Immunizations

• Influenza: Recommended for all persons to receive one dose annually.
• Td booster: Recommended for all persons to receive every 10 years.  Alexi should receive if it has been 10 years since her last booster.
• Varicella: Recommended for all adults with no evidence of immunity.  Alexi should receive vaccination she has no evidence of immunity.
• MMR: Recommended for all adults with no evidence of immunity.

Screening

Alexi should be screened for the following:

• Alcohol misuse: Recommended as likely moderate benefit for men and women.
• Depression: Recommended as likely moderate benefit for men and women.
• HIV: Recommended as likely significant benefit for men and women.
• Hypertension
• Obesity
• Tobacco use and cessation
• BRCA gene screening: Recommended as likely moderate benefit for women with the appropriate family history.  Both Alexi’s maternal aunt and grandmother had breast cancer, however it is not clear if it associated with the BRCA gene, therefore she should hold off on screening.
• Intimate partner violence: Recommended as likely benefit for women of childbearing age.
• Cervical Cancer: Recommended as likely significant benefit for women between the ages of 21 and 65.  She should receive a PAP smear every three years or every 5 years with HPV testing.  Ensure she is up to date with this screening.

Health Promotion/Disease Prevention Concerns – please address all that are relevant for this patient:

• Injury Prevention

• • Traffic safety: Wearing a seat belt.
  • Firearm safety: Ask if she has a gun in her home, if it is stored in a safe place.
  • Burn Prevention
  • Water safety

• Diet

Patient is struggling with significant weight loss as a result of a recent diagnosis of ulcerative proctitis  with a PMHx of anorexia nervosa.  In addition, Alexi has limited time for meal preparation.  Alexi should be vigilant about her food choices as to not aggravate her proctitis, avoiding dairy products, spicy foods and raw fruits and vegetables and eating a diet rich in fiber.  To maintain her weight, she should be eating foods rich in nutrients, fat and protein.

Breakfast: Alexi should consider swapping her coffee for tea, a less aggravating choice for proctitis.

Lunch: Alexi should avoid eating salads, as raw fruits and vegetables can cause flare ups.  She can consider having a grain bowl, with cooked vegetables and a grain, as well as a protein such as an egg or tofu.

Snacks: She should pack snacks that can be eaten on the go such as mixed nuts or protein bars.

Dinner: She can continue eating her husband’s dinner and takeout as long as she is careful to choose foods that will not affect her proctitis.

• Exercise

Although patient is not engaging in a regimented exercise schedule, she is leading a moderately active lifestyle and has a BMI of 17.

Exercise routine that should be implemented is muscle strengthening focused and not weight loss focused.  Alexi should implement 50 minutes 3 times a week or 30 minutes 5 times a week of either strength training exercises such as yoga, pilates, or weight lifting or light intensity exercise like walking, swimming or even doing household chores.

Brief Intervention

• Substance Use

Based on Alexi’s reported alcohol use it is necessary to ask follow up questions.  Because her score is 3 on the first three AUDIT questions, ask the full AUDIT panel.  The results will indicate the level of intervention necessary.  Her results might indicate giving her basic alcohol education, simple advice, brief counseling and continued monitoring or referral to a specialist.

If she is at low risk she should be given a brief education about safe alcohol use and be encouraged to not drink on two days of the week, never drink when operating machinery, she should be made aware of contraindication of any medications she is taking and she should be told to refrain from drinking if pregnant or considering pregnancy.

If she is at moderate risk to high risk it is important as the clinician to evaluate the ways in which alcohol is affecting her life.  Ask questions about medical problems like blackouts, depression, hypertension, sexual problems and sleep disorders.  Ask about any behavioral problems Alexi has been experiencing.  Another indication might be if Alexi has had a significant injury recently that was a result of intoxication.

In addition, it is helpful to use the CAGE questions to evaluate her risk for alcohol abuse.  These include the following: Have you ever felt the need to cut down on drinking?  Have people been annoyed by your drinking? Have you ever felt guilty about drinking?  Have you ever felt that you needed to drink when you woke up to calm down or assuage a hangover?

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

file:///C:/Users/lbtuc/Downloads/AFP%20-%201%20pg%20Adult%20Screen%20USPSTF%20(3).pdf

file:///C:/Users/lbtuc/Downloads/CDC%20Adult%20Immunization%20Schedule%20(1).pdf

file:///C:/Users/lbtuc/Downloads/CHI%20-%20PreventingSexually%20Transmitted%20Infections%20(3).pdf

file:///C:/Users/lbtuc/Downloads/CHI%20on%20Brief%20Int.%20for%20Alcohol%20(1).pdf

file:///C:/Users/lbtuc/Downloads/NIDA%20brochure%20(1).pdf

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/preventive-medicine/principles-of-screening/