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HPDP Case Study

Christina Shamrock, PA-S, Fall 2019

HPDP CASE STUDY: JUANA NEGRON

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

For Juana, I will first of all recommend getting a flu shot since it’s November. Then I would give her the Tdap, run titers for MMR to see if she has immunity. I would speak to the patient about  Zoster vaccine (RZV, 2 doses). Since Juana is a smoker, she may need a Pneumococcal vaccination. If Juana is interested, I she can get the Hep A and Hep B vaccine as well if she wanted additional protection.

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. 
  • I would screen Juana for Alcohol misuse and depression as a part of my social history assessment. If there was something to address, I would offer a brief counseling session and refer her to a specialist. It is mentioned twice that she worries a lot. Having someone to talk to could be beneficial for Juana whether it’s me or a specialized therapist, depending on her preference.
  • HIV infection if she was sexually active,  an IV user, or had any other STIs
  • BRCA gene testing since she has a FH of breast cancer
  • Tobacco use and cessation (to access and be able to recommend the best harm reduction strategy – ask questions like “How many cigarettes, on average, do you smoke per day? How soon after waking do you smoke your first cigarette?” to determine the Heavy Smoker Index)
  • Obesity (BMI, Waist circumference)
  • Diabetes (A1C markers in blood)
  • Hyperlipidemia (lipid blood panel)
  • Hypertension (Take Blood pressure)
  • Cervical cancer (pap smear and HPV test)
  • Colon cancer (fecal occult blood (or immunochemical) test, sigmoidoscopy, colonoscopy, computed tomography colonography, or multitargeted stool DNA test)
  • abnormal glucose/diabetes – blood glucose and A1C marker
  • breast cancer (mammogram).

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).

Even though her history states that she is working with non-toxic agents, Asbestos and Lead used to be thought of as non-toxic as well as many other chemicals. I would recommend Juana to exercise every possible precaution and avoid contact with the agents she’s working with as much as she can – wear gloves at all times she is handling them as well as wearing a face mask for respiratory protection if she’s pulverizing the poison.

  • If not addressed in the areas below, include any harm reduction suggestions/actions that are relevant to this patient

Since it seems like Juana smokes ½ packs (10 cigarettes) a day, I would speak to her about cutting down the number of cigarettes first (start with one less a day), then offer alternatives like a chewing tobacco and cessation tools such as patch, gum and lozenges. Since Juana has been smoking for a while, should she decide to quit,  I would also suggest group therapy sessions so she can see that she is not the only one going through this and have support.

  • Diet
    • Please identify any relevant dietary issues for this patient

    Juana is on the right path wanting to lose weight since it can significantly improve her health if done in a synergy with some lifestyle modifications. Given her age, being at her weight poses many risks including diabetes and heart disease.

    Diet intervention I would offer would be co-crated with my patient together since it has to be something she can easily do. I like to begin any diet intervention with an addition rather than subtraction. I would suggest the patient adds whole grains, leafy greens (raw and cooked), nuts and seeds, legumes, berries and fresh fruit and vegetables to her diet. I understand that can be strenuous for a budget so we would have to be creative to outline what works for her. Having all the healthy food at home would hopefully help her gravitate towards it.

      From the foods to avoid, given her high blood pressure, I would recommend staying away from processed food (The further the way it is on our plates from the way it occurs in nature, the worst it is for us), red meat, refried hydrogenated oils, foods high in sodium and trans and saturated fat.

      It may seem like a lot but once she learns how to read labels, it becomes easier. I would briefly go over reading food labels with the patient.

       Another great option is meal replacements since they offer a fixed amount of nutrients delivered to patient’s bodies. However, that is a temporary intervention rather than a long time change.

  • 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)

           Juana has hypertension so I would recommend her to avoid foods high in sodium. I would like to add that we usually think of sodium as salt and assume non-salty foods must not contain a lot of it but it is not true: sodium is a tasteless preservative and it is ubiquitous in many processed foods. Thus, reading food labels is very important.

           For Juana, given her history of smoking and hypertension, a diet recommended by American Heart association can provide some framework directing her food choices.

         Knowing that patient has extra weight, a diet intervention should be co-created and implemented if she feels like she’s ready for it.  For a  more detailed plan, I would have to have a conversation with her making sure we don’t sacrifice too many of her favorite foods as well as add some things she might enjoy.

