Case study – Alexis Burr

Immunizations

• Annual Flu vaccine

Screening

• According to the screening guidelines of several organizations since the patient is at an increased risk of getting breast cancer due to family hx and should get a mammogram of the breast
• According to the screening guidelines of several organization the patient is in age range for patients that are recommended to get a pap smear every 3 years or every 5 years if she had the HPV vaccine
• According to USPSTF- Screening in Adults:
  • Depression screening
  • HIV infection screening
  • Hypertension
  • Intimate partner violence
  • Alcohol Misuse screening
  • 4 or more standard drinks in a day 

Injury prevention

• traffic safety
• fall prevention

Diet

• Due to her ulcerative proctitis the patient should eat more fiber, antioxidant foods, and drink more water
• She should also avoid any dairy products or utilize lactose free products
• Avoid
  • caffeine products
  • alcohol
• Breakfast I would recommend the patient eat more grains such as oatmeal having more grains will allow her to stay fuller for longer throughout the day and oatmeal is a good source of fiber as well
• For lunch having salad is a good choice
  • Patient can incorporate green leafy vegetables such as spinach, celery, and broccoli – high in fiber
  • add more vegetables
    • high in fiber content such as potatoes, turnips, and carrots
    • high in antioxidants – squash and bell peppers
  • if she would like she can add some protein as well such as kidney beans, baked beans, and legumes which are also high in fiber.
• Additionally, the patient should always try to make time for eating lunch even fifteen minutes is sufficient as long as she eats something
• Taking snacks such as nuts or sliced fruits would also be very healthy for the patient and can help if she is too busy to eat a proper lunch rather than having no lunch
  • The patient can incorporate fruits that are high in fiber content such as raspberries and prunes as snacks
  • Fruits high in antioxidants – blueberry, cherries, and tomatoes
• For dinner, the patient can choose healthy choices from the “unhealthy chains” she goes to. She can also freeze some home-made food on the weekend and when she gets back from work or if the husband is home he can warm up the food by the time she gets home.
• Other than what is previously discussed the patient should continue limiting her red meat intake and fried foods
• Patient does not have to overdo her fiber intake but rather keep her fiber intake to around 25 g to 35 g daily
  • patient can also take dietary fiber supplements in order to meet the daily recommended levels of fiber 

Exercise

• According to the CDC guidelines of performing 150 minutes a week of moderate exercise and Penn state medical center guidelines for patients with ulcerative proctitis of performing 30 minutes exercise 5 days a week, I believe that the patient meets these criteria due to her busy schedule.  I would only recommend that the patient go for a brisk walk on the weekends if she felt she spent a lot of time sitting throughout the week. The patient can even aim to complete 75 min of intense exercise a week and try going for a run around the neighborhood. Additionally, patient can take up some moderate muscle strengthening exercises two days out of the week if possible. Increasing her level of exercise would be beneficial by preventing stroke which she is at an increased risk for due to past family history of stroke.

Harm Reduction

• The patient states that she sometimes asks her colleagues to drop her off if she feels unsafe driving home after having a few drinks. In this situation, I would recommend to her that she should always have a friend drive her home even when she has only one drink

Brief Intervention

• Substance abuse
  • I would start the alcohol screening with CAGE questions and then proceed to AUDIT questions to gauge the patient’s level of use
    • Have you ever felt you have to cut down on your drinking?
    • Have people Annoyed you by criticizing your drinking?
    • Have you ever felt Guilty about drinking?
    • Have you ever felt you needed a drink first thing in the morning to get rid of a hangover?
  • Alcohol abuse(AUDIT)
    • How often do you have a drink containing alcohol?
    • How many drinks containing alcohol do you have on a typical day when you are drinking?
    • How often do you have six or more drinks on one occasion?
    • Based upon these questions if the patient scored above a 4 I would proceed to ask the remaining 7 questions of AUDIT. Depending on the total score I would be able to assess the patient’s risk for excessive drinking and be able to properly recommend the proper course of action such as alcohol education, simple advice, or referral to a specialist.
• Ask
  • I would proceed by discussing and asking the patient if it is ok to broach the subject of her alcohol use and screen her alcohol use
  • “Is it ok if we discuss your alcohol use?
  • “How important is it to work on quitting alcohol use right now?
• Assess
  • This is where we evaluate the patient’s level of drinking and determine if it is risky use or addiction
  • “Can you tell me how many drinks you usually have in a day?”
  • “On a scale of 1 to 10, one being not ready at all and ten being very ready to make a change in your drinking habits, how ready do you think you are to make a change?
• Advise
  • Discuss the harms of excess drinking
  • “Can you tell me a little bit of what you know about the harms of drinking?”
  • “What can you tell me some of the benefits of quitting alcohol consumption?”
• Agree
  • This is where we discuss the quit date and what steps the patient can take to quit or minimize her drinking
  • “When do you think would be a good time for you to quit?
  • “can we discuss and formulate a course that will be effective in helping you quit?
• Assist
  • This is where I would provide any medications or referrals for group support to assist the patient in quitting. Also, this is where I would set up a date for a follow up to check on her progress
  • “Do you want more information about the different medications or treatments to quit?”
  • “Is it alright if we meet up again in a month so we can see how you are progressing?

 Items to Address:

1. Substance Abuse
2. Diet
3. Exercise
4. Screening
5. Immunizations
6. Harm reduction
7. Injury Prevention

 

Sources:

Summary of Recommendations for Clinical Preventive Services

USPSTF- Screening in Adults

http://www.colonrectal.org/services.cfm/sid:6694/ulcerative_proctitis/index.html

http://www.colonrectal.org/high_fiber.cfm

http://pennstatehershey.adam.com/content.aspx?productId=113&pid=33&gid=000134

https://www.cdc.gov/cancer/dcpc/prevention/policies_practices/physical_activity/guidelines.htm