2017 fall: HPPA 512 HPDP: Case Study

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Barry Anderson




He received all childhood vaccinations which include Hib, MPSV4, MenB, MMR, varicella, HAV and HBV.

He needs:   Influenza

Tdap (Td booster if he already got Tdap before)

Zoster, PCV 13, PPSV 23 because of his risk factors




Alcohol misuse

Tobacco use and cessation

Substance abuse

HIV infection

Hepatitis B virus infection

Hepatitis C virus infection

Syphilis (serology)

Herpes (type specific serology for HSV-2)

Chlamydia and gonorrhea (urine NAAT and rectal swab, oropharyngeal swab if ROI)

Lung cancer with LDCT


Health Promotion/Disease Prevention Concerns


Injury prevention concerns: Safe sleep environment (using safe shelters)

Burn safety (smoking attention)

Injection safety (skill, knowledge and cessation)
Traffic safety (do not travel after drug use)

Firearm safety (safe place)


Harm reduction:                    Safer Sex education (using condom)

Needle exchange programs (using clean, new needle)

Overdose protection programs


Diet:  Malnutrition concern (low protein, vitamin deficiency, unbalanced diet)

I would recommend alcohol cessation and a healthy eating pattern (high protein, low fat, low carbohydrate, and low salt), including a variety of vegetables (dark green, red and orange), whole fruits, whole grains, fat-free or low-fat dairy (milk, yogurt, cheese, and/or fortified soy beverages), a variety of protein foods (seafood, lean meats and poultry, eggs, legumes, nuts, seeds, and soy products).

Diet plan example: (2400-3000 calories per day)

Breakfast: strained orange juice, whole wheat, and served with butter (omit cream)

Lunch: three to four glasses of rich milk, wheat bran, fish

Dinner: celery or vegetable salad with nuts and oil; turnips, carrots, winter squash, or

onions; white meat of chicken; A potato or a corn muffin.


Exercise: He needs regular exercise. Of course, his nutrition supply should be compatible with his exercise level.

Exercise plan example (75 minutes vigorous-intensity aerobic activity and 2 days muscle strengthening):

Monday, Wednesday and Friday: 25 minutes of jogging

Tuesday and Thursday: weight lifting




  1. Smoking


  1. Ask about tobacco use.


Vital signs stamp:

Vital Signs:

BP: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PULSE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ RR: _ _ _ _ _ _ _ _ _ _ _ _ _ _

WT: _ _ _ _ _ _ _ _ _ _ _ _ _ _ HT: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ BMI: _ _ _ _ _ _ _ _ _ _ _ _ _

Tobacco Use:

Current_ _ _ _ _ _ _ _ _ _ _ Former _ _ _ _ _ _ _ _ _ _ _ _ _ _Never _ _ _ _ _ _ _ _ _ _ _ _


Question sample: Do you smoke currently?


  1. Assess his level of tobacco dependence.


Ask how much and how long he has smoked. To assess his level of addiction, administer the Heavy Smoking Index (HSI), which consists of 2 simple questions:

How many cigarettes, on average, do you smoke per day?

1-10 (score 0); 11-20 (score 1); 21-30 (score 2); 31+ (score 3)

How soon after waking do you smoke your first cigarette?

Within 5 minutes (score 3); 6-30 minutes (score 2); 31-60 minutes (score 1); 61+ minutes (score 0)

An HSI score greater than or equal to 4 indicates a high level of nicotine dependence in adults.


  1. Advise him to quit smoking.


For example: “As your physician and someone who cares about you and your health, I would like to help you quit smoking because quitting smoking is the best thing you can do to improve your health.”


  1. Assess readiness to quit. Ask each patient who smokes whether he would like to quit.


Open-ended questions: “What are some of the reasons you would like to quit smoking?”

Affirming statements: “It’s great that you are motivated to quit smoking.”

Reflective listening: “It sounds like trying to quit smoking has been frustrating for you.”

Offer support (counseling and/or pharmacotherapy) to help move the patient toward quitting smoking.


  1. Counsel patients to quit.


Motivational interviewing, pharmacotherapy, brief and including practical suggestions for quitting and the best ways of managing withdrawal symptoms and getting support:

Set a quit date—ideally within 2 weeks.

Consider nicotine replacement products and other medications and use them correctly.

Try to avoid smoking triggers, such as alcohol.

Anticipate future challenges to prevent relapse.

Get support. (get a “quitting buddy” and call 311 to be referred to free or low-cost counseling services and medications)


Sample question: Could we set up a quit date, such as one week later?


  1. Prescribe pharmacotherapy to him if he wants to quit.


Patch and ad libitum NRT (gum and/or lozenges) strongly recommended.

Strongly encourage group or individual counseling of 4 or more sessions of at least 10 minutes each.


  1. Follow up with patients who are trying to quit.


If possible, schedule follow-up within the first week and a second follow-up session within the first month, by person or phone.



B: Substance use


Brief interventions can follow the “A’s” format: Advise, Assess, Assist, Arrange.


NIDA-Modified ASSIST drug use risk assessment and brief intervention:

Lower Risk (Score 0-3): Provide feedback on score. Offer continuing support. Reinforce abstinence

Moderate Risk (Score 4-26): Provide feedback on score. Offer continuing support. Advise, Assess, and Assist. Consider Arranging referral.

High Risk (Score ≥27): Provide feedback on score. Offer continuing support. Advise, Assess, and Assist. Arrange referral.

Adapted from NIDA Resource Guide: Screening for Drug Use in General Medical Settings. www.drugabuse.gov/nidamed/resguide/screeningtool.html.


  1. Advise: Provide information and feedback about personal risk.


The brief intervention begins with a strong statement of the specific health risks posed by the patient’s drug use and advice to make a change if he is engaged in any risky use. Let the patient know that there is a moderate or high risk of developing a substance use disorder, based on his NIDA-Modified ASSIST responses. Emphasize the health consequences of the patient’s current substance use and how changing behavior will improve his health. Point out that there are many ways to change substance use behavior and that you are here to provide support, treatment, and referrals.


Sample question: “Based on your NIDA-Modified ASSIST responses, there is a high risk of developing a substance use disorder. Would you like to know the health consequences and what would happen after changing your behavior?”


  1. Assess readiness to change and set priorities.


Encourage the patient resistant to change or further treatment to engage in preventive care and to agree to continue the discussion at the next visit. Focus on: a. Health improvement goals—changing drug use: As with smoking cessation, goals may range from abstinence to using less frequently or in smaller quantities. Avoiding settings in which drugs are likely to be used may help reduce drug use.

  1. Harm reduction (eg, overdose prevention, safer use, sterile syringes, condoms). If drug

abstinence is not a realistic goal, preventing adverse consequences is a priority.


Sample question: “Given what we have talked, are you interested in changing your use?”


  1. Assist the patient in developing a plan.


What are the patient’s short- and long-term goals? Help the patient craft a plan for cutting back or eliminating drug use. Keep expectations realistic and develop contingency plans. Remind the patient that relapse and other setbacks are often part of the process.


Sample question: “Would you please tell me your short- and long-term goals?”


  1. Arrange follow-up if possible.


Several visits may be required to help the patient move toward recovery. Summarize the discussion and plans for follow-up and end the visit on positive terms. Also recommend that the patient who use drugs seek voluntary mutual support groups such as Narcotics Anonymous, Cocaine Anonymous, or Rational Recovery, and refer the patient with high-risk use to drug treatment.


Sample question: “Would you please set up a next appointment date?”



Items/issues should be addressed first: heroin use and loss of weight