Case Study Elements: Alexi Burr

Heba Fakir

Please review a case study of your choice and address the issues below.  Once you have constructed the list of what should be done, please indicate which items/issues should be addressed first.

The first thing I would address is Mrs. Burr diet. Mrs. Burr suffers from Ulcerative Proctitis and she lost a lot of weight. She also has a history of Anorexia which she went to rehab briefly for. The 2^nd thing I would address is making sure she is up to date with all her vaccinations. Then, I would have a discussion on injury prevention (she has a baby and another young child) along with a brief intervention on harm reduction with regards to her drinking habit. Afterward, we would examine her physical activities. The last thing I would address would be the screening guidelines. 

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

Starting from 19 years old, Mrs. Burr (34 years old) should have received:

-her annual Influenza vaccine

-1 dose of Tdap and then a booster every 10 years

– 1 dose of MMR

-2 doses of Varicella

-2-3 doses of HPV

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. 

Screen for HTN, Cervical Cancer, Tobacco use, HIV Infection, Folic Acid Supplements (if she plans on having another baby)

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).
• Traffic Safety (for everyone)
• Burn Prevention (for infants and preschool children)
• Fall Prevention (for infants and preschool children)
• Choking Prevention (for infants)
• Drowning Prevention (for infants and preschool children)
• Safe Sleep Environment (for infants)
• Cardiopulmonary resuscitation (for infants)
• Poison Prevention (for preschool children)
• Firearm Safety (for preschool children)
• Diet
  • Please identify any relevant dietary issues for this patient

Mrs. Burr has a past history of anorexia as a teenager and she has a history of Ulcerative Proctitis.

• 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.

For Ulcerative Proctitis episodes, having a high fiber diet may make her symptoms worse. If Mrs. Burr has diarrhea she may need to avoid caffeine, fructose, lactose, and sugar alcohols which can make her diarrhea worse. In addition, taking some nutritional supplements or vitamins can help reduce some proctitis symptoms like omega-3 fatty acids, probiotics, vitamin C, and vitamin E.

As for Mrs. Burr’s regular diet, she eats fruits and vegetables with very little red meat and avoids fried food. She also eats salads and toast with almond butter with a cup of coffee. Overall, Mrs. Burr’s diet seems to be healthy except for the dinner. I would recommend that if Mrs. Burr brings dinner from outside she looks at Nutrition Label and try to pick the foods with no trans fat, low sodium, high in vitamin A, high in vitamin C, calcium, and iron. I would not modify Mrs. Burr’s diet too much, in case she falls back into her Anorexia. Right now Mrs. Burr BMI is 19.5 which is on the low normal range but still considered normal. I understand that Mrs. Burr is also having a hard time getting the chance to eat because of her hectic lifestyle, but I recommend Mrs. Burr not skip her meals. She can try meal prepping on the weekends, or can sign-up for those meal kit programs. If Mrs. Burr BMI falls below any more, then I would recommend she return to see me to discuss further recommendations.

• Exercise
  • Determine whether this patient is likely to be getting adequate exercise as per current guidelines

Mrs. Burr used to have a formal exercise program, but with her current lifestyle, she does not have time to get in the same amount of exercise time as she did before.

• 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

I would recommend Mrs. Burr try to gradually increase her physical activities. She can start from something small, like dancing with her kids, or brisk walking from one end of the campus to the other end. Mrs. Burr can also assess the intensity of her workouts by singing while doing the activity to figure out if it’s a light activity.

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

Mrs. Burr mentioned that she drinks as many as 4 glasses of wine after work on Friday night to blow off steam. I would recommend Mrs. Burr switch to small glasses of wine or use a lower strength drink (lower ABV %), and have a glass of water before she starts to drink. Or to alternate her alcoholic drinks with water/other nonalcoholic drinks.

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. 

The only thing I would address with Mrs. Burr is the 4 glasses of wine she drinks on Friday night.

I’d start off with asking permission:
“Do you mind if we can talk about the amount of wine you consume on Friday nights?”

Next, I would ask open-ended questions:

 “Tell me more about when this first began”

I would give affirmations:

“You showed a lot of strength by doing that.”

Afterward, I would use reflective listening skills:

“It sounds like you recently became concerned about your drinking.”

Then I would assess her readiness to change:

“On a scale from 1- 10, where 1 I definitely not ready to change and 10 is definitely ready to change, what number best reflects how ready you are at changing the amount you drink on Friday nights?”

From there I would give support if she was having a difficult time changing by asking:

“How can I help you get past some of the difficulties you are experiencing?” Or I can ask “If you were to decide to cut back on your drinking, what would you have to do to make this happen?”

I would then summarize:

“It sounds like you are concerned about your alcohol intake because it is costing you a lot of money and you tend to lose yourself when drunk. You also said quitting is hard because it helps you destress from your work and home. That’s why you are having a hard time quitting.”