Juana Negron

Immunizations

– Influenza

– Td booster (if last one was 10+ years ago)

– In any case, can do an antibody titer to determine whether or not she requires anything else, as to avoid unnecessary immunizations

Screening

– Breast Cancer with mammogram

– Colon Cancer with colonoscopy

– Cervical Cancer

• Choice of PAP smear or PAP with HPV testing (depends on how often she wants to be tested or how often she was tested previously, every 3 years with PAP alone, or every 5 years with PAP and HPV)

– HTN

– Abnormal glucose/diabetes

– Alcohol misuse

– Depression

– Obesity

– Tobacco use and cessation

– HIV infection

– Hep C

– Diet/activity for CVD prevention

• Obese (BMI 30.9) and a smoker

Health Promotion/Disease Prevention Concerns

– Injury Prevention

• Traffic safety (seat belt)
• Falls prevention
• Poisoning prevention (works with non-toxic agents but regardless)
• Safe sleep environment (difficulty sleeping for some time)

– Diet

• Juana has tried dieting and losing weight but was never successful. She states that she doesn’t have a lot of will power and even if she does lose the weight, she gains it back. She mostly cooks and eats Puerto Rican food.
• Since Juana has tried diets in the past and wasn’t successful, I would propose continuing with the Puerto Rican cuisine since it’s what she enjoys but substituting the dishes with healthier ingredients. Puerto Rican cuisine tends to be high in calories, complex carbohydrates, fats and sodium.
• However, since she is obese and has borderline high blood pressure, she should limit her intake of red meat and dairy, utilize lean meat and non-fat dairy products. Increase intake of fish/fruits/vegetables/whole grain. Try to eat foods from plant sources as much as possible. Minimize intake of trans fats, saturated fats, processed carbohydrates, salt, and added sugar.
• Regarding specifically Puerto Rican diet, to make it healthier she can minimize oil use and stew/boil/bake instead of frying, which decreases fat content and calories. She can also utilize spices instead of salt. It’s great that she cooks herself because she has full control of what ingredients she is using.
• In general, she should limit herself to smaller portions or use a smaller plate. She should include more colors on the plate like fruits and vegetables. Also, can try dividing the plate in quarters for meat/protein, starch, vegetables and fruit, drinking water and eating a salad first before a meal to feel fuller.
• Should also look up how to prepare her favorite Puerto Rican dishes in a healthier way.

http://www.eatright.org/resource/food/planning-and-prep/snack-and-meal-ideas/puerto-rican-favorites-made-healthy

https://ohioline.osu.edu/factsheet/HYG-5257

– Exercise

• Currently, Juana does not exercise and her physical activity comes from her work and walking her 2 dogs about 2 blocks 3 times a day.
• She is not getting adequate exercise as per current guidelines, which are:
  • Aerobic Activity (150 min/week of moderate intensity & 75 min/week of vigorous intensity)
  • Muscle-strengthening (2 or more times/week which includes all major muscle groups)
• Juana is obese, current smoker, h/o asthma (controlled by medication), borderline high blood pressure, arthritis in both hands, trouble sleeping, and going though stress.
• I would first discuss the exercise plan with Juana to determine her goals, if any, and to see if there are any limitations.
• I would also stress that any exercise is better than no exercise, and if she prefers shorter periods of exercise in a day rather than a long one that would be fine.
• Juana can start exercising slowly and gradually increase her physical activity. She can start with a few minutes of physical activity a day and slowly increase it to 30 mins.
• I could also test whether or not she gets winded after walking one flight of stairs.
• If she decides to do aerobic exercise, I would determine her target heart rate, and teach her how to take her own pulse or how to do the talk test.
• She is asthmatic, which is controlled by medication. Sports and exercise can also help to keep her symptoms under control as long as she continues using her medication.
• She is already walking her dogs, which is a great start. She can utilize swimming, which is a great option since it increases heart rate without stressing the body, tones muscles, builds strength, and builds endurance. It is also a great exercise for people with arthritis and asthma.
• She can start doing some activities she enjoys that involve physical activity, like gardening, bicycling, cleaning the house, stretching, tennis, dancing, etc. She doesn’t necessarily need to join a gym.
• Exercising is specifically important in her case because she is obese (BMI 30.9) and has borderline high blood pressure, which could go down is she starts exercising. Exercise can also increase the production of endorphins that can help alleviate the stress she is experiencing.

 https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072704/

https://www.healthline.com/health/benefits-of-swimming#benefits

https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/exercise-and-stress/art-20044469

– Harm reduction

Replacement of tobacco with smokeless nicotine alternatives (NRT).

• Depending on what Juana’s preference is, she can try gum, patch of lozenges over the counter.
• Could also prescribe her Wellbutrin SR®, Zyban®, Chantix®, as well as nasal sprays and oral inhalers.

She can also try smoking less, even though she said half a pack is the best she can do right now.

