Angelina Gambino


Case Study – Alexi Burr


Immunizations

• Influenza – 1 dose annually 


Screening 

• Alcohol misuse

• Depression 

• Hypertension

• Obesity

• Tobacco use and cessation 

• HIV infection 

• BRCA gene screening – Alexi’s maternal grandmother and aunt had breast cancer. No breast cancer screening (mammogram) needed because of age

• Intimate partner violence 

• Cervical cancer – Pap smear every 3 years, or every 5 years with human papillomavirus cotesting starting at age 30



Injury Prevention

1. Traffic Safety 

A. Infants – Seat should be rear-facing in the back seat and never in the front seat if there is an air bag on the passenger side. Infants should never be unattended in a car. Parents should be wearing seatbelts as well.

B. Preschool-aged Children – Toddlers can be put in a forward-facing care safety seat when they are 1 year and 20 pounds, but they should stay rear-faced until they reach the highest weight or height in that position by the safety seat. Pre-school aged children should always be in the back seat and never be left unsupervised in or around cars. Driveways and streets are dangerous places for children to play. Pre-school aged children should never cross the street alone and should be watched when near driveways and streets. A bicycle helmet should be worn.

2. Burn Prevention 

A. Infants – Smoke alarms should be installed in homes and maintained. Hot water temperature should be set to a maximum of 120 degrees F to avoid burns. Parents shouldn’t carry hot liquids or food and their infants at the same time. Avoid heating milk or formula in the microwave because it can heat unevenly and burn the infant. Electrical outlets should be covered with non choking hazard devices.

B. Pre-school aged children – Smoke alarm batteries should be regularly checked. Children should be kept away from hot oven doors, irons, wall heaters, and grills. Hot food and drinks should be out of children’s reach. Electrical outlets should be covered. 

3. Fall Prevention 

A. Infants – Windows and stairway guards/gates should be used. Infant walkers should not be used and infants should never be left alone on any furniture. 

B. Pre-school aged children – Toddlers that are learning to walk and climb need to be protected from furniture that can topple over, stairways and open windows.

4. Choking Prevention 

A. Infants – Small parts or objects pose a choking hazard to young children. Round/cylindrical and compressible objects/foods can pose life-threatening risks of airway obstruction. Balloons pose a similar risk. Parents should avoid clothes and toys with long strings and cords that could risk strangulation, and should cut looped blind and drapery cords. Suffocation may happen from entrapment in cribs, waterbeds or plastic bags. Parents should always remain aware of hazards in other homes they bring their infants to.

5. Drowning Prevention 

A. Infants – Parents should never leave infants and young children in the bathtub, near buckets, or other bodies of water without constant supervision. Buckets should be emptied and properly stored immediately after use. Infant bath seats or supportive rings are not a substitute for supervision. 

B. Pre-school aged children – Backyard swimming pools or spas must be completely fenced on 4 sides that separates them from the house and yard. The fence should have a self-closing, self-latching gate, should open away from the pool and should be checked to ensure it works properly. Children under 5 years old should swim with close adult “touch” supervision. 

6. Poison Prevention 

A. Pre-school aged children – Medicines and household products should be kept out of sight and reach of children and be locked up when possible. They should be purchased and kept in the original childproof containers or blister packs. Ipecac is not recommended and should be discarded if it is present in the home. The poison control telephone number should be kept handy (1-800-222-1222).

7. Safe Sleep Environment 

A. Infants – Should be kept in supine position in a crib that conforms to current safety standards. Infants should not sleep on soft surfaces such as water beds or sofas, and any soft materials should not be placed in their sleep environment. If bumper pads are used they should be removed when the infant learns to stand. The crib sides should never be left down when the infant is in the crib.

8. Firearm Safety

A. Pre-school aged children – Parents should keep handguns out of place where children live and play. If parents have a firearm in the home, the unloaded gun and ammunition must be kept in a separate locked cabinet.

9. Cardiopulmonary resuscitation 

A. Infants – Parents should be trained in infant and child cardiopulmonary resuscitation and learn how to access their local emergency medical services (911). 



