Patient Name: John Liou
Immunizations: List the immunizations this patient should have – assume that they have all had their childhood immunizations (including HPV vaccine where appropriate.
Assume that you are seeing the patient in November.
High Dose Flu shot, tDAP, Zoster Live, Zoster Recombinant, pneumococcal conjugate, pneumococcal polysaccharide, COVID-19 vaccine, COVID-19 Booster
No MMR or Varicella because he was born before 1957, assuming he had his 2-3 doses of HPV vaccine through age 26 years
MMR may be given in situation where there is no evidence of immunity to measles, mumps, or rubella
I would explain to patient Liou that patients do not get the flu from the flu shot
Screening: List the screening tests that you would order for this patient. If you decide to order any that have inconsistent guidelines, please say why you think they are indicated for this patient.
Alcohol misuse, unhealthy drug use, depression, tobacco use and cessation, Hep C virus infection, colorectal cancer, lung cancer via low dose CT (patient has total 80 pack-years), osteoporosis, abdominal aortic aneurysm, Tuberculosis (TB). Would only screen for HIV, Hepatitis B, and Syphilis if patient is at an increased risk.
Health Promotion/Disease Prevention Concerns – please address all that are relevant for this patient:
Injury Prevention: Identify any injury prevention concerns that should be discussed (just list them). If not addressed in the areas below, include any harm reduction suggestions/actions that are relevant to this patient
According to the patient history, patient Liou was recently diagnosed with Parkinson’s Disease. His condition has made it increasingly difficult for him to stand for more than a few minutes at a time or walk for any length of time. He complains for hip pain, back pain, and tripping often which deters him from walking. Because of this, patient Liou is considered a fall risk. However, I do not think that he should be completely sedentary. After reviewing his medications and ruling out any interactions I would place patient Liou on Parkinson’s medication and recommend physical therapy for Parkinson’s Disease. According to Hopkins Medicine, physical therapy for those with Parkinson’s teach patients to “make overexaggerated movements” as a means of “[retraining] the muscles and [slowing] down the progression of hypokinesia”. This type of therapy, combined with his new medication, may be beneficial for patient Liou and he might not be at such a risk for falling if his symptoms improve. In order to prevent injuries when he is at home, perhaps his wife or a home health aide can supervise and assist him. A home health aide might allow patient Liou to remain living in the home he and his wife have lived in up until this moment. Since patient Liou leans against the wall when he feels dizzy due to his GERD medication, I would discontinue the GERD medication causing this symptom and replace it with a different medication. If patient Liou feels very unsteady on his feet, perhaps he can employ the use of a cane to help with ambulating. A wheelchair can be recommended in later stages of Parkinson’s but the patient would need to be wheeled around.
Diet: Please identify any relevant dietary issues for this patient. While thinking about diet, consider any specific health issues this patient has and how diet should be modified to address them (you may have to look some up since you haven’t studied them yet). Based on your assessment, outline a plan to address any dietary modifications you think are indicated for this patient.
Patient Liou’s diet consists of a traditional Chinese diet. He states that he eats a fair amount of vegetables and not too much meat but his diet is high in sodium. He also admits to indulging in sweets “perhaps … too often”. Since patient Liou suffers from hypertension and GERD, I think it is essential to reduce the amount of sodium he consumes per meals as salt can raise his blood pressure. Perhaps his wife can continue to prepare and cook meals in the same manner but reduce/exclude the amount of salt that she uses. I would encourage him to continue eating vegetables and suggest some healthy meat options such as turkey or chicken breast so that he can increase his protein intake. Since patient Liou enjoys his sweets I would not want to entirely take them away; I would suggest that he reduce consumption of these sweets or opt for sugar free sweets that may be less detrimental for his health. I would follow up with patient Liou in two weeks to see how he is feeling about his diet change and whether he has been adhering to it.
Exercise: Determine whether this patient is likely to be getting adequate exercise as per current guidelines. If the patient is not meeting current guidelines, please suggest a plan to meet them that is specific to this patient’s goals and concerns.
