Ms. Alexi Burr is a 34 y/o woman who lives in a suburban home with her husband and 2 children. At the time of her visit her vital signs are as follows: BP 122/68, RR 14, P 70, T 98.6, BMI 19.5; Waist circumference 22 in. She has a past medical history of anorexia as a teenager (recovered at age 16) and ulcerative proctitis. Ms. Burr’s family history is positive for sickle cell trait on paternal side and untreated anorexia disorder on maternal side. Also, on her maternal side, her grandmother has a history of chronic depression and breast cancer and her aunt also has a history of breast cancer. Her maternal grandfather has a history of stroke. There is a history of hypertension in her paternal grandfather. Ms. Burr attempts to eat healthy and places an emphasis on fruits and vegetables in her diet. There is no structure due to her busy schedule, so her dinner routine tends to be chaotic. Due to this busy schedule, Ms. Burr lacks a formal exercise program and is constantly on the run, which limits her time for exercise. On weekends she admits to blowing off steam by going out with colleagues and drinking up to 4 glasses of wine.
Immunizations:
- Influenza vaccination 1 dose annually (IIV, RIV or LAIV)
- All childhood vaccinations w/ HPV UTD.
- Tdap UTD due to recent pregnancy
Screening:
- Cervical cancer screening
- PAP smear w/ HPV co-testing every 5 years
- Breast cancer: BRCA gene screening
- Pt is still young to begin testing via mammogram, however due to a positive family h/x of breast cancer (maternal grandmother & maternal aunt) BRCA gene screening can be performed.
- Obesity
- Alcohol misuse
- Depression
- Hypertension
- Tobacco use and cessation
- HIV
- Intimate partner violence
Health Promotion/Disease Prevention Concerns
Injury Prevention:
- Traffic safety
Because she has children:
- Choking prevention
- Sport safety
- Burn prevention
- Fall prevention
- Drowning prevention/water safety
- Poisoning prevention
Diet:
Current BMI: 19.5 (normal)
History of anorexia & ulcerative proctitis
Ms. Burr’s current diet consists of an emphasis on fruits or vegetables with very little red meat and fried foods. Due to her busy schedule, she finds it difficult to prepare meals and snacks for both herself and her children. Considering her husband is a stay at home dad, I would recommend that Ms. Burr attempt to ask her husband to begin preparing the meals and snacks for her kids, which will allow her more time to focus on preparing her own meals. Her diet consists of healthy stuff when she remembers to eat. It is important given her history of anorexia that Ms. Burr does not forget her meals. I recommend that she should aim for 3 meals a day with a few snacks in between. Due to her history of ulcerative proctitis I recommend she increase the amount of fiber in her diet and also limit some foods that may worsen her symptoms. Some high fiber foods she can attempt to incorporate into her diet are beans, whole brains, green leafy vegetables and root vegetables. Lactose and caffeine have both been found to worsen proctitis symptoms. Ms. Burr mentions that she tends to have a coffee every morning for breakfast. I would recommend that she attempt to switch to decaf coffee, make sure she limits the amount of sugar and perhaps add in almond milk or another nondairy substitute for milk. She mentions visiting fast food restaurants for dinner some nights, I would recommend she try to limit the amount of nights per week that she does that, either by meal prepping the night before or asking her husband to attempt to cook dinner more nights.
BREAKFAST
Omelette (high protein) with spinach (high fiber)
Oatmeal w/ chia seeds (high fiber, omega-3, calcium) prepared with water or nondairy milk topped with fruits
Decaffeinated coffee w/ almond milk
LUNCH
Salad w/ avocado (protein) & attempt adding figs (high in fiber)
Ms. Burr should attempt to prepare this salad at home (quick & easy)
DINNER
Grilled chicken breast (high in protein), potatoes (high in fiber), steamed broccoli (high in fiber)
SNACKS
Consider snacks that are high in fiber such as prunes or applesauce
Exercise:
Current exercise: no formal plan, describes being “on the run” due to her 2 kids and busy schedule. Sits for several hours at work or stands when lecturing.
Mr. Burr has a busy schedule, but I would emphasize that is still important for her health that she has time to stay active. According to current guidelines, she should be aiming for 150 minutes per week of moderate intensity or 75 minutes per week of vigorous intensity exercise combined with 2 or more times per week of muscle strengthening. I would recommend that Ms. Burr gradually increase the recommended amount. Ms. Burr should be aware of the talk test so that she knows what type of activity she is engaging in, if she can sing while doing the exercise that would be classified as light, if she can carry a conversation that would be moderate and if she is too short of breath to have a conversation that would be vigorous. She mentions walking across campus, I would recommend that she attempt to take more walks during campus, perhaps during her breaks between lectures, rather than just when she is attempting to go somewhere. Being a busy mother, she can also attempt to incorporate her kids in this exercise plan. Going for walks in the park with her kids can help her get more active. Also, if she is free on weekends, perhaps she can attempt to do some exercises with her kids such as taking up a family swimming class, this would enable her to spend more time with her kids and also get them all to stay active. Each week she should increase the amount of exercise she is doing until she meets the guideline goals. Also, Ms. Burr mentions sitting for long periods of time at work, I would remind her to not stay sitting all of the time and try to take a break every hour or every couple of hours and take a 5 minute walk around the office or outside.
Harm Reduction:
Healthy choices in fast food restaurants: Ms. Burr mentions visiting fast food restaurants some nights for dinner. Although it is better that she attempts to limit these visits, Ms. Burr can still practice harm reduction by going to the healthier fast food chains as she states she does, but also by picking the healthier options on the menu.
Designated driver initiative: Ms. Burr mentions going out for drinks on Fridays with colleagues after work. Some nights she has up to 4 drinks and at this time she asks one of her colleagues to drive her home because she isn’t safe to drive. While it is not recommended that Ms. Burr drinks to the amount that she is not safe, it is recommended that if she does find herself in these positions that she continues to have a designated driver to make sure she gets home safely.
Brief Intervention:
Substance use
Ms. Burr admits to drinking, which she describes as social and “only at parties and on most weekends.” During these days which is typically at least once a week, Ms. Burr admits to drinking as many as 4 glasses of wine, at which she needs to be driven home because she “isn’t safe to drive.” In this situation, the 5 A’s of brief intervention can be used.
Ask: What do you think you can better do to manage your alcohol consumption? Or Are you concerned about your drinking’s effect on your health or quality of life?
Assess: According to the NIAAA, a woman consuming more than 3 drinks on any 1 day would be placed in the heavy alcohol use category. Ms. Burr typically consumed 4 glasses of wine on Fridays alone, therefore she falls into this category.
Advise: “Now that we have a better understanding of your situation, can I recommend a plan of action to improve your situation?” Recommend that Ms. Burr attempt to cut her alcohol consumption by half so that she falls below the heavy alcohol use category.
Agree: “Do you think this is a goal you will be able to meet?” if not, let’s attempt to reconsider, maybe start by decreasing the number of drinks by just 1.
Assist: Identify barriers & facilitators. Perhaps the social setting in a bar encourages her to drink more. Consider going out to dinner or changing the setting of the after work get together.
Order to Address Issues:
- Substance use (alcohol)
- Screening
- Immunizations
- Diet
- Exercise
- Harm reduction
- Injury Prevention
Sources:
https://www.niddk.nih.gov/health-information/digestive-diseases/proctitis/eating-diet-nutrition
http://www.colonrectal.org/services.cfm/sid:6694/ulcerative_proctitis/index.html
http://www.colonrectal.org/high_fiber.cfm
https://www.cdc.gov/ncbddd/fasd/alcohol-screening.html
https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking
