Immunizations:
1) Influenzaà I would talk to him about the benefits of the Flu vaccine, but if he still resists than I cannot give him the shot.
2) Td/Tdap
3) Varicella
4) Zoster
5) PCV13
6) PPPSV23
7) Hep A
8) Hep B
9) MPSV4
10) Men B
11) Hib
Screening:
1) Alcohol Misuse
2) Depression
3) HTN
4) Obesity
5) Tobacco Use and Cessation
6) Lipid Disorder
7) Abnormal glucose/diabetesà Even though this is not in the guidelines, I would still check because the patient is overweight, and has many other health concerns. I would want to be positive that the patient does not have diabetes, because that would only add to the list of problems. Also Mr. John admits to eating sweets too often, which is a red flag for diabetes.
8) AAAà Even though this is against guidelines, males that smoke are at much higher risk of getting AAA. The patient also complains of back pain, which is a symptom of AAA. Please see link below.
9) Lung Cancer
Injury Prevention:
Mr. John is susceptible to falling, as he is tripping more often due to early signs of Parkinson’s Disease. It is important that Mr. John practices primary prevention by reducing his risk of falling. Mr. John also mentioned that he would like to get stronger, so he could continue to engage in his normal activities, such as ranking leaves, gardening, maintaining his house, as so on. According to the Journal of Safety Research, fall risk can be reduced by modifying risk factors, such as, lower-body weakness and problems with gait and balance. The most effective intervention strategies used clinical assessment, patient follow-up, as well as individualized fall risk reduction. Forms of exercise that could reduce the risk of falling include: Tai Chi, balance and gait training, and strength building. These forms of exercise could be done at home through individualized in-home programs. Other injury prevention strategies include eliminating tripping hazards, using non-slip mats in the bathtub and shower floors, installing grab bars next to the toilet and shower, putting handrails on both sides of the stairway, and improving home lighting.
Diet:
Starting out with the positives, it is a good thing that Mr. John includes many vegetables in his diet. It is also beneficial for him if he continues to eat less meat. One the other hand, a traditional Chinese diet has a high salt content, which is not helping Mr. John with is HTN or COPD. Mr. John also admits to eating sweets often, which would cause his HTN and GERD to worsen.
In order to address this issue there needs to be lifestyle changes made to Mr. John’s diet, even if his wife resist. As clinicians we need to notify the wife of the benefits of changing Mr. John’s could bring, hopefully changing her mind. For the HTN, there needs to be modification to the salt intake. I would recommend the DASH diet to my patient, in which they would intake more fruits, vegetables, and low-fat dairy foods. Mr. John would have to cut back on high saturated fat, cholesterol, and trans fat foods, such as fried foods, including eggs with yolk in them. It is good that Mr. John does not eat much meat anyways, but if he could modify his diet where he would eat fish and poultry instead of red meat, it would help his health as well. Eating more whole-grains and nuts, and limiting sweets, would benefit him exponentially.
It is important the COPD patients get their protein, and for Mr. John, taking into consideration that he has HTN, I would recommend that he obtains his protein through eggs (without the yolk), nuts, beans, whole-grains, and once again, low-fat diary products. However, due to Mr. John’s Parkinson’s Disease, it is recommended that Mr. John stay away from proteinic meals, in which I would recommend that Mr. John eat protein but in limited amounts, such as once a day, and even then, control the portion of protein that is taken in, so the medication that Mr. John is taking would be absorbed in the best way possible. Also taking his medications 30 minutes before, or 60 minutes after a meal would help with the absorption of his medications. According to The Michael J. Fox Foundation, people with Parkinson’s should specifically avoid soy sauce, which tends to be a very common ingredient in traditional Chinese diet, so that needs to be adjusted. Dietary changes that could be made to ease the symptoms of Parkinson’s disease include eating a lot of fiber and drinking lots of fluid. Mr. John can obtain his fiber from eating fruits, with the peel on it, vegetables, legumes, oatmeal, and whole grain breads and cereal.
Due to Mr. John’s GERD, it would be wise for him to stay away from foods that weaken the LES, such as fatty foods, including, chocolate, peppermint, coffee, alcoholic beverages, citrus fruits and juices, tomato products, and pepper.
It is important to take into consideration that the diet plan provided causes Mr. John to make dramatic lifestyle changes in his diet. However, these recommendations should not be taken up at once, but instead in pulsations, where Mr. John could adjust slowly to improve his diet.
