HPPA 552 CC – Final reflection

From beginning to end of clinical correlation sections, I have developed a good history taking skills. According to patient’s chief complaints, I am able to have more complete HPI and including pertinent positives and negatives. Also, I am much better at developing differential diagnosis, and know what focused physical exam, labs, and image study are needed for the patient after taking history. I found out it is a little hard for me to get patient’s consent, like before the procedure, how to explain to the patient that the worst result of surgery’s is death, but it does not happen most of the time. During the clinical year, I still need to work on patient management and developing treatment plan. I hope I can get a lot of hands on experience, especially physical exams and interactions between different patients, especially how to re-direct patients back to topic when they are talking too much about something else, and how to take detailed sexual history without feeling embarrassed.

During the clinical correlation sections, the most often site I used for the topics is Uptodate, which I think is really helpful. In addition, I also check Medscape, Pubmed, and algorithm form textbook. For screening guidelines, I often check USPSTF and ACA. It is important to stay in current with guidelines and offer screening tests to appropriate patients. In the clinical year, I think I will keep visiting these sources for any topics that I do not know. I will advise students in the class behind me to remember that, do not jump to conclusion before you have detailed history, physical exam and labs done. Get broad differentials first, and with those differentials in mind while asking patient more questions, then narrow down. There are many possibilities, some history or physical exam findings can lead to different directions. Again, diseases do not read the textbook, so keep atypical presentations in mind as well. It is really good to rotate with different professors, because each professor works in different specialty and they provide different cases types, and I learn a lot from these cases.

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HPPA 530 EBM-Mini-Cat

DAILY INHALED STEROIDS AND BONE GROWTH

 

Scenario given:

It is known that systemic steroids can slow bone growth.  Your 8 year old asthma patient’s mother is concerned that perhaps the daily inhaled steroids (given via a metered dose inhaler or MDI) could have the same effect.  What can you tell her?

 

Clinical Question:

Do daily inhaled steroids affect height?

 

PICO Question:

In pediatric patients with asthma, does administering daily inhaled steroids slow bone growth?

 

 

P I C O
Pediatric with asthma Meterdosed inhaler

MDI

Placebo Bone growth
Prepubertal children Corticosteroid No corticosteroids Height
Mild to persistent asthmatic Inhaled corticosteroid

ICS

Development
Fluticasone Skeletal maturation
Linear growth

 

 

Search Strategy:

Searched Terms: “Inhaled steroids bone growth”

Database and Articles Returned:

Cochrane: Inhaled steroids bone growth → 10252

Cochrane: inhaled steroids bone growth/Cochrane database of systematic reviews → 1

Pubmed: Inhaled corticosteroids growth → 840

Pubmed: bone growth inhaled steroids → 76

Filters: humans; age birth – 19 years old; Best matches

Trip database: (asthmatic children)(inhaled corticosteroid)(height) → 232

 

Selection Methods:

Systematic reviews, meta analyses, and relevant RCTs that looked at the effect of ICS on bone growth or bone growth velocity in asthmatic children. The search yielded thousands of results that we then narrowed down based on level of evidence,  sample size, date of the study, and pertinent key words used in our PICO question.

Articles Chosen for Inclusion:

 

Influence of inhaled corticosteroid on pubertal growth and final height in asthmatic children.

Leonibus CD, Attanasi M, Roze Z.

Pediatr Allergy Immunol 2016: 27: 499–506. publication 21 February 2016

DOI:10.1111/pai.12558

Abstract

Background: Controversial data exist on the possibility that inhaled corticosteroids

(ICs) affect growth in children with mild-to-moderate asthma. We assessed whether

ICs affect growth and final height (FH) in asthmatic children compared to controls.

Methods: A retrospective study was conducted on 113 asthmatic children compared

with 66 control children. Asthmatic children presented with mild-to-moderate asthma

and had exclusive ICs. Anthropometric data of four specific time-points were collected

for both groups (pre-puberty, onset and late puberty, and FH) and converted to

standard deviation scores (SDS). Growth trajectories were assessed as follows: (i) in

puberty, using peak height velocity (PHV) and pubertal height gain SDS (PHG-SDS);

(ii) until FH achievement, using FH-SDS and FH gain SDS (FHG-SDS). Repeated

measurement analysis was performed across longitudinal study visits. A general linear

model (GLM) was performed in asthmatic group evaluating the effect of corticosteroid

type, treatment duration, and cumulative dose on FH corrected for multiple

variables.

Results: At pre-puberty, height and weight SDS were similar between the groups

(p > 0.05). Height SDS progressively declined over the study period in asthmatic

patients from pre-puberty to FH (p-trend < 0.05), whereas it did not change over time

in controls (p-trend > 0.05), in both boys and girls. Asthmatic children had exclusive

ICs [budesonide (n = 36) vs. fluticasone (n = 43) vs. mometasone (n = 34)] for a mean

period of 6.25 1.20 years and a mean cumulative dose of 560.07 76.02 mg. They

showed decreased PHG-SDS and lower PHV compared to controls (all p < 0.05). FHSDS

and FHG-SDS were significantly reduced in asthmatic group compared to

controls. FH in asthmatic patients was 2.5 2.89 cm lower in boys and 2.0 2.03 cm

lower in girls than controls. The GLM showed that FH achievement was dependent on

the type of ICs, duration of the treatment, and cumulative dose (p < 0.05).

Conclusions: ICs affect pubertal growth determining reduced final height in asthmatic

children compared to controls, in a dose- and duration-dependent manner.

Link: https://onlinelibrary.wiley.com/doi/abs/10.1111/pai.12558

 

Impact of Inhaled Corticosteroids on Growth in Children with Asthma: Systematic Review and Meta-Analysis.

Loke YK1, Blanco P1, Thavarajah M1, Wilson AM1.

PLoS One. 2015 Jul 20;10(7):e0133428. doi: 10.1371/journal.pone.0133428. eCollection 2015.

BACKGROUND: Long-term inhaled corticosteroids (ICS) may reduce growth velocity and final height of children with asthma. We aimed to evaluate the association between ICS use of >12 months and growth.

METHODS: We initially searched MEDLINE and EMBASE in July 2013, followed by a PubMed search updated to December 2014. We selected RCTs and controlled observational studies of ICS use in patients with asthma. We conducted random effects meta-analysis of mean differences in growth velocity (cm/year) or final height (cm) between groups. Heterogeneity was assessed using the I2 statistic.

RESULTS: We found 23 relevant studies (twenty RCTs and three observational studies) after screening 1882 hits. Meta-analysis of 16 RCTs showed that ICS use significantly reduced growth velocity at one year follow-up (mean difference -0.48 cm/year (95% CI -0.66 to -0.29)). There was evidence of a dose-response effect in three RCTs. Final adult height showed a mean reduction of -1.20 cm (95% CI -1.90 cm to -0.50 cm) with budesonide versus placebo in a high quality RCT. Meta-analysis of two lower quality observational studies revealed uncertainty in the association between ICS use and final adult height, pooled mean difference -0.85 cm (95% CI -3.35 to 1.65).

CONCLUSION: Use of ICS for >12 months in children with asthma has a limited impact on annual growth velocity. In ICS users, there is a slight reduction of about a centimeter in final adult height, which when interpreted in the context of average adult height in England (175 cm for men and 161 cm for women), represents a 0.7% reduction compared to non-ICS users.

treatment over a period of several years in children with persistent asthma.

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4507851/

 

 

Inhaled Corticosteroids in Children With Persistent Asthma: Effects on Growth.

Cochrane Database Syst Rev. 2014 Jul 17;(7):CD009471. Doi: 10.1002/14651858.CD009471.pub2.

Zhang L1, Prietsch SO, Ducharme FM.

BACKGROUND: Treatment guidelines for asthma recommend inhaled corticosteroids (ICS) as first-line therapy for children with persistent asthma. Although ICS treatment is generally considered safe in children, the potential systemic adverse effects related to regular use of these drugs have been and continue to be a matter of concern, especially the effects on linear growth.

OBJECTIVES: To assess the impact of ICS on the linear growth of children with persistent asthma and to explore potential effect modifiers such as characteristics of available treatments (molecule, dose, length of exposure, inhalation device) and of treated children (age, disease severity, compliance with treatment).

SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived from systematic searches of bibliographic databases including CENTRAL, MEDLINE, EMBASE, CINAHL, AMED and PsycINFO; we hand searched respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov and manufacturers’ clinical trial databases to look for potential relevant unpublished studies. The literature search was conducted in January 2014.

SELECTION CRITERIA: Parallel-group randomised controlled trials comparing daily use of ICS, delivered by any type of inhalation device for at least three months, versus placebo or non-steroidal drugs in children up to 18 years of age with persistent asthma.

DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, data extraction and assessment of risk of bias in included studies. We conducted meta-analyses using the Cochrane statistical package RevMan 5.2 and Stata version 11.0. We used the random-effects model for meta-analyses. We used mean differences (MDs) and 95% CIs as the metrics for treatment effects. A negative value for MD indicates that ICS have suppressive effects on linear growth compared with controls. We performed a priori planned subgroup analyses to explore potential effect modifiers, such as ICS molecule, daily dose, inhalation device and age of the treated child.

MAIN RESULTS: We included 25 trials involving 8471 (5128 ICS-treated and 3343 control) children with mild to moderate persistent asthma. Six molecules (beclomethasone dipropionate, budesonide, ciclesonide, flunisolide, fluticasone propionate and mometasone furoate) [corrected] given at low or medium daily doses were used during a period of three months to four to six years. Most trials were blinded and over half of the trials had drop out rates of over 20%.Compared with placebo or non-steroidal drugs, ICS produced a statistically significant reduction in linear growth velocity (14 trials with 5717 participants, MD -0.48 cm/y, 95% CI -0.65 to -0.30, moderate quality evidence) and in the change from baseline in height (15 trials with 3275 participants; MD -0.61 cm/y, 95% CI -0.83 to -0.38, moderate quality evidence) during a one-year treatment period.Subgroup analysis showed a statistically significant group difference between six molecules in the mean reduction of linear growth velocity during one-year treatment (Chi² = 26.1, degrees of freedom (df) = 5, P value < 0.0001). The group difference persisted even when analysis was restricted to the trials using doses equivalent to 200 μg/d hydrofluoroalkane (HFA)-beclomethasone. Subgroup analyses did not show a statistically significant impact of daily dose (low vs medium), inhalation device or participant age on the magnitude of ICS-induced suppression of linear growth velocity during a one-year treatment period. However, head-to-head comparisons are needed to assess the effects of different drug molecules, dose, inhalation device or patient age. No statistically significant difference in linear growth velocity was found between participants treated with ICS and controls during the second year of treatment (five trials with 3174 participants; MD -0.19 cm/y, 95% CI -0.48 to 0.11, P value 0.22). Of two trials that reported linear growth velocity in the third year of treatment, one trial involving 667 participants showed similar growth velocity between the budesonide and placebo groups (5.34 cm/y vs 5.34 cm/y), and another trial involving 1974 participants showed lower growth velocity in the budesonide group compared with the placebo group (MD -0.33 cm/y, 95% CI -0.52 to -0.14, P value 0.0005). Among four trials reporting data on linear growth after treatment cessation, three did not describe statistically significant catch-up growth in the ICS group two to four months after treatment cessation. One trial showed accelerated linear growth velocity in the fluticasone group at 12 months after treatment cessation, but there remained a statistically significant difference of 0.7 cm in height between the fluticasone and placebo groups at the end of the three-year trial.One trial with follow-up into adulthood showed that participants of prepubertal age treated with budesonide 400 μg/d for a mean duration of 4.3 years had a mean reduction of 1.20 cm (95% CI -1.90 to -0.50) in adult height compared with those treated with placebo.

AUTHORS’ CONCLUSIONS:Regular use of ICS at low or medium daily doses is associated with a mean reduction of 0.48 cm/y in linear growth velocity and a 0.61-cm change from baseline in height during a one-year treatment period in children with mild to moderate persistent asthma. The effect size of ICS on linear growth velocity appears to be associated more strongly with the ICS molecule than with the device or dose (low to medium dose range). ICS-induced growth suppression seems to be maximal during the first year of therapy and less pronounced in subsequent years of treatment. However, additional studies are needed to better characterise the molecule dependency of growth suppression, particularly with newer molecules (mometasone, ciclesonide), to specify the respective role of molecule, daily dose, inhalation device and patient age on the effect size of ICS, and to define the growth suppression effect of ICS.

Link: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009471.pub2/abstract;jsessionid=7F41CF0F17D601E965DE12E9747D5787.f02t04

 

 

Effect of Inhaled Glucocorticoids in Childhood on Adult Height.

Kelly HW1, Sternberg AL, Lescher R, Fuhlbrigge AL, Williams P, Zeiger RS, Raissy HH, Van Natta ML, Tonascia J, Strunk RC; CAMP Research Group.

N Engl J Med. 2012 Sep 6;367(10):904-12. doi: 10.1056/NEJMoa1203229

BACKGROUND: The use of inhaled glucocorticoids for persistent asthma causes a temporary reduction in growth velocity in prepubertal children. The resulting decrease in attained height 1 to 4 years after the initiation of inhaled glucocorticoids is thought not to decrease attained adult height.

METHODS: We measured adult height in 943 of 1041 participants (90.6%) in the Childhood Asthma Management Program; adult height was determined at a mean (±SD) age of 24.9±2.7 years. Starting at the age of 5 to 13 years, the participants had been randomly assigned to receive 400 μg of budesonide, 16 mg of nedocromil, or placebo daily for 4 to 6 years. We calculated differences in adult height for each active treatment group, as compared with placebo, using multiple linear regression with adjustment for demographic characteristics, asthma features, and height at trial entry.

RESULTS: Mean adult height was 1.2 cm lower (95% confidence interval [CI], -1.9 to -0.5) in the budesonide group than in the placebo group (P=0.001) and was 0.2 cm lower (95% CI, -0.9 to 0.5) in the nedocromil group than in the placebo group (P=0.61). A larger daily dose of inhaled glucocorticoid in the first 2 years was associated with a lower adult height (-0.1 cm for each microgram per kilogram of body weight) (P=0.007). The reduction in adult height in the budesonide group as compared with the placebo group was similar to that seen after 2 years of treatment (-1.3 cm; 95% CI, -1.7 to -0.9). During the first 2 years, decreased growth velocity in the budesonide group occurred primarily in prepubertal participants.

CONCLUSIONS: The initial decrease in attained height associated with the use of inhaled glucocorticoids in prepubertal children persisted as a reduction in adult height, although the decrease was not progressive or cumulative.

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3517799/

 

 

 

Effects of Beclomethasone and Factors Related to Asthma of the Growth of Prepubertal Children.

Camargos PA, Lasmar LM.

Respir Med. 2010 Jul;104(7):951-6. doi: 10.1016/j.rmed.2010.02.002

Abstract

Few studies on the concomitant effects of beclomethasone dipropionate and asthma-related factors on the growth of prepubertal asthmatic children have been published to date. In this prospective long-term ‘real-life’ cohort study we recruited 82 prepubertal steroid-naïve asthmatic patients aged 3 + years, excluding those with birth weight lower than 2500 g, malnutrition, and other concurrent chronic diseases. Height/age and weight/age Z scores were calculated every three months. Random effects multivariate longitudinal data analysis was used to adjust height/age and weight/age Z scores with independent variables. Among the studied patients, 63.4% were male, aged 4.7 + or – 1.5 years, 68.3% suffered from severe persistent asthma and had normal values for height/age and weight/age Z scores at enrolment. They were followed for 5.2 years (range 2.3-6.1) and used a mean daily beclomethasone dipropionate dose of 351.8 mcg (range 137.3-1140.0). Height/age and weight/age Z scores were not affected by either duration of treatment or doses of beclomethasone dipropionate up to 500 mcg, 750 mcg and higher than 750 mcg (p-values > 0.17). The multivariate analysis final model showed that severe persistent asthma was associated to lower height for age Z score (p = 0.04), whereas hospitalizations because of acute asthma (before and during follow-up) were associated (p = 0.02) to lower weight for age Z score. Growth parameters were not affected by the use of beclomethasone dipropionate.

