Immunizations
Considering that it is November, she should be receiving the influenza vaccine. Further, I would verify whether she received a Tdap booster in the past 10 years – if she has not, I would recommend her to get that as well.

Screening
Ms. Burr should be screened for the BRCA gene, as she is of Ashkenazic Jewish decent, and has two family incidences of breast cancer. Given her history of ulcerative proctitis, I would also recommend colon cancer screening, even though she is under 45 years of age. This is because ulcerative proctitis increases the risk of colorectal cancer. As a 34-year-old woman, she should be screened for cervical cancer via Pap Smear, if it was not done within the last five years. As a woman of childbearing age, she should also be screened for intimate partner violence. Lastly, she should be screened for alcohol misuse, depression, hypertension, tobacco use and cessation, hepatitis C virus infection, HIV infection. It is important for her to be screened for hypertension, as has paternal grandfather had high blood pressure and her maternal grandfather suffered from two strokes. Her current blood pressure reading is 122/68, which shows a slightly higher than normal reading of her systolic blood pressure. It is also important for her to be screened for alcohol misuse, as she is consuming 4 or more drinks in one sitting, on occasion. It is important for her to be screened for depression, considering her mother has an untreated anxiety disorder and her maternal grandmother suffered from chronic depression.

Health Promotion/Disease Prevention Concerns:
Injury Prevention
Given that I know Ms. Burr enjoys drinking alcohol at parties and on Fridays at the bar with her colleagues, I would remind her of traffic safety. I would discuss the importance of general traffic safety and refraining from driving under the influence, as it can cause great harm to herself and others.

Diet
Ms. Burr was diagnosed with ulcerative proctitis, resulting in her losing 20 pounds, so her current BMI is 17. According to the CDC, normal BMI ranges from 18.5 to 24.9, so she is underweight. She has a history of anorexia, so it is vital that Ms. Burr focuses on gaining back healthy weight. She notes that she eats “mostly healthy food” as she has an emphasis on consuming fruits, vegetables, little red meat, and no fried foods. However, she has trouble with her third meal of the day, as she states dinner is “all over the place.” If her husband does not cook a meal for them, she tends to pick something up from an “unhealthy” chain or prepared foods from the supermarket.
Given her busy lifestyle of working, taking care of her kids and herself, I would suggest that her and her husband work together to implement Meal Planning in their lives. This allows them to set aside a specific amount of time, strictly dedicated to improving her diet and allowing her to gain healthy weight. I would positively reinforce her behavior on eating healthy most of the time – considering she intakes fruits and vegetables, limits her red meats, and does not eat fried foods. I would remind her that little modifications to her diet can make a significant impact on her health.
Because Ms. Burr has ulcerative proctitis, I would tell her to avoid alcohol, caffeinated or carbonated drinks, and dairy products, as these can contribute to inflammation. I would tell her to ease on the alcohol when she goes out, and possibly switch from coffee to tea, for a less caffeinated beverage. According to UCSF Health, omega-3 fatty acids have an anti-inflammatory effect that may be beneficial in ulcerative proctitis. So, she should incorporate foods with omega-3 fatty acids in her diet.

Breakfast:
As of now, Ms. Burr is eating a toast with almond butter and coffee. Given that she needs to gain healthy weight, I would encourage her to add protein to her breakfast – for example, she can eat two boiled eggs, along with her current breakfast. Because caffeine should be avoided in ulcerative proctitis, I would tell her to possibly switch to tea, as it has a lower amount of caffeine per serving as compared to coffee. As a complete alternative, I would recommend her to make overnight oats with almond or oat milk, drizzled with fruits of choice and honey. This gives her a quick, healthy alternative breakfast that can be meal prepped beforehand, and eaten on the go.
Lunch:
Ms. Burr prepares a salad at home to eat for lunch. This is a healthy lunch, and I would remind her to make sure she is including protein and healthy fats in this salad, possibly by adding a protein of choice (shrimp, chicken, etc) and she can drizzle olive oil on her salad for antioxidants and healthy fats. Furthermore, she can include avocado and chickpeas in her salads for fiber.
Dinner:
She is currently eating home cooked food by her husband or grabbing quick dinners on her way home. For this, I would recommend eating meal prepped foods that her and her husband worked together to make. Some examples include quinoa bowls with grilled chicken and a serving of vegetables, whole-grain pasta with protein and pasta sauce of choice, or baked salmon with boiled rice and vegetables. These meals should include a proper number of calories, grams of protein, carbohydrates, fats, and omega-3 fatty acids, which are essential for her healthy weight gain.

