Rose Lidsky
Health Promotion Disease Prevention
Fall 2016
Case Study: Alexi Burr
Immunizations
Alexi should receive an influenza immunization.
It should be confirmed with Alexi that she received at least 1 MMR vaccine. If she has been immunized once and there are no other indications, I would not need to provide another vaccination.
If she did not yet have a second dose of the varicella virus, that should be administered to her, as well. This is especially so because per the CDC, the guidelines for varicella state that the vaccine should be emphasized for individuals with a greater risk of exposure and transmission, such as teachers.
According to the CDC, when a woman is pregnant she should receive a 1 dose Tdap vaccine regardless of when she received a prior Td or Tdap vaccination (“Adult Immunization Schedule”). Therefore, I can perhaps assume that Alexi would not need an additional Td vaccine, as she was pregnant relatively recently. Of course, there is no certainty that the patient received her vaccine at the time of her pregnancy and it would be worth confirming.
Screening
Alcohol misuse
Depression
HTN
HIV infection
BRCA gene screening, due to a history of breast cancer in her family
Intimate Partner Violence
Cervical cancer, pap smear
Lipid disorder, as she had a grandfather that had 2 strokes, and one of which was at a young age
Gonorrhea, syphilis, chlamydia should be checked as well, because STI’s are the most common cause of proctitis (Ehrlich, “Proctitis”).
(Swenson and Ebell, “Introducing a One-Page Adult Preventive Am Health Care Schedule: USPSTF Recommendations at a Glance”).
Injury Prevention
Alexi should be ensuring that she and her children are safe with injury prevention. This should be done in various settings. When driving, she should be sure to practice traffic safety. She should wear a seat belt and ensure her infant is in a rear-facing car seat in the back seat of the car. Her toddler can be placed in a forward-facing car seat. When playing outdoors, the toddler should not be allowed to cross streets by herself. She should be supervised if playing on any tricycles or other such toys and should be encouraged to wear a helmet to protect from serious injury. In the home, Alexi should be certain to make sure the smoke alarm batteries are working and in place. Toddlers should be kept away from heaters, burners, irons, griddles and outlets should be covered. Babies should not be held when working with hot liquids and food at the same time. Milk and formula should be not be heated in the microwave as it can heat the liquid unevenly and burn the baby’s mouth. All the furniture in the home should be firmly in place so that if a toddler were to hold onto it, it would not topple over onto the child. Stairway guards should be utilized for infants to prevent falls from high heights. Infants shouldn’t be left on a high surface without supervision or a railing around them. Small items should not lie around the house within reach of a crawling infant to protect the infant from potential choking hazards. Medicine and household cleaning products should be locked up so as not to allow a toddler to accidently ingest poisonous products. Infants should be placed in crib with nothing else inside in a supine position with the gate up. Any potential firearms in the home, should be placed out of reach of children (Gardner, “Office-Based Counseling for Unintentional Injury Prevention”).
Diet
One of the means by which people recover from anorexia is by sticking to a routine diet (Smith, and Segal, “Eating Disorder Treatment and Recovery”). It seems that now that she has 2 children to take care of, along with her job, she has not been keeping up with that initiative, and is no longer nourishing herself properly. I would advise that she work to make her eating schedule more structured to make sure she is eating all her meals and not foregoing her own health.
Part of what needs to be added to that structure and be incorporated into every meal is protein. For breakfast, perhaps she can have a poached, scrambled or hard-boiled egg with her toast. If that is unsatisfactory to her, maybe she would be interested in drinking a glass of milk or adding a piece or 2 of cheese to accompany her breakfast. When she eats her lunch, she can still have salads but maybe she can add chicken, turkey, tuna, beans or some salmon to it so she gets a serving of protein. If she doesn’t find that appetizing, maybe she can have a yogurt, along with her salad, as an alternative protein serving.
An additional factor for Alexi to consider is consuming anything that could potentially cause her proctitis to flare up. One strategy by which to prevent the development of ulcerative proctitis is to reduce her caffeine intake. Perhaps instead of a cup of coffee, Alexi could have a cup of herbal tea in the morning with her breakfast. Additionally, processed white flour is not good for her proctitis. Her toast should be made of whole wheat unprocessed flour (Ehrlich, “Proctitis”).