Link: https://www.ncbi.nlm.nih.gov/pubmed/

 

 

 

Author (Date) Level of Evidence Sample/Setting

(# of subjects/ studies, cohort definition etc. )

Outcome(s) studied Key Findings Limitations and Biases
Zhang L.1., Prietsch S.O., Ducharme F.M.

(2014)

Systematic Review  25 RCTs, 8741 participants, children under 19 years old, with mild-to-moderate asthma Primary outcome:

-Linear growth velocity

 

Secondary outcomes:

-Change in height standard deviation over time

-change from baseline height in cm over time

-change in height z-score over time

 

-ICS is associated with a decrease of 0.47 cm/y (95% CI -0.66 to -0.27, P value <0.00001) and 0.48 cm/y (95% CI -0.65 to -0.30, P value <0.00001) in linear growth velocity in the first year of usage.

-A decrease from baseline height was seen in the first year, as well as a -0.13 (95% CI -0.24 to -0.01, P value 0.03) change in height standard deviation.

 

-No statistically significant decrease in linear growth velocity or change in baseline height in the second year of ICS treatment.

 

-A reduction of 1.2 cm (95% CI -1.90 to -0.50, P value 0.001 ) was noted at adult height

 

Summary:

ICS has the largest effect on height in the first year, there is minimal effect after that.

-Trials were screened for this review by title and/or abstract, rather than the entire article. This may have left room for relevant articles to be excluded from the review

 

-11 of the RCTs did not give a detailed explanation of their method for randomization, 6 of the RCTs included did not provide their method of randomization at all, this leaves room for a potential bias in the original trials that were included in the review

Summary of Evidence

 

 

 

 

Kelly HW, Sternberg AL, Lescher R, Fuhlbrigge AL, Williams P, Zeiger RS, Raissy HH, Van Natta ML, Tonascia J, Strunk RC; CAMP Research Group. (2012) Randomized control trial 1041 children between ages 5 and 13 years with mild-to-moderate asthma were randomly assigned into three groups: budesonide group, nedocromil group, and placebo group -Adult height

-Growth velocity

-Effects of glucocorticoid dose

-The average adult height was 1.2 cm lower in the budesonide group than in the placebo group (171.1cm vs. 172.3cm, P=0.001, CI=95%), and the average adult height in the nedocromil group was 0.2 cm lower than the placebo group (172.1cm vs 172.3cm, P=0.61, CI=95%)

-The difference in velocity reduction that was seen in the first 2 years of assigned treatment in the budesonide group compared with the placebo group (boys with P<0.001, and girls with P=0.007)

-A larger daily dose was associated with a lower adult height (-0.1 cm for each microgram per kilogram of body weight, P=0.007)

-The adult height in budesonide group were similar to placebo group after 2 years of treatment (-1.3cm, 95% CI)

-805 out of 1041 subjects are White, and 621 out of 1041 are male

– Information of subjects’ health and medication use was obtained by telephone contacts→ hard to reach respondents; can not elicit better response like in face to face interview; reliability of reporting is questionable

-In this study, 98 subjects were lost to follow up, and imputation method was used to fill in missing data, which may affect statistical analyses

 

 

 

 

 

 

 

Leonibus CD, Attanasi M, Roze Z, (2016) Retrospective Case-control  113 asthmatic children with mild-moderate asthma and 33 control children retrospectively chosen from Endocrine Clinic for endocrine diseases not affecting growth and pubertal development  Primary outcome:

– assess longitudinally from prepubertal age to attainment of final height

– the effect of inhaled corticosteroid therapy on growth

– final height in children with mild-moderate asthma compared to control population

 

Secondary outcome:

– type, duration, and dose of IC therapy had effect on final height

 – The final height in asthmatic boys was 2.5 cm ± 2.89 [mean (SD) 173.55 (3.79) vs. 176.04 (2.37), p= 0.028] cm compared to controlled boys

– final height of asthmatic girls was 2.0 ± 2.03 [mean (SD) 161.16 (4.79) vs. 163.44 (3.49), p=0.047] cm compared to the controlled girls

– statistically significant decrease in pubertal height gain SDS in asthmatic group for boys [-0.21 (0.89) vs 0.03 (0.41), p=0.036]

– statistically significant decrease in pubertal height gain SDS in asthmatic group for girls [ -0.36 (0.93) vs 0.02 (0.48) SDS, p=0.012]

– mean height SDS declined in asthmatic group from pre-puberty to FH from 0.26 (0.82) to -0.29 (0.65) in boys, girls 0.40 (0.96) to -0.17 (0.79) p<0.05 while the control group did not significantly change from 0.16 (0.64) to 0.20 (0.59) SDS in boys, while girls from 0.15 (0.65) to 0.19 (0.55) SDS, p>0.05

 – The study had several participants in which the final height measurement was not taken due to drop out and the authors did not include their data in study

– The authors do not inform the readers of the age range and other demographics of the experimental and control group

– the authors understand and state that there might be some selection bias

– the authors did not specifically looked at the bone age and biochemical markers of puberty

– A limitation that is not mentioned is that the study was done in italy and the population might be more homogenous in population and should be taken into consideration when looking at the results

 

 

 

 

 

 

Loke, YK., Blanco, P., Thavarajah, M., Wilson, A.M. (2015) Systematic Review and Meta-Analysis 23 RCTs, 3 observational studies on children with asthma of any severity Growth Velocity

 

Final Adult Height

Growth velocity: Pooled mean difference -0.48 cm/year (95% CI -0.66-0.29 cm/yr)

 

Final adult height: Pooled mean difference of -1.2 cm (95% CI -1.9 – 0.5 cm)

 

Observational studies found 0.7-0.9 cm reduction in final adult height (95% CI -3.35-1.65, I2=0%)

 

Section called “risk bias assessment” describes criteria used by two reviewers to filter and score selected studies. A third final reviewer than evaluated the previous reviewers’ results. Their specific qualifications are listed.

 

The study did not list a demographics table.

 

They included two extra observational studies in a review that comprises RCTs. Although they used it primarily to better understand the results from their meta-analysis, it could have imposed some bias.

Camargos PA, Lasmar LM. (2010) Prospective long-term cohort study Cohort following 82  prepubertal asthmatic patients at 3 month intervals till age 9/9.5y/o. -Severe persistent

 

– Height/age Z-scores

– Weight/age Z scores –

– Growth Velocity

 

Of non-users and BDP users (500mcg/day): no deviation between height and weight when compared to national growth chart.

(p-values >0.17) – not significant

 

Similar results found with higher dosed BDP (500-750mcg/day) with no deviation after age 5 when compared to national growth chart.

(p-values >0.17) – not significant

 

Multivariate analysis final model showed that “severe persistent asthma” was associated to lower height for age Z score (p = 0.02), scores 0.47 SD lower than pts with “moderate asthma” – not significant since

Values fall within range of Z score

 

Participants (majority male) came from low-income families and with mother of low education status. Although this study states they were well nourished and of average height/weight, the SES of the pts should be noted.

 

Another limitation is the use of the USNC for Health Statistics/CDC growth chart for participants living in Brazil

 

 

Conclusion(s):

Both meta analyses concluded (reviewing 23-25 RCTs each) that the use of Inhaled Corticosteroids for asthma in pediatric populations results in less than a 1.2 cm decrease in final adult height. The systematic reviews also found <0.66 decrease in bone growth velocity (Zhang et. Al., 2014, Loke et. al., 2015).

Certain studies found greater changes in height than others. As stated previously, the two meta-analyses (Zhang et. al., 2014, Loke et. al., 2015) found a decrease in adult height of 1.2cm whereas the case-control (Leonibus et al., 2016) found a decrease in height by 2.5 cm for boys and 2.2 cm in girls.  Moreover, the prospective long-term cohort also found a decrease in childhood height; however, it was not statistically significant (Camargos & Lasmar, 2010).

When deciding which of these findings should be more heavily weighted, the level of evidence should be considered; the Leonibus et. al. is a case-control that used a homogenous population of mainly Eastern European Caucasians because the study was conducted in Italy (2016). The two meta-analyses, on the other hand, uses larger sample sizes from many studies giving it more power.

Clinical Bottom Line:

Changes in adult height and growth velocity are minimal when considering the risks associated with the disuse of ICS for pediatric asthmatic patients. As such, pediatric asthmatic patients should continue to use ICS to prevent asthma exacerbations and further complications.

When discussing the side effects of ICS to the family of the patients, we would inform them there would likely only be a decrease in height of about 1.2cm, but it could result in a decrease in height of 2.5 cm for boys and 2.2 cm in girls.

 

In conclusion, our clinical recommendation was based on the evidence primarily found in the two major meta analyses and systematic reviews analyzed.

 

Attach Word document:

Mini-CAT

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H&P 2

H&P 2

 

Reflection

More pertinent positives are included and explained in HPI. In physical examination part, more abnormal findings are listed and described in each body system. In addition, assessment, plan, differential diagnosis parts are added. Plan of H&P for the patient has more details and clinical reasoning. Differential diagnosis has listed from most likely diagnosis to less likely diagnosis. And also, each differential includes reasons why I think it will be the diagnosis and what lab tests or images study can rule it out. When interviewing patients, show respect and understanding, use more open-ended questions during the interview to encourage the patient to express his or her concerns and feelings freely first, and know when to use close-ended questions to clarify. Sometimes, patient can be very talkative, and talk about things that are not related. I learned how to re-direct patient back to track and asks more about current complaints. After talking to patient, repeat back important points so that patient can correct if there are any misunderstandings. At beginning, the HPI is more like listing each step of OLDCARTS. But, now, it includes more details of OLDCARTS, more like a continuous story of the patient’s chief complaint, like the setting of the complaint and any prior episodes and progress of the complaint. In addition, at the end of paragraph, additional pertinent negatives and positives are provided which may explain the patient’s presenting chief complaint. Pertinent negatives also help with differential diagnosis as well.

Basically, I can do the head to toe exam thoroughly, but may need more time to finish the whole exam. Sometimes, little points will be missed, and it is easier for me to do the exam when the patient has specific complaints. I feel very confident to do exams of upper and lower extremities, like range of motion, strength and special tests. The weakest areas will be percussion, and I am bad at determining grading levels. For example, grading pulse and grading pitting edema, it is hard for me to know what increased pulse and bounding pulse are feel like, and what should be described as slightly pitting and deeper edema. When start the clinical year, I hope I get to know when is head to toe exam necessary and when to perform specific part of physical exams only according to patient’s complaints. In addition, I want to learn more about treatment plan.

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Policy Brief – Opioids Prescribing

HPPA 518 Health Policy Brief Assignment

To: Elizabeth Crowley

From: Jinjin Lin

Date: January 18, 2018

Re: Federal Restriction on opioid prescribing for pain management

 

Statement of Issue:

The addiction and abuse to opioids and other prescription pain relievers is a serious problem that affects the health and economic welfare of Americans. It is estimated that there are 2.1 million people in the United States suffering from substance use disorders related to prescription opioid pain relievers and there are 91 Americans die every day from an opioid overdose. The total number of opioid pain relievers prescribed in the United States has dramatically increased in the past 25 years. In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills. This great availability of prescribed opioid should take the major liability by increasing the negative consequences related to opioid addition and abuse. Without the restriction of prescription, people can get opioid easier which may lead to opioid dependence and abuse.

  • Drug overdose is a leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers.
  • The use of prescription opioids can have a lot side effects, even when they are taken as directed, such as physical dependence, increased sensitivity to pain, constipation, nausea, vomiting, dry mouth, sleepiness, dizziness, and confusion, and depression. 
  • In economic view, prescription opioid abuse is costly. It is estimated that the nonmedical use of opioid pain relievers costs insurance companies up to $72.5 billion every year.
  • Repeatedly long term opioid drugs use tends to induce tolerance. Tolerance occurs when the person is no longer responding to the drug as strongly as he or she did at first, thus he or she needs to increase the dosage in order to achieve the same effect.

 

 

Policy Options

  • A federal restriction initial supply limit on prescribing opioid for acute pain. A policy brings limitation of the number of days an initial opioid prescription can last. The new policy limits the number of the initial prescriptions, which is setting a 5 days supply limit for first time using opioid prescriptions.
  • Advantages: to slow the opioid epidemic; limit over prescription of opioid addictive drugs for acute pain; and minimize the risk of opioid dependence. For patients who need an initial opioid prescription, supplying with 5 days or fewer opioid can reduces the likelihood of long term opioid use.
  • Disadvantages: the number of pills dispensed will depend upon the strength of the opioid as well. Patients will also be prescribed opioids that provide pain relief over a shorter duration instead of a longer one. For some acute pain situations, such as fractured ribs, a 5 days supply is not reasonable in terms of effective pain relief. Clinicians will have a lot of appointments for refill related visits, which makes it more difficult to care for other patients.

 

  • A federal restriction initial supply limit and dosage on prescribing opioid for pain management. Besides setting a 5 days limit for initial opioid prescription; the policy also imposes a dosage limit for long term use, which restricts the strength of the actual dose a clinician can prescribe. For long term opioid users, the policy will reduce their daily does to 100 MME.
  • Advantages: Slow the opioid epidemic, and limit over prescription of opioid. Providers prescribe the lowest effective dose possible for the shortest duration and that’s effective at relieving a patient’s pain, which can reduce the tolerance. Limit daily dosages and require that immediate release formulations of drugs be given before extended release versions are prescribed.
  • Disadvantages: For those chronic pain patients usually take dosage of 300 MME, this 100 MME limit is too restrictive and harmful to them. Because those chronic pain patients’ bodies have become tolerant to all but the highest doses.

 

  • A federal restriction on prescribing opioid with authorized exemptions for certain patients, such as cancer treatments and hospice care. Prescribers should re-evaluate opioid prescriptions and provide other medications or physical therapy for pain management.
  • Advantages: Slow the opioid epidemic, reduce prescription of opioid, and reduce the tolerance. Change clinician prescribing behaviors. Chronic pain affects 100 million Americans, but opioids are not appropriate for many pain patients. Patients with central pain syndromes, for example, tension headaches, respond better to antidepressant and anticonvulsant medications than to opioids. If opioids are prescribed, they should be used in combination with non-opioid therapy, such as exercise therapy and physical therapy.
  • Disadvantages: For certain patients, physicians would have to seek authorized exemptions for those patients who need more medication or longer duration of opioids therapy. Some patients may desperate for relief and turn to heroin as their only option.

 

Policy Recommendation:

Easy access to prescription opioids has helped epidemic that now kills about 90 Americans every day. With hope to slow the epidemic and curb the nation’s opioid crisis, a federal restriction on initial supply and total dosage limit of opioid prescribing should be pursued as a way to prevent over prescribing which may lead to an opioid abuse. In addition, clinicians can obtain authorization for certain patients who are on cancer treatment or in hospice care. Even though this restriction policy may increase chances that patients come back to the clinics and ask for refills, it will prevent the possible development of physical or psychological dependence on opioid; change clinician’s prescribing behavior; and reduce the changes of abuse. Longer prescription durations and higher dosage will increase the likelihood of long term use of opioid. This policy is meant to balance the needs of the patient; to curb not just potential long term opioid use but also potential opioid misuse. The epidemic is getting worse, hidden in plain sight, and this policy is necessary to reduce the oversupply of prescription opioids.

 

References:

https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/prescription-opioid-heroin-abuse

https://www.cdc.gov/drugoverdose/opioids/prescribed.html

https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170948/

http://www.nejm.org/doi/full/10.1056/NEJMsr1601307#t=article

 

 

 

Posted in HPPA 518 Health Policy | Leave a comment

STDs intervention program

HPPA 516 Public Health Assignment

Interventions to address STDs in adolescents and young adults in Corona, Queens

Jinjin Lin

Scope of the Problem

  • Many adolescents and young adults engage in sexual intercourse, often with multiple sex partners and without using condoms. There are 47.8% of high school students reported having had sexual intercourse, 7.1% of them reporting having had sexual intercourse for the first time before age 13. Although most adolescents do not have concurrent sex partners at any given point in time, the number of sex partners cumulates over time. Specifically, among high school seniors, approximately 22.4% reported having had sex with at least four different sex partners. Moreover, among sexually active adolescents, only 61.5% reported using a condom the last time they had sexual intercourse.

 

  • Young people are at greater risk of getting an STD for several reasons. For example, young people’s immature reproductive and immune systems make them more vulnerable to infection by various STD pathogens biologically; a lot young people do not get the recommended STD tests; and young people do not want to talk sex issues with their clinicians. Young people ages from 15 to 24 years account for nearly half of all new STDs cases, including HIV. If STDs are not treated, the infections may lead to serious complications including infertility, chronic pain, cervical cancer, and death. In addition, from an economic and social view, STDs also cost a lot. The lifetime medical costs of STDs acquired by youth ages from 15-24 are estimated $6.5 billion.

 

  • Internet is increasingly becoming ubiquitous among adolescents and young adults. Many young people tend to use the Internet to seek health information and meet new sex partners. However, little has been done to maximize the Internet’s potential as STDs prevention tool. Over 31% of young people are using the Internet to get health information, and 17% searching for information on health topics that are difficult to discuss with adults, such as drug use and sex. Regardless of household income, or race, young people represent the predominant demographic using the Internet.

 

  • Individual level interventions are insufficient over periods of time. Because adolescents and young adults interact more often with school, neighborhood system, and family, they can involve in to prevent sexual risk behaviors of adolescents and young adults and change behaviors. All adolescents and young adults are expected to benefit from these interventions, especially those are experiencing STDs and those are at risk.

 

Planning

 

  • Behavioral and environmental changes: overall to decrease sexual risk behaviors.
  • Delay first sexual intercourse
  • Reduce the number of sex partners
  • Decrease the number of times having unprotected sex
  • Increase condom use
  • Get hepatitis B and HPV vaccines
  • Improve awareness of STDs

These behaviors and environmental factors can be changed by educating adolescents and young adults. Education helps young people to take responsibility for their own health. Health programs in school and community and education from family can help youth adopt lifelong sexual attitudes and behaviors that support overall health.

 

  • Key stakeholders are health program directors and managers in school and community, funders, family members, and health care providers in Corona, Queens.
    • Invite these stakeholders to a meeting, or series of meetings, depend on how much time they have available to spend with me.

At meeting, I will briefly describe my interventions and obtain a clear understanding of stakeholder interests, perceptions, and concerns relate to my interventions.

  • Involve stakeholders in key activities throughout the planning and implementation of evaluation, such as identifying and prioritizing interventions that need to be evaluated; and developing evaluation questions that are grounded in the perceptions, experiences and interests of stockholders.
  • To obtain additional information in Corona, Queens:
    • Review existing STDs records of public schools and Corona community, need to get permission.
    • Conducting sexual behavior surveys among adolescents and young adults in school and Corona community.

 

  • Funding:
  • Fund for Public Health NYC
  • New York Community Trust
  • NYC Department of Youth and Community Development
  • County Health Officials of New York
  • Astoria Corona District Health Center
  • Foresee my interventions program:
  • Based on feasibility standards, practical procedure and cost effectiveness, I think my intervention program can be feasible in the long run. The intervention program matches the goals of community health. Our goals are to seek to increase the skills of adolescents and young adults to avoid sexual risk behaviors. By teaching young people how to solve health problems, it also helps young people to develop positive connections with their parents, schools, and communities. And it mainly based on schools and family educations, which won’t cost a lot. The intervention will reduce sexual risk behaviors in the long term.

 

Development & Dissemination of the Intervention

 

  • Goals: Educational and behavioral intervention programs to reduce adolescent and young adults sexual risk behaviors in longer term.

 

  • Framework and inputs include:
  • Time: review community STDs records and conducting sexual behaviors surveys; meetings with stakeholders; design the educational information; conduct clinical services and implementation plan.
  • Funding: setting up community-based New Media channel; healthcare professionals online design sessions and answering questions; school-based health program education sessions and screening test cost; handouts and condoms display cost.
  • Physical space: school-based program need a lecture room or a class room to make modeling activities possible.
  • Confidential issues, especially for online consulting.

 

  • Interventions:
  • New Media technologies and many wireless technologies should be included in the interventions. A community-based specific channel is created for young people, which include general information about promoting safe sex and preventing STDs education. For example, show a video how to put on a condom correctly; and a media campaign to increase public awareness of STDs problems. Information should be distributed weekly and allow users (young people) to ask questions, give feedback and communicate with healthcare professionals anonymously after each session.
  • School-based STDs prevention program. Just as schools are important settings for preparing students academically, they are also critical for helping young people take responsibility for their own health. The educational session should be hold weekly and include modeling activities, such as how to begin a discussion about condoms with a sex partner; and role plays of communicating with sexual partners. In addition, school-based sexually transmitted disease screening. School health department has healthcare professionals available to screen STDs.
  • Family level intervention. Promote increasing communication between adolescents and parents about STDs prevention, and increase parental monitoring of adolescents and adolescents’ perceptions of enhanced parental monitoring. This leads to fostering a sense of increased family support as well. Family level intervention can be done at any time, does not need to restricted to a specific time.

 

Evaluation & Maintenance

 

  • Evaluation:
  • Evaluation criteria:
  • The number of young people in the school and community who are familiar with the program and its goals.
  • The number of young people who report using condoms while having sex after the intervention program.
  • The number of sex partners they have after program.
  • The reported cases of young people with STDs to see if the number of cases are decreasing.
  • The number of young people get Hep B and HPV vaccination.
  • The survey to see if young people change their sexual behavior after intervention program.
  • Evaluation should be done yearly.
  • Intervention is successful if flowing criteria are met after first year of program:
  • 80% of young people know about the intervention program and goals.
  • The number of young people who report using condoms increase by 20%.
  • The number of sex partners should decrease.
  • The number of cases of STDs among young people decrease in the first year.
  • The number of young people who are getting Hep B and HPV vaccines increase by 20%.
  • Survey results show an increase awareness of STDs, and safe sex and behavioral changes.

 

  • Unsuccessful intervention:
  • If the intervention program is not successful, there will be no one or only few young people know about this intervention program; the number of young people report using condoms will be no change or only increase a little; the number of cases of STDs among young people will not decrease; and the survey will show no difference of young people’s awareness of STDs and behavioral change.
  • The intervention plan needs to be modified if it did not reach its goals. To assess the quality of implementation of the intervention and the results or any side effects of it, also collect feedback from adolescents and young adults to improve the intervention. Take a look into the program carefully from start of the interventions, include the plan, process of interventions, amount of energy, resources, and money to identify any barriers for young people to access this program, including cultural sensitivity; any ways in which an intervention process can be made more efficient and effective. Make modifications to interventions, goal redefinition or establish a new goal.

 

  • Maintenance:

I will consider sustainability throughout the duration of the STDs intervention program. Even this program funded with start-up grants, it will also benefit from constantly monitoring viability. To pursuit multiple sources of funding if the interventions are effective and being evaluated annually, I can apply for health funding from local county healthcare agencies to support the program in the long run.

  • Monitor whether the community has embraced this STDs prevention program among young people and get feedback.
  • Discuss the possibility of future financial support from the community.
  • Advance public health relations to highlight the need for the interventions for young people and publish its success results.
  • Keep the local media informed of updating program or invite a member of the press to participate in meetings and make the public more aware of what the STDs prevention program is.

 

References:

http://www.queenslibrary.org/services/community-information/community-resources-database

https://www.northwell.edu/sites/northwell/files/Northwell%20Health%20Queens%20County%20CHNA%202016.pdf

http://www.advocatesforyouth.org/publications/publications-a-z/550-youth-development-strengthening-prevention-strategies

https://www.cdc.gov/std/life-stages-populations/adolescents-youngadults.htm

https://www.cdc.gov/std/stats14/adol.htm

http://ctb.ku.edu/en/table-of-contents/analyze/where-to-start/identify-targets-and-agents-of-change/main

http://www.fphnyc.org/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800004/

https://www.cdc.gov/std/program/bpmm/overall_process_model.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836340/

http://www.who.int/hiv/pub/sti/en/stdcontrol_en.pdf

http://www.sonoma-county.org/health/about/publichealth_hiv.asp

https://www.peelregion.ca/health/resources/pdf/EffectiveHealth.pdf

http://ctb.ku.edu/en/table-of-contents/evaluate/evaluation/framework-for-evaluation/main

https://energy.gov/eere/femp/institutional-change-process-step-5-measure-and-evaluate

http://www.esu1.org/SPED/RtI-interventions.html

 

Posted in HPPA 516 Public health | Leave a comment

Reflection paper

Looking back over the semester, I am amazed that all ethical principles I have learned. In this essay, I will use principles of dignity, autonomy and beneficence to support my concerns in clinical practice in the future.

Many experiences influence my decision to become a Physician Assistant. I moved to the U.S. eight years ago with the dream of becoming a healthcare professional who can help others live healthy lifestyles. Although I have disadvantages as an international student, I always give my 200 percent in working toward my dream. While working as medical assistant, I see the affinity between patients and PAs, and I find enormous pleasure in interacting with patients. My optimism and personal interest lends myself to connect with patients. I find that each patient has a story, and the patient needs personal interaction and sympathy. Further, I find out that PAs are more likely to share medical knowledge with patients to enable them to better understand their health conditions. I hope to master the skill in the PA program, so I can empower patients to play an integral role of their own healthcare.

In clinical practice, the most important things for me is to respect patients and their healthcare decisions; to assure the patient’s welfare; to improve healthcare outcome by delivering best patient care and treatments. If patients think they are being treated with respect, they are more satisfied, and more likely to do what the clinician tell them, which improve the healthcare outcomes as well. In addition, patients will trust the clinician, and are more willing to share sensitive information, such as sexual history, which can be crucial in some cases. Further, as a healthcare professional, to treat illness and make sure patients are treated properly are my top tasks; and improve quality of patient care is my primary goal.

Principle of dignity, autonomy, and beneficence are important to my ethical decision-making process and these principles also support my concerns in clinical practice. The best ethical principles to support respecting patients and their decisions are dignity and autonomy. Dignity is about the worth, stature, or value of human beings and respect to individuals (Sulmasy, 2013). The way patients being treated has an influence on their dignity. In healthcare, it is important for us to give the patient full respect and honor the patient’s dignity. As a PA, I need to see the patient as a human being, not just focus on the illness or disease they have. I need to understand not only the illness they have, but also the significance it had on their lives. Be thoughtful and take some small actions to make patients feel that their dignity is intact, such as maintain eye contacts, and listen with smiles on my face when I interview patients. Patients have their rights to make autonomous decisions and choices about their own health, and we should respect their decisions (Yeo, Moorhouse, & Dalziel 2010). In the healthcare decision, patients are free to take actions, they are able to do what they wish to do. When I practice medicine, I want to build up rapport with patients, and I do not want to throw over medical terms or just force patients to do the procedure. It is important to consider the patient’s thoughts and wishes, respect their autonomy, and their decisions and choices. After giving adequate information about their diseases, we must allow patients to express their wishes, participate in their care, and make their autonomous decisions about what to do with their bodies. The decision is made by the patient, and it matches his or her values and wishes. If the patient is participating in making decision, he or she may have a higher chance to follow the treatment plans that choose by himself or herself. Beneficence supports promoting the patient’s welfare, and delivering best patient care. In healthcare, beneficence principle asks us to do good, to promote health and wellbeing of patients (Yeo & Moorhouse, 2010). I want to provide best healthcare to patients, which is also the fundamental goal of medical practice. As a PA, it is my obligation to do good and to help patients improve their health. Any decisions I made in clinical practice should favor the patient’s benefits and those decisions are based on maximizing benefits of the patient. In addition, the procedures, treatments, and care recommended and done must be match the good intension to benefit the patient.

Principles of autonomy, dignity, and beneficence form the foundation for me to make ethical decisions and support my concerns in PA clinical practice in the future.

Posted in HPPA 514 Biomedical Ethics | Leave a comment

Case study – Juana Negron

Immunizations

Juana Negron is a 52 years old female, and she comes to visit in November. Vaccines recommended for her are list in the table:

 

Vaccines recommended Notes and explanations
Influenza Annually
Td booster every 10 years If she has not got it yet
Zoster May give to the patient because the patient has asthma, chronic lung diseases.

However, controversy found that Food and Drug Administration for use among and can be administered to persons aged ≥50 years, ACIP recommends that vaccination begin at age 60 years.

 

PPSV23 Adults aged 19 through 64 years with chronic lung disease (including chronic obstructive lung disease, emphysema, and asthma), or who smoke cigarettes need to administer PPSV23.

The patient is 52 years old smoker with asthma.

 

Screening test

The patient started smoking when she was 20 years old and has a total of 40 pack-years. Her family history includes a father who had colon cancer at age 50 and a mother who had breast cancer at age 55. She is 5ft 4 inches, 180 lbs, her waist circumference is 40 inches, and her BMI is 30.9, which is obese.

According to USPSTF, the patient is recommended to screen alcohol use, depression, hypertension, obesity, tobacco use and cessation, and HIV infection. Other recommended screening tests are list in the table:

Screening tests recommended Notes and explanations
Glucose level/diabetes Recommended for patient 40-74 if overweight or obese, patient is obese
Hepatitis C virus infection screening Normal risk if born 1945-1965, and patient’s age 2017- 52 = 1965
Lipid disorders screening Strongly recommends screening women aged 45 years and older for lipid disorders if they have increased risk for coronary heart disease. The patient is obese and she smokes for 32 years, which are risk factors for coronary heart disease
Breast cancer screening, mammogram Recommend women aged from 50-74, interval can be 1 or 2 years depend on individual situation, the patient’s mother had breast cancer at age 55
Colon cancer screening, colonoscopy every 10 years The patient is 52 years old and her family history reveals her father had colon cancer at age 50
Cervical cancer screening PAP smear is recommended every 3 years for age 21-65 female, or PAP smear and HPV every 5 years for aged 30-65 women
Lung cancer, LDCT screening Recommended for people at high risk, 55-74 or 55-80 with 30 pack-years and currently smoking or quit within past 15 years. The patient reports 40 pack-years smoking and currently smoking

 

Health Promotion/Disease Prevention Concerns

Injury Prevention: concerns should be discussed with the patient

  • Traffic safety
  • Burn prevention
  • Falls prevention
  • Choking prevention
  • Water safety
  • Safe sleep environment
  • Poisoning prevention
  • Firearm safety
  • Sports safety

 

Diet: The patient has typical Puerto Rican food. She has a history of “borderline high blood pressure”, asthma, and arthritis in both hands.

  • Diet issues: Typical Puerto Rico food, plantains and sofrito, which are high fat, high sugar and high sodium food.
  • Health issues with diet modifications:
  • The patient has a history of “borderline high blood pressure”, sodium intake should be monitored and controlled. Sodium has been linked to high blood pressure, high sodium intake increases the risk of hypertension.
  • Asthma:
  • Vitamin D-rich foods, such as milk and eggs.
  • Eat plenty of fruits and vegetables, such as carrots and leafy greens. They’re a good source of antioxidants such as beta carotene and vitamins C and E, which may help reduce lung swelling and irritation.
  • Magnesium-rich foods, such as spinach and pumpkin seeds.
  • Avoid sulfites. Sulfites can trigger asthma symptoms in some people. Used as a preservative, sulfites can be found in wine, dried fruits, pickles, and fresh and frozen shrimp.
  • Arthritis in both hands:
  • Three to four ounces of fish, twice a week or more. Cold-water fish, like salmon, tuna, sardines, are good sources of inflammation-fighting omega-3 fatty acids.
  • Beans, red kidney beans and pinto beans, one cup, twice a week. Beans are loaded with fiber and phytonutrients, which help lower CRP, an indi­cator of inflammation found in the blood.
  • Whole grains, 6 ounces of grains per day. Fiber and fiber-rich foods can lower blood levels of the inflammatory marker C-reactive protein.
  • Diet plan:

Breakfast: whole grain bread or cereal or wheat toast, one boiled egg, one glass of non-fat milk or non-fat yogurt, kiwi or any fruits.

Lunch: tuna sandwich on wheat bread with no mayo added or leafy greens based dishes, with spinach salad as a side, apple or any fruits.

Dinner: whole grain rice, cold-water fish (twice a week or more), beans (twice a week), chicken based dish (twice a week), fruits.

Snacks: baby carrots, pumpkin seeds.

Limit sodium and fat intake, like preserved processed food and fried food.

 

Exercise:

  • The patient reports that she does no exercise other than her activities on her job and walking her 2 dogs (about 2 blocks 3 times a day). Her waist circumference is 40 inches, and her BMI is 30.9, which is obese.
  • The patient does not meet guidelines. CDC recommend for adults to have 150 min/wk moderate-intensity and 75 min/wk vigorous- intensity aerobic activity, and muscle-strengthening equal or greater than 2 times per week.
  • Concerns includes: exercise beginner, weight bearing, asthma, and arthritis in both hands which limit the exercise intensity of hands.
  • Goals: weight loss
  • Exercise plan:
  • Considering she is a beginner, her weight bearing situation, asthma, and arthritis in both hands, she can begin physical activities slowly increased to 30 mins a day. Remember to warmup and cool down before and after exercise. Some light intensity and low-impact activities include: walk dogs (longer distance), light stretching, swim lap, and ride a bike in easy gears. Muscle-strengthening 2-3 times a week. After one week, she can increase the intensity to moderate level for 30-45 mins a day. Moderate-intensity activities include: walking briskly, recreational swimming, double tennis, and bicycling at 5-9 mph.
  • Her goal of loss weight must take step by step. Patient needs to be educated that she has asthma, and arthritis which limit her vigorous intensity activities. Weight loss can be achieved by lower activity levels, but it takes longer. In addition, patient needs to understand that maintain weight loss is really hard. Physical activity and diets appears to be critical for long-term weight management. Weight regain (following weight loss) was reduced by engaging in high levels of physical activity. Increased physical activity helps to maintain energy balance, and high levels of physical activity is necessary to compensate for increased energy efficiency following weight loss.
  • Monitor heart rate during exercise: her maximum heart rate, 220-52 = 168, and target heart rate for moderate level, 50%-70% of maximum heart rate, which is 84-118.
  • In addition, follow up in 4 weeks, if she feels joint soreness that lasts more than 2 hours after workout, she needs to adjust the intensity and duration.
  • Further, she may have wheezing, tight chest, cough, or shortness of breath after 20 min exercise, which are symptoms of exercise-induced bronchoconstriction (EIB). When EIB symptoms occur, they can be treated with short-acting beta-agonists. In addition to medications, warm-ups, cool-downs and wearing a mask or scarf over mouth may prevent or lessen EIB symptoms. She needs to limit exercise when she has a viral infection, temperatures are low, or pollen and air pollution levels are high. Exercise recommended for asthma people:
  • Swimming, exposed to warm, moist air as exercise, which does not tend to trigger asthma symptoms. Swimming also helps strengthen upper body muscles.
  • Walking, leisure biking and hiking are also good sporting activities for people with EIB.
  • Team sports that require short bursts of energy, such as baseball, football, tennis and short-term track and field are less likely to cause symptoms than sports that have a lot of ongoing activity such as soccer, basketball, field hockey or long-distance running.

 

Harm Reduction:

Designated driver initiatives, healthy food choices, screening tests, anxiety, exercise and smoking concerns are discussed in other sections.

Safer sex education to reduce STD, and harm from her job that pest control at ground zero, should be discussed with the patient.

Brief Intervention

Obesity: patient’s waist circumference is 40 inches, and her BMI is 30.9.

The 5A’s counseling for obesity

5A’s Example questions
Ask:

  • Ask permission to discuss weight; be nonjudgmental.
  • Explore readiness for change (using 1-10 scales).
  • After give the number, follow-up with what make patient say that number, and what will make patient to move up to a higher number.
  • “May I talk to you about your weight?”
  • “Are you ready to work on your weight? Would it be okay if I helped?”
  • “On scale from 1-10, which number you will give for your readiness for change?”

 

Assess:

  • Assess health status and obesity indicators, such as BMI, waist circumference, DM or pre-DM condition.
  • Explore drivers and complications of excess weight, and barriers to lose weight.
  • “Please tell me about your past weight gain and loss.”
  • “Can you discuss your daily diet and physical activity?”
  • “Does your family members have overweight/obesity?”
  • “Do you have any concerns about weight loss?”
Advise:

  • Ask permission to give advice and information.
  • Health risks of obesity.
  • Benefits of modest weight loss.
  • Need for long-term management.
  • Advise treatment options, such as lifestyle change, medications and surgery.
  • “I have some information about how to manage weight, do you want to discuss with me?”
  • “What do you know about the effects of overweight and obesity on health risks?”

 

Agree:

  • Establish expectations.
  • Determine whether this is a god time to pursue weight loss.
  • Identify behavioral changes to be made/attempted.
  • Formalize a plan together.
  • “Is it a good time for you to purse weight loss?”
  • “What would you like to weight?”
  • “Now that we have a better understanding of your situation, can we explore and come up with a plan of action to improve things?”
Arrange/Assist:

  • Provide resources.
  • Assist by referring to appropriate professionals or formal support group.
  • Arrange regular follow-up.

 

  • “Would you like me to refer you to someone who can help you with meal planning and exercise regimen?”
  • “Would you like me to provide some support groups information?”
  • “Can we schedule a follow-up appoint in 4 weeks?”

 

Smoking Cessation: The patient started smoking when she was 20 and has a total of 40 pack-years. She stopped once for about 6 months, but then went back to smoking. Asthma noted.

Main intervention: counseling and pharmacotherapy

The 5A’s counseling for smoking cessation

5A’s Example questions
Ask:

  • Ask if the patient is currently smoking/using tobacco?
  • If yes, how much and what kind of tobacco.
  • Explore readiness for change (using 1-10 scales).
  • After give the number, follow-up with what make patient say that number, and what will make patient to move up to a higher number.
  • “Do you smoke? Or have you ever smoke?”
  • “Are you ready to work on your smoking? Would it be okay if I helped?”
  • “On scale from 1-10, which number you will give for your readiness for change?”

 

Advise:

  • Ask permission to give advice and information.
  • Health risks of smoking.
  • Benefits of quitting, short-term and long-term benefits.
  • Advise medications and other tools to help.
  • “I have some information about how to manage smoking, do you want to discuss with me?”
  • “What do you know about the effects of smoking on health risks?”

 

Assess:

  • Assess health status.
  • Assess addiction to nicotine, using heavy smoking index (HSI).
  • Determine what other motivating factors may exist.
  • “Have you ever tried to cut back on or quit smoking?”
  • “What keeps you from quitting?”
  • “Do you worry about cravings or weight gain?”

 

Agree:

  • Discuss setting a quit date
  • Agree on what medications if any will be used and when to start them.
  • Identify behavioral changes to be made/attempted.
  • Formalize a plan together.
  • “Is it a good time for you to quit smoking?”
  • “I have some information regarding medications that help quit smoking, do you want to discuss a little bit of them?”
  •  “Now that we have a better understanding of your situation, can we explore and come up with a plan?”
Arrange/Assist:

  • Provide prescriptions if needed.
  • Assist by referring to appropriate internet, formal support group, or other regular check-in options.
  • Arrange follow-up.

 

 

  • “Would you like me to provide some support groups information?”
  • “Can we schedule a follow-up appoint in 4 weeks?”

 

  • Specially for the patient, cigarette smoking has special meaning her asthma. In asthma, allergic inflammation of the bronchial tubes causes mucus production, leading to cough and phlegm. In long-term cigarette smokers, chronic inhalation of smoke from burning tobacco leaves also stimulates the mucous glands in the bronchial tubes to make excess mucus, giving rise to daily cough with phlegm. In asthma, spasm of the muscles surrounding the bronchial tubes and swelling of those tubes makes breathing difficult. Some cigarette smokers develop irreversible narrowing of their bronchial tubes from inflammation and scarring, causing permanent breathing problems. Persons with asthma who smoke cigarettes are in “double jeopardy”: they risk episodes of breathing difficulty due to asthma on top of everyday shortness of breath from the cigarette smoke-induced lung diseases, emphysema and chronic bronchitis.

Pharmacotherapy available to support patients in quitting smoking:

  • Nicotine replacement therapy (NRT) à reduce craving. It includes OTC: patches, gum, lozenges; and prescription: spray and inhaler.
  • Bupropion (Wellbutrin SR®, Zyban®) à best choice for patients with history with depression. Increases quit rate, and it includes Wellbutrin SR and Zyban.
  • Varenicline (Chantix®) à active nicotine receptors in brain to prevent cravings. It includes Chanitix. Special consideration for people with neuropsychiatric issues.

 

Overall, I think the first issue need to be addressed is smoking, and then obesity.

 

References:

AFP – 1 pg Adult Screen USPSTF.pdf

5 As in Obesity.pdf

 CDC – What to Tell Pts About Smoking.pdf

https://www.mayoclinic.org/diseases-conditions/asthma/expert-answers/asthma-diet/faq-20058105

https://www.healthline.com/health/asthma/asthma-diet

http://www.arthritis.org/living-with-arthritis/arthritis-diet/anti-inflammatory/the-arthritis-diet.php

https://www.aaaai.org/conditions-and-treatments/library/asthma-library/asthma-and-exercise

http://www.asthma.partners.org/NewFiles/BoFAChapter30.html

 

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Patient-centered Interview video

 

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H&P

H&P

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First SOAP note

Headache Case

Complied case information

Mr. J is a 27-year-old man who arrives at his primary care physician’s office complaining of a headache.

He has a long history of mild tension-type headaches managed with acetaminophen. Three days ago, a severe headache suddenly developed while he was weight lifting.

He describes this headache as the “worst headache of his life.” The headache slowly resolved over about 2 hours. He is now feeling completely well. He has been afraid to exercise since this headache.

Mr. J’s past medical history is notable only for mild asthma for which he uses albuterol as needed.

On physical exam, he appears well and not in any distress. His vital signs are temperature, 36.9°C; pulse, 82 bpm; BP, 112/82 mm Hg; RR, 14 breaths per minute. His neck is supple and detailed neurologic exam is also normal.

Mr. J is referred from clinic for a noncontrast head CT. The results are normal.

Given the acute-onset during exercise, the normal neurologic exam, and the lack of symptoms during the intervening 3 days, the patient was thought to have primary exertional headache. A sentinel headache, preceding a SAH, however, was a must not miss alternative. Given this, the patient underwent lumbar puncture that revealed no RBCs and no xanthochromia. He subsequently experienced a similar headache 2 weeks later with exercise. He was then treated with preexercise propranolol with good response.

 

SOAP NOTE

S: A 27-year-old man who complains of having a headache. The patient reports three days ago, a severe headache suddenly developed while he was weight lifting. He describes this headache as the “worst headache of his life.” The headache slowly resolved over about 2 hours. He is now feeling completely well. He has a long history of mild tension-type headaches managed with acetaminophen. The patient’s past medical history is notable only for mild asthma for which he uses albuterol as needed.

O: the patient appears well and not in any distress. neck is supple, detailed neurologic exam is normal.

Vital signs: temperature, 36.9°C; pulse, 82 bpm; BP, 112/82 mm Hg; RR, 14 breaths per minute.

A noncontrast head CT, normal.

 

A: Primary cough headache, primary exertional headache, headache associated with sexual activity, benign thunderclap headache, and intracerebral hemorrhage.

R/O SAH (Subarachnoid hemorrhage)

P: lumbar puncture

treated with preexercise propranolol

 

Summary of SAH differential diagnosis:

  • A middle-aged patient experiences “the worst headache of his life.” Soon after the headache begins, the patient vomits and develops neck pain and stiffness. Patients may also lose consciousness. If the patient is alert at the time of medical assessment, focal neurologic signs and meningismus may be present on the physical exam.
  • SAH is primarily caused by rupture of a saccular aneurysm in or near the circle of Willis.
  • It is generally accepted that anywhere from 10% to 50% of patients will have a warning or sentinel headache in the weeks preceding the SAH. This headache is usually the same sort of abrupt onset (thunderclap) headache as SAH but resolves within 24 hours.
  • Among headaches presenting to the emergency department, SAH accounts for

12% of patients with the “worst headache of my life”

25% of patients with the “worst headache of my life” and neurologic findings

  • Findings that common in patients in whom SAH is ultimately diagnosed: Headache, 90%

In patients presenting with headache, 82.4% report a thunderclap headache, and 99.2% reported the worst headache of their life.

Stiff neck, 75%

Change in mental status, 60%

Stupor or coma, 27%

  • Diagnostic tests:
  • The initial diagnostic test is a noncontrast head CT. The sensitivity of this test varies with the time since the onset of symptoms.
  • CSF examination for RBCs and xanthochromia is the most accurate diagnostic method. Most experts suggest delaying the lumbar puncture for 6–12 hours after the onset of a headache (if clinically safe) in a patient with a suspicious headache and normal CT scan since it takes 12–24 hours for the sensitivity to reach nearly 100%.
  • Importance of correct diagnosis: All patients in whom SAH is suspected should undergo a noncontrast head CT. If the CT is normal, a lumbar puncture should be performed in any patient with more than a minimal pretest probability.
  • About 25% of patients with SAH are initially misdiagnosed.
  • Patients with less severe clinical presentations are most commonly misdiagnosed.
  • Patients who are initially misdiagnosed are only about half as likely to have a good or excellent outcome.
  • Treatment:
  • Prevention of rebleeding: the primary treatment of a SAH is to occlude the culprit aneurysm to prevent rebleeding. For example, deploying platinum coils via arterial catheters within the aneurysm to cause occlusion, and neurosurgical clipping of aneurysms.
  • Prevention of cerebral vasospasm and resulting ischemia: calcium antagonists, primarily nimodipine, decrease the risk of vasospasm.
  • Management of hydrocephalus.

 

Modified Fisher Grading Scale for SAH

 

 

Reflection

This is my first time doing a SOAP note. I feel generating differential diagnoses and plans are most challenging parts for this exercise. Before we have a final diagnosis, it is important to consider all possibilities of medical problems that relate to this patient with headache. First, we have to think about those conditions which are common and which present in the common manifestations. Second, we think about those conditions which are common but which may present in an uncommon way. Third, consider those conditions which are uncommon but which present in the common way. Forth, consider medical conditions which are not only uncommon but also present in an uncommon way. For example, in this headache case, differential diagnose includes: primary cough headache, primary exertional headache, headache associated with sexual activity, benign thunderclap headache, intracerebral hemorrhage, and subarachnoid hemorrhage. After we have more findings on history and physical examination and after tests like head CT done, we can shortlist these possibilities. After a normal CT result, we rule out SAH. And the plan is to do a lumbar puncture for the patient, and treated with preexercise propranolol. Overall, considering the various diagnosis regarding the various possibilities are very helpful to the patient in deciding the further action.

 

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