  • Based on your assessment, outline a plan to address any dietary modifications you think are indicated for this patient

     The fact that Juana likes to cook is a great place to start.  A lot of dishes in Puerto Rican food are fried. For starters, I would suggest to switch frying in oil to baking. Almost every oven has a Convex setting which is basically very high temperature of air circulating. It is similar to frying and produces a crunchy finish to food. With a proper marinade convex oven food is even better, let along a healthier option for her and her family. Another idea is to get an air fryer if she budget allows.

      When we are recommended to avoid fried food, it is the fried oil that is bad for our bodies. Frying with broth (on the days she doesn’t have time to turn on the oven) is also a great way to make food quickly.

      I would suggest Juana pays attention to the oil she uses: for example, Avocado oil has a much higher burning point so it’s proteins don’t denature as easily maintaining more of it’s nutritional value.

      I would like to address the importance of avoiding processed meat and read meat. Studies show that red and processed meat consumption lead to a higher chance of mortality from cancer and heart disease. Eating chicken, however, was not associated with the mortality1. Therefore, if Juana switches beef and pork to chicken and fish, it could help preserve her health.

      An increased use of Omega-3-fatty acids is a powerful intervention to prevent the occurrence of cardiovascular disease. Flaxseeds is a cheap safe alternative to marine products which are famous for containing it. Recent studies of alpha-linolenic acid (which flax seeds are very rich in) show a staggering 71% decrease in a CVD rate and conclude that their protective effect  is beyond the more conventional cholesterol-lowering actions of most cardiovascular drugs2.  The seeds have to be consumed in. a grinded form as they don’t get digested otherwise. Eating a tablespoon of flaxseeds a day as well as adding them to various dishes (they don’t denature in high temperature so they’re great for baking and soups) can be a healthy practice Juana can start without extra effort.  

     Puerto Rican food is very rich and flavor dense. It has a lot of rice and beans which are a great start to any dish. For Juana, I included some Puerto Rican food recipes that will help her see that the food can be healthy but still retain the richness of taste.

  • Exercise
  • Determine whether this patient is likely to be getting adequate exercise as per current guidelines

The Physical Activity Guidelines for Americans recommend that adults get at least 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous-intensity physical activity, or an equivalent combination each week3. Juana states she walks about 3 blocks 3 times a day – that’s 9 blocks (15-20 min) a day adding up to 100 min a week. Patient does not meet recommended Physical Activity 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

     Patient mentioned she wanted to lose weight and also that she worries a lot. Exercise helps us release endorphins – happiness hormones that make us feel more confident, grounded and inspired.

   I would like to invite Juana to find an activity that she would enjoy . I would need to speak to the patient to help her find something she would feel inspired to do at least twice a week.  Signing up for group sessions is a great way to assure adherence to the schedule. Since often having extra weight can be associated with a negative body image, finding dancing classes where she can socialize with women of her weight category (yes, they exist and they’re fabulous – http://rozthediva.com/n7pq092qdpjujn5khv64bjdh5jh3p8 Roz is a good friend of mine and her sessions helped countless women to revision how they feel about their bodies) can be beneficial to Juana’s mental state, self-love as well as her cardiovascular health. But if she is not ready for such leap of faith, adding an extra block to every dog walk is a good place to start.

Brief Intervention – where relevant to your chosen patient, please explain how you would conduct a brief intervention for:

Counseling this patient will take way more than one session since it can be a lot of information for a person for one day. On the first visit, my goal might be just to establish a rapport and gain patient’s trues as well as assigning a follow up meeting. The interventions I would offer are dietary, exercise and quitting smoking and all my suggestions would be geared towards a gradual shift rather than a radical change.

  • Obesity

ASK First, I would like to ask Juana if she wanted to speak about her extra weight. Questions such as “Would it be alright if se spoke a little about your weight?” or “Are you concerned about your weight’s effect on your health and quality of life?” Would be a good place to start

ACCESS – then I would need to find a away to elicit information important for creating a weight loss plan. I already know her BMI and weight circumference, as well as the fact that she likes to cook Puerto Rican food, now I will need to find out what other things might be  contributing t Juana’s weight gain. I would ask her about her daily meals, if she eats our often, if she eats before going to bed, etc.

