Case Study

Talia Bardash

Case Study — Yusuf Khoury

Immunizations

  1. Influenza inactivated or influenza recombinant, since it is November. 
  2. Zoster recombinant two doses
  3. Tdap booster, if he had not been to the doctor in ten years.

Screening

  1. Obesity
  2. Alcoholism
  3. Tobacco use
  4. HIV
  5. Colorectal Cancer  
  6. Depression – Even though he already is diagnosed with depression I would screen to monitor the depression.
  7. HTN – Even though he is taking hypertensive medication we would monitor his blood pressure. 
  8. HepC – He should be screened since he was born between the years 1945-1965.
  9. CVD – He should be screened since he is obese, diabetes, and abnormal glucose levels. 
  10. Prostate Cancer, should only be given after discussing with the patient about his family history, benefits and harms, and then if he wants to proceed you may.

Injury Prevention

  1. Traffic safety

Diet –

His diet is very heavy in carbs, sugar, and junk food. It is important that this diet be modified for many different factors. One of them is that Mr. Khoury has a BMI that indicates that he is obese and secondly, he has a history of Type 2 diabetes and so it is important that he eats things that will help him maintain proper blood sugar levels. It is especially important that he focus on his diet since he has rejected taking insulin. Mr. Khoury’s also admits to not being able to resist the cookies and other sweets that are provided at his office. For these reasons I devised a plan that will modify Mr. Khoury’s diet. The first aspect that I will address is meal planning. It seems that Mr. Khoury might benefit from having his meals planned and made beforehand so that he does not need to order out, eat so much bread, and will help to try and keep him from not being able to resist the sweets that come to his office.

I would say that we need to start slowly and we can’t cut out the carbs and all his habits right away. I would say that we should allow him to continue to have some sandwiches throughout the week, but not every single day. We should exchange some of his lunches to salads with protein such as chicken, salmon etc. that will provide him with a feeling of satiety. We should offer him some vegetables and fruit as snacks throughout the day. Obviously, we cannot tell him to cut all of the sweets right away. So we should try to say that maybe he should only have the sweets on every other day and also should try in his head to limit it. He should ideally not have more than three cookies and not more than ten. It is important that he does not eat so much sodium and try to make sure he does not eat so much sugar. One other diet plan that I could offer Mr. Khoury is the Mediterranean diet. The diet will incorporate healthy foods such as fruit vegetables, fish, and whole grains. These foods will help keep him full and healthy.

Exercise-

I would also discuss with Mr. Khoury about his lack of exercise. Even though he is “allergic to exercise” it is important for him to be more active throughout the day because he is not getting adequate exercise. Again, it is important to start slowly and remind Mr. Khoury to not overdo it in the beginning. Firstly, Mr. Khoury sits all day at work because his job is a desk job. He also commutes to work on the subway and lives only a block away. So I would tell Mr. Khoury that he should every two hours get up from his desk and go for a 10-20 minute light walk. This will help Mr. Khoury from sitting all day. Also, Mr. Khoury said that he walks his dog and this is when his arm hurts so I would suggest that Mr. Khoury should continue to go for the walk, except that he should not hold the leash. He should go walking with either his wife or a friend. This will also help him become more social.

It seems that his arm pain stems from maybe carpal tunnel syndrome from using the computer and walking the dog and so it is important that he does not involve himself in exercise that would put excessive stress on his wrist.

Additionally, Mr. Khoury lives in a building with an elevator. A very great way to get exercise is to take the stairs. Obviously he does not and should not strictly take the stairs, but every other day it may be a great form of exercise to take the stairs. He could also take the first few flights of stairs and then take the elevator from the higher floor to his apartment.

Lastly, Mr. Khoury seems to sleep at an excessive rate. So I would suggest that when his wife goes to the mosque, he should join her and if the mosque is in walking distance he should walk with her there.

Mr. Khoury should also sign up for a gym close to his apartment. He could go over the weekends for no more than two hours. He should do light exercises such as walking on the treadmill or the elliptical slowly.

After Mr. Khoury feels that he can handle these beginning exercises he could increase the one that he feels he is benefiting from. It is important to remind Mr. Khoury that both the diet and the exercise plan should be a slow process. It is more important right now at the beginning to begin the routine of exercising and eating healthy. It will be less healthy if he tries to rush the process.

Harm Reduction-

Instead of eating a full tray of cookies, limit the amount of cookies and therefore the amount of sugar ingested. We could also exchange his snacking cookies for a different healthier snack such as veggie straws with low sodium. This will reduce the high amount of sugar, calories and sugar that add to his diet.

Brief Intervention –

I would provide a brief intervention for obesity. The brief intervention would follow the five A’s. I would ask, assess, advise, agree and then assist. I would first ask if it was okay for me to begin discussing his weight. Mr. Khoury may not want to discuss his weight yet or may be uncomfortable so it is important that I first start by asking if it is okay to discuss his weight.  A sample question would be, “Mr. Khoury, is it okay if we discuss your weight?” Mr. Khoury’s response will allow me to see if Mr. Khoury is ready for change. I would then assess the situation that led to his obesity. For example, what are the complications and barriers that could keep him from achieving a weight loss goal. I would also assess where he is on his stage of obesity; did he just gain all this weight or was it something that he struggled with his whole life. In this stage I would also address his statement that he does not want to take insulin. I would discuss with him the connection between Type 2 diabetes and obesity and the importance of maintaining proper blood sugar levels. An example of a question would be, “Do you have any additional medical conditions that I should know about?” The next stage is to advise. This is when I would advise Mr. Khoury on the benefits of weight loss, plans and the idea that it is not about losing the weight right away, but about being slow in the weight loss process. An example would be, “now that we discussed the situation, can I offer a plan that can benefit you?” The next stage is to agree. In this stage it is important to make sure that the patient agrees to a realistic weight loss plan set by the me. It is important to make sure that Mr. Khoury has a realistic mindset about what will happen over the next couple of months and year. A normal weight loss is only 10% of a person’s total weight for the whole year. Additionally, it is important to make sure that the patient doesn’t try to get a normal BMI. That is actually unhealthy. An example of this stage would be explaining these details with Mr. Khoury, such as stating that “this year Mr. Khoury it would be amazing if you lost 19 pounds and no more than that.”  The last stage is assist. This means that the physician and the patient agree of the treatment and the provider will help to provide the patient with different ways to help the provider lose weight. I would in this stage assist Mr. Khoury in trying to search out different positive resources that could be used to help him lose weight. For example, I would refer the patient to a dietitian who can help meal plan and ensure that he will eat the best food.

What Order-

I would first address his pain, then the obesity and then depression.

Reference:

  1. USPTF Screening Recommendations for Adults as of June1, 2018 file:///Users/Talia/Downloads/PreventiveHealthCareSchedule2018%20(3).pdf
  2. City Health Information: Helping Patients Make Healthy Choices file:///Users/Talia/Downloads/CHI%20Healthy%20Eating%20Choices%20(4).pdf
  3. Writing an Exercise Rx. Fa 16.pptx
  4. Nutrition- Very Briefly.pptx
  5. Obesity (1).pptx
  6. CDC- Adult Obesity Causes and Consequences
  7. 5 As in Obesity.pdf
  8. file:///Users/Talia/Downloads/Table%201%E2%80%933_Expert%20recommendations%20for%20cardiovascular%20risk%20pr%20(2).pdf