– Brief Intervention

– Smoking Cessation

• I would utilize the 5 A’s for smoking cessation:
  • Ask
  • Advise
  • Assess
  • Arrange
  • Assure
• Smoking is part of the normal screening process, and Juana won’t feel singled out because every patient is being asked whether or not they smoke or not. I would ask Juana whether or not she smokes and how ready she is to quit smoking on a scale of 1-10. Based on that answer, I would ask her what was the reason for telling me that number and what will help to increase it. I would ask for her permission to disclose some information, so that she doesn’t think I am lecturing her. I would explain the health risks if she continues to smoke and the short as well as long benefits if she were to quit. Since Juana tried to quit twice in the past and was able to stop for about 6 months, I would counsel her on medication and other tools that could provide additional help. Depending on Juana’s preference, she can try gum, patch or lozenges over the counter. I could also prescribe her Wellbutrin SR®, Zyban®, Chantix®, nasal sprays and oral inhalers, after discussing which medication is right for her. I would continue to assess her health status. She has asthma that is controlled by medication, borderline high blood pressure, and arthritis in both hands. I would tell her that quitting smoking would be very beneficial for her asthma, and could lower her blood pressure. I would then proceed to assess her addiction to nicotine by using the Heavy Smoking Index (HSI). I would ask Juana if there are any motivational factors that contribute to her smoking. She said that last time she started smoking again was because of weight gain and feeling nervous. She is currently worried about her living situation, she has been having difficulty sleeping lately, and is having anxiety about her son. If she were to follow the diet plan discussed previously, the weight gain factor could be controlled. We could also discuss how to control her nervousness. If Juana is willing to give smoking cessation another try, I would set a quit day with her and follow up with an appointment in 2 weeks. If she decides to start taking any medication, I would discuss with her how and when the medication should be used. We would discuss possible behavioral changes that she should be working on and formalize a plan. I would provide her with the prescription for the medication if she decides to start taking something. I would discuss with her joining a support group, as well as internet or check-in option.
• Ask
  • Juana, are you currently smoking?
  • On a scale of 1 to 10, how ready are you to quit smoking?
  • What makes you say (given #, let’s say 4)? What would help you to get to 5?
  • What keeps you from quitting?
• Advise
  • I would like to help you quit. Can I tell you some of the things we know that can increase your odds of success?
  • There are medications that could help you quit. Would you like to discuss them?
• Assess
  • How many cigarettes, on average, do you smoke per day?
  • How soon after waking up do you smoke your first cigarette?
  • What reasons might you have to quit?
  • Can you think of any beneficial aspects if you were to quit?
  • You said that you currently smoke about a half a pack a day, can you think of any reasons that will decrease this number further?
• Agree
  • Can we discuss setting a quitting date?
  • It’s great that you were able to quit before, are there any current challenges that prevent you from quitting now?
  • Can we discuss behavioral changes that could prevent relapse?
• Arrange/Assist
  • Could I provide you with a support group that can offer encouragement?
  • I think we should meet in 2 weeks for a follow-up, would that work for you?

– Obesity

• I would also utilize Ask, Assess, Advise, Agree, Arrange/Assist when discussing obesity.
• I would ask Juana if it okay to discuss her weight and the effects it may be having on her health. We would discuss her diet and physical activity, as well as her past weight gain and loss. I would ask her if there are any medical conditions that she has or if any of her family members are overweight or obese. I would discuss health risks of obesity and benefits of moderate weight loss, especially since it lowers blood pressure, and Juana has borderline high blood pressure and is obese. I would tell her that the maximum sustainable weight loss is 10-15% over the 52-72-week period, which in her case would be 27 pounds. I would discuss with her any treatment options, as well as need for long-term management, specifically how exercise doesn’t really promote weight loss, but contributes more toward weight maintenance. She had stated that in the past, she had trouble keeping the weight off, so perhaps losing and keeping off 27 pounds is more manageable and realistic. I would then continue to ask her if this is an appropriate time for her to consider losing weight, as well as how much she expects to lose and keep off. We would then address any barriers she may have to losing weight, and I will provide her with any additional resources, a referral to a specialist perhaps. I would provide her with any additional resources and set up a follow-up appointment in 2 weeks to see how she is doing.

Ask

• Can we discuss your weight and the effects it may be having on your health?

Assess

• Could you please tell me about your past weight gain and loss?
• Could we discuss your daily diet and physical activity?
• Are any of your family members overweight or obese?
• Are there any medical conditions that I should know about?

Advise

• What do you know about the effects of overweight and obesity on health risks?

Agree

• Is this an acceptable time for you to go through weight loss?
• What would your ideal weight be?

Arrange/Assist

• Would you like me to refer you to someone who can help you with menu planning and exercise plan?

I believe in Juana’s case, screening should be done first, because from that information we can formulate the rest of the visit. Then, I think that brief intervention should be next, followed by health promotion and disease prevention concerns. From brief intervention, we gather a lot of information from the patient and can follow up with HPDP concerns as supplementary information. I would then finish the visit off with immunizations.

Sources:

HPDP Lectures

This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.