ADVICE – First, I would ask Juana if she would like to hear my advice. “Now that we’ve got a better understanding of your situation, can I recommend a course of action to improve things?

AGREE – we would have a conversation that would help us agree on a realistic course of action. Small, achievable goals are an overall better tool for weight loss then long term plans. Agreement is important as this is where the patient commits. It’s best to begin with small realistic changes – walking up the stairs instead of taking the elevator, switching morning cereal to fruit, decreasing portions, etc. We would agree on a plan that Juana feels could work for her.

ASSIST – my part is heling Juana identify and assess facilitators and barriers to achieving the desired goal. (Ex: Does Juana “eat away” the stress? How can that be changed? Is there a gym and a place where it’s possible to buy a healthy lunch quickly near her work?). Big part of assisting is following up with the patient since, even if the initial weigh loss occurred, it is very hard to keep it that way. Studies have shown that those attending in person follow up meetings, even only once a month, have been able to maintain their results for longer.

  • Smoking Cessation

Deep inside Juana knows smoking is killing her and it is my job to help her arrive at that realization. There’s many techniques a provider can use to address smoking cessation. It is important to note that in a real time conversation it is hard to keep it following a certain format but a general outline would look something like this:

I would employ a motivational interview strategy to hep Juana realize she needs change if she is ready for it.

I’d begin with some open ended questions like : “Tell me about your smoking”, “Have you tried to quit in the past?” “What made you decide to quit in the past?” “What went well, what could have went better?” ”What made you start again?”

Then, I would make sure I show support and encouragement to increase her self perception and provide appreciation and understanding. Examples would be “Thank you for being so open about it”, “It’s really great you have made a decision to quit before” “It takes a strong person to be able to make that decision”

After that, I would use some reflective listening to hear what patient has to say. I would specifically look for things like “I want”, “I might be able to quit “,”I like the idea of…”, “Smoking prevents me from”…

Then I would summarize what patient just said “I see how it can be hard for you to quit smoking right now, when you feel like it’s the only thing that helps you relax and you are under so much stress”

Addressing Juana’s concern about the weight gain if she quits, I would explain that it can take up to 6 months for a healthy body to make adjustments to an absence of nicotine so, during that time, she might temporarily gain a little weight, but also once she quits her tolerance for exercise would increase and she would eb able to walk more and take stairs instead of an elevator and to finally take that dance (yoga, Pilates, handball….) class she wanted. Her skin will look better and she will feel more energy.

I would access Juana’s readiness to quit using a Readiness ruler. If her number is low, I’d ask what makes her pick the number she selected and what would help to take her to a higher number.

 I would also try to have her think of what will happen if she quits (saved money, less fatigue, being able to exercise more and lose weight more efficiently, how happy her sons would be)

Then I would ask for a permission to make a recommendation.

Juana is a 40 pack yesrs smoker who smokes half a pack (10 cigarettes) a day. According to a CHI handout, that is a low HIS (Heavy Smoker Index) score. For people who fall under it, CHI recommends lozenges and a nicotine patch. However, depending on the results of my screening for depression (Juana mentioned she worries a lot), Juana might qualify for a Bupropion treatment which might. Work very well for her if she decides to quit.

1Rohrmann, S., Overvad, K., Bueno-de-Mesquita, H. B., Jakobsen, M. U., Egeberg, R., Tjønneland, A., … Linseisen, J. (2013). Meat consumption and mortality–results from the European Prospective Investigation into Cancer and Nutrition. BMC medicine11, 63. doi:10.1186/1741-7015-11-63

2Rodriguez-Leyva, D., Dupasquier, C. M., McCullough, R., & Pierce, G. N. (2010). The cardiovascular effects of flaxseed and its omega-3 fatty acid, alpha-linolenic acid. The Canadian journal of cardiology26(9), 489–496. doi:10.1016/s0828-282x(10)70455-4

3https://www.cdc.gov/physicalactivity/walking/index.htm

4 https://namimn.org/wp-content/uploads/sites/188/2018/06/FactSheet_Smoking_MotivationalInterviewing_2018.pdf

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