Amber Shaikh 

Case Study: Damien 

Damien is a 33 year old male who lives in NYC with his girlfriend and son. He has a medical history of Gout and hypertension.  He is on Hydrochlorithiazide, diltiazem, and allopurinal but is not always compliant due to his inconsistency with health insurance. He is recently changing his job from a truck driver to working in a UPS processing center, and will now have steady health insurance. He states his diet is poor and he does not exercise often. He is being seen today for a generalized exam and to get prescriptions for his Gout and HTN.  

Vitals:  BP: 140/88 P:72 T:98.6 

 Height: 5ft and 10 in Weight: 200lbs  BMI: 28.7 (overweight) Waist circumference: 43 inches 

Immunizations  

• The patient has all his childhood vaccinations and is being seen in November, so he should receive the following immunizations as per CDC recommendation based on his age and past medical history: 

• Influenza inactivated or influenza recombinant 

• He needs 1 dose annually, and since has not had proper health insurance since he was 18, he should get the flu vaccine at this visit. Especially considering his visit is in November, the flu vaccine is important considering this is the start of flu season. 

• Td Booster 

• This booster needs to be given every 10 years after the patient has received their one dose of Tdap at the age of 12. 

• MMRV titers  

• Even though he has his childhood vaccines, we should do titers to check if he needs a booster. 

• Pneumococcal Polysaccharide (PPSV23) 

• Due to his history of hypertension, he should get 1 or 2 doses of this depending on indication and health concerns.  

Screening 

• For Damien I would order the following screenings: 

• Alcohol misuse 
• Depression 
• Dyslipidemia 

• Obesity 
• Tobacco use and cessation 
• HIV infection 
• Tuberculosis/PPD 

•  this is indicated because he is starting a new employment, and has not had consistent health insurance since he was 18 

• These recommendations are by the USPSTF for adults with no other severe contraindications.  

Health Promotion/Disease Prevention Concerns: 

• Injury Prevention  

• Traffic safety-seatbelt when driving 

• This is important for Damien as he is a truck driver, and for general driving purposes as well 

• Fall prevention/lifting injury 

• I believe this is relevant for everyone for prevention of breaks and injuries. This is also important because of his new job at UPS, he may be required to lift heavy boxes and operate machinery.  

• Drinking and driving 

• Because he occasionally drinks, this is important to ensure safe driving practices and to avoid using machinery when intoxicated. 

• Firearm safety 

• Considering he lives in Brooklyn, this is important for him to ensure the safety of him and his family.  

• Diet  
• Relevant dietary issues for this patient include: 

• Damien is a 33 year old male who has a history of Gout and Hypertension. Due to his inconsistency with health insurance, he has not been compliant with his gout and HTN medications. His diet is also concerning because it is heavy in red meat and dairy which raise the level of uric acid in his blood causing his gout flare ups. Gout is heavily influenced by diet, and changes in his current habits will greatly help him in the future. His current diet of snacks, cakes, pastries, red meat and full fat dairy is also a hazard due to his medical history of hypertension. By encouraging healthy changes in his diet, Damien can manage his blood pressure and limit the chances of future risks of heart attack, stroke and other health issues.  

 

• Specific health concerns that are influenced by diet modification in our patient include:   

• Gout is heavily influenced by diet, age and gender. It mainly affects males who are overweight. It is due to a buildup of urate crystalS in areas such as the first metatarsalphalangeal joint, knees, and wrists. It causes severe swelling and pain in those areas. Urate crystals come from a diet that causes increased uric acid  and purines in the body. This can be controlled by having a diet that is low in red meat, high fructose corn syrup, fat, processed sugar and alcohol. Instead foods rich in whole grain, vegetables, low fat dairy, seafood and increased water intake are associated with a reduced risk of purine build and gout flare ups. Fruits rich in vitamin C like cherries and citrus is also good for reducing Uric acid build up in the body. Specific examples of foods he should avoid include red meats like (organ and game meats), fish (herring, trout, sardines), seafood (scallops, crab), sodas, artificial fruit juices, and yeast products. 

 

• High blood pressure has many causative factors; genetic, environmental, dietary, or a combination of these. For HTN, a DASH diet is recommended. Certain things to avoid include: excess red meat, high sodium, foods that are high in saturated and trans–fat, sodium, and processed sugar and complex carbohydrates. Things to add in your diet to help reduce blood pressure include: whole grains, vegetables, fruits, low fat dairy and poultry is ideal for managing blood pressure. Controlling one’s diet can lead to better management of blood pressure and reduced risk of future heart disease.  

