Case Study Elements: John Liou

 

John Liou

John Liou is a 75 year old retired construction worker with a history of hypertension, benign prostatic hypertrophy, COPD, GERD, and he was recently diagnosed with Parkinson’s Disease. He has exhibited a slow decline in physical function over the past five years.  He has lost some weight (about 10 pounds in 5 years), but would still be considered overweight.  He is generally de-conditioned, and is having difficulty standing and walking for any length of time. He will lean against a wall if the need for standing is more than a few minutes. He is complaining of some hip and back pain and has been having trouble with tripping more often (a common early symptom of Parkinson’s) which is making him more fearful of walking.  He tends to sit when at home, and is in general quite sedentary.  He is able to navigate stairs within the home with some difficulty and until very recently was able to manage some light gardening and home maintenance chores.

He lives with his wife of 54 years in a small, two-story house in Flushing.  His wife is concerned about their future and how long John can manage at home.  She would like to move to an apartment, so that John will no longer need to worry about raking the leaves, and managing all the home tasks he has always performed in the past, but John is resistant to this idea.  You have discussed this idea with him in light of his recent diagnosis, but he says that he wants to stay in the home he and his wife have lived in for many years.  He asks you if there isn’t some way you can help him get stronger so they can continue to do so.

His past medical history is noted above.  His immunization records indicate that he has not received any vaccines since his last tetanus (Td) vaccination 10 years ago.  He was offered the flu vaccine last year, but declined it saying that he heard you could get the flu from it.

His family history is vague – he left China as a very young man and has not been in touch with his family since.  He knows that his parents died in an earthquake after he left, but he knows little about their health concerns.  He has one sister who lives in California, but he hasn’t been in very close touch with her either.  He thinks she had some “woman’s trouble” at some point and had surgery, but he doesn’t know the details.  He has three children, all alive.  His son has hypertension and one daughter had a congenital heart condition, but that was taken care of with surgery when she was young.  His grandchildren are all alive and well.

John has been a smoker all his life.  He has cut down some, but is still smoking one pack a day (total 80 pack-years) and is taking 15 different medications.  He was recently prescribed a new medication for his GERD symptoms which brought on intense dizziness to the extent that he could not walk without leaning against the wall.  He discontinued the medication and the symptoms faded over a 24 hour period.

His diet is a traditional Chinese one, prepared by his wife mostly.  He eats a fair amount of vegetables and not too much meat.  His diet is fairly high in salt, but he says that his wife has been resistant to changing her way of cooking “after all these years”.  He confesses that he does enjoy sweets and agrees that perhaps he eats them too often, “But it’s one of my few pleasures these days”.

 

Other information:

BP 120/70, seated         T 98.7               R 20                 P 84, regular

Hgt 5 ft. 6 in.                 Wgt 170 lbs.

Medications:

• Hydrochlorthiazide 25mg daily
• Enalapril 2.5 mg twice daily
• Nifedipine XR 30 mg daily
• Potassium Chloride 20 meq daily
• Tiotropium inhaler 2 puffs daily
• Albuterol inhaler 2 puffs daily
• Omeprazole 40 mg daily
• Cimetadine 400 mg at bedtime (now discontinued after dizziness)
• Carbidopa/Levodopa (25/100) 3 times daily
• Naproxen sodium 200 mg 3 times daily
• Tylenol 350 mg – two tablets twice a day as needed
• Ferrous sulfate 300 mg daily
• Docusate sodium 100 mg daily
• Hydrocortisone cream 1% to scalp prn flaking and itching
• Calcium carbonate 500 mg – two tablets twice daily
• Sennokot (an over the counter laxative) as needed for constipation

Gen: Alert, oriented, with a somewhat increased AP diameter of his chest.  Breathing with soft, but audible grunting sounds at times when he exerts himself.  His facial expression is flat, though he smiles broadly when he makes a joke.

