Case Study Elements 

Please review a case study of your choice and address the issues below.  Once you have constructed the list of what should be done, please indicate which items/issues should be addressed first.

Immunizations 

• List the immunizations this patient should have – assume that they have all had their childhood immunizations (including HPV vaccine where appropriate)
• Influenza shot
• If TD vaccine has not been administered in the last 10 years then give him a TD shot as well 
• Human papillomavirus (HPV) Male (since he is a diabetic)assuming he did not have it
• Pneumococcal polysaccharide (PPSV23) and can be followed by a dose of  Pneumococcal 13-valent conjugate (PCV13) one year later.
• Hepatitis B

List the screening tests that you would order for this patient.  If you decide to order and that have inconsistent guidelines, please say why you think they are indicated for this patient.  

Screen for: 

• Alcohol misuse ( USPSTF recommended for ages 18-up)
• Hypertension  (He has preexisting conditions such as diabetes for his case anything that is 140/90 is considered high) (Even though he is on medication for his BP it is slightly elevated during today’s visit so I would want to make sure there is no need to increase or change his medication, explore if he is taking his medication, or maybe alter his diet.)
• Depression  (Even though he is on medication is seems he is still showing symptoms of depression there maybe a need to change or increase medication it needs to be further explored.)
• Obesity (USPSTF recommends screening ages 18-up) Also he is in the category for being overweight and his rather sedentary lifestyle may lead to obesity.)
• Screening for smoking and counseling to promote cessation (USPSTF recommends screening for ages 18-up)
• HIV infection (USPSTF recommends screening for ages 18-up)
• Serum Lipid screening ((USPSTF recommends screening for men ages 30-up normal risk)
• ASA screening age 45-79
• LDL/HDL (recommended for men 35-up normal risk) 
• Screening Hep C (USPSTF recommended for his age group) 
• Colorectal cancer (colonoscopy) (recommended for ages 50-70 normal risk)
• Screening for Prostate Cancer (First inform him about benefits/harms of screening with PSA only if he agrees). He has a family hx of prostate cancer so I would discuss this with him.

Health Promotion/Disease Prevention Concerns – please address all that are relevant for this patient:

Injury Prevention 

Identify any injury prevention concerns that should be discussed (just list them).

• Traffic safety 

First I would like to address the shoulder pain even though I am not convinced that its a heart issue I still would not want to take any chance. His symptoms suggest he might be suffering from angina and who knows their body better that the patient. Mr Khaoury is does not seem like someone that would take the time out of his day to come to a clinic if he did not have a real concern. If I overlook it and it happens to be a real heart issue that would be far worse than just testing him and ruling it out. For this concern I would order or perform an Electrocardiogram (ECG or EKG) and stress test to rule out any heart issues such as angina. Diet is the next most important area to address next since his weight and diet are important factor that may be contributing to his uncontrolled diabetes and HTN. It is important to explore his eating habits so we can come up with a plan that he may be able to benefit from before starting him on insulin and increasing or changing his HTN medications. 

 Next it is important to explore if Mr Khoury is taking his HTN medication or not and if yes then why is his BP high today. Does he need a change in medication or increased dose of his current medication? The answer this I will ask him questions about when and how he is taking the medication. I will repeat BP in different positions and if it is still high have him take his BP

at home at different times and keep a log to see if it is continuously high and a change is needed. 

Finally we can explore his wrist pain. For the wrist pain I will order an x-ray to rule out any fracture or broken bone but in his case I do not expect to see either. He has not suffered any fall or trauma to his hand to have caused a fracture or broken bone. If the x-ray comes back negative then I feel his symptoms are suggestive of carpal tunnel syndrome. According to medscape there is a possibility that he might have early carpal tunnel syndrome (CTS), paresthesias are intermittent, and the hand is reported as falling asleep, with pins and needles sensation. Most often, the symptoms are in the thumb, index, and middle finger. Classic CTS includes symptoms affecting at least 2 of the first 3 digits, but not the palm of dorsum of the hand. Therefore I may prescribe him some pain medication and refer him to a Neurologist. 

Please identify any relevant dietary issues for this patient 

The patient is a diabetic whose diabetes is not controlled at all. Normal fasting glucose should be in the range of 72-108 mg/dl. Mr. Khoury has a fasting blood glucose of 160 mg/dl which is very high and needs attention. Also his HgA1c level is 9.0 which is also high the normal range should be lower than 5.7. His systolic blood pressure is elevated as well and should be monitored to see if any change in medication is needed. Mr. Khoury’s age, his PMHx of HTN and diabetes along with the fact that his mother mother had a stroke at 68 all increase his risk of developing CAD. I would recommend that Mr. Khoury make some changes to his diet to see if it can help lower his blood glucose level and his BP,  which in turn can help in lowering his risk of CAD. His BMI indicates that he is overweight changing his diet and increasing the amount of physical activity can help his overall health and weight issue. 