Exercise:
According to the information provided, Mr. John has been experiencing slow decline in physical function over the past five years, is de-conditioned, has difficulty standing and walking for any length of time, is unable to navigate stairs, and when at home is quite sedentary. Mr. John is not getting adequate exercise per current guidelines. With this being said, the clinician needs to take into consideration Mr. John’s physical capabilities and adjust an exercise plan accordingly. Because Mr. John is in a sedentary state, according to CDC guidelines, Mr. John should start off by exercising a few minutes a day, taking the Parkinson’s into consideration, he should very slowly increase this time to 30 minutes a day. The exercise that I would recommend for Mr. John, that would not only help him reach his goal of gaining strength, but also seen to show improvement in Parkinson’s patients, is Tai chi. Tai Chi is a noncompetitive martial art that has many health benefits and comprises of gentle physical exercise and stretching. Tia Chi has been shown to improve balance control, fitness, flexibility, and reduces the risk of falls in older people. Mr. John’s heart rate should reach at least 73 bpm while exercising and if his heart rate exceeds 101 bmp, that would be a huge accomplishment, but should not be expected any time soon. Just in case Mr. John does make significant improvements with his physical activity, it should be noted that Mr. John’s heart rate should not exceed 123 bmp, which would cause muscle soreness and decreased oxygen to his muscles while exercising.
Harm Reduction:
Mr. John has COPD as well as HTN and his 80 pack-year needs to be addressed. The best harm reduction strategy for Mr. John would be replacement of his tobacco cigarettes with nicotine alternatives, such as NRT. Nicotine Replacement Therapy would include gums, patches, oral inhalers, lozenges, and nasal sprays. These options would need to be discussed with Mr. John and whether he is willing to cut back on the number of cigarettes he smokes a day. Even subtle changes such as cutting back on one cigarette a day will help reach the goal toward his health.
Brief Intervention:
Mr. John is neither obese nor does he participate in substance use. A Brief Intervention needs to be conducted for smoking cessation. I would use the 5 A’s model:
Ask– The information provided already tells the reader that Mr. John is a 80 pack-year smoker and he is currently smoking, so there is no need to ask if he is currently smoking. The reader is also informed that Mr. John has “cut down some”, which makes the reader assume that Mr. John might have some willingness to quit smoking, but needs some motivation. I would explore Mr. John’s readiness to change in this step as well, by asking him “On a scale of 1 to 10, how willing are you to change?” If Mr. John responds by telling me a number that is less than 10, I would ask him “What would make you number go up by one?”
Advise– First I would start off by asking “Is it okay if I give you some advice and information on smoking?” After receiving Mr. Johns permission, I would tell him about the health risk of smoking as well as the benefits of quitting. For example, if Mr. John stops smoking, there will be an immediate reduction in the rate of his COPD progression. I would also notify Mr. John of medications he could take in order to decrease his smoking addiction.
Assess– This where I would assess the health status of Mr. John and also assess his addiction to nicotine by using the heavy smoking index. The reader is already notified that Mr. John smokes a pack a day, which is 20 cigarettes, so that would be a score of, and I would ask him “How soon after waking do you smoke your first cigarette?” and based on this question, I would determine if Mr. John has a high level of nicotine dependence. This would also be my chance to determine what other motivating factors may exist, such as how second-hand smoke would be bad for his wife, children, and grandchildren. I would also mention how cutting back on smoking would save him lots of money.
Agree– Assuming Mr. John wants to quit, I would discuss a quit date with him, which should be 2 weeks from that day. I would also schedule a follow up within the next week to see how Mr. John is progressing. Another follow-up visit will also be necessary within the next month, considering that Mr. John might relapse during this time. This is also when Mr. John and I will agree on medications that he will take to help with his addiction, which as stated before would be the gum, nicotine patches, inhalers, and so on. Mr. John and I would formalize a plan together, which would be most realistic in his situation and agree to discuss his progression within the next week.
Arrange/Assist– This is when I would provide Mr. John with his prescriptions, as needed, and arrange for follow-ups and stated before. If I feel that Mr. John needs support, whether it be from a support group, the internet, or myself, I would make arrangements for Mr. John so he is most successful in his lifestyle change.
Sources:
I used Professor Shami’s PowerPoints and other materials that were provided on Blackboard by Professor Shami.
https://bbhosted.cuny.edu/bbcswebdav/pid-31020747-dt-content-rid-133190770_1/xid-133190770_1
https://bbhosted.cuny.edu/bbcswebdav/pid-31020661-dt-content-rid-133190735_1/xid-133190735_1
https://www.sciencedirect.com/science/article/pii/S002243750500071X
https://www.michaeljfox.org/understanding-parkinsons/living-with-pd/topic.php?nutrition
https://www.webmd.com/heartburn-gerd/guide/reflux-disease-gerd-1#2-7
https://www.medicalnewstoday.com/articles/265507.php
https://www.webmd.com/hypertension-high-blood-pressure/guide/dash-diet#1
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