Nicole Arrington

 

Patient Name:  Jackson, Damien

Age:  33

Occupation: Truck Driver

Center For Disease Control Recommended Adult Immunization Schedule for ages 19 years or older

 

 

Immunizations

Influenza vaccination (IIV or RIV) (no allergies indicated)

Tetanus, Diphtheria, Pertussis

Measles, Mumps, Rubella

Varicella If No evidence of immunity to varicella: 2-dose series 4–8 weeks apart if previously did not receive varicella-containing vaccine (VAR or MMRV [measles-mumps-rubella-varicella vaccine] for children); if previously received 1 dose varicella-containing vaccine, 1 dose at least 4 weeks after first dose

 

 

Screening Tests:

In accordance with recommendations from the USPTSTF, Damien Jackson should receive screening tests recommended for adult patients consistent with his age, social history, and family history. This is listed below under General Screening Tests.  However, he is adopted so tests relevant to his family history are will not be based on his biological family history but on current guidelines specific to his health needs.

 

 

General Screening Tests
Adult Preventive Health Care Schedule: Recommendations from the USPSTF: Alcohol misuse Depression Hypertension Tobacco use and cessation: HIV Infection
Specific Tests Treatments and Improved Prognosis
Tobacco Use and Cessation (To promote longevity and enhance the length of his life, recommendation by The US Surgeon General To Stop Smoking recommended.  Use Motivational Interview-Listed Below)
USPSTF Counseling Recommendations: Diet/activity for CVD prevention 28 (B) if overweight or obese and with additional CVD risk   Obesity/weight loss: Dietary Activity and Disease Prevention	Counseling to promote healthy diet and physical activity28 (B) Recommend that overweight or obese patients with other CVD risk factor(s) be offered or referred for intensive behavioral counseling   Mr. Jackson’s other CVD risks include HTN and being overweight. Patients: BMI:  28.7, indicating patient’s weight is in the Overweight category for adults of his height/weight. For his height, a normal weight range would be from 129 to 174 pounds. Appropriate dietary and exercise issues need to be discussed to address the following:   ·      High BMI and reported “Beer Belly” – Begin moderate exercise regimen that considers patient is on his feet for work.  Recommendations for exercise based on his preference with suggestions (swimming, cycling, etc.)   ·      , 1 Gallon milk per day- Provide information on nutritional guideline, fat content of milk, alternative choices such as reducing quantity to 8 oz of low fat or skim milk at dinner, water to alleviate thirst.

Disease Prevention and Health Promotion

 

Injury Prevention

1. Traffic Safety
2. Fall Prevention
3. Choking Prevention
4. Safe Sleep Environment
5. Poisoning Prevention

Prevention of Inactivity

 

“The US Department of Health and Human Services and the CDC recommend that adults engage in 150 minutes of moderate-intensity (such as brisk walking) or 75 minutes of vigorous-intensity aerobic activity or and equivalent mix.  In addition, the CDC recommends activities to strengthen all major muscle groups at least twice a week. (Access Medicine Chapter 1-06)

 

“Damien loves to be active, but also seems to express fatigue when he has done relatively little. He says he’d like to get more exercise and have a healthier life style but does not seem to be able to really put together a plan for this…He has been noted to enjoy the outdoors, his church community and basketball.”

 

• Give Exercise Plan To Patient
• Perform Fitness Assessment

Incorporate exercise as part of patient’s routine, and base it around activities enjoyed. Patient may need to start with only 10 minutes every day of low intensity moderate exercise first four weeks, since he gets fatigued easily, and before proceeding with exercise prescription below.  Since he likes basketball and the outdoors, walking or hiking may be an option, or other activities such as swimming or cycling since he is on his feet all day.   After 4 weeks:
Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.	Total:
Walk 30 minutes	Basketball 30 minutes	Resistance 20 Band or Light Weights *	Basketball 30  minutes	Walk 30 minutes	Walk 30 minutes	20 minutes Resistance Bands or light weights*	150 -190 minutes exercise *Increase resistance gradually

 

 

 

 

Prevention of Overweight and Obesity

Diet Issues For Damien Jackson

Damien Jackson has poor diet characterized by drinking up to a gallon of (full fat) milk a day, consuming a good deal of meat, sugary drinks, snack food, pastries, and cakes of all kinds.

 

Patient education on nutrition and exercise are needed because Damien Jackson regards drinking a gallon of regular milk per day as healthy behavior.  We can build on some of his favorite foods such as edamame and incorporating  a low-fat milk into a structured nutrition plan.

NutrionDiet Plan:

Step 1: Assess Readiness.