While thinking about diet, consider any specific health issues this patient has and how diet should be modified to address them (you may have to look some up since you haven’t studied them yet)

I would help Mr.Khoury come up with a diet suitable to his lifestyle taking into account his regular eating patterns and making a plan that would be easy for him to follow. I feel the best diet for Mr Khoury is the Mediterranean diet since it has been shown to help protect against heart disease, stroke, and some cancers. Research shows it may also help individuals improve blood sugar and lose weight. Further one research article from public health and nutrition states there is a the adherence to a Mediterranean Dietary Pattern ensures an adequate intake of fruits, nuts, vegetables, cereals, legumes or fish, important sources of nutrients linked to depression prevention.. I would also recommend the “Dietary Approaches to Stop Hypertension.” this diet can help reduce his blood pressure through eating foods that are low in saturated fat, total fat, and cholesterol, and high in fruits, vegetables, and lowfat dairy foods. The DASH eating plan also includes whole grains, poultry, fish, and nuts, and has low amounts of fats, red meats, sweets, and sugary beverages. It is high in potassium, calcium, and magnesium, as well as protein and fiber.Changing Mr. Khoury may help him decrease his weight, lower his HTN, blood glucose level and help his depression. I would recommend that he substitute some of the foods that he is currently having such as instead of half and half use lowfat milk and instead of chips have some crunchy vegetables with his soup. I would also recommend him having smaller meals throughout the day and not wait till he is very hungry. Also He should be drinking lots of water and exclude any sugary drinks.

Exercise:

Recommendations made by the CDC include:

• 150 minutes of exercise for adults along with 2 days of muscle strengthening activities each week.

Mr Khoury states he does not get much exercise other than walking his dog. He sleeps for long periods  during the weekends and is not very social. This all points to a very sedentary lifestyle and the CDC recommends people with this type of lifestyle to first begin with a few mins physical activity a day and increase slowly to 30 mins.

I would explore his options with him and make some recommendations such as maybe he can join the mosque with his wife. Also get off one stop earlier on his way home from work or to work and walk the remainder distance. He can also walk his dog twice a day for maybe 15 mins instead of one long walk. By incorporated these changes way we can come up with a plan together for every day of the week so he can have a structure to follow.

Harm Reduction

If not addressed in the areas above, include any harm reduction suggestions/actions that are relevant to this patient

• Healthy choices at a restaurant.

Brief Intervention – where relevant to your chosen patient, please explain how you would conduct a brief intervention for:For this section please outline the format for the brief intervention and give example questions you would use for each section.  

Obesity: He is overweight and it is important to prevent him from becoming obese.

Using the 5 A’s of obesity management.

Ask permission to discuss weight: 

“May I talk to you about your weight?”

“Are you concerned about the effects of your weight on your health or quality of life?”

“Would it be alright if we discussed your weight?”

I would go on to explain the effects of weight on his present health conditions HTN and diabetes as well as the ones he is at risk for such as CAD.

I would assess his willingness to change asking these questions:

“Are you ready to work on your weight? Would it be okay if I helped?” “How important is it for you to work on your weight?”

“How confident are you that you can take action on your goal?”    

Screen for substance abuse ( alcohol, tobacco, and drugs)

If any issues exist I can do a brief intervention if not then it can be excluded.

For smoking I would use the the 5 A’s in smoking cessation.

If there is any sign of substance abuse I would use the 5 A’s of Brief Intervention 

Ask– questions about substance use

Advise– patient to stop or cut down

Assess– willingness to make change

Assist– to make change if ready

Arrange– for further assessment, treatment, and follow up 

If he admits to drinking alcohol use AUDIT-C screening tool for adults.

If he admits to illicit drugs use National Institute on Drug Abuse’s Modified ASSIST (NIDA-Modified ASSIST) screening tool.

After completing the tool it can be decided if further intervention is needed.

 

Citations:

https://emedicine.medscape.com/article/1141168-clinical#b4

https://www.medicinenet.com/wrist_pain/symptoms.htm

https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c

https://www.diabetesselfmanagement.com/blog/what-is-a-normal-blood-sugar-level/

http://www.diabetes.org/food-and-fitness/food/planning-meals/diabetes-meal-plans-and-a-healthy-diet.html

https://www.nhlbi.nih.gov/files/docs/public/heart/hbp_low.pdf

http://dadun.unav.edu/bitstream/10171/4928/1/SUN%2028.pdf

CDC Adult Immunization Schedule 2016

AFP – 1 pg Adult Screen USPSTF

 Introducing a One-Page Adult Preventive Health Care Schedule: USPSTF Recommendations at a Glance

Nutrition, Powerpoint presentation

Obesity, Powerpoint presentation