 

• Example Diet plan, addressing Damien’s health concerns: 

• The main goal for a diet plan for Damien includes replacing his current diet of red meat, full fat milk, snacks, sugary drinks, cakes and pastries with healthier alternatives that still work with his life style and help reduce his risk of gout flare ups and lower his blood pressure.  
• Diet plan:  

• For breakfast He can have unsweetened cereal with fat free milk, rather then the full fat milk. He can also have a serving of his favorite fruit (preferably something high in vitamin C) with his cereal with either freshly squeezed juice or water. If he prefers coffee, he can also have 1 cup of that in the morning as well.  
• For lunch Damien can have either grilled chicken or if he prefers, on some days he can have a grilled steak salad. He can also put some chickpeas in his salad for extra protein and nuts for some healthy fat. If he likes to drink milk, he can replace it with skim milk.  
• For a snack Damien can replace salty and sugary snacks with a small handful of nuts or fruits such as berries or grapes. Cherries are also great for reducing purine and uric acid levels in the body, reducing the risk for a gout flare.  
• For dinner, Damien can haven oven roasted salmon or chicken with steamed vegetables, on the side he can have whole grain pasta tossed with some olive oil and lemon pepper. For dessert he can have fruit like melon, citrus, or cherries, low fat yogurt, or even a small piece of dark chocolate. If he needs a drink before bed, he can either drink water or a non-caffeinated herbal tea.  
• Exercise  

• As per current CDC guidelines, adults should do 150-300 minutes of moderate exercise a week or 75-150 minutes of vigorous activity a week. In general however it is recommended to do more “on your feet” activities rather than just sitting down. Our patient was doing a lot of sitting due to his truck/bus driving job, however now with his new job with the UPS he will be on his feet more. Damien says he loves to be active but is unable to do so due to feeling fatigue with minimum activity. He says he does not get enough exercise now but wants to find a plan that allows him to change that. The goal for exercise for our patient is to make him more active without easily getting fatigued, maintain a regular exercise plan, help with weight loss, lower his BMI and reduce his waist circumference, and improve his overall heart health and endurance.  

 

• Example Exercise plan addressing Damien’s health concern: 

• To make a good exercise plan that Damien will stick to, it is important to take into account his interests and hobbies which include outdoor activities and partaking in is church activities and basketball. Considering he lives on the 3rd floor and uses the stairs, he should continue doing that. 
• For Aerobic exercise I would recommend 20 minutes of moderate exercise up to 5 times a week. For resistance exercise I would recommend 2 times a week for 20 minutes.  

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Out door church activity/basketball	Go up and down stairs 3 times.   20 minutes of walking in the park with his son.	Use stairs and walk around at work.  20 minutes of jogging around the block	Use stairs  Do low resistance weight exercises-abdominal crunches 4 x10 and leg press 3 x10	Use stairs 3-4 times in the day. Play basketball with friends or son for 20-30 minutes.	Use stairs  20 minutes of walking and 10 minutes of jogging	Rest day

• Harm Reduction  

• Because the patient smokes cigars, we can replace tobacco with smokeless nicotine alternatives (patches/buporiaon) 
• Encourage healthy choices in restaurants, since he likes edamame, he can pick more salad items or items that have more vegetables 
• Have him drink skim milk, 2% mil or fat free milk, in exchange for his 1 gallon of full fat milk a day 
• Drinking water or low sugar juice instead of alcohol 

Brief Intervention –  

Considering that Damien has a history of smoking 4 cigars a week and has an elevated BMI, I would counsel him on the following: Smoking cessation and obesity. 

Smoking Cessation 

CDC identifies smoking and tobacco as major modifiable risk factors, which means they can be altered. Damien smokes 4 cigars a week, which is not a safer alternative to cigarettes, but one that has its own set of harms. One cigar can contain as much tobacco as an entire pack of cigarettes, and the cigar smoke is more concentrated and toxic then cigarette smoke. Health risks of cigar smoking include nicotine addiction, cancer, tooth loss, erectile dysfunction and heart disease. Reducing tobacco use can potentially prevent 80% risk of heart disease, stroke/CVA, and type 2 Diabetes. One technique to address this is through motivational interviewing. This intervention technique allows people to address their problems in their own way and talk themselves into change. You can use the mnemonic “OARS” to address certain aspects of this intervention: 

O-open ended questions: “how important is smoking cigars to your daily routine?” 

A-Affirmations: “Its very impressive that you were able to cut down to 4 times a week, I can understand how difficult that must have been for you” 

R-Reflections: “You told me that this might not be the right time to start cutting back on the number of cigars you smoke due to your transition in jobs, and your struggle with maintaining a healthy meal plan and exercise routine.” 

