Case #1 Answers:
E.B. is eligible for influenza and pneumococcus vaccines as an asthmatic. Varicella could also be offered if she has not contracted clinical chicken pox. Hepatitis B is not a large concern with her lifestyle and occupation. Influenza is recommended for persons greater than 65 years of age; residents of nursing homes or chronic care facilities; adults with chronic cardiopulmonary disease including asthma; and adults with chronic metabolic illnesses including diabetes mellitus, renal failure, and immuno-compromised status. The influenza vaccine is recommended on yearly basis. It is believed that the influenza vaccine is 70 to 80 percent effective in preventing or reducing severity of illness in adults under age 65. Pneumococcal vaccine is recommended for persons greater than 65 years of age; adults with chronic illnesses (including cardiopulmonary disease, diabetes, alcoholism, cirrhosis) and patients with immuno-compromising illnesses (including lymphoma, myeloma, chronic renal failure, nephrotic syndrome, or transplantation). Most patient can go six years between repeat pneumococcal vaccination. In controlled trials the pneumococcal vaccine is 76 to 92 percent efficacious in preventing pneumococcal pneumonia in healthy young adults.
E.B. would be eligible for screening for breast cancer by physical examination and mammography, cholesterol, and hypertension. All major authorities agree that mammography should be performed on women ages 50 to 75 on a one to two year basis. The role of mammography in women in their 40s is a current topic of controversy. Some organizations including the National Cancer Institute recommend mammography every one to two years for the women in their 40s. Currently the US Preventive Services Task Force does not recommend mammography in their 40s. Until conclusive prospective trials are available, physicians should counsel their individual patients accordingly. The Expert Committee on the Diagnosis of Diabetes recommends routine fasting glucose levels every 3 years in adults age 45 and older.
A. Osteoporosis prevention
E.B. is approaching the age for menopause. She should be counseled in advance of menopause on of the use and indications of estrogen replacement. She should also be instructed to take a diet which is high in elemental calcium.
E.B. has a good diet which is low in fat and high in fiber. She could also be counseled on appropriate foods which are high in calcium.
C. Drug and alcohol use
E.B. meets the clinical criteria for alcoholism. She also uses cocaine in a manner which could become addictive or could be injurious to her health. Appropriate counseling and consultation with professionals in substance abuse is warranted.