Case Study HPDP

Calandra James is a 66 year old recovering alcoholic (sober for 8 years) and she now describes her health as basically good, but says that she struggles with what she calls “an addictive nature”. This has expressed itself in her history of drinking and a past history of smoking (she quit 5 years ago after a total of 40 pack-years), and more recently she has noted that her eating has an addictive aspect as well. She joined Weight Watchers and lost 75 pounds over a year and a half. However, she has gained back 15 pounds of it over the past year. She says, “I spend way too much time trying to stave off hunger, trying to keep calories to 1500-1800/day and pushing myself to get in enough exercise to achieve a daily calorie deficit (she takes long brisk walks, rides a bike to do errands, swims at the local beach during the season, and has a set of free weights and resistance bands that she uses at home).

Her family history includes an alcoholic father and brother who are still actively drinking, a mother who had breast cancer at age 52, but has been cancer free since then and is now 88, and a sister who has Type 2 Diabetes. She has a long-term lesbian partner who lives a few towns away. She mostly eats salads and prepared foods from the grocery store. A typical breakfast is scrambled egg whites with whole wheat toast. Lunch is a yogurt and sliced fruit with peanut butter spread on it. Snacks are humus and pita chips and or vegetables, and dinner is salad with some sort of protein. She allows herself two pieces of dark chocolate (80 calories) as dessert most nights. She says she finds her current diet tolerable, but “joyless”.

BP: 128/74 T: 99 P: 68, regular R: 18 Hgt: 5 ft 6 in Wgt: 160 lbs Waist circumference: 37 in

Immunizations:

Pt. reports having all of her childhood vaccinations.
At this visit patient has the option and will be offered the Flu vaccine either the inactivated or the recombinant, zoster recombinant vaccine, PCV13 (if she has not received first dose) then follow up in a year for the PPSV23, and the Tdap booster if she has not received it in the past 10 years.

Screening:

Lung Cancer: due to her quitting less than 15 years ago and having over a 20-pack year history.
Breast Cancer: if she did not have a mammography last year that means she is due for one this year. She also has a positive family history of breast cancer which gives even more reason for the screening due to an increased risk factor.
Colorectal cancer screening: Pt. has the option of a colonoscopy, flexible sigmoidoscopy, CT colonography, fecal immunochemical test, fecal occult blood test, or sDNA-FIT testing. Unless she has received a colonscopy within the last 10 years, flexible sigmoidoscopy within the last 5 years, CT colonography within the last 5 years, or sDNA-FIT testing within the past 3 years.
Diabetes screening: even though the patient is not extremely overweight and seems to eat healthy I would like to do a screening for diabetes due to the positive family history of it just to cover all bases efficiently.
Hepatitis C: I would like to screen for this seeing that she was born between 1945-1965.
BRCA gene risk assessment: due to the familial history of breast cancer.
Osteoporosis: recommended for all women 65 and older.
Depression: due to her quitting smoking and drinking I believe she is at risk of suffering from depression, also due to her mindset of having an “addictive nature”.
Hypertension: recommended because she is 66 years old and has a history of smoking and alcohol which puts her at risk of developing hypertension.
Alcohol misuse: even though she quit this would be a good screening test seeing that she has a family history of alcoholism in her father and brother.
Tobacco misuse: again even though she quit smoking 5 years ago this should be done to verify she has indeed stopped and to monitor her taking in to account her 40-pack year smoking history.

Health Promotion/Disease Prevention Concerns:

Injury Prevention:

Traffic safety
Burn prevention
Falls prevention
Choking prevention
Drowning prevention/water safety

Diet:

