Case #1 Answers:













Answer 1
B.L. is eligible for Tetanus-diphtheria booster after 10 years and screening for Rubella vaccination. She should be counseled on the availability of Hepatitis and Varicella vaccines. Booster immunizations with diphtheria and Tetanus toxoid should be given every 10 years after the primary series has been completed. Patients should also be reboosted if they receive a dirty wound and have not been revaccinated within a 5 year period. The primary series of three doses of Td followed by a booster is highly effective with protective antibodies lasting as long as 15 to 25 years. As a result of routine immunization, only 51 cases of Tetanus and 2 cases of diphtheria were documented in the United States in 1994.

All women of child-bearing age should be screened for immunity to Rubella. Those who have neither 1) documentation of prior immunization after 12 months of age or 2) documented immunity by antibody test, should be re-immunized. Reported history of infection should not been taken as an evidence of immunity. Rubella vaccine is approximately 95% effective at conferring immunity and is probably life-long.













Answer 2
B.L. is eligible for screening for hypertension, cholesterol, and cervical cancer. The US Preventive Services Task Force recommends that blood pressure be checked every two years if the last diastolic and systolic blood pressures are below 85 and 140 mm Hg respectively. The patient should have annual blood pressure determinations if they have an elevated diastolic blood pressure in the range of 85 to 89 mm Hg.

Cholesterol screening is recommended at the interval of every five years in normal risk individuals. The National Cholesterol Education Program recommends that total cholesterol screening begin in adults at age 20. Other organizations believe that screening can begin at a later age.

In high risk individuals, cervical cancer should be screened for on a yearly basis. In women who are low risk for cervical cancer and have had multiple yearly normal PAP smears, PAP smears can be performed on a every three year basis. Thin Prep smears have been recently FDA approved for screening purposes. This cytologic advancement allows for greater diagnostic sensitivity for cervical cancer over conventional techniques.













Answer 3
A. Injury
Because B.L. has been a recent and recurrent victim of domestic violence, she should be counseled accordingly to prevent future injury. She should also be counseled not to carry a hand gun as a mode of personal protection.

B. Nutrition
The patient's diet consists of high fat and low vegetable content. She should be counseled to eat a variety of foods. In order to maintain a healthy weight, she should choose a diet which is: 1) low in total fat, 2) <30% of her calories arising from fats, and 3) low in cholesterol. She should choose a diet with plenty of vegetables, fruits, and grain products; equaling more than five servings a day. She should use sugar and salt only in moderation and limit alcoholic beverages to one beverage per day.

C. Exercise
B.L. should be counseled about the benefits of exercise. She should be encouraged to engage in safe exercise on a regular basis. This should include involvement in physical activities for enjoyment as well as competition. Involvement in physical activities that can be enjoyed into adulthood such as swimming, tennis and bike riding should be encouraged. Every patient should accumulate 30 minutes or more of moderate intensity physical activity on most days of the week.

D. STD’s and unintended pregnancy
Patient should be counseled on safe sexual practices to prevent sexual transmitted illnesses and unintended pregnancy. For use of a spermicide offer her no protection from sexual transmitted illnesses including HIV virus.

E. Smoking cessation
As a young smoker, the patient should be counseled at length about the long term health benefits of smoking cessation. The patient should be provided recommendation for smoking cessation and pharmacologic assistance if necessary. Proper follow-up is essential to successful smoking cessation.













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