"I Feel Fine": Prioritizing Health Maintenance for a 45-Year-Old With a Family History
You are the RN in a primary care clinic seeing a 45-year-old man for a pre-employment physical. He has not seen a provider in 6 years and takes no medications. Findings: BMI 33.2; BP 146/90 in the right arm and 142/88 in the left; point-of-care A1c 6.1%; LDL 138 mg/dL; he smokes 1 pack per day and has since age 18. His father was diagnosed with colon cancer at 52 and died at 55. He has no personal history of cancer, no rectal bleeding, and no family history of lung or breast cancer. He says, "I feel fine. My dad didn't get sick until his fifties, so I've got time." He asks about "that lung scan" a coworker had and whether he needs one.
1. Which findings require action before he leaves today, and how do you defend that ranking?
Read the worked answer
Rank by near-term harm × modifiability × whether today's visit is the only chance.
- Blood pressure - 146/90 and 142/88. Both readings meet the threshold for stage 2 hypertension (≥140/90), which is a diagnosis requiring confirmation and a plan, not a "recheck next year." Confirm with correct technique - he has a BMI of 33.2, so cuff size matters and an undersized cuff falsely elevates the reading; repeat seated after 5 minutes, both arms. If confirmed: baseline BMP, lipids, A1c, urinalysis, ECG, and same-day initiation of a treatment plan.
- Colorectal cancer screening - overdue now. A first-degree relative with colon cancer means start at age 40 or 10 years before the youngest affected relative, whichever is earlier (52 − 10 = 42). He is 45. This is not a "when you turn 50" conversation. Colonoscopy is preferred; the order should be placed today.
- A1c 6.1% = prediabetes (5.7–6.4%). Refer to a diabetes prevention program, repeat A1c annually.
- Smoking (27 pack-years) is the largest long-term risk multiplier and must be addressed today, but it is not a same-day diagnostic decision.
The judgment point: hypertension is the most time-sensitive, family history is the most overlooked.
2. He says, "My dad didn't get sick until his fifties, so I've got time." How do you respond, and what do you set up?
Read the worked answer
Correct the misconception directly and without shaming: a family history moves screening earlier, not later. His father was 52 at diagnosis - that is exactly why he starts now at 45, not at 50.
- Say: "Your dad's history is the reason we start early. Ten years before his diagnosis is 42, and you're 45 - so you're already due."
- Do: place the colonoscopy referral today, explain the bowel prep in plain terms, and use teach-back ("tell me in your own words when you'll start the prep").
- Expect the barrier: cost, time off work, and fear of the prep. Address these now rather than at the front desk.
- Document the family history (first-degree relative, age 52) in a structured field so it fires future decision support.
Also correct the framing of his risk: he has three modifiable risks (BP, weight, smoking) plus one non-modifiable risk (genetics) - the genetics determine when he starts screening, not whether he can change his outcome.
3. He asks whether he should get the low-dose CT lung scan his coworker had. What is your answer, and what do you document?
Read the worked answer
No - not yet, and say why with numbers. Low-dose CT screening criteria are: age 50–80, at least 20 pack-years, and currently smoking or quit within the past 15 years.
- He is 45, so he fails the age criterion despite 27 pack-years (1 pack/day × 27 years).
- Do not simply say no. Say: "You qualify on smoking history but not on age. At 50 we'll talk about it - and if you quit now, you'll still qualify for 15 years after your quit date."
- Document the pack-year calculation and the counseling so the next clinician can act at 50 without re-deriving it.
- Tie it back to the bigger lever: at 27 pack-years, cessation now reduces risk more than any scan would detect later. Offer pharmacotherapy and quitline referral today, not "have you thought about quitting."
The judgment point: a screening test that is correct in principle but wrong for this patient right now is still the wrong order - and telling the patient when to come back converts a refusal into a plan.