Mrs. Payne is a 45-year-old female presenting for her annual exam. She has not had a visit in over 5 years. The nurse practitioner will interview her, update her medical history, conduct a physical exam, address recommendations regarding her smoking, weight, and lack of exercise. The patient will be educated on menopause, nutrition, physical activity, weight loss, smoking cessation, and cancer screenings. She is scheduled for follow up on lab results and a 3-week visit to monitor her progress.

1. MED-U-CASE-
STUDY
FNP 590 HEALTH PROMOTION, EDUCATION AND DISEASE ACROSS THE
LIFESPAN
UNITED STATES UNIVERSITY

2. ELABORATED BY: DIANA BACH, ARNOLD CASTRO,
GEORGE DAMASCO, THESALONICA HILLARD, HAHN
KIM, HILARIO NOVENO, LIEN SIGALA, CHRISTINA
YOUNG

3. 45-YEAR OLD FEMALE
ANNUAL EXAM
CASE #1

4. MRS.
PAYNE

5. Mrs. Payne, is a 45-year-old female who is here for a health maintenanceMrs. Payne, is a 45-year-old female who is here for a health maintenance
exam. It looks like she hasn’t had a visit for over five years. Patient statesexam. It looks like she hasn’t had a visit for over five years. Patient states
she would like to be check out since its been a while and needs to have ashe would like to be check out since its been a while and needs to have a
Pap smear and mammogram.Pap smear and mammogram.
Nurse practitioner student (working with Dr. Stephanie Lee at her familyNurse practitioner student (working with Dr. Stephanie Lee at her family
medicine clinic): Will interview patient and find out if she has any concerns,medicine clinic): Will interview patient and find out if she has any concerns,
update her past medical history, do a brief review of systems and physicalupdate her past medical history, do a brief review of systems and physical
exam. Will also update patient’s immunization status, address suggestionsexam. Will also update patient’s immunization status, address suggestions
and recommendations on her smoking, excessive weigh, lack of exercise,and recommendations on her smoking, excessive weigh, lack of exercise,
and osteoporosis prevention. Will educate about menopause, nutrition,and osteoporosis prevention. Will educate about menopause, nutrition,
physical activity, weight loss, smoking cessation, and breast cancerphysical activity, weight loss, smoking cessation, and breast cancer
screening. Mrs. Payne to schedule a follow up on her lab results and also ascreening. Mrs. Payne to schedule a follow up on her lab results and also a
three week follow up visit to monitor her progress.three week follow up visit to monitor her progress.
CASE OVERVIEW

6. HEALTH PROMOTION
SCREENING
BY ARNOLD CASTRO

7. RECOMMENDATIONS FOR BREAST CANCER
SCREENING MAMMOGRAPHY
American Cancer Society- Women ages 40 to 44 should have the choice to start annual breast cancer screening
with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be
considered. Women age 45 to 54 should get mammograms every year. Women age 55 and older should switch to
mammograms every 2 years, or have the choice to continue yearly screening.
US Preventive Services Task Force- Biennial screening mammography for women aged 50-74 years (Grade
B recommendation) Decision to start regular, biennial screening mammography before the age of 50 years should be
an individual one and take patient context into account, including the patient's values regarding specific benefits and
harms.
Most guidelines do not recommend routine mammography for women younger than 40 years unless they fall into a
high risk category such as women with a known BRCA mutation.

8. CERVICAL CANCER SCREENING
In 2012, the American College of Obstetrics and Gynecology (ACOG), the American Cancer Society (ACS), American Society for
Colposcopy and Cervical Pathology (ASCCP) and USPSTF guidelines recommend that:
Between the ages of 21-29 years -- screening should be performed every three years.
Between the ages of 30-65 years -- screening can be done every five years if co-tested for HPV (preferred) or every three years with
cytology alone (acceptable). However, they stipulate that certain risk groups need to have more frequent screening. They include
women with compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or have
been exposed to diethylstilbestrol (DES) in utero (DES is a nonsteroidal estrogen that was given to pregnant women to prevent
miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and was discontinued in 1971).
Women older than 65 years who have had adequate screening within the last ten years may choose to stop cervical cancer screening.
Adequate screening is three consecutive normal pap tests with cytology alone or two normal pap tests if combined with HPV testing.
Women who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.

9. LUNG CANCER SCREENING
As of 2013, the USPSTF recommends annual screening with a low-dose CT scan to screen for lung cancer in
patients aged 55-80 years old who have smoked for 30 pack years.
To be considered, the patient should also be currently smoking or have quit within the prior 15 years.
OVARIAN CANCER SCREENING
The USPSTF, the American College of Obstetricians and Gynecologists, and the American College of Physicians
all recommend against routine screening for ovarian cancer in asymptomatic women.

