CASE STUDY – Damien Jackson
Immunizations:
The pt should receive:
- Td booster
- Influenza vaccine
Screening
The first 6 screenings are always indicated by USPSTF for individuals over the age of 18.
- Alcohol misuse – given the infrequent nature of alcohol consumption, I would ask and record the number of drinks he consumes on a daily basis over a one week period
- Depression
- Hypertension – as he has a history of hypertension I would be sure to obtain an accurate BP on his initial visit
- Obesity – with a BMI of 28.7 and a waist circumference of 43 inches, he is overweight
- Tobacco use and cessation – I will ascertain how many cigars he typically smokes in a week, indicate how smoking can affect his health and assess his readiness to change
- HIV infection
Additionally I would screen for:
- Lipid disorder – this is indicated for males 20-35 years if at increased risk of CVD, which given the fact that he is male, African American, overweight, and a smoker early screening would be indicated
- Diet/activity for CVD prevention – given that he lives (up to his recent career change) a sedentary lifestyle, is a smoker, has a poor diet, and is overweight counseling on how diet and exercise affect his risk for CVD is indicated
Health promotion/disease prevention concerns
Injury prevention –
- Smoking cessation and alcohol consumption
- Diet and exercise
- Maintain healthy BP and blood cholesterol levels
- Medication adherence
- Occupational injury associated with lifting heavy boxes, i.e. lift with your legs not with your back to prevent sprains/strains
- Traffic safety
- Firearm safety
Diet – From his statements Mr. Jackson is mostly concerned about his “beer belly” and having a healthier life style and yet he admits to a poor diet consisting of a lot of meat, snack food, pastries, and cakes. He is also consuming one gallon of whole milk per day. Although it may not happen all at once, if he would like to maintain a healthier lifestyle while decreasing his risk for CVD and gout flares he is going to have to modify most areas of his diet.
There are a few important issues that need to be addressed in Mr. Jackson’s diet, specifically weight management/weight loss, blood pressure control, and control of episodes of gout. Depending on the results of his screening test I may also want to discuss diet modifications for dyslipidemia, although they will be similar to the suggestions for BP and gout management.
Suggestion for diet change:
- Stop consuming a gallon of milk every day, try substituting this with one gallon of water, drinking adequate amounts of water has been linked to fewer episodes of gout – if he feels that he must continue to drink milk he should only drink fat free milk
- Instead of drinking milk, try and incorporate fat free milk into breakfast by consuming one bowl of oatmeal with some milk, fruit, nuts and honey if he would like to sweeten it OR have a bowl of heart-healthy whole grain cereal and add fruit
- Try and incorporate more complex carbohydrates – fresh fruit vegetables, or whole grains
- Decrease the amount sugars consumed, he mentioned that he is trying to cut back on sugary drinks but he should also try and eat less of the simple carbohydrates present in snack food and sweets, if he feels that he has to eat dessert he should try and limit it to twice a week – for snacks he can try dried fruit and nuts or nut butters spread over whole grain bread
- Decrease the amount of red meat and seafood consumed as both have been linked to increased episodes of gout, overall protein from animal meat should be limited to 4-6 ounces per day – try and consume more fat free dairy products such as cheese and yogurt instead
- He mentioned that he likes edamame and salads, legumes can be a great alternative source of protein for individuals that are prone to gout, for lunch he should try to eat salad, incorporating as many vegetables as possible as well as legumes such as edamame, beans, or lentils and low fat/fat free cheese
- Although he does not consume alcohol on a regular basis, he should continue to limit consumption and when he does drink should avoid drinking beer all together
Exercise – According to the CDC, adults should be getting 150 minutes of moderate intensity exercise or 75 minutes of vigorous intensity exercise every week. Mr. Jackson is currently not meeting either of those guidelines. His career as a long-haul truck driver and bus driver has contributed to his sedentary lifestyle, and his new job with UPS should help him stay more active and help meet guidelines for muscle strengthening exercises, although he will have to be sure to lift heavy objects appropriately to reduce the likelihood of injury.
