HPDP Case Study – Yusuf Khoury – Graded

Yusuf Khoury is a 57 year old accountant with a history of Type 2 diabetes and moderate to severe depression somewhat controlled by medication. He comes to see you today with a complaint of shoulder and left hand pain when he walks his dog and left wrist pain when us uses his computer. He is concerned that the pain may be caused by his heart because he has been told that left arm pain can be a symptom of heart attack, however you’re not so persuaded. He describes the pain in his shoulder as aching, but not worse at the end of the dog walk than it was at the beginning. It is located mostly in the shoulder and upper arm and is not accompanied by chest or jaw pain, shortness of breath, nausea, palpitations or discomfort anywhere else. It resolves when he stops walking the dog and does not occur when he walks at any other time. The wrist pain is located mostly in the ventral surface of his wrist and gets progressively worse while he’s at work, sometimes accompanied by numbness and tingling in his thumb and first finger. The wrist pain occasionally also bothers him at night. He has taken ibuprofen 400 mg. for this pain which does help some – relieving at the end of the day from 6/10 to about 3/10. Over the weekends, the wrist pain doesn’t bother him at all and his arm only bothers him when he walks the dog

His desk job requires many hours of sitting at his computer and very little walking during his typical work day. He commutes to work via subway which is one block from his home and leaves him one block from his office. Apart from walking the dog, he gets no regular exercise. In fact he says, “I’m allergic to exercise”.

He typically buys breakfast at the shop in the ground floor of his office building – usually a buttered roll and large coffee with half and half and Equal. “Sometimes I get a piece of fruit too from the guy with the stand on the corner”. He usually orders in for lunch from one of the local restaurants – a sandwich or sometimes soup with a bag of chips. He admits that his office mates usually have a big plate of cookies or other sweets in the break room and that he has a hard time resisting them.

His family history is significant for a father who also had Type 2 diabetes and prostate cancer at age 70. His mother had hypertension and a stroke at age 68. He has one sister who is alive and well and a brother who has macular degeneration.

He lives with his wife and their dog in an apartment building with an elevator.   He spends most of his weekends at home, sleeping for long periods of time. He rarely leaves his apartment on weekends and has very little social life, though his wife is very involved in the local mosque and frequently tries to get him to join her there. He says, “It just seems like too much effort”.

Yusuf does monitor his blood sugar and blood pressure regularly and keeps a log of his measurements. Lately his glucometer readings have been in the 180-200 range fairly often. His blood pressure readings have been under 140/90 on his current medication. You are considering whether he needs to be started on insulin, but so far he has resisted this suggestion.

Other information:

BP 142/86     P 72                R16                 T 99

Hgt 5ft 11.5 in                                 Wgt 190         Waist circumference 43

Finger stick glucose this morning (fasting) 160

Hgb A1C         9.0

Medications:

• Metformin 500 mg twice daily – anti diabetic
• Glyburide 5 mg twice daily – anti diabetic
• Paroxetine 20 mg twice daily – SSRI for depression
• Enalopril 5 mg twice daily – ACE inhibitor

 

Case Study Elements

Immunizations

Vaccine	Recommendation/Reason For Patient	Administered at Current Visit
Influenza	Needs one dose annually	Yes
Tdap	Needs booster every 10 Yrs	Yes, if not previously received in last 10 years
Varicella	Childhood vaccination (2 doses)	No, Already received
HPV Male	For ages 11 – 26 (3 doses)	No
Zoster	Recommended after age 60	No
MMR	Childhood vaccination (1-2 doses)	No
PCV13	To be administered at age 65 or over	No
PPSV23	he has DMII, Needs one dose at this visit, second dose to be administered 1 year after PCV13 (at age 65 and over)	Yes
Hepatitis A	No indications	No
Hepatitis B	DMII Risk	Yes. If not received before with DMII diagnosis
MenACWY	No Risk Factor	No
MenB	No Risk Factor	No
Hib	No Risk Factor	No

 

 

Cancer Screenings	Recommendation	Indicated for visit
Colon	Age 50-75, Colonoscopy every 10 years	Yes, if patient did not receive a colonoscopy in last 10 years, or has other risk factors
Lung	No screening recommended for those with average risk	No
Prostate	Age 55-69, inform men about benefits/harm – use shared decision making	Shared decision making, talk to him about pros/cons of screening especially since father had Prostate Cancer
Skin	Evidence insufficient	No

 

