Ms. Burr’s BMI is equal to 19.5, which is Normal.

Ms. Burr is being seen in my office in November.

Immunizations

The patient has all of her childhood immunizations. The patient should receive the following vaccines:

• Influenza, which is 1 dose annually
• I would review her chart to see when her last Tdap immunization was. Pregnant woman are supposed to receive 1 dose of Tdap each pregnancy. Seeing as though she recently gave birth to her child, she should have received 1 dose of Tdap during her pregnancy with that child. As such, she shouldn’t receive Tdap or a Td booster at this visit.

Screening

The patient should be screened for the following as per USPSTF:

• Alcohol Misuse
• Depression
• Hypertension
• Obesity
• Tobacco Use and Cessation
• HIV Infection
• Intimate Partner Virus – Ms. Burr is a childbearing-aged woman
• Pap Smear with Co-Testing HPV – Ms. Burr should have Pap Smear with Co-Testing for HPV every 5 years. Pap Smears start at age 21, though Pap Smear with Co-Testing begins at age 30. Being that Ms. Burr is 34 years old, she should have Pap Smear with Co-Testing.
• BRCA Gene Screening – Ms. Burr has a Maternal Grandmother and Maternal Aunt with H/O Breast Cancer. As per the USPSTF, Ms. Burr should be screened as she has family members with breast cancer.
• It is important to note that Ms. Burr was likely screened for Sickle Cell Disease as a newborn as per the USPSTF recommendations.

Health Promotion/Disease Prevention Concerns

Injury Prevention

• Traffic Safety including the use of Safety Belts

Diet

• Ms. Burr has a Normal BMI of 19.5. This falls between 18.5 to 24.9.
• Seeing as though Ms. Burr was diagnosed and treated for Ulcerative Proctitis, there are several dietary modifications she can make to increase her prognosis. As per Colon & Rectal surgery associates (http://www.colonrectal.org/services.cfm/sid:6694/ulcerative_proctitis/index.html), increasing fiber in the diet via high-fiber foods or fiber supplements can ease symptoms. Additionally, restricting dairy consumption can control symptoms like cramping, gas, diarrhea, or abdominal bloating.
• It appears that Ms. Burr has difficulty in consistently having meals. This may be the result of many factors including the fact that she has time constraints being that she has returned to work and is focusing primarily on the needs of her children. Regarding the composition of her diet, consuming fruits/vegetables while limiting red meat and fried foods, this is very good. I would advise Ms. Burr to continue eating her meals in this manner. Mainly, my advise to Ms. Burr would be such that she attempt to have more consistent plans for meals. Seeing as though her husband is mostly a stay-at-home dad, perhaps he can help in preparing meals for Ms. Burr. I would emphasize how useful “Meal Prep” could be, especially for Ms. Burr’s particular time constraints.
• Plan – Continue diet with an emphasis on fruits and vegetables. Continue to limit intake of red meat and fried foods. Increase fiber intake via high-fiber foods or fiber supplements (consider Metamucil). Limit, or perhaps eliminate, consumption of dairy products. Consider implementing Meal Prep. I would give the patient information regarding Meal Prep and where she can find useful resources on the computer. Additionally, I would emphasize the importance of maintaining a diet that is low in saturated fats, trans fats, cholesterol, sodium, and added sugars.

Outline of a Typical Day’s Meal (Modified and with Meal Prep Incorporated):

Breakfast – Toast with Almond Butter and Coffee

Lunch – Salad (Prepared at Home)

Dinner – Grilled Chicken with Steamed Broccoli

Exercise

• Ms. Burr is not likely to be getting adequate exercise at present according to current guidelines. The CDC guidelines for adults includes 150 minutes/week of moderate-intensity aerobic activity or 75 minutes/week of vigorous-intensity aerobic activity and muscle strengthening at least 2 times/weekly involving all major muscle groups.
• Plan – I would consider Ms. Burr to be part of the “Active, but less than recommended levels” group. As such, I would recommend she gradually increase to the recommended 150 minutes/week of moderate-intensity aerobic activity and muscle strengthening at least 2 times/weekly. Though it may be difficult for Ms. Burr to incorporate exercise because she is busy with her children, there are certainly interventions that can be incorporated. I would cater my exercise plan to things that Ms. Burr enjoys. For example, if she likes dancing, perhaps she can do Zumba after putting her children to bed. This can be for as few as 10 mins. to up to 1 hour; incorporating this activity can be catered to however much time Ms. Burr feels she can utilize. Additionally, during her days at work (as a schoolteacher), perhaps when she has periods off she can utilize the school gym or track to do either strength training or aerobic activity.

