Andres Hernandez

Case Study – Calandra James 

Immunizations

Assuming Calandra has all her childhood immunizations including HPV, she should also have: 

• Influenza (IIV) or Influenza (LAIV) or live (LAIV), if done recently for the flu season. 
• Tetanus, diphtheria, pertussis (Tdap or Td), if done within the last 10 years.
• Zoster recombinant (RZV) or Zoster Live (ZVL) 
• Pneumococcal conjugate (PCV13) or polysaccharide (PPSV23)

Screening

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

• Depression screening
• Hepatitis C virus infection screening
• HIV infection screening – patient has an intimate partner and they don’t live together; we don’t have additional details so it’s better to test to make sure. 
• Syphilis screening- although indicated for increased risk, the patient has a partner, and we aren’t sure if the relationship is monogamous, so better to just test if patient agrees. 
• BRCA gene risk assessment -patient has a family history of breast cancer. 
• Chlamydia and gonorrhea – unsure if patient is in a monogamous relationship, test if patient agrees.
• Cervical Cancer screening- only if patient hasn’t been adequately screened in the past or else not recommended. 
• Abnormal Glucose/Type 2 diabetes mellitus screening- family history for diabetes mellitus. 
• Breast cancer screening
• Lung cancers screening – screen annually patient has >20-pack-year-history and quit less than 15 years ago. 
• Osteoporosis screening– indicated for women patients over 65. 

Health Promotion/Disease Prevention Concerns 

Injury Prevention

It’s amazing that given the patient’s age of 66 years, that she still maintains active by doing activities like brisk walks, bike rides, swimming, lifting weights and using resistance bands. However, the patient mentioned she exercises to keep herself in a calorie deficit. My advice would be to make sure the patient does not push herself too much because patients of this subpopulation are more susceptible to muscle injuries and bone fractures. Instead, the patient should exercise because it’s good for the body. The patient should focus on the benefits of exercise such as greater mobility, flexibility, muscle strengthening, endurance involving the cardiovascular system. The purpose of a diet is for staying within your calorie limit because burning calories through exercise is inefficient. Since the patient enjoys bike rides, I’d advise the patient to wear a helmet if she doesn’t already. 

Diet

The patient biggest issue is that spends too much energy trying to keep herself in a calorie deficit. She finds her diet tolerable but joyless. Also, the patient mentions that eating has an addictive aspect and which she considers a “giant issue”.  For this patient, I’d want to determine what her maintenance calorie requirement is that way we have a better understanding of how much the patient can eat. If the patient still wants to lose more weight loss, we can introduce meal replacement as it has been shown that those who replaced 1 meal and snack a day maintained an average of 10.4 kg weight loss over 27 months. Additional studies have shown that significantly greater weight is lost when the dieters are provided portion-controlled food or detailed menus of what they should consume. Since the patient doesn’t cook much maybe a detailed plan of what to eat could motivate the patient to prepare the foods herself or we could explore options of getting the patient already portion controlled meals. Regarding the addictive aspect of eating, we can explore behavioral therapy that involves modifying eating and thinking habits that contribute to this unwanted behavior. We would set specific goals for behavior change that will be monitored and reviewed with their interventionist to identify areas in need of improvement. Calandra’s typical daily food choices are healthy the problem is she isn’t satiated and deals with hunger. Until we get an exact calorie intact for maintain I would advise adding more vegetables to the diet as they are low calorie and have a high fiber composition that could help with feel full. Since she doesn’t find her current diet enjoyable, we can discuss foods she does enjoy and incorporate some into her diet to create more balance in her life instead of worrying of her calorie limit all the time. Lastly, Calandra has gained 15 pounds back after loosing 75 pounds over the past year and half. This needs to be addressed early because she could regain back all the lost weight if this pattern of slight weight gain continues. 

Exercise

Exercise for aerobic active it 150 min per week of moderate intensive exercise and muscle-strengthening at least twice a week. Calandra surprises this recommendation because she exercises daily by doing brisk walks, bike rides, swimming, doing some weights and resistance bands. Not concerns Calandra is not meeting current exercise guidelines. Instead, I’m concerned she might be overworking herself because she’s so focused on being in a calorie deficit. I advised that we address that concern in the diet portion and that exercise should be used for its health benefits and not for solely for weight loss. 

Harm Reduction

Even though Calandra expresses an “addictive nature”, she has managed to quit smoking and alcohol, and her only issue right now that has an addictive quality to it is her relationship with food. For that we have recommended behavioral therapy to help change those habits. But in the meantime, maybe we can suggest only having healthy foods in her pantry and fridge, so when she does feel like binging, at least it would be on healthier food choices which would reduce the harm done to her overall health in comparison to reacting to eating junk food or fast food. 

Brief Intervention

Calandra has already quit smoking and she doesn’t abuse any substance therefore we will only conduct a brief intervention regarding her weight-loss ups/downs and follow the intervention as already outlined in the diet plan. 

I will use the 5 As model for counseling: 

• The first A stands for Ask, and it involves asking the patient for permission to discuss the topic: “Calandra, can we discuss your weight and the effects it may be having on your health?”
• The second A stands for Access, which means exploring for an indicator that maybe the cause of issues: “Can you please tell me about your daily diet and physical activity?”
• The third A stands for Advice, where you give any advice associated with risks, treatment options, management, etc.: “Do you know about the effects of eating when food has an addictive quality?” / “Do you know about the effects of trying to stave off hunger and exercising to make sure you’re still in within the calorie deficit?”
• The fourth A stands arrange/assist where you can identify and address barriers, provide resources, or arrange a follow-up: “Would you like me to refer you to someone who can help you with changing habits associated with food?” / “Would you like me to refer you to help with keeping your diet in a caloric deficit while also feeling satiated?”