Screenings	Recommendation/Risk	Current Visit
Alcohol misuse	Normal Risk	Yes
Depression	Normal Risk	Yes, he is Dx with Depression and taking SSRI, follow up on Rx and if CBT is needed
Hypertension	Normal Risk	Yes, he has HTN and taking medication, follow up on Rx and educate that his BP should be under 140/90
Obesity	Normal Risk	Yes, He is over with a 43 in waist circumference
Tobacco use and Cessation	Normal Risk	Yes
HIV Infection	Normal Risk	Yes
Hepatitis B infection	With Specific Risk Factor	Yes, risk with Dx DMII
Syphilis	With Specific Risk Factor	No
Hepatitis C infection	With Specific Risk Factor	Yes, being born between 1945-1965
Lipid Disorder	Normal Risk	Yes
Abnormal glucose/diabetes	With Specific Risk Factor	Yes, being overweight, and Dx DMII. His fasting glucose is at 160, and his A1C is at 9.0 which requires Rx evaluation and education
Aspirin for CV risk	If Benefit>Risk	Yes
Abdominal Aortic Aneurism	If “ever smoked”	Yes, If he has smoked before

 

Health Promotion/Disease Prevention Concerns – please address all that are relevant for this patient:

• Injury Prevention
  • Traffic Safety
  • Seatbelt use
  • Firearm safety, if he owns or is around firearms
  • Musculoskeletal pain – Shoulder/upper arm/Wrist pain prevention

• Diet
  • Khoury has a sweet tooth and likes to eat cookies and other sweets at work, which can contain a high glycemic index. This probably contributes to his high glucose levels and high A1C level.
  • Some health issues to consider in his diet plan are that he has HTN, Diabetes (A1C = 9.0), increase risk of CVD, CAD, PAD and he is overweight.
  • Emphasize that small changes made in his diet gradually can promote better health in the long run.
  • A low glycemic diet may be more effective for weight loss and preventing weight regain. Also Mr. Khoury should use meal replacements and controlled meals to help with his diet plan.
  • For Mr. Khoury I would focus on gradually limiting his caloric intake, along with decreasing his sugar and salt intake. He should focus on eating more vegetables and fruits along with whole grains and fiber.
  • Following the Healthy Plate model, <¼ whole grains such as brown rice, whole grain pasta or whole wheat bread, ¼ healthy protein like fish, poultry, beans and nuts, tofu, limit on red meats and cheese. At least ½ the plate should be non-starchy vegetables like green beans, broccoli, cabbage, cauliflower, carrots, any leafy greens, and such.
  • For meal options such as breakfast he should opt for a whole-wheat roll or oatmeal with fruit, and possibly opt for a medium size coffee instead. For lunch he should consider eating salads with grilled chicken or opt for fish and steamed vegetables.
  • Dessert options include, a frozen treat with 100% fruit, whole fruit on a toasted whole grain waffle, Plain Yogurt with a splash of maple syrup
  • Snacks can be single serving of applesauce, Baby carrots with or without hummus or grape tomatoes, Single fruits such as apples, pears, oranges, etc., Mixed nuts with almonds, cashews, pistachios, raisins, pumpkin seeds, can customize to what they like.
  • Lastly, since there are endless suggestions, I would tell Mr. Khoury to focus on eating real food, eating in moderation, to include mostly plants, and to eat with family as a means of catching up on their day, which would help him eat slower and take breaks.

• Exercise
  • It is recommended by the CDC that adults get 150 minutes of moderate intensity aerobic activity and 2 or more days of muscle strengthening activities per week. Or 75 minutes of vigorous – intensity aerobic activity, and 2 or more days of muscle strengthening activities per week. Being that Mr. Khoury is 57, this means his maximum heart rate is 220 – 57 = 163 bpm. A heart rate of 82 – 114 bpm is moderate level and a heart rate of 114 – 139 bpm is vigorous.
  • Increase activity has been shown to help with diabetes, hypertension, and depression. However he is currently not getting enough adequate exercise and seems to be mostly sedentary since he only walks his dog and does not like to exercise.
  • To begin we should assess his willingness to exercise, how fit he is and if there are any limitations such as arthritis or joint problems, then to determine his goals.
  • He should start with a few minutes of physical activity daily and to slowly increase to 30mins. Another option is to go on longer walks with his dog, or play catch with them.
  • Since he takes public transportation and lives/works close to his stop, he should instead utilize small steps in his exercise plan such as walking to the next stop to get on the train and get off a stop earlier and walk to work.
  • Also he should take the stairs instead of elevators in his building as well as at work.
  • He can schedule breaks at work such as every two hours to get up and move for about 10 minutes. Or to spend 25 -50 % of his lunch time to walk around his office especially if he knows he will try to eat some sweets at work.
  • It is important to stress that he should not focus on his speed or pace at the moment but to build up consistency of exercising. After building that, he can slowly add more activities to his routine and try different things such as biking, swimming, stretching, going to the gym, and such.
  • He can also do these activities with his wife so they would be able to motivate each other. In time he should add more moderate/intense activities such as weight training.
  • If Mr. Khoury wanted to start on a vigorous exercise program, he would need an exercise stress evaluation since he has diabetes and cardiac risk factors.
  • A good goal for Mr. Khoury would be about a 10% weight loss in over 12 months, so about 19lbs/12 months = 1 – 2 lbs. per month.