He has noted enjoying playing basketball and the outdoors. In addition to the health benefits of his new job where he will be on his feet and moving around more, he should try and get back to playing basketball 1-2 times per week, maybe his church has a league he can join, or he can teach his son to play. Seeing as he enjoys the outdoors maybe he can take his son to the park on the weekends to ride bikes. Also making additional trips up and down the stairs to his apartment can be a good source of exercise.
Brief intervention
Obesity – Mr. Jackson is not yet considered obese, but with a BMI of 28.7 and waist circumference of 43 inches he would be considered overweight with a high waist circumference. Without implementing lifestyle changes, as his practitioner I would be concerned that continued weight gain could lead to obesity.
- ASK is of particular importance, as most people are sensitive about their weight. You are seeking permission to discuss the patient’s weight in a nonjudgmental manner. This is an early important step in assessing the patient’s readiness to manage weight. As Mr. Jackson has expressed interest in a healthier lifestyle I would ask if he felt comfortable discussing his weight with me or how he felt that he weight impacted his life negatively.
- ASSESS I would then ensure that the height, weight and waist circumference measurements we have for Mr. Jackson were accurate and would further assess health status by using the Edmonton Obesity Staging System.
- ADVISE After establishing a collaborative relationship by asking about Mr. Jackson’s desire to discuss weight loss and assessing his health status I can now advise him on steps to take to prevent further weight gain. I will encourage his desire to achieve a healthy lifestyle and provide him with direction of how to do so – which can be seen in the diet and exercise plan outlined above. – i.e. “Now that we understand what your goals are, is it ok if I give you some suggestions to help you achieve the healthier lifestyle you spoke about?”
- AGREE Before continuing with treatment it is essential that Mr. Jackson agree to the treatment plan. By agreeing to follow the guidelines set out in the weight management plan he is stating his determination to do the work and achieve change. Our overall goal will be to implement lifestyle changes while still maintaining quality of life.
- ASSIST As Mr. Jackson would most likely score a 0 on the Obesity Staging System I may not refer help at this time but will educate him on becoming aware of any triggers that may cause poor eating habits and can provide information on local support groups. Finally, I would ask that he follow up so we can check in on his progress.
Smoking cessation – Mr. Jackson may feel that he is not a heavy smoker, but may also be unaware that one cigar contains 70 times more nicotine that a cigarette. As I don’t believe that the quantity of cigars smoked on a weekly basis warrant the use of the 5 R’s or Heavy Smoking Index I would again implement the 5 A’s to address his willingness if not to quit smoking cigars all together to at least limit his smoking habits.
- ASK I would ask how many cigars Mr. Jackson smokes on a daily/weekly basis.
- ADVISE I would then make him aware of the risks associated with smoking tobacco and how smoking a cigar compares with smoking a cigarette in terms of the amount of nicotine delivered.
- ASSESS I would ask if cigar smoking is something he feels has negatively impacted his life in any way and ask if he is willing to cut back.
- AGREE Depending on how Mr. Jackson would care to proceed, whether by not changing his smoking habits, decreasing the number of cigars smoked, or quitting completely I would seek to identify any behavioral changes that need to be made or triggers for smoking. Should he decide to stop smoking all together we would discuss a quit date and any medication that may be helpful – most likely an OTC medication in his case.
- ARRANGE Should he decide to quit completely I would ask that he follow up with an appointment in 1 month and will be sure to call him at the end of the first week to check in. If he should decide to try and cut back on the number of cigars smoked I would encourage him to do so and make a point of asking him about it at his next appointment.
References—
Adult Preventative Health Care Schedule: Recommendations from the USPTF
Modified 5 As – Minimal intervention for obesity counseling in primary care
Smoking cessation lecture (10/24/17)
https://www.cdc.gov/vaccines/schedules/syndicate.html
https://www.cdc.gov/vaccines/schedules/syndicate.htmlhttps://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lipid-disorders-in-adults-cholesterol-dyslipidemia-screening
https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897
https://www1.nyc.gov/assets/doh/downloads/pdf/chi/chi-34-7.pdf
https://www.cdc.gov/cancer/dcpc/prevention/policies_practices/physical_activity/guidelines.htm
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