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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