Case Study

by Jaspreet k Sra

Jaspreet Sra

Case Study

Alexi Burr

Alexi Burr is a 34 y/o female who has a prior medical history of anorexia (during teens) and recently diagnosed with proctitis. She has two children and is being seen in my clinic in November of 2020. 

Immunizations

Since Alexi has already received her recommended childhood vaccinations, the following immunizations would be required. 

  1. The first one required would be the Influenza vaccine. It is recommended for individuals that are 6 months and older to receive one dose annually. November also falls in the flu season which makes this vaccine more important to be given. 
  2. TDAP vaccine is required once and then a booster shot is required every 10 years or during pregnancy (weeks 27 to 36). Since, Alexi gave birth to a child less than 10 years ago hence, it is unlikely she will require the booster shot. 
  3. Depending on the chart review measles, mumps, rubella (MMR) one dose would also  be recommended  

Screening

Following screening tests are recommended as per USPSTF

  1. Alcohol misuse- All though she is not drinking daily, she does drink to the point where it is not safe to drive. She is engaging in risky behaviour by doing so. 
  2. Depression – Alexi is experiencing a rough time right now where she has limited time for herself which can lead her to go into depression which is why I would screen her depression. Furthermore, her maternal grandmother had chronic depression. 
  3. Hypertension– Her paternal grandfather was diagnosed with hypertension. 
  4. Tobacco use and cessation
  5. HIV infection
  6. BRCA gene risk assessment: It is recommended if the patient has personal or family history of the BRCA- related cancer or ancestry. Alexi’s maternal grandmother and maternal aunty also had breast cancer.  
  7. Intimate partner violence: This is recommended in those women that are of child bearing age. 
  8. Cervical cancer –  This screening should be done starting from the age 21 to 29 with cytology alone every three years. Once the female is 30 to 65, cytology and high risk HPV co-testing should be done every 5 years.  Alexis is 34 years old and hence,  she should have a PAP smear (cytology testing) with an HPV test every five years. 
  9. Sickle Cell screening should have been when she was a new born baby according to HRSA. 

Health Promotion/Disease Prevention Concerns

  1. Injury Prevention 

→ Traffic Safety – discuss the importance of using seat belts in the back seat and front seat. Even though, in certain states seatbelts are not mandatory in the back seat it can still prevent injuries in the setting of an accident and should be discussed with the patient. 

  1. Diet

→ Mrs Burrs, BMI is 19.5. This falls within the normal limits range of 18.5 to 24.9. Unfortunately BMI alone does not provide the best depiction of Alexis’ health and diet and other aspects should be considered as well. 

→ Even though her BM is within normal limits, her diet can still be improved. She should be applauded on how she incorporates  salads, vegetables,  fruits and avoids red meat and fried foods. However, she states she usually eats “when I remember to eat”. Missing meals can leave a severe impact, cause her BMI to decrease to underweight as she is borderline and have a negative impact on her ulcerative colitis. 

  • In order to prevent any negative impacts, Alexi can work towards incorporating actions that will help her improve her diet. Even though she is very busy, she should try meal prepping for one to two days of the week. In the long run this will help save her time. Also when she plans for her childrens meals, she can simultaneously work on her meals. Furthermore she can cook meals/ snacks that both her and her children can eat. Another action she can take to help save time  is cook with her children. By giving her children small responsibilities, it will keep them pre – occupied and save time in the long run. 

→ A health issue that needs to be taken in consideration, is her ulcerative colitis. She can make several modifications to her diet to improve her condition and prevent it from getting worse. 

  • Having a balanced diet is imperative to avoid making the symptoms worsen. Having ulcerative colitis can have a negative impact on the body to digest and absorb food/ nutrients which causes vitamin deficiencies. This can spiral down to having other diseases. 
  • Crohn’s & Colitis Foundation discusses the appropriate actions to take in terms of diet for those with ulcerative colitis. She should consume food with high fiber or take fiber supplements.
  • Avoiding lactose foods and foods with a large amount of fat, spices and sugar can also help Alexi. These along with alcohol and caffeine are considered trigger foods.  
  • There is less concern for her eating foods with a high level of fat. Drinking alcohol is something I would recommend, since she drinks with her friends often.  
  • She drinks a cup of coffee every day which I would recommend to switch to a decaffeinated coffee or tea. 
  • I would also advise her that if she is experiencing symptoms of ulcerative colitis she may have to switch her diet  to low fiber foods, lean protein, refined grains, cooked cruciferous vegetables 
  • Emphasizing the importance of a diet that is low in sodium, trans fat, cholesterol, saturated fats and added sugars is very important. 

