Martin Vanegas

CUNY York PA Program

HPDP

Patient: ALEXI BURR

Immunizations

• List the immunizations this patient should have – assume that they have all had their childhood immunizations (including HPV vaccine where appropriate) Assume that you are seeing the patient in November

If my patient Mrs. Burr, my 34-year-old female patient has had all of childhood immunizations, there are a few immunizations that come to mind that she should have already received. Based on the current CDC recommendations for immunizations, this includes an annual influenza vaccine as November makes it part of flu season, A TD booster every that she should have 10 years after the original Tdap vaccine, MMR vaccine, Varicella vaccine, HPV vaccine (ages 19-26). The immunization that should be addressed first for Alexi is the annual influenza vaccine since November is part of flu season.

Screening

• List the screening tests that you would order for this patient.  If you decide to order any that have inconsistent guidelines, please say why you think they are indicated for this patient.

There are a few screenings test that I would order for Mrs. Burr. Based on the USPSTF recommendations, I would order a screening test for BRCA gene testing, hypertension, tobacco use and cessation, HIV screening, cervical cancer, weight loss, alcohol misuse and depression screening. The reason behind the BRCA gene testing is that she has Ashkenazi Jewish ancestry and has a family history of breast cancer from her maternal grandmother and aunt. Also, the reasoning behind the alcohol misuse screening, is that she admitted to drinking on most weekends to the point where she gets drunk on at least four glasses of wine and having to make one of friends drive her home. The reasoning behind the depression screening is that she has a history of anorexia, and her maternal grandmother had a history of chronic depression. Although not at the age requirement for screening for colorectal cancer (>45), this would be a conversation of risks and benefits over this screening that I would have with this patient as her having a history of ulcerative proctitis puts her at higher risk of getting colon cancer in the future. Out of all of the following screening tests that I have listed for the patient, the ones that should be addressed first would include hypertension, tobacco use and cessation, HIV testing, cervical cancer screening. The secondary screening tests include the BRCA gene testing, alcohol misuse and depression screening, weight loss (due to current BMI of 17) and possibly the colorectal cancer screening even though she is not of age requirement for it.

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

• Injury Prevention
  • Identify any injury prevention concerns that should be discussed (just list them).

One of the injury preventions concerns that should be discussed for patient Alexi may include traffic safety.

• Diet
  • Please identify any relevant dietary issues for this patient
  • While thinking about diet, consider any specific health issues this patient has and how diet should be modified to address them (you may have to look some up since you haven’t studied them yet)
  • Based on your assessment, outline a plan to address any dietary modifications you think are indicated for this patient

There are some relevant dietary concerns for Alexi that should be addressed. Based on the information that she gave me, Alexi has PMH of anorexia and is diagnosed with ulcerative proctitis. She states that she eats mostly healthily with an emphasis on fruit and vegetables and tries to avoid red meat and fried foods. The issue lies with Alexi not being able to bring food or snacks for her lunch stating that she doesn’t have enough time to prepare it and in the setting of dinner as she states that it’s “all over the place” and usually gets food from unhealthy fast-food chains or premade food from the local supermarket for her and her family. I believe that Alexi’s issue when it comes to her diet revolves around her not having enough time to prepare herself food due to family constraints. I believe that simple acts of meal preparation ahead of starting the week would prove to be the most beneficial thing that she could do in terms of time restraint. Also, I would recommend a way to try to increase her calorie intake as her BMI is around 17 and due to her history of anorexia. A BMI of 17 is considered underweight for her height and current weight (5 Feet, 100 lbs.). The ideal BMI for the patient should be 18.5-24.9. A healthier approach to increasing her calorie intake that I would recommend as her provider may include in adding more lean meats and high protein foods (chicken, turkey, tufo, beans) and healthier carbohydrates (brown rice, sweet potato) along with her continued diet of eating green vegetables and fruits as she previously mentioned.

• Exercise
  • Determine whether this patient is likely to be getting adequate exercise as per current guidelines
  • If the patient is not meeting current guidelines, please suggest a plan to meet them that is specific to this patient’s goals and concerns

In terms of exercising, my patient is not getting adequate exercise as per the current guidelines. Alexi has previously mentioned that she is no longer in any formal exercise program, and she sits for long periods of time as an economics professor. She does mention that she stands for long periods of time and has to walk from one end of her campus to the other on a daily basis. I believe that adding just a little more to her walk everyday would prove to be beneficial for her current health. I can mention that waking up a little earlier in the morning and going to bed earlier would allow her enough time to have a brisk walk in the morning for even just a few minutes and gradually increasing it to thirty minutes would have an impact on her current health. She mentioned that her husband is mostly a stay-at-home father and works from home, so he would be able to watch the kids in the meantime.

• Harm Reduction
  • If not addressed in the areas above, include any harm reduction suggestions/actions that are relevant to this patient

In terms of harm reduction, I feel that Alexi currently needs to continue practicing harm reduction if she continues her current trends. Alexi has previously mentioned that she sometimes has designated drivers when she goes out drinking with her colleagues. It is important to note that she should always have a designated driver when she drinks regardless of the amount of alcohol she has ingested. Also, it’s important to point out that she needs to continue picking out the healthier options when it comes to ordering from fast food places.

Brief Intervention – where relevant to your chosen patient, please explain how you would conduct a brief intervention for:

• Obesity
• Smoking Cessation
• Substance Use

For this section, please outline the format for the brief intervention and give example questions you would use for each section. 

A brief intervention for Alexi’s substance use in terms of excess alcohol >3 a day during Friday nights and the weekends would invoke me on conducting the 5 A’s of brief intervention (Ask, Advise, Assess, Assist, Arrange). I would be inclined to do this as alcohol abuse over time can lead to some serious health concerns like cirrhosis, gastritis, and pancreatitis. I would first ask about the use of alcohol and then if she admitted she drinks like she stated on Fridays and weekends. Then I would proceed to the second A in intervention. I would then advise her to try to stop and or cut down on alcohol use and then assess her willingness to make that change herself. Lastly, as her provider in charge of her health I would urge her to schedule a follow-up contact within the next 7-10 days.