Pt. appears to have good habitats however she states that her diet is “joyless” and that she has to fight off hunger. I would like to give her some advice on how to still have a good diet that will allow her to feel more full or satisfied, while spicing it up a little bit, in a healthy way of course
Pt. has no significant personal health issues however, does has a family history of type 2 diabetes. I am not sure if she is concerned about this but if she is I would recommend a low-carbohydrate regimen to her
I am recommending to her a low-carbohydrate diet. I would like for her to limit her intake of of grains and starchy vegetables or fruits. I would also like her to increase her protein intake.
Breakfast: To start, her breakfast is pretty good already the only thing I would take out would be the whole wheat toast because it is high in carbs. Instead I would ask her to substitute the toast for an avocado which is loaded with healthy fat and fiber. She can even get a protein shake in there to spice it up a little.
Lunch: For lunch I would ask that she a get a Greek yogurt because it is high in protein. I would recommend that she rule out the peanut butter because contrary to popular belief it does not a good source of protein and actually has high amounts of saturated fats which are bad for you. Keeping the fruits are a good idea however, I ask that she uses no starchy fruits such as watermelon, strawberry, raspberry, or oranges. Regarding her snacks, I would ask that she stop the pita chips but to continue the vegetables just making sure they are non- starchy ones. Some vegetables I would recommend would be green leafy ones like broccoli, kale, or Brussel sprouts.
Dinner: For dinner her normal routine is pretty good all ready but I would ask her to try and make the time to cook more. I would also ask her to spice it up so she does not get bored with it. She stated she has salad with some sort of protein but didn’t specify what the source of protein was. I would inform her that switching up the source of protein can make the diet more “joyful” she can try things such as salmon, chicken, beef, lamb, turkey, or trout. She can also add some vegetables to her dinner such as bell peppers, asparagus, green beans, mushrooms, or cauliflower. She can even combine the two on some days and create a soup that is vegetable based including one of the non-starchy ones we have discussed or that is protein based an includes one of those sources that we have discussed. She can even go as far as to combine the two in one soup to get the best of both worlds. I would advise her to keep the dark chocolate as a dessert but to try and limit it to 3 days out of the week.
This new low-carb diet should help the patient keep the weight off she is trying to while also decreasing her risk of developing Diabetes 2 which she is at increased risk for due to her family history. I also believe this will help her spice things up and bring the joy back to her diet with the various dishes she can make.

Exercise:

Based on what she has told me the patient most likely does at least 150 mins a week of aerobic exercise through her walks, bike riding, and swimming during the appropriate seasons. She also probably does at least two days of strengthening seeing that she uses free weights and resistance bands at home.
The only thing I would recommend to her would be to keep it up and try to consider doing more than 150 mins of moderate aerobic exercise a week, or to try and increase the pounds of her free weights.

Harm reduction:

Counseling for safe sex and STI prevention

Brief intervention:

Pt. reports being a recovering alcoholic but states she has been sober for 8 years therefore no intervention is needed. I would just encourage the patient to continue on as she has been and congratulate her on this big accomplishment with words of positivity.
Obesity: She is not considered obese when assessing her BMI of 25.8 but can be considered slightly overweight. However, it does seem like her weight is currently bothering her therefore I would go through motivational interviewing with her to listen to her thoughts and tell her how good she is already doing.
- Ask- Ms. James is it okay with you if we discuss your weight as of now and how it could affect your health currently or in the future?
- Asses- Can you tell me in detail about the time you lost 75 pounds in a year and a half and what seemed to work for you then? Can you also inform me about this recent weight gain of 15 pounds and what may have impacted this?
- Advise- Are you aware of the possibly negative health impacts regarding being overweight or obese? I know you currently are not happy with your weight can you describe to me your ideal weight?
- Agree- I believe you have been doing amazing up to this point do you believe that your diet can be improved on? Do you see your family history of diabetes as motivation to stay at a reasonable weight?
- Arrange/Assist: Are you ready to discuss with me different diet plans so we can come to a mutual agreement on which would be best for you taking in to account both your goals and current lifestyle? Would you like me to refer you to someone who can help you stay on track regarding the diet plan?
Pt. reports a history of smoking but states that she quit 5 years ago therefore no intervention needed with in that regard. Similar to the last point made I would simply encourage the patient to continue as she has been doing and give her accolades for not smoking for 5 years through words of affirmation and support.
Mental health: I would however like to discuss with the patient the feeling of an “addictive nature” that she believes she has. I would ask something like “I know you mentioned that you believe you have an addictive nature; would you be willing to tell me a little more about that?”. I would also ask her “How does this addictive nature make you feel and how does it affect your everyday life?”. The reasoning behind me exploring this with her is to see if this mind state is due to her beating herself up for her previous addictions of smoking and alcohol, and possibly something that needs to be explored further by a psychologist. If after this conversation, I believe that is the case I would ask her if she would like a referral to a psychologist to delve into this “addictive nature” mindset further. To conclude this conversation, I would also inform the patient that it is okay to not be perfect. I would give her words of encouragement by telling her she is doing amazing, to abide by the things we have discussed at this visit and to keep up the good work!