Carly Schreiber

Professor Shami 

HPDP Case Study 

John Liou

Immunizations: 

1. Influenza: IIV, RIV or LAIV – 1 dose (annually)
2. Tetanus: Td booster – 1 dose (every 10 years) 
3. Zoster: RZV or ZVL – 2 doses if RZV or 1 dose if ZVL 
4. Pneumococcal: PCV13 or PPSV23 – 1 dose

Screening: 

1. Hypertension 
2. Depression 
3. Obesity 
4. Tobacco use and cessation
5. Lung cancer – John is a current smoker, 80-pack year history 
6. HIV infection
7. Colorectal cancer
8. Abdominal aortic aneurysm – John is a male smoker

Injury Prevention: 

Types of injury prevention for John include traffic safety and fall prevention. 

1. Traffic Safety – general traffic safety is always important such as wearing a seat belt. This applies to everyone but especially to John since he has difficulty walking or standing and I imagine he takes public transportation or travels by car in order to get places.
2. Fall Prevention – John has experienced a slow decline in his physical functioning specifically over the past 5 years. He is also overweight with a BMI of 27.4. Due to his hip and back pain and his difficulty standing or walking over any length of time along with his recent diagnosis of Parkinson’s disease, John has been tripping lately which has led to a fearfulness to walk. Therefore, fall prevention should be set in place such as wearing more supportive shoes or asking his wife or an aid to help John ambulate. Another example is for railings to be installed in his shower and around the house so he has something to balance and hold on to. If John’s walking gets much worse and he gradually becomes fully sedentary from his current largely sedentary state, maybe insurance would cover a chair to lift him up and down the stairs if it becomes too difficult for him. 

Diet: 

John’s current diet is traditionally Chinese and prepared by his wife. This diet includes a high intake of vegetables, a low intake of meat and high in salt. John also enjoys eating sweets and readily admits to eating too many but he claims that it is one of his few pleasures. John is still overweight with a BMI of 27.4 although he has lost some weight, specifically 10 pounds in the past 5 years. As a normal weight BMI is from 18.5-24.9, we need to work to lower John’s BMI and help him to lose weight in a healthy, gradual fashion. His wife cooks him his meals and is resistant to changing her habitual cooking routines. In order to not place too much of a burden on his wife while improving his eating habits, specifically by lowering his salt and sweets intake & raising his protein intake, small steps must be taken. 

A traditional Chinese diet is known to contain large amounts of monosodium glutamate (MSG), carbohydrates like white rice & noodles and greasy, fried foods. However, there are many healthy aspects of a traditional Chinese diet which can be emphasized for John’s diet to help him get healthier and lose some weight. First, John can substitute white rice for brown rice to avoid white flour. Next, John should balance his meals more by introducing greater amounts of protein. While too much red meat is unhealthy, especially according to Chinese medicine, a Chinese diet will allow John to eat around two ounces of meat twice a week which will give him greater amounts of iron and protein. In line with Chinese-style dishes, John should eat soup with every meal to fill his stomach with a healthier alternative which will lessen his desire for sweets for dessert. He can also substitute regular noodles for egg noodles which will increase his protein intake and lower his carbohydrate intake. Regarding the excess salt and John’s wife’s resistance to changing her cooking habits, he can ask her to lessen the addition of salt while keeping everything else the same so as not to greatly disturb her regimen and simultaneously helping to reduce salt intake. Regarding John’s desire for sweets, he can still enjoy them three times a week instead of every day and should make an effort not to eat late at night. Due to John’s largely sedentary state, it is difficult for him to burn off his calories. Therefore, it would be very helpful if he minimized the amount of sweets he ate a week along with not eating late at night when he is going to sleep. Because John is hypertensive and cannot really engage in exercise , it is imperative he loses weight and eats foods that help bring down his blood pressure. Reducing sodium intake is key, especially because he already consumes too much salt. Additionally, eating a healthy diet containing whole grains, fruits, vegetables and low-fat dairy products with minimal to no saturated fat and cholesterol can help lower his blood pressure. John also has GERD, so eating foods that will help his acid reflux can help his symptoms. Fruits, vegetables, lean proteins like eggs and meat, carbohydrates like whole grains and potatoes are all good options for helping John’s GERD.

Our goal is to help John lose weight, get healthier and eat foods that will address his present illnesses such as hypertension and GERD. However, John doesn’t seem to get much pleasure from many activities right now and eating is one of the few. Therefore, we want him to continue to enjoy eating while being smart about his health. Since his wife cooks for him, it’s necessary she gets on board so we can all help Mr. Liou. In order to make it easier for them, a weekly diet plan can be created for John for his wife to follow:

Breakfast – eggs with low-fat cheese and vegetables // oatmeal with berries // whole grain toast with low-fat cottage cheese or low-fat peanut butter

Lunch – sandwich with a protein of choice and a side of vegetables // salad with a protein of choice and a side of carbohydrates such as quinoa or potatoes // sushi with brown rice and fish 

Dinner – traditional Chinese meal with a balance of whole grains/brown rice, vegetables, lean protein such as meat, chicken or fish 