Exercise
The CDC recommends that adults should get 150 minutes per week of aerobic activity (at moderate-intensity), or 75 minutes per week of aerobic activity (at vigorous-intensity). Currently, her only activities are feeling like she’s “on the run” with two kids and a busy schedule and standing during lecturing/walking from one end of the campus to the other.
Because she is not meeting current guidelines, I would suggest starting by taking out at least 30 minutes per day for weight training. This can be done at home by purchasing small dumbbells, considering it may be hard to leave her two children at home to go to the gym. This would allow her to strengthen her muscles and put on healthy weight. Because her form of exercise is currently only cardio, she may benefit from weight training at home. If she wants a way healthy way to unwind and destress after a long day of working, she can also do at home 30-minute yoga challenges. If there is any other form of exercise that she enjoys, like a specific sport, walking, or dancing, she can try to do this and engage her kids as well, so that the process is more enjoyable and realistic.

Harm Reduction
For Ms. Burr, harm reduction can be reducing the amount of wine that she drinks. She states that she is currently drinking to a point where she is unable to drive home. This is dangerous but is also not good for her condition of ulcerative proctitis and given her family history of hypertension. Another form of harm reduction can be buying a healthier option when she has to pick up dinner.

Brief Intervention
Substance Use
Ms. Burr is not obese, nor does she smoke, so I would only conduct a brief intervention for Substance Use. This is because she drinks 4 glasses of wine on a Friday, to the point of intoxication, to blow off steam after a long week of work. It seems she is using this as a stress relief, although there are healthier alternatives to do so. Furthermore, alcohol is dangerous for her because she has ulcerative proctitis and a family history of hypertension and breast cancer. According to the New York City Department of Health and Mental Hygiene, excessive alcohol consumption is associated with “hypertension, liver and heart disease, and cancers of the breast, mouth, pharynx, larynx, esophagus, liver, colon, and rectum” which is especially concerning for Ms. Burr.
According to the NIDA Quick Screen, Ms. Burr is an at-risk drinker because she has 4 or more drinks per day, occasionally when she drinks on Fridays. In particular, I would ask her – “In the past year, how many times have you drank 4 or more alcoholic drinks in a day?” Her answer would demonstrate that she does not meet criteria for addiction, but she is a risky user.
After screening, I would provide brief intervention using the 5 As. This stands for Ask, Advise, Assess, Assist, Arrange. I would begin by asking, “Is it okay with you if we discussed your alcohol usage?” Then, I would proceed to advise her of the specific health risks posed by alcohol use, and that limiting this behavior would improve her overall health. Next, I would assess her desire to change by asking, “Given what we have discussed, are you interested in changing your alcohol consumption?” If she is, I would proceed by assisting her in developing a plan. For example, I would ask her, “Are you using alcohol to decompress/destress, and are you open to other activities that may give you a similar feeling of decompression?” I would then suggest other stress relieving activities that she can partake in, weekly. Last, I would arrange a follow up visit and let her know about various sources that she can be in contact with to limit alcohol consumption, if her behavior does get any worse.

The order in which I would address these concerns are:
1. Substance abuse
2. Screenings
3. Diet
4. Exercise
5. Injury prevention/harm reduction
6. Immunizations

References

https://nida.nih.gov/sites/default/files/pdf/screening_qr.pdf
https://www1.nyc.gov/assets/doh/downloads/pdf/chi/chi28-3.pdf
https://www.aafp.org/dam/AAFP/documents/journals/afp/USPSTFHealthCareSchedule2021.pdf
https://www.cdc.gov/physicalactivity/basics/adults/index.htm
https://www.cdc.gov/healthyweight/assessing/index.html#:~:text=If%20your%20BMI%20is%2018.5,falls%20within%20the%20obese%20range.
https://www1.nyc.gov/assets/doh/downloads/pdf/chi/chi30-1.pdf