John Liou Case Study

The first issues of Mr. Liou should be addressed is the injury prevention, due to his old age and Parkinson’s disease.

Immunizations:

Assume that Mr. Liou has all his childhood immunizations, including HPV vaccine where appropriate

1. Influenza –1 dose annually, because Mr. Liou has been seen in November
2. Td booster – every 10 years, because Mr. Liou’s last Td vaccination is 10 years ago
3. Zoster – 1 dose, because Mr. Liou is 75 year old (older than 65 years)
4. PCV13 and PPSV23 – if pt has not received CV or PPSV23 before, administer PCV 13 followed by PPSV23 at least 1 year after PCV13

Screening

1. Alcohol misuse – USPSTF recommend screening for any adult at age 18 to 80
2. Depression – USPSTF recommend screening for any adult at age 18 to 80
3. Lung cancer screening – LDCT screening, Mr. Liou is at high risk of lung cancer, 75 year old male currently smoking with 80 pack-years
4. Colon cancer screening – based on Mr. Liou’s own personal preferences, life expectancy, overall health, and prior screening history to make a decision about whether to be screened
5. Skin cancer screening – only if Mr. Liou has any suspicious moles/other spots should be further investigated
6. Prostate cancer screening – Even though Mr. Liou has benign prostatic hypertrophy, I will NOT suggest to order prostate cancer screening due to two reasons. First, the National Cancer Institute says that an enlarged prostate does not increase the risk of prostate cancer. Second, the USPSTF recommends against routine screening in men 70 and older. However, the decision making should be based on the conversation with Mr. Liou about pros and cons and also his past PSA levels and his health. (Prostate cancer screening is not recommended for men ages 76 or older. A high PSA level does not generally mean that a man should have a prostate biopsy.)

Health Promotion/Disease Prevention Concerns:

1. Injury Prevention

• Falls prevention – due to old age and Parkinson’s disease
• Burn prevention – due to old age and current smoker
• Choking prevention – eating problem due to Parkinson’s disease
• Traffic safety

2. Diet 

• Relevant dietary issues:

1. Less meat intake
2. High sodium consumption
3. High sugar intake

• Specific health issue and how diet should be modified to address them:

1. Hypertension: Using the DASH diet. Based on the recommendation of American Heart Association, Mr. Liou are encouraged to eat a diet that is rich in fruits, vegetables, whole-grains, low-fat dairy products, skinless poultry and fish, nuts and legumes, non-tropical vegetable oils. As well, limit saturated and trans fats, sodium, red meat, and sweets and sugar-sweetened beverages. Avoid high-sodium diet; high-calories consumption; be aware of alcohol intake.
2. COPD: Choose complex carbohydrates, such as whole-grain bread and pasta, fresh fruits and vegetables; limit simple carbohydrates, including table sugar, candy, cake and regular soft drinks; choose mono- and poly-unsaturated fats, which do not contain cholesterol; limit foods that contain trans fats and saturated fat.
3. GERD: Prevent or relieve the symptoms from GERD by changing diet. Mr. Liou may needs to avoid certain foods and drinks that make his symptoms worse, such as fatty foods and fried foods; chocolate; coffee and caffeinated drinks, including tea and soda; peppermint; citrus fruits and products, such as lemons, oranges and orange juice; greasy or spicy foods, like black pepper, garlic, raw onions; tomatoes and tomato products; alcoholic drinks, particularly red wine. Other dietary changes that can help reduce his symptoms include decreasing fatty foods; eating small, frequent meals instead of three large meals; don’t overeat; don’t eat before bedtime.
4. Parkinson’s disease: No singular diet can treat Parkinson’s disease or its symptoms, but a healthy and balanced diet can improve general well-being. Mr. Liuo should avoid cured, fermented or air-dried meats or fish; aged cheeses; fermented cabbage, like sauerkraut, kimchi; soybean products, including soy sauce; red wine and tap beer
5. Overweight: Eat more veggies, fruits, whole grains, fish, beans, and low-fat or fat-free dairy; and keep meat and poultry lean. Limit empty calories, like sugars and foods with little or no nutritional value.

• A plan outline to address dietary modification:

1. Use More Spices and Less Salt, for example, eat fresh, plain frozen, or canned “with no salt added” vegetables and meat; use herbs, spices, and salt-free seasoning blends in cooking and at the table; use low- or reduced-sodium or no-salt-added versions of foods
2. Try reduced-fat, low-fat, or fat-free milk, yogurt, or ice cream and nondairy options like soy or almond milk;
3. Try lean meat, poultry without its skin, fish, tofu, or eggs;
4. Try marshmallows, angel food cake, gelatin desserts, fruit-based desserts, or low-fat pudding instead of chocolate, cookies, cakes, pastries, or peppermints.
5. Increase fluid consumption. Aim to drink six to eight 8 ounce glasses of water per day;
6. Increase dietary sources of fiber consist of fruits, vegetables, legumes, whole grain breads and cereals; increase the omega-3’s intake, such as salmon, mackerel, herring, sardines, trout, pilchards and anchovies;
7. Increase foods that are rich in potassium, magnesium calcium, and vitamin D;
8. And also change eating habits, including eat five or six small meals each day, instead of several large meals; allow 2 hours to digest your food before lying down.

