Case Study

Calandra James

1.List the immunizations this patient should have:

  • Annual flu vaccine- only attenuated or recombinant, as there is no recommendation regarding the live flu vaccine for over age 50
  • Tdap or Td if she hasn’t gotten one in the past 10 years
  • First dose of the two dose zoster recombinant vaccine, which is preferred, and suggested to be given above age 50. Or, the single dose zoster live vaccine, which is less optimal, and is suggested to be given to someone over 60.
  • Pneumococcal conjugate vaccine if she didn’t get it since she turned 60, followed one year later by the pneumococcal polysaccharide vaccine.

2. List the screening tests that you would order for this patient:

  • I think the most important screening would be a lung cancer screen for Calandra. It is recommended to screen patients ages 50 to 80 who have a 20 pack-year history who are current smokers or who quit within the past 15 years. Calandra definitely fits the description as she is 66 years old, quit smoking 5 years ago and has a 40 pack-year history.
  • Next, I would do a BRCA gene assessment due to her family history and the fact that her mother had breast cancer. I would also do a mammogram (breast cancer screen) which is recommended to be done every other year from age 50 to 74.
  • It is also written in the guidelines that adults from 45 to 75 should undergo routine colorectal cancer screening. The history did not inform us whether she had a colonoscopy within the past ten years, thus I would say that if she didn’t, then I would proceed with a colonoscopy.
  • It is also important to screen Calandra for several things due to her addictive nature, as she’s admitted to have. Despite the fact that she said she quit drinking and smoking I would still do an alcohol misuse and tobacco use screening. Additionally, I would do an unhealthy drug use screening as that may be related to her addictive nature.
  • I would also run a depression screening because of her comments regarding being too hard on herself.
  • She is over age 65 so I would do an osteoporosis screening.
  • Pt is slightly overweight (BMI 25.8) and has family history of type 2 diabetes mellitus and thus would screen her for that as well.
  • I would screen for TB as she goes to soup kitchens, which I assume would put her near and around homeless people.
  • It is also recommended to screen her for hepatitis C (all adults aged 18 to 79).
  • If she is at increased risk for chlamydia, gonorrhea, hepatitis B and syphilis I would do screening for those. The history does not give us information on whether she has other STIs, if her partner has an STI or if she uses IV drugs so we don’t know if she is at increased risk.
  • As Calandra is older than 65 she it is no longer necessary to screen her for cervical cancer, according to the USPSTF.
  • Calandra has a BMI of 25.8 and therefore we do not need to do an obesity screening.

3. Identify any injury prevention concerns that should be discussed:

  • I think the most important injury prevention that Calandra has to be sure to utilize is infection prevention. She is constantly exposed to infection spread in soup kitchens/homeless shelters and therefore she has to make sure to protect herself.

4. Please identify any relevant dietary issues for this patient:

  • First of all, I think it is important to address Calandra’s struggles with losing weight and keeping it off, in the form of motivational interviewing. I would explain the importance of choosing a diet that seems manageable for herself and also make sure to point out that losing weight slowly over a longer period of time proves to be more successful in the long run. I would also express that I am impressed at what she has achieved in her weight loss journey so far.
  • Although studies have shown that the type of diet doesn’t really matter as long as the person is in a calorie deficit I would focus on a low sugar diet for Calandra as there is history of type 2 diabetes mellitus in her family.
  • I would also try to encourage her to start cooking more of her own meals because store bought foods often times have unnecessary calories, additives and sugars in them.
  • To me, her current diet seems healthy overall. However, I would suggest to add fruits into her diet. Of course, fruits have sugar but it will help make her diet more enjoyable and possible to stick to. I would definitely inform about the sugars in fruits and which fruits to be wary of, but I think that by introducing that into her diet she will feel more satisfied with her diet.
  • Additionally, I would suggest adding some variation in her diet. She can introduce other sources of protein, such as salmon or chicken. Snacks may include some healthy fats and proteins like nuts. She can also introduce healthy whole grains into her diet. By adding in variation it will also help elevate her diet and make it more exciting.
  • Lastly, I would stress the importance of drinking lots of water and limiting sugary drinks.

5. 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:

  • The CDC guidelines for exercise includes at least 150 minutes of moderate intensity aerobic activity per week and at least 2 strength training sessions. In the history it does mention that she takes long brisk walks, rides bikes to do errands, swims during the season and has weights at home which she uses. The history, however, does not point out how many minutes per week that she is involved in each activity and how often she uses the weights. I would conclude though, that because she is cognizant of how active she is and she should be she is at or near the goal and I would just reinforce and remind her of the goals. I would also suggest that if she wants variation in her workout routine maybe she should look into rock climbing or dancing classes which tend to be fun and social while being exercise and healthy for your body.

6. If not addressed in the areas above, include any harm reduction suggestions/actions that are relevant to this patient:

  • I would say that an important harm reduction area for Calandra would be when she spends time with her father and brother, who are both active drinkers. Spending time with family is not something Calandra should just cut out, despite the fact that they still drink, which may bring out her old habits. However, I think it is important to set up a plan to help herself abstain from drinking alcohol when around her father and brother and slipping into old ways. One suggestion could be to enlist the help of her mother or sister to hold her accountable and prevent her from drinking, or, to bring a non-alcoholic beverage that she likes along so she can drink that instead.

7. Where relevant to your chosen patient, please explain how you would conduct a brief intervention for- obesity, smoking cessation, substance use:

  • Calandra has admitted to stopping to smoke 5 years ago and therefore I would not need to do an intervention for that.
  • Calandra has a BMI of 25.8 which is slightly overweight so I would employ techniques that we’ve learned in regard to motivational interviewing to conduct an intervention.
  • Additionally, Calandra has exhibited addictive behaviors, and even if at the moment she is not currently using substances I would provide an intervention to help instill her refrain from these substances.

For both interventions I would use the elicit-provide-elicit approach:

  • Elicit information to see what information she knows regarding these topics:
    • “What do you know about the effects of elevated BMI on overall health?”
    • “What do you know about the effects of alcohol and drugs on your body?”
  • After hearing her response I would quickly summarize what she stated and then ask permission to continue and provide more information:
    • “You are concerned that your elevated BMI will cause for you to have type 2 DM, like your sister. Is it ok if I share what I know about elevated BMI and DM?”
    • “You are concerned that because you used to drink alcohol you may slip back into it and cause liver damage. Is it ok if I share what I know about alcohol cessation and recurrence?”
  • After receiving permission I would proceed to provide information and then elicit more from Calandra:
    • “An elevated BMI may cause to increased risk of many health conditions including DM and HTN. What are you thinking now?”
    • “Alcohol cessation is requires hard work and maintaining the cessation also requires lots of motivation in order to prevent recurrence. What are you thinking now?”
  • After hearing her response I would elicit one last time to see if she was interested in coming up with strategies to help her in these areas:
    • “Would you be interested in discussing strategies on how to achieve optimal weight loss/ maintain you sobriety?”
  • After hearing her response I would come up with a plan to help her.