This Case Study was written based on the following hypothetical patient profile for Health Promotion & Disease Prevention:
Yusuf Khoury is a 57 year old accountant with a history of Type 2 diabetes and moderate to severe depression somewhat controlled by medication. He comes to see you today with a complaint of shoulder and left hand pain when he walks his dog and left wrist pain when us uses his computer. He is concerned that the pain may be caused by his heart because he has been told that left arm pain can be a symptom of heart attack, however you’re not so persuaded. He describes the pain in his shoulder as aching, but not worse at the end of the dog walk than it was at the beginning. It is located mostly in the shoulder and upper arm and is not accompanied by chest or jaw pain, shortness of breath, nausea, palpitations or discomfort anywhere else. It resolves when he stops walking the dog and does not occur when he walks at any other time. The wrist pain is located mostly in the ventral surface of his wrist and gets progressively worse while he’s at work, sometimes accompanied by numbness and tingling in his thumb and first finger. The wrist pain occasionally also bothers him at night. He has taken ibuprofen 400 mg. for this pain which does help some – relieving at the end of the day from 6/10 to about 3/10. Over the weekends, the wrist pain doesn’t bother him at all and his arm only bothers him when he walks the dog
His desk job requires many hours of sitting at his computer and very little walking during his typical work day. He commutes to work via subway which is one block from his home and leaves him one block from his office. Apart from walking the dog, he gets no regular exercise. In fact he says, “I’m allergic to exercise”.
He typically buys breakfast at the shop in the ground floor of his office building – usually a buttered roll and large coffee with half and half and Equal. “Sometimes I get a piece of fruit too from the guy with the stand on the corner”. He usually orders in for lunch from one of the local restaurants – a sandwich or sometimes soup with a bag of chips. He admits that his office mates usually have a big plate of cookies or other sweets in the break room and that he has a hard time resisting them.
His family history is significant for a father who also had Type 2 diabetes and prostate cancer at age 70. His mother had hypertension and a stroke at age 68. He has one sister who is alive and well and a brother who has macular degeneration.
He lives with his wife and their dog in an apartment building with an elevator. He spends most of his weekends at home, sleeping for long periods of time. He rarely leaves his apartment on weekends and has very little social life, though his wife is very involved in the local mosque and frequently tries to get him to join her there. He says, “It just seems like too much effort”.
Yusef does monitor his blood sugar and blood pressure regularly and keeps a log of his measurements. Lately his glucometer readings have been in the 180-200 range fairly often. His blood pressure readings have been under 140/90 on his current medication. You are considering whether he needs to be started on insulin, but so far he has resisted this suggestion.
BP 142/86 P 72 R16 T 99
Hgt 5ft 11.5 in Wgt 190 Waist circumference 43
Finger stick glucose this morning (fasting) 160
Hgb A1C 9.0
• Metformin 500 mg twice daily
• Glyburide 5 mg twice daily
• Paroxetine 20 mg twice daily
• Enalopril 5 mg twice daily
Based on the patient’s age and sex the following immunizations are recommended by the CDC 2020 guidelines: Influenza (administer annually), Tdap (1 dose then booster every 10 years), MMR (1-2 doses), and RZV (2 doses).The following additional vaccinations are recommended by the CDC 2020 guidelines based on the patient’s health history of diabetes mellitus type 2 and hypertension: PPSV23, Varicella (2 doses), and Hepatitis B. ZVL may be substituted for RZV but RZV is the preferred vaccination. Hepatitis A is optional for those not at risk but who want protection. Therefore, it would be recommended the patient to receive Twinrix (Hepatitis A + Hepatitis B given at 0, 1, and 6 months intervals) for added Hepatitis A protection.
The United States Preventative Services Task Force (USPSTF) recommends the following screening based on the patient’s age and sex: Alcohol misuse, depression, hypertension, obesity, tobacco use, HIV, and Hepatitis C (For people born between 1945-1965), colorectal cancer, dyslipidemia/cholesterol, and abnormal glucose/type 2 diabetes mellitus. However, several of these screenings would be contraindicated to the patient based on his disease state.
This patient should not receive a primary depression screening, hypertension screening, or abnormal glucose/type 2 diabetes screening because he already has these disease processes. Although some of the screening methods are the same as monitoring the disease (ex: both screening and monitoring of hypertension involve checking blood pressure) it is important to note that general screening is used for the purpose of identifying disease in a person who is unaware they have it. In place of these screenings, the patient will be monitored for their depression, diabetes, and hypertension in the form of tertiary screenings to prevent disease progression.
While the CDC considers all people with diabetes mellitus type 2 at an increased risk for Hepatitis B and therefore recommends vaccination, the USPSTF does not and therefore, does not recommend Hepatitis B screening for this patient. The CDC recommendations are based off of findings of increased risk of infection due to sharing glucose meters with poor sanitation in assistant living facilities/nursing homes/long-term care. Because the patient does not appear to share his glucose meter with anyone and does not meet those housing parameters, a screening would not be recommended, but the vaccination should still be considered so that he has immunity if he enters into a living facility in the future.
Although the patient’s father was diagnosed with prostate cancer at age 70, the patient is not considered high risk for a PSA screening because the guidelines state a first degree relative should have the diagnosis before age 65. However, the patient still meets the moderate risk category because he is over 50 years of age. A PSA and possible digital rectal exam are appropriate for prostate screening for this patient according to the American Cancer Society (ACS).
Special attention should be given to the dyslipidemia/cholesterol screening results since the patient’s mother had a positive history of a stroke and the patient currently has uncontrolled hypertension (recorded as 142/86 mmHg today). The screening results should be used in conjunction with the Atherosclerotic Cardiovascular Disease (ASCVD) risk calculator by the American College of Cardiology to determine if a patient should start a statin and whether that statin should be given at a low or high dose.
Colorectal cancer screening may be given as a fecal occult blood test (annually), fecal immunochemical test (every 1-3 years), sigmoidoscopy (every 5 years or every 10 years with annual FIT test), CT colonography (every 5 years), or Colonoscopy (every 10 years) in the absence of abnormal findings such as blood or polyps. Because some tests are more invasive than others and have different time intervals in between testing, shared clinical decision making with the patient is especially important for this screening method choice.
The USPSTF also recommends a dilated eye exam annually based on patient’s DM-Type 2. This screening is not only important for the early detection of diabetic retinopathy but also for his positive family history of macular degeneration.
INJURY PREVENTION/HARM REDUCTION
Injury prevention will largely be focused on pedestrian safety, traffic safety, and suicide prevention for this patient. It is advised that he carries a flashlight when walking his dog at night and does not walk with his cellphone out on his commute to work to avoid getting hit by a motor vehicle. He should always wear his seatbelt in a motor vehicle and never drive while impaired. Because of his history of moderate to severe depression, reducing access to lethal means and making sure appropriate resources such as the National Suicide Prevention Lifeline are accessible to the patient would be prioritized for injury prevention measures. Although the patient does not need the full PHQ-9 questionnaire because he has already been diagnosed with depression, the last question of “Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?” should still be asked to screen for suicide prevention.
The patient’s diet is high in sugar, starch, sodium, and fat. His current meal choices might be spiking his blood sugar levels and worsening his diabetes over time. The salty food and fatty food choices are also a concern for his cardiovascular health as they may be contributing to his hypertension and/or adversely affecting his cholesterol.
Modifications include incorporating fiber-rich foods such as vegetables, fruits, nuts, beans, peas, and whole grains into his diet. It is unclear what type of protein the patient is incorporating into his sandwiches for lunch, but it should be a lean, heart healthy protein option like salmon, tuna, or unprocessed chicken. His current source of carbohydrates seems to come from bread and chips. Instead, he should receive his carbohydrates from vegetables, beans, whole grains, and fruits. Fish, nuts, or avocado would be better sources of fat for the patient than the butter he currently has on his roll every morning. Last, he should avoid or limit the amount of sweets he consumes including the equal he puts in his coffee every morning. Certain fruits that will not adversely affect his blood sugar may be an alternative to sweet snacks. Switching to these food choices will likely also help the patient to lose weight which will further help improve his current disease states and lower his risk of acquiring certain diseases.
Switching to a different diet all at once may be unobtainable, therefore, the recommendation would be to switch out one unhealthy food item with a healthier one for at least one or two of his meals each day, gradually continuing these modifications over time until a healthy diet has been achieved.
Because the patient has stated “I’m allergic to exercise” and has admitted to moving very little throughout the day, he may be initially resistant to meeting the current guidelines for cardiovascular and strength training exercises. Subtle changes in his routine that get him to walk more throughout the day should be the initial focus. Instead of taking the elevator in his apartment building, he should take the stairs. He should also consider walking to the next subway stop and/or getting off one stop earlier on his route to work. Taking a walk on his lunch break or walking an extra block with his dog are additional opportunities to acquire more steps throughout the day. The goal is to get the patient eventually briskly walking for 150 minutes each week.
The pain in his left shoulder, hand, and wrist should be further evaluated before he begins strength training exercises to prevent a possible further injury. Once any limitations have been identified, performing muscle-strengthening activities at least two days per week will also be advised. This can be done at home through a YouTube exercise tutorial, in a park, or with machines at a gym giving the patient a wide range of options.
The discussion on why it is important to incorporate exercise into his routine would focus on the positive benefits it can have on improving his mental health, diabetes, and hypertension.
Making sure the patient understands the connection between obesity and his current disease states would be the main focus of an interventional conversation. Informing him of how his current weight puts him at additional risks for acquiring further health complications would be addressed as well. The diet and exercise plans outlined above would be discussed in this conversation so that the patient has clear directions on how to improve his weight. Although his BMI is only slightly over the normal range of 40in, therefore, weight loss should be considered.
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“A And B Recommendations: United States Preventive Services Taskforce.” A And B Recommendations | United States Preventive Services Taskforce, www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations.
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