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MKSAP 19 "Quiz Me!" Question: Answer and Critique
B: Hemoglobin A1c measurement
Screen for type 2 diabetes mellitus.
The most appropriate screening test is hemoglobin A1c measurement (Option B). This patient should be screened for type 2 diabetes mellitus because he has several risk factors. The American Diabetes Association recommends screening for type 2 diabetes in adults aged 35 years or older and considering screening in adults of any age with a BMI of 25 or greater (or ≥23 in Asian Americans) who have one or more additional risk factors for diabetes. These risk factors include a first-degree relative with diabetes, high-risk race or ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander), history of cardiovascular disease, physical inactivity, hypertension (≥140/90 mm Hg or taking antihypertensive therapy), HDL cholesterol level less than 35 mg/dL (0.90 mmol/L), triglyceride level greater than 250 mg/dL (2.82 mmol/L), polycystic ovary syndrome, or other conditions associated with insulin resistance.
The U.S. Preventive Services Task Force (USPSTF) also recommends screening for diabetes in patients aged 35 to 70 years with overweight or obesity as part of a cardiovascular risk assessment.
The USPSTF does not recommend screening for coronary artery disease with either resting or exercise ECG (Option A) in asymptomatic patients at low risk, defined as a 10-year cardiovascular event risk of less than 10% using the pooled cohort equations. In patients at intermediate or high risk for such events, evidence was inadequate to assess the relative benefits and harms of screening.
According to the USPSTF, evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea in asymptomatic adults with the currently available tools, so a sleep study (Option C) is inappropriate. Because obstructive sleep apnea is widely underrecognized, clinicians should have a low threshold for investigating sleep apnea in patients with symptoms consistent with the disease. This patient is asymptomatic.
The USPSTF concludes that evidence is insufficient to recommend for or against screening for thyroid disease, so thyroid-stimulating hormone measurement (Option D) is incorrect. The American Thyroid Association and the American Association of Clinical Endocrinologists, however, recommend measuring thyroid-stimulating hormone in individuals at risk for hypothyroidism (e.g., personal history of autoimmune disease, neck irradiation, or thyroid surgery); they additionally recommend considering screening in adults aged 60 years and older. This patient has no indication for screening.
The American Diabetes Association recommends screening for type 2 diabetes mellitus in patients aged 35 years or older; screening should be considered in patients of any age with overweight or obesity and one additional risk factor for diabetes.
The U.S. Preventive Services Task Force recommends screening for diabetes mellitus in patients aged 35 to 70 years with overweight or obesity as part of a cardiovascular risk assessment.
American Diabetes Association Professional Practice Committee. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2022. Diabetes Care. 2022;45:S17-S38. PMID: 34964875 doi:10.2337/dc22-S002