As previously stated, because of patient Liou’s Parkinson’s he has become more sedentary and deconditioned. According to his medical history, he has exhibited a slow decline in physical function in the past 5 years and he is still considered overweight despite losing 10 pounds within this 5-year period. Since his ability to exercise is affected by his diagnosis of Parkinson’s, I would stick to my aforementioned plan of placing him on Parkinson’s medication and suggesting physical therapy. Although it might not allow him to meet the current guidelines, it will prevent him from being sedentary for long periods of time. Since he is still able to manage light gardening and some home maintenance chores, I would allow him to do continue doing so as long as he is showing improvement with the regimen provided and he is being supervised by another person (home health aide, son, daughter, grandchild, etc). I would follow up with him in two weeks
Harm Reduction: If not addressed in the areas above, include any harm reduction suggestions/actions that are relevant to this patient
Harm Reduction for patient Liou would include reducing his intake of sweets if he does not want to stop eating them entirely or opting for sugar free sweets. Additionally, if he would like to continue performing his daily activities he would need to be on medication, attending physical therapy, and under supervision as explained in the sections above. One thing I would like to add in this section that I did not mention elsewhere is in regards to his smoking habits. Although he has cut down on smoking, patient Liou still smokes one pack a day. I would suggest slowly reducing the number of cigarettes he smokes per day until he is only smoking half a pack a day and then from there we can work together to perhaps cut him down to a quarter pack a day.
Brief Intervention: where relevant to your chosen patient, please explain how you would conduct a brief intervention for:
Obesity
Although patient Liou is not considered obese based on his current height and weight, I would ask him about his weight using the 5As. The 5As are used in “intervention for obesity counseling in primary care”. The 5As stand for ask, assess, advise, agree, and assist. I would first seek permission to inquire about patient Liou’s weight. Then I would determine his health status and create a plan with him tailored to what activities he can participate in to promote weight loss. I would receive verbal consent that he agrees to this plan and provide resources if needed to help achieve a healthy weight loss goal.
Smoking Cessation
As per his medical history, patient Liou has been a smoker his whole life. He has reduced the number of cigarettes he smokes to one pack a day and has a total of 80 pack-years along with taking 15 different medications. I would use the same 5As method explained above to help him cut down on smoking.
Substance Use
N/A. aside from tobacco use, patient Liou does not use any other substances
For this section please outline the format for the brief intervention and give example questions you would use for each section.
ASK: “Hello Mr. Liou, would it be okay for us to talk about a couple of things regarding your health? I would like to ask you some questions about your weight and smoking habits. Is that alright with you?”
ASSESS:
Patient Liou is 75 y/o M w/ current medical h/o hypertension, BPH, COPD, GERD, and recent onset of Parkinson’s Disease. He has become more sedentary d/t sxs of his Parkinson’s ie: hip pain, back pain, tripping often, trouble standing or ambulating.
“How have you been feeling lately? Are you feeling depressed or anxious? Do you feel like you eat more or smoke more when you’re stressed?”
ADVISE: “Okay, I hear what you’re saying… so taking all these things into consideration, let’s try to come up with a plan that can you reach your smoking cessation goals and weight loss goal. I want to stop the medication that you’re taking for GERD and put you on a new one that won’t make you so dizzy. I also want to talk to you about perhaps starting physical therapy for Parkinson’s and starting you on a new medication for Parkinson’s that can help with your symptoms. I know you’d like to stay in the same home that you and your wife have been living in so maybe we can think about getting a home health aide who can monitor you and help you while you fulfill your daily activities. I think it would be helpful for you to cut down on smoking little by little, maybe smoking one or two less cigarettes a day until you reach your goal and for weight loss we can start with modifying your diet so that it includes less sodium, which will help with your high blood pressure, too”
AGREE: “I know it might be hard at first to make these adjustments especially where smoking is concerned but we want to take baby steps. I just want you to consider having the home health aide because it can allow you to still have autonomy and reduce the chances of you getting seriously hurt if you were to fall. All that being said, how does this plan sound?”
ASSIST: “I want to schedule an appointment with you in the next two weeks to see how you’ve been feeling about the plan and to talk about any resources you might need that can better help you reach your goals. This is a team effort and I want to make sure that what we’re doing is tailored to your needs and what you’re capable of doing.
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