Devora Schapiro 11/24/19
Case Study: Calandra James
- IIV or RIV- influenza vaccine
- Td booster if she is due (hasn’t had a booster every 10 years)
- Zoster RSV preferred= 2 doses since she is older than 65
- Pneumococcal PCV13 and then later PPSV23 one year later
- Alcohol misuse- although she says she is sober, with her past history I would definitely screen again- questions
- Depression – questions
- Hypertension- 128/74 is listed (slightly elevated)- sphygmomanometer
- Obesity- she has a BMI of 25.8 so she is slightly overweight- height weight BMI
- Tobacco- although she has quit smoking, with her past history I would definitely screen to make sure she has not picked it up again- question
- glucose/diabetes- BMI of 25.8 makes her slightly overweight therefore at risk, family history- A1C
- Hep C- she was born between 1945-1965
- Colorectal cancer- colonoscopy
- Breast cancer- mammogram
- Lung cancer- age group, 40 pack years, quit only 5 years ago- low dose CT
- Osteoporosis- age over 65
- Traffic safety- including seatbelts and wearing a helmet when she rides her bike
- Firearm safety (for all ages)
- Water safety- she swims for exercise, make sure no drinking or drugs with water
- Sport safety- make sure she has the correct form and is using her weights and resistance bands safely
- Healthier alternatives, for example light yogurt if she is eating full fat
Her current diet could be improved in 2 ways: one she could cook more and two it is currently “joyless for her” so helping her choose a greater variety of food would probably improve her attitude toward food and cooking in general. She is doing a good job with fruit and vegetables already. For breakfast should could continue to eat eggs but perhaps add some flavorful vegetables like onions, spinach or mushrooms to make it taste better, she could also switch to whole grain bread from whole wheat, it tastes better and the grains are less processed. For lunch she should stop eating yogurt every day, to reduce her dairy intake. She could instead have a piece of fish and fruit. She should also stop eating peanut butter as it is very high in fat and high in calories. Adding the fish to her lunch would make up for the protein deficit. For dinner, it is important to clarify the type of protein she is putting in her salad, hopefully she is not eating too much red meat. Perhaps she can eat her vegetables cooked instead of in salad form and eat a little bit of chicken or additional fish for dinner as well. The higher protein content will satiate her more. She is doing pretty well with snacks as well, perhaps increasing the number of vegetables and decreasing the pita chips with hummus. She could dip vegetables in hummus instead. She could also have more fruit. I would also suggest she cut back on the chocolate. Maybe from once a day to once every other day and then further cutting back. One final suggestion I would make is to try to eat with her partner or her sons whenever she can, eating with people she likes and slowly is a good way to start to improve her mood in her diet.
Bsed on her statement ““I spend way too much time trying to stave off hunger, trying to keep calories to 1500-1800/day and pushing myself to get in enough exercise to achieve a daily calorie deficit…” I can assume she does the exercises she listed daily so she is likely meeting 150 minutes a week of moderate activity and at least 2x a week muscle strengthening (walking, lifting weights, biking). However, she did state that she only swims during the season and at the beach. So I would suggest possibly joining a gym or a community center with a pool and swimming laps several times a week. She mentioned struggling to have time for all this, but I think she can slowly add this to her schedule after she retires.
Obesity: not necessary, she is overweight (BMI 25.8) but not obese. We have also already discussed her diet and exercise in terms of her weight.
Smoking cessation/substance use: not necessary because she has already been screened for both and denies current usage (has used in the past though so will continue to keep an eye out for possible relapse)
Powerpoints: Nutrition, Intro (harm reduction), and writing an exercise Rx
Calandra James is a 66 year old recently retired administrator for City Harvest, a group that gathers leftover food from restaurants and distributes it to food banks and soup kitchens. She is a recovering alcoholic (sober for 8 years) and she now describes her health as basically good, but says that she struggles with what she calls “an addictive nature”. This has expressed itself in her history of drinking and a past history of smoking (she quit 5 years ago after a total of 40 pack-years), and more recently she has noted that her eating has an addictive aspect as well. She says that eating is “a giant issue for me”. She joined Weight Watchers and lost 75 pounds over a year and a half. However, she has gained back 15 pounds of it over the past year. She says, “I spend way too much time trying to stave off hunger, trying to keep calories to 1500-1800/day and pushing myself to get in enough exercise to achieve a daily calorie deficit (she takes long brisk walks, rides a bike to do errands, swims at the local beach during the season, and has a set of free weights and resistance bands that she uses at home). I am trying to focus on healthful eating and respecting my body, but it’s really a struggle.”
Her family history includes an alcoholic father and brother who are still actively drinking, a mother who had breast cancer at age 52, but has been cancer free since then and is now 88, and a sister who has Type 2 Diabetes. She has a long-term lesbian partner who lives a few towns away. She also has 2 adult sons who live several states away. She says she is looking forward to retirement because she hopes to find a way to relax and stop beating herself up all the time.
When you talk to her a little more about her eating habits, you learn that she does not really cook much. She mostly eats salads and prepared foods from the grocery store. A typical breakfast is scrambled egg whites with whole wheat toast. Lunch is a yogurt and sliced fruit with peanut butter spread on it. Snacks are humus and pita chips and or vegetables, and dinner is salad with some sort of protein. She allows herself two pieces of dark chocolate (80 calories) as dessert most nights. She says she finds her current diet tolerable, but “joyless”.