In general the dietary modifications I would recommend are: 

  1. Eat more fibrous food such as beans, broccoli, apples, berries, avocados, whole grains. 
  2. Replace coffee with decaffeinated coffee 
  3. Continue eating fruits and vegetables
  4. Limit the alcohol- try decreasing it from 4 glasses of wine. 
  5. Implement Meal prepping
  6. Avoid  food with high lactose, sugar and fat.

I would also re-emphasize the importance of health and how she needs to take care of herself to take care of her kids. I would also commend on her being able to gain 20 pounds and tell her to regularly check her weight to ensure it’s not decreasing too much. 

Example of a Day’s meal

Breakfast options:  

  1. Oatmeal with fruits
  2. Whole grain toast with almond butter
  3. Whole grain waffles with fruits ( put chocolate chips in her kids waffles) 
  4. Boiled eggs with whole grain bagel 

Lunch Options:

  1. Whole grain tacos with chicken and veggies 
  2. Salad with grilled chicken, light dressing 
  3. Whole grain pasta with veggies 

Snack Options: 

  1. Fruits / fruit juice (home made in magic/nutri bullet and not juicer to preserve the fibers)  
  2. Walnuts, almonds 
  3. De-caf tea 
  4. Pan fried vegetables 
  5. Yogurt 

Dinner Options 

  1. Grilled chicken and vegetables
  2. Lean protein – meats, fish with vegetables 
  3. Tofu with vegetables 

 Exercise

CDC has certain guidelines created for physical activity which includes 150 minutes per week of moderate intensity activity or 75 minutes per week of vigorous intensity activity. This should be associated with muscle strengthening exercises  more than 2 times per week that involves the major muscle groups. All though, Alexi is mostly on her toes running around and taking care of the kids, she is not doing moderate or vigorous intensity activity. 

My recommendations would be to incorporate physical activity within her days. Due to the lack of time, she can try implementing some type of vigorous or moderate activity for a few days. During the days her husband is home, while he takes care of the kids Alexi can do vigorous activity. If she is able to utilize 20 minutes of vigorous aerobic activity for 4 days a week she will be able to fulfill the aerobic activity category. She can also join the gym at the university where she can spend  time to do muscle strengthening activities. She can also do activities with her kids such as dancing, playing games that can count as moderate activity. 

I have created a plan that she could use: 

Aerobic Activity
Four days a week: Running, bicycling, race walking 

In order to ensure Alexi is doing moderate or vigorous activity she would have to measure her heart rate. 

Max HR: 220 – age = 220 – 34 = 186 

Moderate Level: Max HR x 50 to 70%Activities: walking briskly, swimming, tennis, scrubbing floors, washing windowsVigorous  level: Max HR x 70 to 85% Activities: race walking, jogging, swimming labs, tennis, cycling >10 mph 
Target HR:  Low end 186 X50% = 93 BPM High end 186 x70%= 131 BPM Target HR: Low end: 186 x70%= 131 BPM High end: 186 x 85%= 158 BPM 

Explaining these heart rate goals will help Alexi understand what type of category she falls under while doing  exercise and adjust according to what she prefers. There are many youtubers that do exercises such as HIIT, tabata- which are usually  high intensity. She can play such videos on the TV and make her kids join her. She can actually do the work out, while her kids attempt to. When she walks around campus, she can attempt to race walk rather than walk briskly. 

In order to incorporate muscle strengthening activities in her daily life, she can join the university’s gym where she can use resistance machines. One day she can focus on her lower extremity while the second day she focuses on her upper body. However, if she does not have time she can incorporate the following exercises while she’s cooking, before she’s sleeping etc. They do not take much time and can be done while she’s taking care of her kids. In fact she can make her kids join her. 

