Yusuf Khoury

57 y/o male with a PMH of Type 2 DM and moderate to severe depression control by meds.

Immunizations:

Influenza: 1 dose yearly

I will double check that his immunization for booster for Td/Tdap is up to date.

Pneumococcal 23-valent polysaccharide (PPSV23): it is recommended that patients with DM between the age of 19-64 should be vaccinated

*Pneumococcal (PCV13) (1 dose): administer least 1 year after PPSV23 vaccination.

Hepatitis B: for patient below 60 y/o with DM

Screening

Screening for alcohol misuse, Depression, Hypertension, Obesity, Tobacco use and cessation, HIV infection, Lipid disorder, Abnormal glucose/diabetes, Hepatitis C virus infection.

He is positive for depression, hypertension, overweight, abnormal glucose/diabetes.

Depression: patient is currently on medication; however, he is still show signs of depression. We can assess if he is taking his medication.  He needs to visit the psychiatrist and it is recommended to start seeing a therapist who uses cognitive behavioral therapy to help him with thoughts and behaviors that can improve his mood and daily tasks.

Hypertension: today’s readying is borderline high 142/86 mmHg. Ask if medication is taken on time daily (assess patient adherence) otherwise, he might need to increase the dose.

Overweight: see on “Health Promotion/Disease Prevention Concerns” section

Abnormal glucose/diabetes: the normal range is 5.7 to 6.4; but his Hgb A1C = 9.0 very high; he is on medication: Again we have to first assess patient adherence, if he is adherence, we need to address his diet, and if his sugar is not going down, then we will need to suggest insulin injection subcutaneously.

Colorectal cancer screening: based on his age, it is recommended to get a colonoscopy every 5 to 10 years. There is a talk to discuss about the pros and cons of the screening because it requires sedation, so he needs someone to pick him up. The exam may not detect all polyps and cancer.

Prostate exam (digital rectal exam) suggested for every year. However, the PSA test should be discussed to consider the risk and benefits. We will only recommend PSA test if in the prostate exam we feel the prostate is hard, abnormal, or lumpy.

Health Promotion/Disease Prevention Concerns –Based on Yusuf medical history, vital signs: his BMI indicates he is overweight, waist circumference is 43; the main concern is that with waist circumference greater than 40 inches with physical inactivity, type II diabetes, and hypertension, he has high risk on cardiovascular diseases. We need to create a plan that would help Yusuf to have a better lifestyle.

Diet

Patient eats his breakfast usually outside of home and gets a “buttered roll and large coffee with half and half and Equal” and sometimes “a piece of fruit”. For lunch, he also eats outside on local restaurants: “a sandwich or sometimes soup with a bag of chips”. It is hard to resist the “cookies and other sweets” from the break room.

Because the patient has type II diabetes and he is overweight, a proper diet should have less saturated fats and no trans fats, a lot more fruits, unprocessed grains, whole grains, and non-starchy vegetables (no carbohydrates), add dried beans and legumes, have less red meat but if you must, then eat lean meats and low fat dairy, eat more cold water fish like salmon, mackerel, herring, or sturgeon. He should completely avoid sugar or corn syrup sweetened drinks It would be great to know how many calories is consuming.

It is alright to get breakfast from the corner store guy, but it is not very healthy to eat that breakfast every day. The best solution would be to bring your meal prepared from home. You can prepare whole grains roll with hummus instead of butter, and the large coffee with skim milk instead of half and half.

The major goals for this diet is

•        Balance calories with physical activity to manage weight

•        Consume more fruits, vegetables, whole grains, fat-free and low-fat dairy products, seafood

•        Consume less salt, saturated fats, trans fats, cholesterol, added sugars, refined grains

•        Mediterranean diet could be a good choice

•        Consider a lettuce roll- up (Boston lettuce works well for this) instead of a sandwich

Exercise

Diet alone will not help the patient reach his target weight. We know from the history that the patient does not like to work-out.

Encourage him to start walking his dog and use the stairs more than the elevator. Along with the recommended psychological therapy, working out will increase endorphins, which may stimulate the patient’s mood positively. After a week, he can go running or jogging with his dog since we want aerobic activity; stay always hydrated with water. The patient can exercise every day, three times a day, which coincide with his dog’s potty time and walking. Each walking can be about 10 minutes.

Due to his DM, HTN he should exercise to prevent CVD. To start he can walk more with the dog or his wife and try to participate in the social events like the local mosque. We have to provide counseling for CVD prevention with a diet and exercise plan (as shown above). Explain the patient why he is at risk and what behaviors are important to change.

Harm Reduction

Mr. Yusuf is used to buy breakfast, lunch around his office building, we can suggest doing that only two times a week and the rest to bring his meal from home with the guideline recommended before. He should choose food that are healthier like a salad bar. We do not expect him to change his habits in a drastic matter, so encouraging small but sure steps can have higher chances of success and also boost his mood.

Brief Intervention

Patient is not obesity, but he is overweight, so we need to counsel him in order not go down into obesity, also due to the diabetes he is in risk for CVD. So, we can still use the 5 As of obesity Ask, Assess, Advise, Agree, and Assist: using a motivational interview style for behavior changes. We ask permission to talk about his weight like: “Are you concerned about your weight and the effect on your health or your quality of life?” or “Would it be alright if we discussed about your weight?”. Them we assess from the physical exam: BMI, waist-hip ratio, causes for weight gain. Advise the risk of obesity as well as the benefit for mild weight loss, we need to visualize the long-term benefits. Agree on expecting a realistic target weight loss, we can suggest a 10% of the current weight to be the most optimal, in his case is to lose 19 lb. However, we should focus on the patient’s mental and physical health than on his weight. Assist is to find facilitators and barriers that could affect on Mr. Yusuf’s attempt to manage his weight. His dog is significant to motivate him to leave his home. Depression is one of the barriers that can impede his weight management. We can educate him by explaining the positive attribute or working out to improve his depression.

 

Sources:

-CDC Adult Immunization Schedule USA 2016

-AFP – 1 pg Adult Screen USPSTF

– Introducing a One-Page Adult Preventive Health Care Schedule: USPSTF Recommendations at a Glance

-Nutrition, very brief power point presentation

–https://beckinstitute.org/get-informed/what-is-cognitive-therapy/

– 5 As in Obesity