S-Summarize: “I understand you are coming in concerned about your history of gout and HTN, and with your new health insurance you want to get prescriptions for your medications. You also told me that you have a social history of smoking 4 cigars a week, and that you want to cut back. You are not sure if it is the right time for you to address the smoking at this point in time due to your other current problem history, but it is something that you want to consider doing in the near future with proper assistance and guidance.” 

I can also follow this up with the 5A intervention for more thorough questioning and to get a more focused understanding of where the patient stands. 

ASK-”how important is quitting cigar smoking to you” 

ASSESS: Use the Heavy smoking index calculator (HSI) to assess the patient’s level of tobacco dependence 

ADVISE: “As your provider and someone who cares about you, I advise you to consider cutting back on your cigar smoking to best benefit your overall health” 

AGREE: “I understand this is difficult, and I am very proud of the progress you have made so far” 

ASSIST: “I would like to help you and work with you to make a plan most easily cut back on your cigar smoking. I will also refer you to other professionals for more help.” 

You can also talk to the patient about possible prescriptions to help them quit smoking: Nicotine replacement therapy, Bupropion, or Chantix. 

Obesity 

Obesity is a common national problem that tens of millions of people are struggling with, with no easy solution. It is important to recognize unhealthy behaviors and causes early, while they are still easy to manage. Since our patient has a BMI of 28.7 where the normal is 18.5-24.9, and a waist circumference of 43inches, where the average is 40 inches; is it important to counsel our patient about obesity using the 5A brief intervention method. The following are examples of the questions I would ask during this brief intervention section: 

ASK- “Are you at all concerned about your weight and the effects it has on your health or quality of life?” 

ASSESS- “Please walk me through your daily diet and physical activity” 

ADVISE-”What knowledge do you have about the effects of being overweight on your health?” “Weight has a significant impact on your overall health, and being able to control that early on will be of great value” 

AGREE-”Is now a good time for you to think about weight loss plans? How much weight would you like to ideally lose?” 

ARRANGE/ASSIST- “We can talk about your preferences and come up with a weekly meal plan that will help you lose weight and satisfy your cravings” “We can also refer you to a nutritionist to talk about your diet in more detail” 

Priority order: 

1. Smoking cessation 

1. Diet management 

1. Harm Reduction 

1. Exercise plan 

1. Immunizations 

1. Screening 

1. Injury prevention 

References: 

Article: Adult Preventive Health Care Schedule: Recommendations from the USPSTF (as of June 1, 2018) 

Article: Motivational interviewing, the basics 

Article: Modified 5As in obesity 

Article: CHI treating tobacco addiction 

“A 10-Week Physical Activity Program for a Hypertensive Obese Adult.” Physiopedia, www.physio-pedia.com/A_10-Week_Physical_Activity_Program_for_a_Hypertensive_Obese_Adult. 

Bazzano, Lydia A, et al. “Dietary Approaches to Prevent Hypertension.” Current Hypertension Reports, U.S. National Library of Medicine, Dec. 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4366416/. 

“Can the Foods You Eat Help to Control Gout?” Mayo Clinic, Mayo Foundation for Medical Education and Research, 18 May 2018, www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524. 

“Diet for Gout.” American Kidney Fund (AKF), www.kidneyfund.org/kidney-disease/chronic-kidney-disease-ckd/complications/gout/diet-for-gout/. 

“Gout: Nutrition Guide for Clinicians.” Gout | Nutrition Guide for Clinicians, 21 Nov. 2017, nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342063/all/Gout. 

HHS Office, and Council on Sports. “Physical Activity Guidelines for Americans.” HHS.gov, US Department of Health and Human Services, 1 Feb. 2019, www.hhs.gov/fitness/be-active/physical-activity-guidelines-for-americans/index.html. 

“Managing Blood Pressure with a Heart-Healthy Diet.” Www.heart.org, www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/managing-blood-pressure-with-a-heart-healthy-diet. 

Martin, Terry. “6 Facts About How Cigar Smoking Impacts Your Health.” Verywell Mind, Verywell Mind, 17 Sept. 2019, www.verywellmind.com/facts-about-cigar-smoking-2824739. 

Power point: Helping Pts quit smoking 

Power point: Motivational Interviewing 

Power point: Obesity 

Shmerling, Robert. “All about Gout.” Harvard Health, Apr. 2010, www.health.harvard.edu/newsletter_article/all-about-gout.