Immunizations

• Influenza
• PCV13 (1 dose, if not previously received). If she received PCV13 last year at age 65, and it’s been a year immunization, she should receive 1 dose of PPSV23.

If Calandra has not had the following vaccines (given they were not likely around during her childhood or the time period has expired since previous shot), the following vaccinations are required:

• Td booster (if it’s been 10 years since her last shot)
• Varicella (2 doses)
• Zoster (1 dose)

Screening
Typically the first 6 items are always screened for (see caveated notes below):

• Alcohol Misuse – given her sobriety (former alcoholic – sober 8 years), screening via reinforcing sobriety should be executed.
• Depression
• Hypertension
• Obesity – patient is sensitive to her weight and focused on being healthy and continuing to lose weight. It is important to reinforce behavior and work with her to modify / adjust diet and counsel her to reach her goal and avoid addictive behavior as relating to food.
• Tobacco use & cessation – former smoker (40 pack years – quit 5 years ago), screening via continued reinforcement of cessation should be offered.
• HIV infection
  
• Abnormal glucose/diabetes – patient is still overweight, with a BMI of 25.8 and was formerly 60 lbs heavier, test is indicated.
• Hepatitis C Virus Infection – test is indicated as she was born in 1951.
• Colorectal Cancer – recommended, as patient is 50-75 and should be screened using fecal occult blood testing, sigmoidoscopy or colonoscopy.
• Breast Cancer – biennial screening via mammography recommended for women 50-74 years old.
• Lung Cancer – recommended as patient is > 30 pack years and former smoker quit < 15 years ago.
• Osteoporosis – recommended based on age and gender.
• BRCA gene screening – if she consents given her mothers positive history of breast cancer.
• Hep B, Syphilis, Gonorrhea & Chlamydia, if at higher risk. These tests are not likely necessary because Calandra has a long-term partner. If it came to light that either she or her partner was not monogamous, I would suggest these screening tests to ensure she did not contract any of these illnesses.
• Lipid disorder, if at higher CHD risk. Given her age, 40 pack year smoking she may be at higher risk as well as her weight / obesity status, this test could be indicated.

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).
• Diet & exercise
• Avoidance of alcohol, tobacco or other drug use
• Maintain healthy BP & blood cholesterol levels
• Regular colorectal cancer screening
• Mammograms biennially
• Improved glycemic control
• Traffic safety
• Water safety
• Firearm safety
• Sports safety – relevant to take necessary precautions when swimming and use the necessary safety equipment when bike riding.
• Diet
  • Please identify any relevant dietary issues for this patient: Calandra’s diet is relatively well balanced. She consumes a good amount of fruits and vegetables, chooses whole-wheat toast (instead of white) and works to incorporate proteins into each meal. Calandra is also working to balance her caloric intake with her physical activity, which is key in maintaining weight loss, reducing risk of CHD and DM and loosing weight. One issue that I would note is that Calandra doesn’t prepare the food herself rather buys store bought prepared foods.
• 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): Given Calandra’s history of smoking, obesity, her familial history of cancer and diabetes as well as her age, she should be aware of how her diet can increase her risk factors of these diseases. As it relates to all issues mentioned, Calandra should monitor the portion sizes of the foods she is eating. Weight watchers does a nice job of providing portion sizes to their clients and having knowledge of the program she should continue to use her understanding to ensure she is not overeating. To reduce her risk, Calandra should minimize her red meat intake and work to incorporate more lean meats and fish into her diet. She should moderate her diary consumption and work in non/low-fat dairy sources instead of any full fat items. She should continue to eat abundant amounts of fruits and vegetables throughout the day and avoid trans fats and solid fats wherever possible. A colorful plate is one that includes many of these items and can serve as a great guideline to healthy eating. Again, balancing the caloric intake with physical activity is essential to staying healthy and fit.
• Based on your assessment, outline a plan to address any dietary modifications you think are indicated for this patient: As previously noted, Calandra monitors her diet and caloric intake very closely. Her typical meal already contains a majority of healthy foods and avoids many of the harmful foods as suggested by the American Cancer Society, the American Diabetes Society and the American Heart Association. That said, in evaluating her diet, I would suggest that she begin to prepare her own foods to ensure she is aware of all the ingredients used in their preparation. It is very likely excessive amounts of butter and other trans fats are used, which she may not be accounting for in her caloric intake. If she is preparing her own food, she will know the contents and have a better idea of what she is putting in to her body and calories associated. Secondly, I would confirm that the yogurt she is eating for lunch is non/low-fat, and if it is not, incorporate a low-fat yogurt into her diet. I would suggest whole grain pita chips to replace any ‘normal’ ones she is eating as to minimize processed carbohydrates in her diet. Lastly, in an attempt to avoid sugar, I would recommend no more than the two pieces of dark chocolate she is consuming. I would totally eliminate the chocolate from her diet because I want to work with her to take the focus off of her starvation and make her food choices more about a life-style and moderation and less about the feelings of starvation.
• Exercise
  • Determine whether this patient is likely to be getting adequate exercise as per current guidelines: It is challenging to decipher whether or not Calandra is getting adequate exercise as per current guidelines. Given Calandra mixes up her exercise methods between the walks, the bike rides and the swims it is likely she is hitting 150 minutes of exercise per week but would need more details as to the amount of time she is increasing her heart rate and how many times a week she is doing these exercises to make an accurate plan.   The CDC recommends adults exercise 150 minutes and participate in 2 days of muscle strengthening activities each week. Again, Calandra is definitely getting cardio exercise in that she is regularly taking long brisk walks, bike rides to do errands and swims when in season as well as her muscle strengthening activities with her free weights and resistance bands but exact timing is unclear and would be helpful to further assess her case.
  • 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 speaking with Calandra further, I would like to learn the timing and rate of each activity, so I can work with her to ensure she is at minimum meeting the CDC recommendation of 150 minutes of cardio per week. I would also like to work with her to incorporate other exercises into her lifestyle to not make it feel like a chore but to more realistically that she is living a healthy active lifestyle. Given she retired recently, she will have more time on her hands and ample opportunity to engage in different types of activities or participate in various exercise classes to incorporate her diet with her exercise plan so it her weight is not a struggle for her any longer.