 

 

Immunization	Last Dose	Type	Risk Factors/Why Given
Influenza	> 1 year	Inactivated Flu Vaccine	Be sure to explain that this immunization prevents against most prevalent Influenza strains, and that is why he may have gotten the flu last year. Give this because it is November and flu season is starting for the most protection. Increased Risk Factors: ….Adults 65 and older are also at increased risk of flu ….COPD ….DM
Tetanus, Diptheria, Pertussis	> 10 year	Tdap 1 dose or Td 1 dose	Patient needs Tdap booster as it must be given every 10 years.
Shingles	Childhood	Zostavax 1 dose	After age >60, each individual should get shingles vaccine  (with some exceptions)
Hepatitis B	—-	3 dose	Increased Risk Factors: …DM
Pneumococcal	____	PPSV23 1 dose	Increased Risk Factors: …DM …COPD …Smoker

 

Test	Why
Fasting glucose	DM  maintenance (already diagnosed)
DM	DM maintenance (already diagnosed)
Tobacco Use and Cessation	High risk smoker
Hypertension (Blood Pressure)	HTN
Obesity (BMI)	Overweight
Low Dose CT Lung	> 30 pack/year current smoker 55-80 per ACS and USPSTF. AAFA recommends against screening anyone at high risk. I would screen him because of his COPD, which puts him at an even higher risk of lung cancer.
CRC CT Colonography every 5 yrs. Or annual FOB or FIT OR Stool DNA test every 3 years Flex. Sig. every 5 yrs OR Colonoscopy every 10yrs. OR Dbl-contrast BE every 5 yrs	Decision is based on patient preference and clinic’s availability. Mr. Liou is elderly and screening for CRC may not benefit him as he has degenerative disease with many serious comorbidities, like COPD. I would present the option to test for CRC and let him decide what he would like to do. Guidelines are as follows: USPSTF: Designates a specific interval between Stool DNA test of every 3 years, while ACS presents with an uncertain interval between tests. AAFP follows the same guidelines, but lists additional factors, like family history, as reasons to test earlier.
Lipid Disorder (Total Cholesterol, Fasting LDL-C, HDL-C, and VLDL)	Male >35 overweight per USPSTF along with increased CAD risk.
AAA	Current smoker 66-75 male per USPSTF with COPD
Aspirin Use	The USPSTF recommends men ages 55-79 years take an aspirin in order to prevent MI so long as there is not an increased risk of GI hemorrhage. Due to his history of GERD, I would tentatively screen for aspirin use, assuming that the GERD symptom is isolated from any possibility of GI bleed.
Fall Prevention/Vitamin D	Increased fall risk due to Parkinson’s
Counseling on CVD prevention/exercise	Overweight adult. His unique issue of Parkinson’s and decreasing mobility must be taken into account when planning.
Waist Circumference	Overweight BMI of 27.4
Smoking HSI/smoking cessation counseling	Current smoker
Drug Use
Depression	Especially given his comment about sweets being one of his few pleasures currently
Alcohol Misuse
STIs/HIV	Patient sexual history is insufficient to assess STI risk, but I would include this if he had multiple sexual partners without condom use.
EKG	Patient is unsure about family history and states that his daughter had a heart defect, possibly indicating an increased risk of heart disease. DM and HTN also indicate EKG screening.

 

Injury Prevention-

1. Fall Risk

2. Possible previous hazards encountered from time working as construction      worker

Diet

Breakfast- Try incorporating lean proteins into your diet here, like fish or even eggs 1-2 times a week.

Lunch- Focus on decreasing salt intake and drinking more water, which may help with the cravings for sweets.

Dinner- Focus on decreasing salt intake. Drink more water. Replace dessert with fruit as a healthy alternative. 

Mr. Liou is eating too much salt and too many sweets. He also needs to eat more protein. Use fruit as an alternative to sweets. Search low salt recipes in traditional Chinese cooking to use as alternatives to high salt foods. Add fish or lean protein into diet at least 4 x per week. He is also taking Ferrous Sulfate which is indicative of iron deficiency, so increasing protein intake would be beneficial. He must decrease his salt intake to help with his HTN and he should limit sweets because they exasterbate the symptoms of diabetes mellitus. Decreasing fatty foods should also aid in GERD symptoms.

Exercise

This patient is not getting the current recommended adequate exercise. The goals would be 150 minutes a week of moderate activity or 75 minutes a week of vigorous activity (Mayo Clinic). Due to the nature of his disease, a stationary bike would prevent injury and give him the cardio exercise he needs; I am cautious about physical exercise given his condition, but I believe sitting on a stationary bike should suffice so long as Mr. Liou exercises with someone else present. I would start him on a moderate exercise plan and work our way up to the suggested 150 min. of moderate exercise a week. Perhaps if the weather is nice this can take place outside so that Mr. Liou can enjoy his garden. Beginning a workout plan would help with his goal of gaining/maintaining strength.