10. SKIN CANCER SCREENING
While skin cancer is the most common type of cancer, the USPSTF is currently reviewing guidelines regarding
screening. Presently, the draft statement states that current evidence is insufficient to assess if there is more harm
or benefit to visual skin cancer screening in adults.
The USPSTF is also currently evaluating if there is any benefit in providing behavioral counseling for skin cancer
prevention.

11. OSTEOPOROSIS SCREENING
For women > 65 years old, screening with dual energy x-ray absorptiometry (DEXA) is recommended.
For women < 65 years old, the USPSTF recommends using the World Health Organization's Fracture Risk
Assessment Tool to risk-stratify
Screening with DEXA is recommended if the risk of fracture is greater than or equal to that of a 65-year-old white
woman without additional risk factors (9.3 percent over 10 years).
IMMUNIZATION: TDAP
Tetanus, diptheria, and acellular pertussis (Tdap) should replace a single dose of Td for adults age 19 through 64
years who have not received a dose of Tdap previously.

12. HEALTH EDUCATION
BY HILARIO NOVENO

13. OBJECTIVES
Verbalize understanding of the:
•Mechanisms of menopause
•Required annual examination for women ages 45 and above recommended vaccination needed given the current
condition
•Engage oneself into the recommended lifestyle modifications
•Physical activities
•Smoking cessation

14. THE MECHANISMS OF MENOPAUSE
MENOPAUSE- is the permanent end of menstruation; end
of women’s childbearing years
•May occur between ages 40 and 60. On average it occurs
at 51 years. Smoking may speed up the process.
•12 months in a row without menstruation since the last
period
•May affect onset of menopause: surgery, chemotherapy, or
radiation
•Hot flushes lasts between 30 seconds to 10 minutes
•There are available treatments. Talk to the doctor for
details.
• Increased risk of heart disease and osteoporosis
PERIMENOPAUSE- is the gradual transition to menopause
•Ovaries don’t abruptly stop; only slow down
•May get pregnant; ovulation may occur
•Lasts for 2—8 years
•Symptoms
•Menstrual irregularity
•Bleeding
•Heavy and >1 week consult a doctor
•Hot flushes
•Vaginal dryness
•Mood swings

15. THE MECHANISMS OF MENOPAUSE
Managing hot flushes
•Wear dress with light
layers
•Using fan
•Regular exercise
•Avoiding spicy foods
and heat
•Stress management
Managing vaginal
dryness
•May use water—
soluble lubricant
•Sexual urge may
also change
Managing mood swings
•Talk to the provider for
resources
•Discuss with spouse

16. REQUIRED ANNUAL EXAMINATION FOR WOMEN AGES
45 AND ABOVE
Mammogram
•Starts at 40 (or earlier with certain risk
factors)
•Every 1 to 2 years, depending on risk
Pap Smear
•Starts at 21
•Every three years. Women older than 65 may
be able to stop testing if low risk.

17. RECOMMENDED VACCINATION NEEDED GIVEN THE
CURRENT CONDITION
Influenza vaccine
•All persons aged 6 months or older who do not have a
contraindication should receive annual influenza
vaccination with an age-appropriate formulation of
inactivated influenza vaccine (IIV) or recombinant
influenza vaccine (RIV).
•In addition to standard-dose IIV, available options for
adults in specific age groups include: high-dose or
adjuvanted IIV for adults aged 65 years or older,
intradermal IIV for adults aged 18 through 64 years,
and RIV for adults aged 18 years or older.
Tdap vaccine
•1 dose followed by tetanus and diphtheria toxoids (Td) booster
every 10 years for adults who have not received tetanus and
diphtheria toxoids and acellular pertussis vaccine (Tdap) or for
whom pertussis vaccination status is unknown
•Adults with an unknown or incomplete history of a 3-dose
primary series with tetanus and diphtheria toxoid-containing
vaccines should complete the primary series that includes 1 dose
of Tdap.
•Unvaccinated adults should receive the first 2 doses at least 4
weeks apart and the third dose 6–12 months after the second
dose.

