Evidence Based Screening Case Study

Christopher Mason

Clinical scenario

Miss. J, (not the patient’s real title or Initial), is a 37-year old female who was recently admitted to the hospital for chronic fatigue leading to exhaustion. As a career she says, “I am a professional writer and aspiring actress.” She lives alone on the Westside of Los Angeles in a one bedroom apartment. During our conversation she disclosed that after a five year period of not smoking; she has begun smoking again. Miss. J says that the stresses that come with her career path as an actress and writer along with the people involved in the same has most likely caused her to do so. Miss. J denies any illicit drug use but does occasionally use alcohol as a stress reducer. As far as she knows no one in her family has died from or developed any type of cancer. Her father passed away from Acute Myocardial Infarction and was a type 1 diabetic. Her mother has steroid induced type 2 diabetes. Miss. J says, “I have managed to avoid both. So far.”

Identification of the Evidence Based Guideline

Based on the interaction with Miss. J, several risk factors became apparent and they include a family history of diabetes, type 1 and type 2. Even with type 2 diabetes having a strong familial association her mother’s was induced by steroids rather than being genetic. The other risk factor that I identified was the smoking of cigarettes and casual use of alcohol as a stress reducer. This places her at an increased risk for use of other illicit drugs, driving accidents, lung cancer, COPD, and high blood pressure, as well as other smoking related diseases.

Reason for Selecting Guideline

Based on the United States Preventive Services Task Force (U. S. Preventive Services Task Force, 2010), being screened for high blood pressure is recommended as an “A” level screening. The current level defining hypertension in adults is equal to or greater than 140 for systolic and equal to or greater than 90 for diastolic. Based on variability between separate readings, it is recommended to obtain greater than 2 readings on different visits over several weeks to diagnose hypertension. (p. 35)

Barriers and Facilitators for Client

Miss. J has only one barrier that I could pinpoint to following up with the screening. Her fatigue. She told me that sometimes she misses appointments because she is too exhausted to drive to them. She agreed that she would make an appointment with her personal physician after being released from the hospital to be screened for hypertension. Adding that she just hoped that she would be able to make the appointments.

One of the facilitators that allowed me to participate in a conversation with Miss. J concerning her hypertension was her stating to me that she wished she could have a smoke. That along with her being a captive audience in the hospital. No one had been to visit with her that I had seen, so I assumed and was correct that she would like to chat.

Receptivity of Client

Miss. J was receptive to the screenings I have listed below. She stated to me that she had recently had a pap smear and tested negative for abnormal cervical cells and HPV. Being asked about the Chlamydia screening because of being sexually active; she said it was something she was interested in receiving more information about.

Evidence Based Screening Guidelines Pertinent to Patient

Type

Clinical Considerations and Currency Situation

Cervical Cancer

Women 21 to 65 (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years. Grade A+ Recommended. (“Screening for Cervical Cancer,” 2014). Yes, she is current.

Chlamydia

All sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. Grade A+ Recommended. (“Section 2. Recommendations for Adults (continued) | Agency for Healthcare Research & Quality (AHRQ)#Chlamydia,” 2014) No, she is not current.

Folic Acid

All women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Grade A+ Recommended. (“Folic Acid for the Prevention of Neural Tube Defects,” 2014) Yes, she takes daily supplement.

HIV

Adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Grade A+ Recommended. (“U.S. Preventive Services Task Force: Final Recommendation Statement,” 2014) Yes, she is current.

Tobacco Use

This recommendation applies to adults 18 years or older and all pregnant women regardless of age. The USPSTF plans to issue a separate recommendation statement about counseling to prevent tobacco use in non-pregnant adolescents and children. Grade A+ Recommended. (“Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women: Reaffirmation Recommendation Statement,” April 2009) Yes, she has been instructed and understands she should quit.

Healthcare Provider Barriers

I am performing my clinical rotation at Cedars Sinai in Beverly Hills. They do not allow us to use electronics in or around the patients/clients. After explaining to my clinical liaison about our subject and assignment we were cleared to use the program as long as we did it outside of the patient’s rooms. This was limiting but not considered a complete barrier.

Confidence in Providing Evidence Based Screening Guidelines

This assignment made me feel uncomfortable at first. I realized that I would be asking some very personal questions to a patient that I did not know. However, it did allow me the chance to become familiar with the AHRQ evidence based guidelines application on the android market. Also, it allowed me to help my patient to learn more about the screenings that she should have based on her lifestyle.

References

Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women: Reaffirmation Recommendation Statement. (April 2009). from http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobaccors2.htm

Folic Acid for the Prevention of Neural Tube Defects. (2014). from http://www.uspreventiveservicestaskforce.org/uspstf/uspsnrfol.htm

Screening for Cervical Cancer. (2014). from http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm

Section 2. Recommendations for Adults (continued) | Agency for Healthcare Research & Quality (AHRQ)#Chlamydia. (2014). from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2a.html#tiptop

U. S. Preventive Services Task Force. (2010). The guide to clinical preventive services, 2010-2011: recommendations of the U.S. Preventive Services Task Force. [Rockville, Md.]: Agency for Healthcare Research and Quality.

U.S. Preventive Services Task Force: Final Recommendation Statement. (2014). from http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm