Sonam Bhandari 

Case study: Mr. John Liou 

Immunization: Mr. Liou has not received any vaccines since his last tetanus (Td) vaccinations 10 years ago. Since, he declined the flu vaccine last year as he believes that he could get the flu from the flu vaccine it Is important to counsel him about the myths regarding vaccine. 

The following vaccines should be administered: 

• Influenza inactivated or influenza recombinant (1 dose annually) 
• Tdap – 1 dose 
• Zoster recombinant – 2 doses 
• Pneumococcal conjugate (PVC13) – 1 dose followed by Pneumococcal polysaccharide (PPSV23) within 1 year. 

Screening:

The patient should be screening for the following as per the USPTF: 

• Alcohol misuse
• Depression
• Hypertension- Since Mr. Liou has hypertension it is important to measure his blood pressure. 
• Obesity 
• Tobacco use and cessation 
• Lung cancer: low dose CT
• Abdominal aortic aneurysm screening: Since, Mr. Liou is 75 and a smoker he should be screened one time for AAA with ultrasonography. 
• Colorectal cancer screening – Need to take into account his life expectancy, health status, comorbid conditions, and prior screening status. 
• Diabetes
• Cholesterol

Health Promotion Disease Prevention concerns: 

Injury prevention:  

• Fall prevention 
• Traffic safety 

Diet:

Mr. Liou’s diet consists of traditional Chinese meals prepared by his wife which contains high amounts of salt which adversely affects his hypertension. He also admits to eating sweets too often. In order to ensure that he is complaint with the change in his diet, I would have him come in with his wife in order to counsel her on the effects of a high salt diet and positive impacts of a good diet on Mr. Liou’s health. Mr. Liou’s HTN and GERD should be taken into account while making a diet plan. For Gerd avoiding citrus fruits, high fat food, chocolate and high fat dessert, and whole milk may help reduce the symptoms. 

Plan: While cooking Chinese food use low sodium soy sauce and limit the amount of salt added to the food- can add other spices to enhance the flavor of food. Since, his wife is hesitant to change her way of cooking she can learn some new easy to cook recipes such as steamed vegetable, salad, use brown rice instead of white, while cooking noodles she can use noodles with low salt content. We can go over some of Mrs. Liou’s recipe and try and see where we can make changes to best benefit Mr. Liou. In terms of his diet I would recommend limiting cutting down his sweet intake to once a week – maybe on Sunday as a treat. He can eat fresh fruits to curb his sugar cravings. 

Example,

Breakfast: Chinese rice Porridge (congee) 

Lunch: Steamed bok choy and cauliflower fried rice. 

Dinner: Chicken with broccoli. 

Exercise:

Since, Mr. Liou is in general quite sedentary he is not getting adequate exercise as per current guidelines of 150 min/week moderate- intensity and muscle- strengthening > 2 times a week involving all major muscle groups. Which can help with hypertension and increased strength training for managing PD. Due to Mr. Liou’s sedentary lifestyle, and his current situation – difficulty standing and walking, exercises should begin with few minutes a day of strength training. Exercises such as Yoga, Tai chi, dance, stretching and balance exercises should be incorporated. I would also give him turning and walking tips which he can use to walk around the block with his wife. 

A weekly exercise plan would look like this: 

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Walk for 5-10 minutes around the block using newly learned walking and turning techniques with wife.	Perform 2x 10 minutes of balance training exercise – single leg stands, quad strengthening exercises, seated stretch.	10 minutes of Tai chi – working on flexibility and strength.	Stretching and Yoga for10 minutes – can be modified to perform on chair if difficult.	In a clear room play some music and slowly dance with your wife for 20 minutes- rest as needed.	Perform 2 sets of 10 reps of strengthening exercise- Wall slides, shoulder blade squeeze, palm squeezes etc.	REST

I would advise him to stop exercising if he feels pain or difficulty, and to make sure his wife is with him while he performs these exercises. 

Physical and occupational therapy sessions to help come up with an exercise programs to improve strengths, help with poor balance and falls. They also would teach Mr. Liou, his wife and anyone else taking care of Mr. Liou how to use appropriate adaptive equipment and walking device. 

These exercises and referral would bring the benefits of weight management, improved cognition, better balance, endurance, improved gait and posture, and bone health leading to less risk of injury from falls – all of which are consistent with Mr. Liou’s goals. 

Harm Reduction: 

• Since, Mr. Liou does not want to move from his two-story house I would recommend moving their bedroom to the first floor and keeping everything he needs on the first floor while avoiding clutter. This allows Mr. Liou to live in his house while also reducing the risk of falls. 
• I would also recommend Mr. Liou use assistive walking device such as cane and later moving to a wheeled walker to help him walk around, install grab bars in bathroom and install handrails on all stairs. 

Mr. Liou should also receive low to moderate statin for CVD prevention if he has a calculated 10-year risk of a cardiovascular event of 10% of greater since he is 1) 75 years old and 2) has hypertension.  Medication reconciliation should also be done. 

Brief intervention: 

Weight management: Although Mr. Liou is not obese, his BMI of 27.4 is concerning. Early intensive counseling and behavioral interventions are necessary. However, Mr. B has already lost 10 pounds, I would first inquire if the weight loss was intentional or unintentional. His response would help guide my line of intervention. The intervention would be provided using the 5As in obesity – Ask, Assess, Advise, Agree and Assist. 

• Ask: I would first ask permission to address the patient’s weight and how it is affecting him. “Would you be okay with discussing your weight?”
• Assess: Assessing Mr. Liou’s health status and identify its effect on his life. Assessment then leads to introducing to the patient the possibility of lifestyle modifications for weight loss and management. Mr. Liou is overweight, has hypertension and now has been diagnosed Parkinson making it difficult for him to walk, stand for a long period of time and making it harder for him to do household chores he did before. Exercising and diet not only has a positive impact on his hypertension, GERD, and weight he would gain strength and could slow the progression of his PD symptoms. 
• Advise: After asking and assessing his situation, I can advise Mr. Liou on different ways to manage his weight after asking permission to give advice asking, “Can I provide you with some methods/plan that can be used to help manage your weight?”  and also ensure that the goals are attainable.
• Agree: After getting permission to advise and providing different plans of action it is important to agree on a plan of action. For example, “Mr. Liou, you have decided that you would like to reduce sweets to once a week, take tai chi classes and go to a physical therapist to increase your strength.”
• Assist: I would assist Mr. Liou by providing him with motivational support and resources he may need. I would provide him with referrals to the physical therapist, look up tai chi classes.

Smoking cessation

Mr. Liou has a smoking history of 80 pack years. Although he has cut down some, he is still smoking one pack a day. Smoking cessation interventions are necessary for him due to his age, COPD, hypertension and Gerd. I would first assess Mr. Liou’s Heavy smoking index to identify the level of intervention needed. I would then utilize OARS to have him thinking about quitting. 

• Open-ended questions: “What effect do you think smoking has on your health?” 
• Affirmations: “It’s great that you were able to cut down on your smoking.” 
• Reflections: “You think that smoking has a detrimental effect on your health but you’re worried that you won’t be able to quit since you’ve been doing it for so long.” 
• Summarize: “You have been worried about smoking effect on your health and you’ve tried quitting, but it is very difficult for you. You’re not sure if you can quit and are wondering if there are any ways to make quitting easier.” 

I would then use 4As- Ask, Advise, Agree and Assist to further the smoking cessation intervention.

• Ask: “Now that we have talked about your readiness to quit smoking would you like me to give you some information that would help you quit?” 
• Advise: Here I would inform him about the nicotine replacement therapies: In the form of patches or lozenges but nasal and oral spray are contraindicated. Oral medication – Bupropion SR or Varenicline HCl should also be considered since his HSI is most likely greater than 2. “I would recommend using varenicline which is oral medication that blocks the nicotinic receptors and helps treat smoking addiction, that needs to be started a week before you quit or you can start with the nicotine replacement therapy through patches to reduce smoking and we can schedule a follow-up to discuss more about the oral medications to quit.”
• Agree: We would agree on a course of action that would most likely result in adherence to the plan. “You feel as though you are not completely ready to quit but would like the nicotine replacement therapy and want to follow up in 2 weeks to talk more about smoking cessation.” 
• Assist: “It is amazing that you have decided to take this action. We are going to schedule a follow up to assess what has worked for you and what hasn’t to either revaluate or continue our course of action.”

Order of Issues to address first: 

Mr. Liou is a 75-year-old retired construction worker, current smoke with 80 pack years with a history of hypertension, benign prostatic hypertrophy, COPD, GERD. He was recently diagnosed with Parkinson’s Disease. Since, his main goal is to become stronger in order to be able to manage home tasks allowing him to continue living in their two-story house the order of issues to be addressed first is:  

• Fall prevention/Exercise
• Immunization
• Screenings
• Tobacco use and cessation
• Diet and nutrition 

References

1. CDC. “Power of prevention” 2009, [PDF file]. Retrieved from  https://www.cdc.gov/chronicdisease/pdf/2009-Power-of-Prevention.pdf
2. CDC. “adult vaccine schedule 2019”, [PDF file]. Retrieved from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
3. CHI. “Treating tobacco addiction” 2010, [PDF file]. Retrieved from  https://www1.nyc.gov/assets/doh/downloads/pdf/chi/chi29-suppl3.pdf
4. Motivational Interview. PowerPoint, Professor Sarah Shami PA-C 
5. Parkinson’s foundation. “Fitness Counts – A body guide to Parkinson’s Disease” 2018. [PDF file]. Retrieved from: https://www.parkinson.org/sites/default/files/Fitness_Counts.pdf
6. U.S. Preventive Services. “USPTF A and B Recommendations” – https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
7. Vallis M. “Modified 5 As” 01/2013. [PDF file].
8. https://wakegastro.com/patient-info/gerd-diet/
9. Writing an exercise Rx. PowerPoint, Professor Sarah Shami PA-C