Diet

Dietary issues

1. Anorexia Nervosa – Alexi’s diet is mostly healthy, filled with fruits, vegetables, with little red meat and no fried foods. Alexi claims she doesn’t have time to focus on her meals and snacks, so I would advise her to keep on-the-go snacks around the house, or include a meal replacement shake in her everyday routine. For example, she can keep small packs of almonds in her purse, granola bars that are low in sugar, or apples and bananas. This way, she ensures she is getting enough nutrition during her busiest days. If Alexi remembers to eat at least 3 meals a day, the return of anorexia nervosa is unlikely. For breakfast she may continue to eat toast with almond butter, but I would suggest she includes a hard boiled egg. For lunch she tries to eat a lot of salads, so I would advise her to add protein such as chicken or turkey to the lettuce. For dinner, her meals are not always home cooked which could suggest her prepared meals are higher in sodium, fat and sugar. I would recommend she pays close attention to the nutritional content in these items and to avoid the meals that are high in those contents. 

2. Ulcerative Proctitis – There are certain foods and drinks Alexi should avoid that can make her symptoms of Ulcerative Proctitis worse. These include alcohol, caffeine, carbonated beverages, dried beans, peas and legumes, dried fruits, berries or fruits with pulp or seeds, raw vegetables, refined sugars, and spicy foods. High fiber foods should also be avoided because they may make her symptoms worse. Foods that may help include salmon and albacore tuna, lean meats and poultry, eggs, probiotics found in yogurt, kefir, sauerkraut and miso, avocados, instant oatmeal, squash, carrot juice, and plantains. These foods will help with digestion, are high in protein, low in fiber, and contain good nutritional value (medicinenet.org). 



Exercise

Although Alexi has a busy schedule, there are still ways to improve her exercise regimen. According to the Office of Disease Prevention and Health Promotion, adults should do at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic activity a week. Adults should also include muscle-strengthening activities at least 2 days a week. Since Alexi spends most of her days sitting, I would advise her to get up and move around for at least a minute every hour and to walk around campus more often. Any kind of physical activity is beneficial, so Alexi should go for walks around her neighborhood with her 2 children. I would recommend using 5 pound weights or resistance bands while doing body weight exercises such as squats, lunges, and pushups either early in the morning before her day begins or late at night before she goes to sleep. The stress in her life could be reduced by incorporating these small changes into her everyday routine. Starting off small and working her way to her previous exercise regimen that she once enjoyed will hopefully allow her to find the time to fit exercise in her schedule and result in positive outcomes (ODPHP). 



Harm Reduction

Alexi has a past medical history of anorexia nervosa, so it is important that she maintains her current normal weight. She stated that her busy schedule has made it difficult to focus on her own diet, however she must be advised that maintaining her own health is very important. To prevent harm, Alexi should keep up with the diet plan that was discussed and make an effort to eat at least 3 meals a day. This will help prevent malnutrition and maintain her normal BMI.



Brief Intervention 

Alexi is not showing signs of alcohol abuse, however I would still offer a brief intervention on her alcohol consumption. She admits that she sometimes has 4 glasses of wine on some occasions and is unable to drive her own car home. The AUDIT is a tool I would use to identify excessive drinking habits in adults. The first three questions I would ask are, “How often do you drink alcohol containing alcohol?”, “How many drinks containing alcohol do you have on a typical day when you are drinking?”, and “How often do you have six or more drinks on one occasion?”. If the subtotal equals 3 or more for Alexi, I would continue to ask questions 4-10 on the AUDIT tool. Based on the score, I would offer alcohol education (for Alexi’s case and how it can affect Ulcerative Proctitis), simple advice, simple advice plus brief counseling and continued monitoring, and referral to specialist for diagnostic evaluation and treatment. 



What should be addressed first?

First, it is important to address Alexi’s diet based on her past medical history of anorexia nervosa and ulcerative proctitis. If Alexi sticks to the diet plan above, she will be able to maintain her BMI and keep the symptoms of ulcerative proctitis at a minimum. When she feels like she is able to make time for herself and feel healthy again, perhaps her stress level will decrease.




Sources


1. Adult Immunization Schedule 2016 (CDC)

2. Adult Preventive Health Care Schedule 2016 (USPSTF)

3. Office-Based Counseling for Unintentional Injury Prevention

4. https://www.medicinenet.com/ulcerative_colitis_diet/article.htm#what_foods_help_manage_and_soothe_ulcerative_colitis_flares

5. Physical Activity Guidelines for Americans – 2nd Edition (ODPHP)

6. CHI on Brief Intervention for Alcohol (2011)