3. Exercise 

• According to WHO Recommended Levels of Physical Activity for Adults Aged 65 and Above, Mr. Liou does not get adequate exercise. Due to poor mobility, he should perform physical activity to enhance balance and prevent falls on 3 or more days per week.
• Exercise plan for Mr. Liou:
  • The goals of this exercise plan: improve functional capacity and ability to perform activities of daily living, increase muscle strength and endurance, improve range of motion, and reduce risk of injury.
  • Choose activities that Mr. Liou enjoy and will do regularly. If walking is too difficult, cycling, swimming and chair activities are good alternatives.
  • Start with shorter sessions (10 to 15 minutes) and gradually build up to 30 minutes, five days per week.
  • Perform low-level strength-training exercises using light weights. Incorporate flexibility, eye-hand coordination, reflex training, and fall prevention activities.
  • Take frequent breaks during activity if needed. The workouts should be comfortable and not strained.
  • Since the fatigue, try exercising first thing in the morning.
  • Since the risk of falling or becoming rigid, hold on to a chair when performing standing exercises or do chair-based exercises instead.
  • Avoid exercising alone

4. Harm Reduction

Current smoking: replacement of tobacco with smokeless nicotine alternatives

Brief Intervention (outline the format for the brief intervention and give example questions you would use for each section)

1. Obesity

• Ask Liou about weight control “Are you concerned about your weight’s effect on your health or your quality of life?” Based on the case information, Mr. Liou he is overweight. So I will ask for permission to discuss weight control.
• Assess Mr. Liou’s health status, obesity indicators; ask about weight, nutrition and/or physical activity habits. “Please tell me more about your daily diet and physical activity.”

Also assess readiness to make behavioural changes, “what is your confidence you could lose weight, rated on a scale of 1 to 5, with 5 being very confident?”

1. If he wants to lose weight now or recently, assess BMI, waist circumference and obesity stage.
2. If he is not ready to lose weight, offer him information and recourses, such as risk of overweight; lose weight strategies; harm reduction approach. And also provide motivational intervention.

• Give clear, specific and personalized behavior change advice, including information about personal health harms and benefits

“I think you need to lose about 17 pounds to lower your cholesterol and blood pressure. If you do this, you may be able to avoid taking medication every day.”

• Collaboratively select appropriate treatment goals and methods based on Mr. Liou’s interest in and willingness to change the behavior

“I believe a realistic goal for you would be to lose about 17 pounds in the next 6 months. You would need to lose about 1 pound a week. What do you think about that plan?”

• Assist in identifying and addressing barriers, provide resources and arrange regular follow-up, “would you like me to refer you to take a consulting course?”

And also arrange follow up for reinforcement and troubleshooting. “I would like you to schedule an appointment in 2 week to let me know how this weight loss plan is going.” When doing the follow up, ask him ”what is working for you?” and “what has been difficult?”

2. Smoking Cessation

• Ask Liou about tobacco use “do you currently smoke or use other forms of tobacco?” Based on the case information, Mr. Liou has been a smoker all his life. He has cut down some, but is still smoking one pack a day (total 80 pack-years). So I have ask for permission to discuss for change
• Since any current tobacco use place a patient at risk, I have to advise Mr. Liou to quit it. “Quitting tobacco is one of the best things you can do for your health. I strongly encourage you to quit.”
• Assess readiness to change, health status and level of tobacco dependence. I will ask Mr. Liou “Are you interested in quitting tobacco?”

1. If he wants to quit now or recently, assess tobacco use and dependence.

“How many cigarettes do you smoke per day?”

“When do you have your first cigarette after waking?”

“How long have you been smoking?”

“Have you quit in the past? If yes, how many times and how did you quit?”

1. If he is not ready to quit, offer him information and recourses, such as risk of second-hand smoke and tobacco use; cessation strategies; harm reduction approach. And also provide motivational intervention.

• Assist to make a quit plan and supports if ready

If him ready to quit now, prescribe him cessation medication and provide self-help materials. If needed, referral to cessation consulting program.

• Arrange further assessment, treatment, and follow up for reinforcement and troubleshooting. When doing the follow up, assess “what is working for you?” and “what has been difficult?”

3. Substance Use

• Ask questions about substance use
• “In the past year, how many times have you used the alcohol, prescription drugs for nonmedical reasons, and illegal drugs?”
• Based on Mr. Liou’s case information, he does not use drug in the past year. The next step is reinforcing abstinence and the screening is complete.
• Based on Mr. Liou’s case information, he does not use alcohol in the past year. Then advise him that “no more than 3 drinks per day and no more than 7 drinks per week.”

 

Sources:

https://www.cancer.gov/types/prostate/understanding-prostate-changes

https://www.mayoclinic.org/diseases-conditions/prostate-cancer/in-depth/prostate-cancer/art-20048087

https://www.mskcc.org/cancer-care/types/prostate/screening/screening-guidelines-prostate

https://www.aafp.org/afp/2006/1115/p1688.html

https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/eating-diet-nutrition

https://www.webmd.com/heartburn-gerd/triggers#2

https://www.michaeljfox.org/understanding-parkinsons/living-with-pd/topic.php?nutrition

https://www.foodforthebrain.org/nutrition-solutions/parkinsons-disease/about-parkinsons-disease.aspx

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

http://www.who.int/dietphysicalactivity/factsheet_olderadults/en/

https://www.medscape.com/viewarticle/719179

https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/living-with-copd/nutrition.html

https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/managing-blood-pressure-with-a-heart-healthy-diet

https://academic.oup.com/fampra/article/31/4/389/710905

http://www.sdta.ca/mrws/filedriver/DentistTobaccoInterventionAlgorithmSept06.pdf