18. RECOMMENDED VACCINATION NEEDED GIVEN THE
CURRENT CONDITION
Pneumonia vaccine
•CDC recommends pneumococcal polysaccharide vaccination for:
•All adults 65 years or older
•People 2 through 64 years old with certain medical conditions
•Adults 19 through 64 years old who smoke cigarettes

19. PHYSICAL ACTIVITIES
150 minutes of moderate-intensity exercise, 75 minutes of vigorous intensity exercise, or a combination of both per
week
Strengthening exercises involving all muscle groups should be incorporated into exercise
Encourage to use available resources such as SuperTracker to keep track of dietary activities and free resources to
help patients get started with physical activity can be found at health.gov.

20. SMOKING CESSATION
There are many available resources to help stop smoking. The following are some tips to consider:
•Self-motivation is the key. A well-prepared self will be able to succeed.
•Symptoms are hard to come by. Conditioning oneself is helpful.
•Support group and diversional activities.
•Keep away from triggers.
•Focus on your goal.
•Reward yourself.

21. NUTRITION COUNSELING FOR
HEALTH PROMOTION
BY CHRISTINA YOUNG

22. MRS. PAYNE DIET
Skips Breakfast
Lunch: sandwich or leftover pasta, an apple or orange, water, and usually a couple of cookies
Dinner: Lean meats, rice, strawberries/blackberries, water
Dessert: cake or ice cream, chips or another helping of dessert while watching TV.

23. NUTRITION
Following review of Mrs. Paynes history and encounter, the areas that need to be addressed with respect to nutritional
status includes:
•A goal of 5-10% reduction in weight. Recommendations include cutting down on frequency and portion size of dessert
and incorporating regular breakfast intake. (Secondary benefits include minimizing chance of developing type II diabetes
due to risk factors of sedentary lifestyle and elevated BMI)
•Increasing calcium and vitamin D rich foods to minimize the risk of osteoporosis due to sedentary lifestyle and
perimenopausal complications.
•Reduced sodium diet to minimize chances of developing hypertension as indicated by positive family history, sedentary
lifestyle, smoking, and elevated BMI.
•Antioxidant rich foods to offset the negative systemic effects of smoking (https://nutritionfacts.org/topics/antioxidants)

24. DAILY TARGET (BASED ON AGE AND SEX)
(USDA, 2017)
•6 oz of grains (at least ½ should be whole grains)
•2 ½ cups of vegetables
•2 cups of fruits
•3-4 servings of dairy
•5 oz of protein daily

25. BASIC GUIDELINES
Start with a few realistic changes
Enjoy your food but eat less
Avoid oversized portions
Balance calories between portion size and activity level

26. MAKE HEALTHY CHOICES
Make half of your plate fruits and vegetables
Choose variety/color
Switch to 1% or skim milk and eat low-fat or fat-free dairy or equivalent substitutes
Make at least half your grains with whole grains such as whole wheat pasta/bread or brown rice,
instead of white rice

28. FOODS TO LIMIT
Saturated and Trans Fats
•Use small amounts of unsaturated
fats such as olive, canola, safflower,
or corn oils.
•Margarine without trans fat or
partially hydrogenated oil
Sodium
•Check labels (less than 2,300mg/day)
•Buy low-sodium, reduced sodium, or no-salt-added products
•Consume fewer foods with high sodium such as cheese,
processed meats, frozen entrees, packaged mixes, canned
soups and vegetables, pickled foods, condiments (salad
dressing, soy sauce, catsup, and mustard)
•Add herbs and spices instead of salt

29. FOODS TO LIMIT
Added Sugar
•Substitute water or unsweetened beverages for
sugary drinks
•Choose fruit as a naturally sweet dessert or sweet snack
instead of foods with added sugars
•Make sweet desserts and snacks, such as cookies, cakes, pies,
and ice cream, a once-in-a-while treat and choosing a small
portion when you enjoy them
•Choose packaged foods that have less or no added sugars such
as plain yogurt, unsweetened applesauce, or frozen fruit with
no added sugar or syrup
Alcohol & Caffeine
•Up to 1 drink per day for women and up to 2 drinks
per day for men

30. CALCIUM
•Calcium intake: For pre-menopausal women 1000
mg/daily is recommended.
•To meet these needs, 3-4 serving of dairy products are
required. Examples of this include: 8 oz of yogurt, 1
cup of milk, 1.5 oz of cheese. (Each serving can provide
around 300mg of calcium)
•Calcium Rich Foods
https://health/gov/dietaryguidelines/2015/guidelines/appe
ndix-11
https://www.choosemyplate.gov/dairy-calcium-sources
VITAMIN D
•600-4000 IU daily
•Dietary sources include fish and fortified
dairy, grains, and cereals
•Vitamin D Rich Foods
https://ods.od.nih.gov/factsheets/VitaminD
-HealthProfessional/

