MKSAP Quiz: Preventive health care visit
A 30-year-old woman is evaluated during a preventive health care visit. She is asymptomatic and has been healthy since her last health maintenance examination 3 years ago. Following a physical exam and Patient Health Questionnaire-2, what is the most appropriate next step in management?
A 30-year-old woman is evaluated during a preventive health care visit. She is asymptomatic and has been healthy since her last health maintenance examination 3 years ago. She does not smoke cigarettes and has one 4-oz alcoholic beverage three to four times a month. She walks for 15 minutes every other day and uses sunscreen when outside. Her mother was diagnosed with colon cancer when she was 50 years old. The patient takes no medications.
On physical examination, vital signs and other findings are unremarkable.
Her score on the PHQ-2 questionnaire is zero.
Which of the following is the most appropriate next step in management?
A. Clinical skin cancer screening
B. Fecal immunochemical testing
C. Generalized anxiety disorder questionnaire
D. PHQ-9 questionnaire
MKSAP Answer and Critique
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The most appropriate next step is to screen for anxiety (Option C). In 2020, the Women's Preventive Services Initiative recommended screening for anxiety in adolescent and adult women, including pregnant and postpartum individuals, with the goal of improving detection, diagnosis, and treatment of anxiety. In addition, the U.S. Preventive Services Task Force (USPSTF) recommends screening for anxiety disorders in all adults aged 19 to 64 years (grade B recommendation); the USPSTF reports that the evidence is insufficient to make a recommendation on anxiety screening in older adults. Screening tool options include the Generalized Anxiety Disorder scale, Edinburgh Postnatal Depression Scale anxiety subscale, Geriatric Anxiety Scale, and Geriatric Anxiety Inventory. Patients with a positive screening result should be further assessed for anxiety and, if an anxiety disorder is confirmed, treated.
The USPSTF recommends counseling for skin cancer prevention for adults older than 24 years with fair skin types (grade C recommendation) and concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling all adults about skin self-examination (grade I recommendation). No professional organizations recommend formal dermatologic evaluation for routine skin cancer screening. This patient does not have any suspicious findings on examination, and a clinical skin cancer screening (Option A) is not indicated.
Fecal immunochemical testing (FIT) (Option B) is an option for screening patients at average
risk for colorectal cancer. However, patients with a family history of colorectal cancer, such as this patient, are considered at increased risk. For those who have a first-degree relative diagnosed with colorectal cancer before age 60 years, colonoscopy is the preferred screening method, and screening should begin at age 40 years or 10 years earlier than the relative's age at diagnosis, whichever comes first. FIT is not currently indicated for this patient, who should begin colorectal cancer screening at age 40 years with colonoscopy.
The PHQ-2 is an abbreviated version of the PHQ-9 questionnaire (Option D) and has been validated as a prescreening tool. A PHQ-2 score of 2 or higher is generally accepted as a positive result that would require administration of the full PHQ-9. A PHQ-2 score of zero, as in this patient, is considered negative and does not warrant additional testing with the PHQ-9.
Key Points
- The Women's Preventive Services Initiative recommends screening for anxiety in adolescent and adult women, including pregnant and postpartum individuals, with the goal of improving detection, diagnosis, and treatment of anxiety.
- The U.S. Preventive Services Task Force recommends screening for anxiety disorders in all adults aged 19 to 64 years.