She seems to not have enough time to put together snacks, lunches and dinner. Maybe she can devote one of the days of the weekend (perhaps Sunday) when she is not working to cook and have meals prepared for the rest of the week. Maybe that way her dinner will be more structured and she won’t need to rely on picking up food from one of the “not so unhealthy chains”, which don’t seem to be an ideal source of dinner for her. When making dinner, she should try to include a protein, starch and vegetable in every meal. An example being tilapia with a baked potato and roasted peppers. In this way, the meal will have all the elements of a healthy and balanced diet and dinner won’t feel like its “all over the place”.
Exercise
As Alexi is sedentary during large portions of the day, she should make sure that she is exercising frequently for her health, which would additionally benefit her proctitis, as well. It seems Alexi has difficulty maintaining an exercise plan, but perhaps a plan can be instituted out of the exercises she currently is involved in in her daily life. For example, she mentioned that she needs to walk across campus frequently. She should try to speed walk when she is walking across the campus. She should ensure that she is walking at a speed that she can talk, but cannot sing. Maybe she can park her car in a further lot to have to walk a little further than her normal distance and once she gets to another building maybe she can continue her exercise by taking the stairs instead of an elevator to whichever floor she needs to get to. Alternatively, she mentioned she is constantly running around because of her kids, I would suggest that if/when she takes her kids somewhere, like to the park, perhaps she can take them to a further park and speed walk as she pushes the stroller. Other routine things she might be involved in is cleaning. I would also suggest that as she cleans the home perhaps she can ensure she is moving consistently for a half hour. The main goal would be to allow the exercising to last for at least a half hour every day. I would work with Alexi to find the best exercising implementation that works for her that we can ensure she is exercising a half hour a day without compromising her schedule and not overwhelming her. On the weekend, I would strongly suggest she sign up for a yoga class (perhaps on Saturday when she isn’t cooking as per the suggestion above). It will provide relaxation and let her blow off steam from the week in a positive and productive way (as opposed to drinking). It will help to minimize stress and the likelihood of depression. Not only that, but yoga (and alternative stress-relief exercises, as well) lower the risk of developing proctitis (Ehrlich, “Proctitis”).
Harm Reduction
A harm reduction strategy for Alexi would be having a designated driver so that when she goes out and drinks with friends, even if she drinks too much, she can have a means of getting home safely. If she can’t rely on her friends and co-workers to be stable and consistent designated drivers, she should have a discussion with her husband so that they can work together, that if she can’t find anyone to drive her, he will be informed of her state and will come pick her up (even if the children need to be schlepped along too).
Brief Intervention
As Alexi did disclose that she often can’t drive home on her own after spending time and drinking with her co-workers to “blow off steam”, I would be interested to explore her use of alcohol further. For the brief intervention relating to alcohol use, I would rely on the screen-assess-intervene model in working with the patient. Screen means asking the patient questions to better understand their risk. The best tool to use with adults is the Alcohol Use Disorders Identification Test (AUDIT), which produces a score based on the patient’s responses that allows the practitioner to assess the riskiness of the drinking habit. It is important that when asking the questions there is no judgement in the tone of the clinician that would discourage a patient from answering the questions honestly. The AUDIT tool questions that should be asked are listed on the following chart:
(Vaca and Winn, “The Basics of Alcohol Screening, Brief Intervention and Referral to Treatment in the Emergency Department – The Western Journal of Emergency Medicine.”)
The assess portion of the brief intervention is based on the scores of the AUDIT test. If the scores are moderate (8-15) to high (>16) further questioning and analysis is necessary to understand what kind of intervention may need to be performed. More questions should be asked to understand why the patient may have become reliant upon alcohol, perhaps there is abuse or other emotional or behavioral issues that are going on. Additionally, there should be a blood test a further physical inspection to see if the person has any medical issues that would be related to alcohol misuse. The final step would be the part where I would “intervene” and discuss the results of the AUDIT with the patient. If Alexi would be at low risk, with a score between 0-7, some light counseling about how many drinks a day are normal (1 drink per day for women) would be appropriate. Also, a warning about operating a vehicle after having consumed alcohol is an important reminder. If she were to have a moderate risk, it would be important to advise her that she needs to minimize her drinking because of the harms she may face and see how we can work together to make a change. If she were to have a high risk of alcohol consumption, I would make it clear how the drinking is poorly affecting her lifestyle and let her know that if she doesn’t stop, it could continue to have even worse effects on her health and quality of life overall. I would then encourage her to share how she thinks we can begin to make a change. If she is moderate to high risk, I would schedule a follow up appointment in another month and particularly for high risk cases, I would call them in a week to see if they have made any progress moving forward (“Brief Intervention for Excessive Drinking”).