• Harm Reduction
  • Khoury typically orders out for breakfast and lunch, so I would encourage him to make “healthy choices” in fast food restaurants or when ordering out in general.
  • Additionally Mr. Khoury is diabetic so I would recommend that he curtail his sugar intake and switch to sugar substitutes when he can.
  • Sunscreen Use –when going outside he should use sunscreen to prevent any sun damage and decease his risk of skin cancer.

Brief Intervention – where relevant to your chosen patient, please explain how you would conduct a brief intervention for:

• Overweight/Obesity

Mr. Khoury is 190 lbs. and 5’ 11.5’’ thus his BMI is about 26.1, which is categorized as overweight. His waist circumference is 43 inches, which indicates he has an increased risk of health problems.

Ask: “Hi Yusuf, I would like to change gears now and if it is okay with you can we discuss your weight and how it is impacting your life and health?” Next would be to explore his willingness to change, “Are you concerned about your weight? Have you tried to lose weight before? Would it be ok to explore options to help you with weight management?

Assess: Discuss health status and overweight indicators and explore drivers, and barriers. “So you know you are 190 lbs. which puts your Body Mass Index at 26.1 which is over weight for someone your size, and also your waist circumference is 43 inches which can also be alarming to your health. This could put you at greater risk for CAD, CVD, PAD, stroke, and such. Being that you already have HTN, DMII, and your family history also puts you at greater risk, I would like to discuss your diet, and physical activity and about any previous weight gain/loss. Are other family members overweight/obese? What barriers may prevent you from losing weight? And what weight would you like to be?“

Advise: To counsel about health risks “Mr. Khoury what do you know about the effects of being overweight on your health?” “Studies have shown that weight loss of 9-15% over 52-72 weeks are most sustainable. This would make a big difference because it can lead to health benefits such as a decrease in BP, blood glucose, LDL cholesterol and triglycerides. It can also decrease your risk of osteoarthritis, depression, HTN, CVD, DM. Also it can increase your energy levels which you can use to exercise and keep the weight off.”

Agree: On expectations, and treatment plan. Discuss with patient to come up with a shared decision and plan on what the goals are and how to achieve them. “Is this a good time to lose weight? I think we should start off with small steps and aim for about a 10% weight loss in the coming year, so that roughly equates to about 1-2lbs a month. How does that sound to you?” Then refer to diet and exercise plan. “Does this plan work for you? What do you like or dislike about it?”

Assist: Lastly is to let the patient know you are here to support them and that you are available to address barriers, and if needed to refer them to other professionals. “So Mr. Khoury I want make sure that you understand everything, please take a look at these resources and call me if you have any questions. Additionally I would like to follow up with you in two weeks, does that work for you?”

After reviewing Mr. Yusuf Khoury’s case, I would prioritize his care first to control his diabetes, by discussing with him the possibility of staring insulin along with a conversation about his depression and how it can be affecting his overall health. Afterwards I would consider a brief intervention with him about him being overweight, following the 5A’s and also discussing a diet and exercise plan. Next would be the screening and immunizations and then harm reduction and injury prevention.

References:

1) https://www.nhlbi.nih.gov/health/educational/lose_wt/risk.htm

2) CDC Recommended Adult Immunization Schedule—United States – 2016. https://www.cdc.gov/vaccines/schedules/hcp/adult.html

3) USPSTF Published Recommendations. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/BrowseRec/Index

4) Gardner, Garry. Office Based Counseling for Unintentional Injury Prevention. American Academics of Pediatrics. Volume 119, Number 1. January 2007. Pg. 202-206

5) CHI – Helping Patients Make Healthy Eating Choices.https://www1.nyc.gov/assets/doh/downloads/pdf/chichi-34-7.pdf

6) CDC Adult Obesity Causes & Consequences. Centers for Disease Control and Prevention, 2016. Web. 30 Nov. 2016

7) Shami, S. (2018). Health promotion & disease prevention: setting the agenda [PowerPoint slides]

8) Shami, S. (2018) Obesity [PowerPoint slides].

9) Shami, S. (2018) Nutrition – Very Briefly [PowerPoint slides].