Case Study Elements: John Liou

Case Study Elements: John Liou

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Last Dose


Risk Factors/Why Given


> 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



Tetanus, Diptheria, Pertussis

> 10 year

Tdap 1 dose


Td 1 dose

Patient needs Tdap booster as it must be given every 10 years.



Zostavax 1 dose

After age >60, each individual should get shingles vaccine  (with some exceptions)

Hepatitis B


3 dose

Increased Risk Factors:




PPSV23 1 dose

Increased Risk Factors:




Screening Tests



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.

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


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.


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. 


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