A few muscle strengthening activities: 

  1. Lunges 
  2. Squats 
  3. While using dumbbells: bicep curls, triceps extensions 
  4. Planks 
  5. Sit ups 

Harm Reduction

  1. Fast food restaurants – choosing the healthy options 
    1. Alexi reports how she sometimes is unable to cook and just picks up dinner from “unhealthy chains”. Rather than going to fast food restaurants she can choose to go to a place that has healthier options such as vegetables, grilled chicken rather than fried chicken, salads etc. 
  2. Designated driver initiatives 
    1. This is something Alexi is following already. She is aware that she cannot drive and ensure someone else drives her home. Commending her on being aware and enforcing this behavior would be important. 
  3. Decaf coffee 
    1. Alexi drinks coffee every day. It would be important to explain that switching over to decaf coffee would be a healthier option for her 

Brief Intervention 

  1. Obesity: Alexi is not obese and her BMI is normal. 
  2. Smoking Cessation: Alexi does not smoke and hence this intervention is not required. 
  3. Substance Abuse: Alexi admits to drinking alcohol and that during certain situations she drinks up to 4 drinks. This prevents her from driving home. Based on  Natl. Institute on Drug Abuse drinking more than 3 drinks/ day or more than 7 drinks per week is classified as risky behaviour. 

Speaking about this with Alexi needs to be done in an appropriate manner. The first step would be to ensure that Alexi is ready to speak about substance abuse. I would use the 5 A’s of brief  intervention. I would also use the CAGE and Audit- C tools.  

5 A’s of brief intervention 

Ask: ask about the substance use – seek permission
1. I know you mentioned, you drink with your friends sometimes. Is it okay if we speak about it?
Advise: I would advise the patient to cut down drinking but would work towards the patient reaching to that conclusion on her own via asking questions
Are you aware of the risks related to drinking alcohol? – Depending on  Alexi’s answer I would continue the conversation and discuss the risks related to alcohol.
Assess: willingness to make change
On a scale of 1 – 10 how strongly do  you feel about cutting down on the alcohol consumption?
Assist:
Depending on her answer I would ask if there are any factors that are stopping her from cutting down the alcohol consumption.
Arrange: further assessment, follow up
If she chooses to cut down, I would speak about it in the follow up visit. If she is still unsure about cutting down, I would ask her if I can provide her some further resources about this risky behaviour.

CAGE
C: “ Has the thought that you need to Cut Down on your drinking crossed your mind ever?”
A: “When someone criticizes your drinking, do you feel annoyed?”
G: “Do you feel Guilty about drinking?”
E: “ During many instances we wake up in the morning (Eye- opener) our nerves kick in or we have a hangover. During that time, do you feel that you need to have a drink? 

AUDIT C

The three questions of AUDIT-C are as follows:

  1. How many times do you think about drinking a drink with alcohol in it? 
  2. How many drinks with alcohol do you have on a day when you are drinking? 
  3. How many times do you have 4 or more drinks during one time? 

The Screen-Assess-Intervene Model should be used and the CAGE, AUDIT-C should be used a screening tool. The scores obtained from these tools would dictate what interventions should be implemented. 

Order of Items/Issues to Address

  1. Substance Use – Alcohol Use
  2. Screening as per USPSTF Recommendations 
  3. Immunizations – Influenza
  4. Exercise – plan
  5. Diet – meal plan
  6. Brief intervention
  7. Injury Prevention – traffic safety

Works Cited 

Adult Preventive Health Care Schedule: Recommendations from the USPSTF (as of August 16, 2019)

C. (2020). What Should I Eat? Retrieved November 17, 2020, from https://www.crohnscolitisfoundation.org/diet-and-nutrition/what-should-i-eat

H. (2020, October 29). Advisory Committee on Heritable Disorders in Newborns and Children. from https://www.hrsa.gov/advisory-committees/heritable-disorders/index.html

Substance Abuse and recovery powerpoint. 

Writing and exercise prescription powerpoint. 

Prevention of Infectious Diseases and sexually transmitted infections powerpoint.