Cardio- 3 x a week for 30 min. on stationary bike

Strength- 3 x 15 reps 3 x a week SEATED lifting weights with spotter

Harm Reduction:

1. Limit sweets to 3 x per week to start, then work on decreasing the amount to a goal of 1 per week.

2.  Attempt smoking cessation, but if it is not feasible, then attempt to limit the amount of cigarettes smoked per day starting with a decrease of 1 cigarette a week then working from there or explore nicotine alternatives.

Brief Intervention: Smoking Cessation

Ask- I would begin by asking him, “Are you currently smoking?” and ask permission to speak about smoking cessation with a question like, “I think quitting smoking is important in order to regain your strength, would it be possible to discuss this further? ”. I’d be assessing if he is ready to make progress on cessation with proper documentation for my findings. I would congratulate him on the fact that he decreased his smoking!

Advise- I would advise him regarding the risks of cigarette use and the benefits of cessation offering alternatives like nicotine therapy or support groups. For example, I’d say, “How does smoking interfere with your routine?”.  I’d urge him by emphasizing his values, for instance, since he liked to garden I would mention that his sense of smell would increase and he could smell flowers, and enhance his gardening, by quitting.  I would also address the discrepancy between smoking hindering his physical health and his desire to remain with his wife in their house; he won’t get stronger by smoking.

Assess- After addressing his health status, I’d assess his nicotine addiction level using HSI tools incorporating other motivating factors like fear of weight gain or food cravings. Some questions I may ask would include, “What keeps you from quitting?” or “I have some tips to share, is it okay if I share them with you?”

Agree- I would make a concrete quit date and explain medication information, if necessary alongside any lifestyle changes that need to be addressed. For example, if his wife smoked, I could ask, “Is there anyway to ask if she could smoke away from you, given that you are trying to quit?” Together we would make a quit plan with support. I would attempt to find out what worked (using open ended questions), or what contributed to decreasing his tobacco use before our talk and how we can tailor his habits to incorporate that into our plan.

Assure/Arrange- If necessary, I would give him a prescription and aid in finding resources for cessation. I could ask, “What kind of support would benefit you the most in smoking cessation?”. Finally, I would summarize what we discussed. I would follow up with him within a week after the quite date and schedule an office visit within the month

What to Address First:

1. Upon his physical exam, an increased AP diameter was noted. If hyperinflation was  extreme, this would be the first issue I’d address. Assuming this wasn’t an emergency, I would continue with the following.

2.   Mr. Liou is in danger of falling and severely injuring himself, so I would first address this when considering his case. I would offer handicap assistance like a walker and handicap proofing his house. I would suggest hiring a home health aide for the manual labor so that Mr. Liou doesn’t worry about chores.

3. Immunizations- Since it has been 10 years since his last vaccines, I would immunize him as soon as possible, especially because it is November and he would be susceptible to the flu and pneumonia at high risk due to smoking and COPD.

4. Smoking Cessation- Mr. Liou has COPD and HTN, both diseases which smoking can exasterbate. I would use the method above to initiate a discussion regarding cessation. 

REFERENCES:

2013 Final Motivational Techniques and Skills. www.bing.com/cr?IG=FE236756134E4E6FBBD1078D42E97C8E&CID=3E4B0432865B614F0C910F7D875D60F1&rd=1&h=4ZMK7LB5gyrYuX9BYNsePXXl1kBFgXmIZ7alro6vIyo&v=1&r=http%3a%2f%2fwww.nova.edu%2fgsc%2fforms%2fmi-techniques-skills.pdf&p=DevEx,5066.1.

“Heart disease risk calculator.” Mayo Clinic, Mayo Foundation for Medical Education and Research, www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/heart-disease-risk/itt-20084942#.

“Immunization Schedules.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 6 Feb. 2017, www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.

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Resnicow, K., Dilorio, C., Soet, J. E., Borrelli, B., Hecht, J., & Ernst, D. (2002). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21(5), 444-451.

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U.S. Preventive Services Task Force. Current Medical Diagnosis and Treatment 2017> Disease Prevention and Health Promotion. Table 1-3: Expert recommendation for cardiovascular risk prevention methods: USPSTF.

U.S. Preventive Services Task Force. Visual Adaption from recommendation statements by Swenson PF, Lindberg C, Carrilo C, and Clutter J. April 5, 2016. 

Vaccines and Preventable Diseases. (2017, November 07). Retrieved December 04, 2017, from https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html#who-should-not-get-vaccines