Harm Reduction

• Harm reduction actions that are relevant to this patient include the fact that she uses designated drivers (her colleagues) when she is impaired and cannot drive. While it may not be desirable that Ms. Burr is drinking to the point of intoxication such that she cannot operate a motor vehicle, choosing to have someone drive her home is an example of harm reduction. Additionally, when she picks up dinner if nothing was prepared, she goes to a “not so unhealthy chain.” Being that she is going to pick up food, she chooses options that are “healthier.” This is an example of harm reduction. Harm reduction interventions that she can implement would include cutting back her drinking on Friday nights from 4 glasses of wine to 2 or 3. While it is still not desirable that Ms. Burr is consuming alcohol, at least she is consuming less, an example of harm reduction.

Brief Intervention

 Substance Use – I would conduct a brief intervention for Alcohol Use for Ms. Burr. This is important because Alcohol Use is the third leading cause of preventable death in the United States. Women that consume either 4 or more standard drinks in a day or 8 or more standard drinks in a week are considered to be in the “Risky Use” category. Ms. Burr admits that she has as many as 4 glasses of wine when going out to the bar with her colleagues on Friday night. She states that she can “blow off steam” on these nights while her husband watches the kids. Ms. Burr’s consumption of 4 glasses of wine in one day places her in the “Risky Use” category. This, in consideration with her attitude towards her Friday nights, should prompt the clinician to perform a brief intervention regarding Substance Use, particularly Alcohol Use in this case. I would begin by using the 5 A’s of Brief Intervention. I would Ask questions about substance use, including screening and seeking permission to discuss. I would then Advise the patient to stop or cut down. After, I would Assess Ms. Burr’s willingness to make change. I would then Assist her to make change if ready. Last, I would Arrange for further assessment, treatment, and follow up. It is important to note that when conducting a Brief Intervention for Alcohol Use, the clinician should use the Screen-Assess-Intervene Model. We would certainly use the CAGE screening tool and the AUDIT-C screening tool for Ms. Burr. Depending on her score, a variety of interventions would be implemented.

For the “Screening” portion, I would ask the following questions.

C – “Have you ever felt you needed to Cut down on your drinking?”

A – “Have people Annoyed you by criticizing your drinking?”

G – “Have you ever felt Guilty about drinking?”

E – “Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?”

The First 3 Audit-C Questions are:

1. How often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
3. How often do you have six or more drinks on one occasion?

The questions I would ask for the “Assess” section would be the following:

Ask – “How do you feel about alcohol consumption as it relates to your health and quality of life?,” “Would it be alright if we discussed your alcohol consumption?”

Advise – “Tell me what health risks are associated with alcohol use,” “Would it be alright if we discussed the benefits of cutting back alcohol consumption?”

Assess – “Tell me on a scale of 1-10 how ready you feel to make a change regarding your alcohol consumption”

Assist – *HYPOTHETICAL* – “You say you are at a 4 out of 10 regarding readiness to make a change. What might increase that number?,” “What factors are preventing you from making a change?”

Arrange – We would agree on a treatment plan that would likely include behavioral modification, and if there were some underlying factor like depression, perhaps CBT. “We have agreed that you will attempt to consume a maximum of 2 glasses of wine on your Friday nights out. What questions do you have for me?,” “Are there any services you feel you may benefit from that I can put you in contact with?”

Order of Items/Issues to Address

1. Substance Use – Alcohol Use
2. Screening per USPSTF Recommendations, including: Alcohol Misuse, Depression, Hypertension, Obesity, Tobacco Use and Cessation, HIV infection, IPV screening, Pap Smear with Co-Testing for HPV, and BRCA gene screening.
3. Immunizations – Influenza
4. Exercise
5. Diet
6. Injury Prevention

Sources:

Adult Preventive Health Care Schedule: Recommendations from the USPSTF

Recommended Adult Immunization Schedule – United States – 2016

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing

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

http://www.aafp.org/afp/2008/0501/p1300.html

Eat More, Weigh Less? How to manage your weight without being hungry

Writing an Exercise Prescription PowerPoint

Health Promotion & Disease Prevention: Setting the Agenda PowerPoint

Substance Use and Recovery PowerPoint

New York City Department of Health and Mental Hygiene Audit-C Questio