Step 2: Make small changes by educating him on the connections between his current health issues: HTN, weight gain, fatigue, drinking up to a gallon of full fat milk a day, consuming a good deal of meat, sugary drinks, snack food, pastries may put him at risk of developing CAD, stroke, kidney disease, developing prostate cancer, colon cancer, type 2 diabetes, high blood cholesterol, gallbladder disease, arthritis, breathing problems (Aim For A Healthy Weight-US Department of Health and Human Diseases Pamphlet).

 

Gradually we can introduce water as an alternative to his consumption of milk and sugary drinks that are not a part of his diet plan.

 

Step 3: Make a nutritional comparison of his current food with suggested.

Step 4: Implement gradual changes

Keeping fresh healthy fruits and vegetables at home may provide an alternative to desserts and high sugar foods that he consumes.

 

Other precautions:

Preventing Cardiovascular Diseases

 

Metabolic syndrome is defined as the presence of any three of the following: waist measurement of 40 inches or more for men and 35 inches or more for women, triglyceride levels of 150 mg/dL (1.70 mmol/L) or above, HDL cholesterol level less than 40 mg/dL (less than 1.44 mmol/L) for men and less than 50 mg/dL (less than 1.80 mmol/L) for women, blood pressure of 130/85 mm Hg or above, and fasting blood glucose levels of 100 mg/dL (5.55 mmol/L) or above.

 

Alcohol Consumption

Limit consumption to no more than two drinks per day (1 oz or 30 mL ethanol [eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey])

 

BP 140/88

 

BMI: 28.7 Overweight Range

Hgt 5 ft 10 in Wgt 200 lbs

Waist circumference: 43 in

Regular meds (when he takes them): hydrochlorthiazide 25 mg daily, diltiazem 120mg daily, allopurinol 100 mg daily

 

Although the patients fasting blood sugar and triglycerides have not been given, his diet along with HTN and waist circumference over 43 inches may indicate metabolic syndrome.  Since the patient is adopted it is also unclear if his hypertension may have a inherited genetic component.  The patient has Hypertension, takes a diuretic, calcium channel blocker, and allopurinol to treat gout.  He may benefit from Dietary Approaches to Stop Hypertension (the DASH Diet) or a balanced healthy eating plan.

 

Plan:

Discuss Modifiable and Non- modifiable Risks for Heart Disease including physical activity, nutrition, tobacco, and alcohol.  Since Damien is adopted, the non-modifiable risks may be limited to genetic testing for certain diseases listed below under genetic testing.

Increase Physical Activity and guide patient to a personalized eating plan that reduces current calories, less saturated and trans-fat.  Test the patient’s blood glucose levels.  Provide patient with nutritional information (including information about High LDL/Low HDL/High Triglycerides) and work to modify risks associated with high fat, high sugar, diets by targeting a healthy weight and BMI.  Ensure the patient’s eating plan is rich in fruits, low-fat dairy, and vegetables. DASH diet may lower blood pressure, as well as adding increased dietary fiber. This may be most appropriate for this patient considering he has HTN.

 

Current Medical Diagnosis & Treatment 2021 > Approach to Hypertension

 

Modification	Recommendation	Approximate Systolic Reduction Range
Weight reduction	Maintain normal body weight (BMI, 18.5–24.9)	5-20mm Hg/10kg weight loss
Adopt DASH eating plan	Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated fat and total fat	8-14 mm Hg
Dietary sodium reduction	Reduce dietary sodium intake to no more than 100 mEq/day (2.4 g sodium or 6 g sodium chloride)	2-8 mm Hg
Moderation of alcohol consumption	Limit consumption to no more than two drinks per day (1 oz or 30 mL ethanol [eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey]) in most men and no more than one drink per day in women and lighter-weight persons	2-4 mm Hg

 

 

Damien weighs 200 pounds.  “If you weigh, a 5 percent weight loss equals 10 pounds, bringing your weight down to 190 pounds. While this weight may still be in the “overweight” or “obese” range, this modest weight loss can decrease your risk factors for chronic diseases related to obesity” (CDC “Healthy Weight, Nutrition, and Physical Activity).

 

 

 

Goal Weight: 132-167  BMI: 18.5-25  Caloric Intake: Approximately 2000 (Aim For A Healthy Weight-US Department of Health and Human Diseases Pamphlet).

Monday – Sunday: Breakfast: Grains: 2oz Grain Fruit: 1 cup (Choice of: apple, raspberries, blueberries, pears, peaches, plums, or other low sugar fruit) Protein:  2-3 oz protein (lean meat, lean poultry, peanut butter) Beverage: 1 cup low fat milk (or substitute i.e almond milk)   Oil: .3-5 oz oil/fat (olive oil)

Lunch: Grain: 2oz Vegetables: 2 cups leafy salad greens (or 1 cup cooked leafy salad and 6 oz cooked vegetables) Fruit:  1 cup (Choice of: apple, raspberries, blueberries, pears, peaches, plums, or other low sugar fruit) Protein:  2-3 oz protein (choice of: eggs, fish, lean meat, lean poultry, Tbsp. peanut butter, or2 oz nuts) Oil/Fat .3-.5 oz (olive oil)

Dinner: Grain: 2oz grain Vegetables: 2 cups leafy salad greens (or 1 cup cooked leafy salad and 6 oz cooked vegetables) Fruit:  1 cup (Choice of: apple, raspberries, blueberries, pears, peaches, plums, or other low sugar fruit) Protein:  2-3 oz protein (choice of: eggs, fish, lean meat, lean poultry) Oil/Fat .3-.5 oz (olive oil)   Other: *increase water intake instead of Milk

 

Tobacco

 

Smoking Cessation

 

Damien Jackson smokes cigars (about 4) when he wants to relax with friends at a cigar bar.  Part of this patient’s care should include education on the dangers of smoking, second-hand smoke, smoking cessation, and pharmacotherapies that may support quitting smoking.

 

Ask ​ ·      Are you currently smoking?​ ·      Explore readiness to change (using 1-10 scale)​ ·      If indicated, follow-up with what makes you say that number or what would help you move to a higher one​

Advise​ ·      Ask permission to give advice and information​ ·      Health risks of smoking ​ ·      Benefits of quitting – short and long term​ ·      Advise about medications and other tools to help ​

Assess​ ·      Assess health status ​ ·      Assess addiction to nicotine – Heavy Smoking Index (HSI)​ ·      Determine what other motivating factors may exist​

Agree​ ·      Discuss setting a quit date​ ·      Agree on what medications if any will be used and when to start them​ ·      Identify behavioral changes to be made/attempted​ ·      Formalize a plan together​

Arrange/Assist​ ·      Provide prescription if needed​ ·      Assist by referring to support group, internet, or other regular check-in option​ ·      Arrange follow-up ​

(Table of 5 A’s from PowerPoint  “Helping Patients To Quit Smoking)

 

 

Asking About Sexual History

CDC guide for taking sexual history provides guidelines to assess and prevent sexually transmitted diseases and infections.   It is important to discuss sexual health by determining the risk for STI by taking a complete sexual history as part of the clinical interview and update the history routinely (www.cdc.gov/hiv/basics/prep.html).

Asking about issues that may be relevant to his specific circumstances can include birth control, protecting, and maintaining sexual health.  Damien is unmarried and has a daughter with his live-in girlfriend.

 

Discuss STI ‘s and the serious health consequences   Discuss contraception if applicable   Discuss measures to prevent infection, reinfection and transmission.   Offer HIV testing to all patients 13-64 years old   Counsel patients about protecting themselves and their partner from STIs.

 

 

Other Specific Issues:

Genetic Testing may be an option for Damien for his own health benefits or if he should choose to expand his family.  Once Damien Jackson has insurance form his new job I would screen for disorders specific to African American men (i.e. colon cancer is higher in African American males and a history of colon cancer could mean the patient may have an increased risk)

 

Adherence to Medications

 

“Regular meds (when he takes them): hydrochlorthiazide 25 mg daily, diltiazem 120mg daily, allopurinol 100 mg daily”

 

The patient is not consistent when adhering to medications, which can negatively impact his health. In addition, scientific data supports adherence rates are higher for shorter term therapies because of the high cost of medicine and the patient may not understand the importance of the benefits of taking medicine.  Irregular insurance coverage is part of the patient’s issue (although he now has regular coverage).  Patient education could include providing alternatives to sporadic adherence to medication and access to medicine, inquiry into why he is not consistent with taking medication (i.e. side effects) and addressing issues related to non-compliance.

 

Plan:

Methods that can be used to improve adherence can be grouped into

four general categories:

1. Patient education.
2. Improved dosing schedules.
3. Increased hours when the clinic is open (including evening hours)

with subsequent shorter wait times.

4. Improved communication between physicians and patients.

(Enhancing Medication Adherence Chapter 6 page 41)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References:

 

www.cdcgov/vaccines/schedules/hcp/adult.html

 

www.cdc.gov/hiv/basics/prep.html

 

The Dash Diet https://pubmed.ncbi.nlm.nih.gov/10450301/

 

Current Medical Diagnosis and Treatment 2021 Lange Michael Pignone;Rene Salazar

accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?=2957&sectioned=249362093

 

PDF Aim For A Healthy Weight Patient Booklet-US Department of Health and Human Diseases Pamphlet https://www.cdc.gov/healthyweight/tools/index.html

 

 

CDC “Healthy Weight, Nutrition, and Physical Activity)https://www.cdc.gov/healthyweight/losing_weight/index.html

 

 

Bosworth, Hayden B. Enhancing Medication Adherence The Public Health Dilemma . 1st ed. 2012. Tarporley: Springer Healthcare Ltd., 2012. Web.