HPDP Case Study – Juana Negron

Juana Is a 52 y/o female. The most concerning issues that should be addressed first are obesity and smoking. Both of these issues require counseling and long-term plans that the patient must abide by, but there is help available to support the patient. Brief interventions have been developed for these issues and are listed below. The patient’s asthma is well controlled and hopefully, with diet, exercise, and smoking cessation, she will not become hypertensive.

 

 

Immunizations

• Influenza inactivated (IIV) or influenza recombinant (RIV)
• Td booster
• Zoster recombinant (RZV)
• Pneumococcal polysaccharide (PPSV23) (due to asthma and smoking)

 

 

Screenings

• Alcohol misuse
• Depression
• Obesity
• Tobacco cessation
• HIV infection
• Cervical cancer (Pap smear with HPV co-testing every 5 years)
• Abnormal glucose/diabetes (patient is obese)
• Hepatitis C virus infection
• Colorectal cancer
• Breast cancer – biennial screening
• Lung cancer

 

Based on family history of only one member over age 50 diagnosed with breast cancer, I would not recommend BRCA Mutation screening unless patient wanted to do so or if the family member had bilateral breast cancer (or additional risk factor). I would recommend chlamydia and gonorrhea screening if further sexual history led me to believe that patient may be at increased risk, but none were stated. The patient may have a new sexual partner since she is divorced and widowed. Depending on a further sexual history I would also consider counseling the patient on STI’s. I was unable to access U.S. FRAX tool to evaluate risk for osteoporosis prior to age 60, but patient is a smoker which is a risk factor according to other sources on osteoporosis. I would engage the patient in shared decision making for the purpose of primary prevention of breast cancer. Due to patients mother having breast cancer at age 55, patient may choose to take medication that reduces risk of breast cancer (if other risk factors were identified). Although I cannot calculate her 10-year CVD risk, I would consider low to moderate dose statin therapy for this patient because she is 40-75 years old and a smoker. If the patients 10-year CVD risk was 10% or greater, I would also initiate aspirin for primary prevention of CVD and colorectal cancer. Lastly, I would counsel the patient to promote healthy diet and physical activity due to obesity and low levels of exercise.

 

 

Injury Prevention

• Traffic prevention
• Falls prevention
• Firearm safety

 

 

Diet

• Relevant dietary issues
  • Patient loves to eat “unhealthy” food and has a hard time sticking to a diet
  • Patient is obese with a waist circumference of 40 in.
• Patient has asthma and borderline hypertension
  • There’s not much sufficient evidence in diet affecting asthma except in the case of food allergies which can trigger or worsen asthma attacks. This patient does not have any known food allergies.
  • The patient is borderline hypertensive. The risk of hypertension can be reduced by diet. As stated in the 2019 research paper “Dietary Approaches to Prevent Hypertension” by Bazzano et al., the Mediterranean diet can help lower blood pressure. Studies cited stated 5.9 to 7.1 mmHg decreases in systolic blood pressure. Other dietary factors that can help lower blood pressure include reducing sodium intake, moderation in alcohol consumption, and potassium supplementation.
  • Dietary plan for patient utilizing elements of the Mediterranean diet:
    • Majority of food consumed would include vegetables, fruits, whole grains and healthy fats.
    • Patient can slowly phase in meals consistent with this diet while adjusting. Eventually, patient should be consuming mostly this diet with only a few meals a week from her previous eating habits.
    • Breakfast options: focus on whole grains, fruit, low-fat dairy, and eggs.
      • low-fat Greek or plain yogurt with whole-grain granola and fruit
      • low-fat milk with whole-grain cereal
      • whole-grain toast with cheese, eggs, and tomatoes
    • Lunch options: focus on vegetables, whole-grains, fish, cheese
      • Sandwich with whole-grain bread, choice of lean cold cuts, cheese, vegetables
      • Grilled fish with vegetables
    • Dinner options: focus on lean meats, vegetables, and whole grains
      • Choice of lean meat with whole-grain pasta and vegetables
      • Chicken breast, cheese, and tomato sauce
    • Snacks: mainly fruits and nuts
    • Replace butter and regular oil for olive oil in cooking
    • Avoid red meat, but if consumed make sure its lean and the portions aren’t large
    • Use spices and herbs to boost flavor of foods that aren’t familiar
    • Minimize salt, replace with spices
    • Minimize alcohol consumption
    • Consider a potassium supplement
    • This dietary plan can not only decrease blood pressure, preventing a diagnosis of hypertension, but can help the patient lose weight, lower cholesterol, and reduce waist circumference.