31. RESOURCES
Choose My Plate provides information on healthy eating http://www.choosemyplate.gov/
My Plate Checklist Calculator: Find out the number of calories needed to maintain vs. lose
weight https://www.choosemyplate.gov/MyPlate-Daily-Checklist-input

32. EXERCISE
BY DIANA BACH

33. PHYSICAL ACTIVITIES
Background
Mrs. Payne is 5’6” 180 lbs. with a BMI of 29 kg/m2
.
She has three children and used to walk during her lunch break but has stated she has stopped because she is too busy.
She also states, “I weigh too much. I would feel better physically and emotionally if I could only lose about 10 or 20 pounds. But I don't know where to start.”
According to the BMI table her weight falls into the overweight category.
Reduction in her weight will reduce her risks of diabetes, hypertension, and cardiovascular disease.
Exercise and physical activity needs to be addressed and by her statement indicates she wants to take the steps towards being more active.

34. QUESTIONS TO ASK/FURTHER ASSESSMENT:
• What activities do you enjoy?
• What daily activities do you do?
• What does the family and kids like to do for fun?
• Do you like the outdoors?
• Do you have family outings?
• Do you enjoy exercise or physical activities with others?
Asking questions will reveal more about the patient and what
exercises and physical activities to suggest in her area or
with her family.

37. STRESS MANAGEMENT
BY GEORGE DAMASCO

38. INTERVENTIONS
Developing Self Awareness
•Self-awareness helps people learn about
interactions among mind, body, and spirit.
•Increase a sense of control and counters
self-defeating perceptions.
Techniques for Developing Self-Awareness
1. Monitoring Stress Warning Signs
2. Learning and Practicing a Relaxation Response
Technique
3. Using Mini-Relaxations
4. Alternative and Complementary Therapies
5. Expressive Writing.

39. INTERVENTIONS
Nutrition: Healthy Diet
•Food is viewed as a positive influence on
health, physical performance and state of
mind. Nutrition is an important component
of early intervention strategies to improve
physical, cognitive, emotional, social, and
spiritual functioning.
Physical Activity
•One of the most effective way to lose weight and
improve self-esteem is to combine exercise with
nutritious eating. Regular physical activity also
increases the ability of older people and those with
certain chronic, disabling conditions, to perform
activities of daily living.

40. INTERVENTIONS
Sleep Hygiene
•Health and the ability to meet life’s
many demands and manage stress
effectively require proper rest.
Cognitive-Behavioral Restructuring and
Affirmations
•A conceptually based short term interventions to modify this
thinking and related behaviors and thereby reduce stress. It is a
technique or series of strategies that help people evaluate their
thoughts, challenge them, and replace them with more rational
cognitive and behavioral responses. An affirmation is a positive
thought, in the form of a short phrase or saying, which has meaning
for the individual.

41. INTERVENTIONS
Social Support
•Having supportive family, friends
and coworkers is an important
contributor to effective coping and
stress hardiness.
Assertive Communication and Empathy
•Is the most effective way to communicate. It is non-
judgmental, express feelings and opinions and reaffirms
perceived rights.
•Empathy is the ability to consider another person’s
perspective and to communicate this understanding back to
that person.

42. INTERVENTIONS
Healthy Pleasures
•Activities that brings feelings of
peace, joy, and happiness.
Spiritual Practice
•Activities that help people find meaning, purpose
and connection.
Clarifying Values
•Recognize the things and values that are important to them, reflect on where they are in life, evaluate
what needs to be changed, and generate an action plan for that change.

43. INTERVENTIONS
Setting Realistic Goals
•Developing an action plan for change to work
toward a more balanced health-promoting
lifestyle that is consistent with a person’s values
and beliefs.
Humor
An enjoyable and effective antidotes to stress for many people.
Humor produces laughter. Laughter creates predictable
physiological changes in the body.

44. ALTERNATIVE STRATEGIES
BY HAHN KIM

45. REFERENCES:
CDC. (2017). Recommended immunization schedule for
adults aged 19 years or older, by vaccine and age group.
Retrieved from https://
www.cdc.gov/vaccines/vpd/pneumo/
Edelman, C.L., Kudzma, E.C., Mandle, C.L.
(2014). Health promotion throughout the life span (8th ed.).
Saint Louis, MO: Elsevier
Health.gov (2015). 2015-2020 Dietary guidelines for
Americans.
Retrieved from https://health.gov/dietaryguidelines/2015/

46. REFERENCES: