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