 

 

Exercise

• Current exercise
  • activities at work (unknown amount or time)
  • walks 6 blocks a day while taking dog on walks
    • average time to walk one block is about 3-5 minutes
    • patient walks for about 25 minutes a day
  • Patient has about 175 minutes of light exercise per week but could increase to moderate exercise or longer exercise at same intensity. Patient could also implement muscle strengthening exercises.
  • Exercise plan
    • Walk briskly while out with dog. Increasing the pace to a moderate intensity activity could greatly improve her health
    • Walk an extra block on each walk with dog. Even though the intensity would remain unchanged, the time per week would increase to about 260 minutes
    • Incorporate weight training: 10 minutes twice a week of light weight lifting.
    • The patients work place allows her to have the option of taking the stairs throughout the day instead of elevators. I would advise the patient to use the stairs for a few floors once a day and slowly increase the amount of stairs.
    • The patient could play games with her grandchildren, including ball games. This would be more enjoyable than a straightforward exercise.
    • The patient has arthritis in both hands, which isn’t affecting her knees as of yet, but swimming could be a great option for exercise that’s light on joints. One hour of swimming once a week could be a great start for this patient.

 

 

Harm Reduction

• Encouraging healthier choices in diet. This would include substituting current meals with meals and food suggested in the diet plan
• Replacing tobacco with smokeless nicotine alternatives. Smoking cessation covered further below

 

 

Brief Intervention

• Obesity
  • The patient would be counseled on the effect of weight on her health. Obesity negatively impacts blood pressure, blood glucose, cholesterol, sleep, depression, and risk of osteoarthritis. The patient has borderline high blood pressure which could be prevented with weight loss. Her overall health would greatly improve as well.
  • 5 A’s questions for obesity:
    • Ask: would you like to talk about how you could manage your weight?
    • Assess: would you like to discuss how your weight, BMI, and waist circumference impacts your health?
    • Advise: losing weight could lower your blood pressure, lower cholesterol, and reduce your risk for heart disease. It could also improve your sleep and mood. There are many options of diets and exercises that we can customize to your lifestyle and preferences. What you like to hear about them?
    • Agree: We have outlined a diet and exercise plan that you could slowly implement into your lifestyle. As you try out these changes, we can adjust them to make sure you are able to stick to these plans. The realistic goal we can aim for is a weight loss of about 18 pounds. How does that sound?
    • Assist: I would like to help you with anything you may struggle with. We can adjust these plans to fit your lifestyle and address your needs. I can also provide you with resources such as support groups. I would like to follow-up with your every two weeks to see how you’re doing and provide any help.

 

• Smoking
  • The patient has tried quitting smoking previously but was not able to do it. She may need a medication such as Chantix or Bupropion. Support groups and counseling may be able to help her quit as well.
  • 5 A’s questions for smoking:
    • Ask: would you like to talk about how you could quit smoking?
    • Assess: what do you think was hardest for you to quit smoking in the past? How much do you smoke?
    • Advise: smoking greatly increases your risk for heart attack, stroke, vascular disease, and cancer. Quitting smoking improves your breathing within days, your sense of taste and smell within a week, and your risk for cancer by 50% after 10 years.
    • Agree: We can try medication or nicotine replacement to help you quit. Chantix lets you keep smoking at first so that you don’t have to quit cold turkey. It’s a medication that’s very successful in helping people quit smoking. A patch, gum, or lozenge would help reduce cravings if you don’t want to take medication. We can find the best option for you. Are you willing to try to quit?
    • Assist: I will be here to answer any questions you may have. We can make a plan together and adjust it as needed. There are support groups that you can join to share your experience and connect with others that are trying to quit. There is also help available for paying for smoking cessation products.

 

References

• HPDP Class resources

 

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4366416/

 

• https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet/art-20047801