• Harm Reduction
• If not addressed in the areas above, include any harm reduction suggestions/actions that are relevant to this patient: N/A, patient is no longer drinking or smoking, is not a drug abuser and is in a monogamous relationship.

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

• Obesity: Calandra is not obese but currently overweight, with a BMI of 25.8. Over the past 1.5 years she has made the effort to lose weight and address the health concerns associated with obesity. Calandra has a self-proclaimed ‘addictive nature’ so I would work with her to ensure that her caloric intake and exercise regime does not control her life and eventually lead to an eating disorder/issue. In conducting a brief intervention for obesity, I would utilize the 5 A’s to speak with Calandra. The 5 A’s consist of Ask, Assess, Advise, Agree, Arrange/Assist and are helpful to manage a patient you’re caring for with obesity.
• Askis particularly important as it relates to a patient’s weight.  Weight is a very sensitive issue for some people so before diving into a conversation about their weight, it is helpful and a best practice to ask the patient if they’re comfortable discussing their weight with you.  Per the Canadian Family Physician Journal, their readiness to discuss their weight is an indicator of their weight loss success.  It is clear Calandra is ready to talk about her weight and it is something that impacts her greatly. It is important for a practitioner to never take on a judgmental tone.  The goal is to keep your patient open and honest. In asking if they’re comfortable to discuss their weight, a practitioner should assess their readiness for change and work with them to put a plan in place to lose weight and keep it off.  Examples of questions practitioners can ask are: “are you comfortable discussing your weight with me?” “are you concerned about your weight?”
• Assess the patient’s health status and obesity indicators and explore causes of weight gain. Examples of statements that can be used are ‘please discuss your daily diet and physical activity.’ It is here that I would work to acquire the relevant information as it relates to her exercise regime to see if any substitutions need to be made to her current exercise routine and work with her to incorporate it into her life.
• Advise the patient of associated health risks, which in Calandra’s case she is aware of but also ensure she is aware of the benefit of long-term weight loss. During this portion, you can asses the patient’s knowledge of effects of weight loss / being over weight, i.e. ‘ what do you know about the effects of overweight & obesity on health risks?’
• Agree on the appropriateness of weight loss, expectations, targets and treatment plan. I would ask Calandra ‘what would she like to weigh?’ and talk through plans to reach a target.
• Arrange/Assist to provide resources and follow up on her weight loss journey. In Calandra’s case, I think a ‘prolonged intervention’ would probably be the most effective. I think regular meetings with a nutritionist associated with check in’s and support groups where applicable is appropriate given her addictive nature. I would ensure Calandra is comfortable with this referral to a nutritionist before making the call.

In working with Calandra during this intervention, I am confident that we would be able to formulate a plan that is satisfactory from her perspective but also meets the needs to continue reducing her risk for associated risk factors but also to avoid any further weight gain and to inspire weight loss.

• Smoking Cessation: N/A, patient quit smoking 5 years ago. I would commend her for stopping 5 years ago and encourage her to seek out assistance if she has the urge to start smoking again, especially given her associated risk factors.
• Substance Use: N/A, patient is recovering alcoholic and sober for 8 years. I would commend her for stopping drinking 8 years ago and encourage her to reach out to her sponsor (and/or me) if she is tempted to begin drinking again, especially given the risk factors associated with her drinking.

References –

CDC. (2009). The Power of Prevention. Retrieved from https://www.cdc.gov/chronicdisease/pdf/2009-power-of-prevention.pdf.

CDC. (2016). Recommended Adult Immunization Schedule. Retrieved from file:///Users/jessicabrown/Downloads/CDC%20Adult%20Immunization%20Schedule%20(3).pdf.

Garry Gardner, H. American Academy of Pediatrics. (2016, June). Office Based Counseling for Unintentional Injury Prevention. Retrieved from file:///Users/jessicabrown/Downloads/Pediatrics%20on%20Office%20Counseling%20on%20Prevention%20of%20Injuries%20(3).pdf.

Shami, S. (2017). Nutrition – Very Briefly [PowerPoint slides]. Retrieved from https://bbhosted.cuny.edu/bbcswebdav/pid-31020726-dt-content-rid-133190758_1/xid-133190758_1

Shami, S. (2017). Obesity [PowerPoint slides]. Retrieved from https://bbhosted.cuny.edu/bbcswebdav/pid-31020737-dt-content-rid-133190765_1/xid-133190765_1

Shami, S. (2017, October). Summary of Recommendations for Clinical Preventive Services. Retreived from file:///Users/jessicabrown/Downloads/Summary%20of%20Recommendations%20for%20Clinical%20Preventive%20Services.17%20(1).pdf.

Shami, S. (2017). Writing an Exercise Rx [PowerPoint slides]. Retrieved from https://bbhosted.cuny.edu/bbcswebdav/pid-31020727-dt-content-rid-133190759_1/xid-133190759_1

USPSTF. (2016, April). Adult Preventive Health Care Schedule: Recommendations from the USPSTF. Retrieved from file:///Users/jessicabrown/Downloads/AFP%20-%201%20pg%20Adult%20Screen%20USPSTF%20(3).pdf