reassess statin decision at 3-month visit
- Annual diabetes screening

### Teaching Points
1. **Risk calculation:** The ASCVD risk calculator is essential for guiding statin decisions in primary prevention. Raw cholesterol numbers alone are insufficient.

2. **Risk-enhancing factors:** Borderline risk patients with risk-enhancing factors (family history, metabolic syndrome, LDL > 160) benefit from more intensive discussions about statin therapy.

3. **Shared decision-making:** Statin therapy for primary prevention is a preference-sensitive decision. Some patients prefer medication; others want to try lifestyle first.

4. **Lifestyle as foundation:** Therapeutic lifestyle change is the foundation of cardiovascular prevention regardless of medication decisions.

---

## Case 3: Immunization Catch-Up and Vaccine Hesitancy

### Patient Demographics
- **Age:** 28 years old
- **Sex:** Female
- **Occupation:** Preschool teacher

### Chief Complaint
"I need some forms filled out for work, and they're asking about my vaccines."

### History of Present Illness
Ms. Emily Rodriguez is a 28-year-old woman who recently started working at a preschool. Her employer requires documentation of immunity to measles, mumps, rubella, and varicella. She is also being asked to get a Tdap booster and annual flu shot. She does not have records of her childhood immunizations and expresses hesitancy about vaccines, stating "I've read some concerning things online."

### Past Medical History
- No chronic medical conditions
- No known allergies
- No previous adverse vaccine reactions

### Immunization History
- Uncertain about childhood vaccines (no records)
- Never received HPV vaccine
- Last flu shot: "years ago"
- Denies history of chickenpox

### Social History
- Engaged, planning to get married and have children in 2-3 years
- Non-smoker
- Social alcohol use

### Physical Examination
- **Vital Signs:** BP 112/72, HR 68, BMI 23
- **General:** Healthy-appearing young woman
- **Skin:** No vesicular lesions
- **Lymph nodes:** No lymphadenopathy

### Assessment of Vaccine Needs

**Immunity Assessment:**
- Order MMR titers (measles, mumps, rubella IgG)
- Order varicella IgG titer
- Order Hepatitis B surface antibody (given healthcare-adjacent work)

**If Non-Immune (Serology Negative):**
| Vaccine | Doses Needed | Schedule |
|---------|--------------|----------|
| MMR | 2 doses | Now, then 4 weeks later |
| Varicella | 2 doses | Now, then 4 weeks later |
| Hepatitis B | 3 doses | Now, 1 month, 6 months |

**Additional Recommendations:**
| Vaccine | Indication | Priority |
|---------|------------|----------|
| Tdap | Booster required | High - workplace requirement |
| Influenza | Annual, required for work | High |
| HPV | Catch-up through age 26, shared decision 27-45 | Moderate |

### Addressing Vaccine Hesitancy

**Patient's Concerns:**
1. "I read vaccines can cause autism"
2. "There are so many chemicals in vaccines"
3. "My immune system is strong, I don't need vaccines"
4. "I'm worried about getting too many at once"

**Clinician Response (Motivational Interviewing Approach):**

"I appreciate you sharing your concerns with me. I can see you've thought a lot about this, which shows you care about your health. May I share some information that might be helpful?"

1. **Autism concern:** "The original study suggesting a link between vaccines and autism has been thoroughly disproven and retracted. Dozens of large studies involving millions of children have found no connection. I understand this concern persists online, but the scientific evidence is clear."

2. **Ingredients concern:** "Vaccine ingredients are carefully tested for safety. The amounts of any additives are far smaller than what we encounter in everyday foods and environment. I'd be happy to review the specific ingredients in any vaccine you're considering."

3. **Natural immunity:** "Your immune system is remarkable, but these diseases can be serious even in healthy adults. Measles can cause encephalitis; rubella during pregnancy causes severe birth defects. Vaccines train your immune system safely."

4. **Multiple vaccines:** "Your immune system handles thousands of antigens daily. The few antigens in vaccines are a tiny fraction of what your body already manages. However, if you prefer, we can spread vaccines across visits."

**Patient Response:** After discussion, patient agrees to titers and Tdap today. Will return to discuss other vaccines based on results.

### Management Plan
- Draw immunity titers (MMR, varicella, Hep B)
- Administer Tdap today (workplace requirement, no concerns expressed)
- Administer influenza vaccine today
- Discuss HPV vaccine at follow-up (within catch-up window at age 28, shared decision-making)
- Schedule follow-up in 2 weeks to review titers and continue vaccination series

### Follow-Up Results (2 weeks later)
- Rubella IgG: Positive (immune)
- Measles IgG: Negative (non-immune)
- Mumps IgG: Positive (immune)
- Varicella IgG: Negative (non-immune)
- Hepatitis B sAb: Negative (non-immune)

**Plan:** Administer MMR #1, Varicella #1, and Hepatitis B #1 today. Schedule second doses appropriately.

### Teaching Points
1. **Catch-up vaccination:** Adults often have incomplete vaccination records. Serology can guide catch-up vaccination efficiently.

2. **Vaccine hesitancy communication:** Listen first, acknowledge concerns, then provide clear, empathetic information. A strong physician recommendation is the most influential factor in vaccine acceptance.

3. **Occupational health:** Certain occupations require specific immunizations. Family physicians play a key role in supporting occupational health needs.

4. **HPV vaccine:** Catch-up vaccination is recommended through age 26; shared decision-making is appropriate for ages 27-45 for those not previously vaccinated.