Snack – lightly salted nuts // low-calorie popcorn // fruits and vegetables 

Dessert – John can eat sweets 3 times a week. Otherwise, he should eat fruit and healthier sweets: low-calorie ice cream bar // black sesame pudding (Chinese dessert) // date/black sesame rice balls 

Exercise:

John is not getting adequate exercise as per current guidelines as he is largely sedentary. As stated above, John has difficulty standing or walking for any length of time. He has hip and back pain and has been tripping lately as an early symptom of his recently diagnosed Parkinson’s disease. He used to engage in light gardening and home maintenance chores but has exhibited a slow decline in his physical functioning and cannot manage these activities any longer. He expresses desire to get stronger so that he can stay in his home as his wife wants to move to an apartment so John doesn’t have to deal with taking care of a household. John’s overweight status also does not help his hip and back pain and his lack of exercise. Another barrier to exercise is John’s COPD and 80-pack year history which results in some grunting upon exertion and difficult breathing. In order to help Mr. Liou gain strength, lose weight and lower his blood pressure, a specific exercise regimen must be set in place. Although John will not meet current guidelines, with moderate aerobic exercise as the minimum, we should introduce very slight exercise for him. As Mr. Liou experiences pain and difficulty walking or standing, his wife who is younger than him can begin by helping him walk for 5 minutes a day. Hopefully over time, John can gradually build up by walking 30 minutes a week. Because John used to enjoy light gardening, his wife or an aid could help him continue to garden by walking him outside and bringing him a low chair so he can continue an activity he enjoys while getting some exercise. Since he has a difficult time standing and is a retired construction worker, John could sit down and do leg and arm exercises like lifting light weights and exercise balls. Another idea for exercise is bringing John to the pool to do water aerobics. The water will help him stand and will allow easier mobility for his limbs. 

Harm Reduction:

• John is a 75 year old man, current smoker with an 80 pack-year history. It is difficult for any patient to quit smoking cold turkey and is quite rare. Especially a patient like John who has been smoking for years, steps to minimize smoking and its consequences must be gradual or he will not follow them. John should begin by smoking one less cigarette a day. Hopefully in a couple weeks, John could continue to lessen the amount of cigarettes he smokes a day.
• John is overweight with a BMI of 27.4. In order to prevent him from becoming obese, John should follow the diet and exercise plan to help him lose weight and get healthier. 
• John is hypertensive which is worsened/caused by his smoking, weight, diet and lack of exercise. If John follows harm reduction for his smoking and weight, hopefully this will reduce harm regarding his high blood pressure as well. 

Brief Intervention: 

John needs a brief intervention in the area of smoking cessation. He has an 80 pack-year history, has high blood pressure, COPD and is overweight. In order to improve several areas in John’s life and health care, a brief intervention and education on the dangers of smoking and its consequences can be highly beneficial for a patient like Mr. Liou. I would use the 5 A’s to counsel, educate and provide solutions/treatments for Mr. Liou.

Ask – I would ask John about his smoking status and his readiness to change on a scale of 1-10. Based on whichever number John chooses, I would follow-up by asking John what would help him move the number up on the scale indicating a greater readiness for change. Example Question: “What would motivate you to express a greater readiness for change in smoking cessation?”

Advise – I would first ask permission to give advice and information on smoking cessation to ensure John is comfortable. I would educate Mr. Liou on both the health risks of smoking such as heart disease, high blood pressure, cancer etc and the benefits of quitting smoking. I would present John with various pharmacotherapies, medications and tools to help with cessation. Example Question: “Do you know the risks of smoking and the benefits of cessation? Do I have your permission to educate you?”

Assess – I would assess John’s health status and his addiction to nicotine using the Heavy Smoking Index (HSI). Based on these factors I would create a plan specific to John and his needs. I would, together with John, determine motivating factors that may exist to help with cessation such as his wife, children and grandchildren. I would explain that by quitting, he’ll be able to enjoy a longer life with his family who need him to be responsible and take care of himself. Example Question: “What are motivating factors to help with your smoking cessation?” 

Agree – I would ensure that both I and John agree on what plan should be set. Without John’s agreement and willingness to follow the plan, he will not take the necessary steps towards cessation. We would agree on which therapies or medications he wants to try and identify any behavioral or life changes that should be made in order to help him reach his goal. For example, if anyone in his family smokes, we could try to get them on board as well so they could help each other quit as a team. We would create a plan that works for John and his current lifestyle, helping him get healthy but not making sudden, drastic changes he cannot follow. Example Question: “Are you comfortable with the plan we have set together? Is there anything you’d like to change?”

Arrange/Assist – lastly, I would provide any prescription if needed and assist John by setting a follow-up date and referring him to various support groups, internet or social media groups and other check-in options. Every patient needs to feel supported, especially an elderly patient like Mr. Liou who has his set habits and lifestyle for years. I would suggest following up in a week and then again within the first month. Example Question: “Do you feel like you have enough or adequate support? Would you like me to give you other resources and referrals for support groups?”