Case Study- Juana Negron

Immunizations

• Influenza Vaccine
• Tdap booster, if she has not received it with the last 10 years

Screenings

• Colon Cancer
• Breast cancer screening- I would recommend she have a mammogram annually because she is at increased risk.
• Cervical cancer screening- Pap Smear + HPV
• Alcohol
• Depression
• Obesity
• Hypertension
• Tobacco use/cessation
• HIV infection
• Abnormal glucose/diabetes

Injury Prevention

• Traffic safety
• Firearm safety
• Water safety
• Burn prevention

Harm Reduction

• In relation to Juana’s smoking, I would suggest she try some smoke-free nicotine alternatives such as the nicotine patch or gum. Would I would also see if she was open to trying Chantix or Zyban.

Diet and Exercise

• Based on the patient’s height and weight, her BMI is 30.9, it is imperative that she improve her diet and exercise.
• Diet: Currently the patient’s diet primarily consists Puerto Rican food. Classic Puerto Rican meals generally consist of meat, beans, and rice. There are changes that the patient can make to her diet while still sticking to the style of food she enjoys.
• • Because the patient has “borderline high blood pressure” and her brother has hypertension, would recommend that she lower her salt intake.

• • Replace canned beans with fresh beans
  • Decrease friend foods
  • Replace white rice with whole wheat rice
  • Reduce sugar intake; due to her weight, she is at increased risk to develop DM
  • Increase intake of whole grains, vegetables and fruits.
• Exercise:
  • The patient currently walks two blacks three times a day when taking her dogs for a walk. It is hard to calculate if she is getting adequate exercise, because I am unsure how long these walks take her, Due to her high weight, I would recommend that she start by increasing the distance of those walks, or add a fourth walk to her daily schedule. During the next follow up visit, I would modify the exercise plan based on how she was handling the additional distance.

Brief intervention

• Obesity: I would begin the brief intervention by first asking the patient permission to discuss the topic with her. I would then talk to her about the benefits of weight loss, and ask her about previous attempts to lose weight, what methods she used, and what went wrong. I would elaborate on the fact that losing weight is more about living a healthy lifestyle, and how that can change her daily life. I would explain to her that a reasonable goal for weight loss is 9-15% over 1-2 years, and for her, this would mean losing around 20 pounds in around a year. I would further go into the reasoning behind this logic, and explain the changes in her hormones. This would be explained in a way that a lay person could understand. I would elaborate as to why this may make it hard to keep the weight off in the initial year. I would also explain all the benefits that even a small amount of weight loss can have on her health, such as a decrease in her blood pressure, LDL cholesterol and blood glucose. At this point I would evaluate to see how much the patient understands about the important of maintaining a healthy weight. If the patient is willing to change her diet and lifestyle with the goal of weight loss in mind, I would then discuss specific diets that may suit her most, and would also mention the role of exercise and that it is important for a healthy lifestyle, and that it may even promote weight maintenance. I would discuss her support system, and possibly additional intervention from a nutritionist is she want additional help maintaining a healthy diet. Once a reasonable goal is set, I would set a follow up appointment so that I could monitor her progress.
  • Questions:
    • “How much weight do you want to lose?”
    • “How is your current weight affecting your life?”
    • “what kind of changes have you made in the past when trying to lose weight?”
    • “what has kept you from losing weight in the past?”
    • “what do you think will happen in you don’t take steps to lose weight?”
    • “how do you think losing weight will impact your life?”

• Smoking cessation: I would start by having the patient fill out a “Quit Card”, this would help her realize how much she is smoking, and maybe open her up to the concept of quitting before we even begin the discussion. I would begin the interview by asking the patient permission to discuss the topic. I would them communicate to the patient that I’m worried about her smoking habits because of the affect it may have on her health. After that I would try to gauge how much my patient understands about the dangers of smoking, and fill in the blanks for her. I would also try and find out what went wrong the previous two times when she tried to quit, and find out how willing she is to try and quit smoking, if she is completely unwilling, this may not be the time for this conversation. Next, I would bring up the various obstacles she may face if she does give quitting another shot, such as lacking a crutch when she can’t sleep or when she gets anxious about her son’s financial difficulties. I would then ask her if she has a support system that can help her through rough times. I would then begin to discuss what options she has available to aid her in the quitting process, I would also set realistic goals with the patient and schedule a follow up visit.
  • Questions:
    • “Tell me about your smoking, how old her you when you started?”
    • “what function does smoking play in your life?”
    • “when do you find yourself craving a cigarette the most?”
    • “How much do you smoke a day?”
    • “what do you think needs to change in your life in order for you to be able to quit?”
    • “what was your longest attempt at quitting, and what happened?”
    • “have your smoking patterns changed, if yes, what do you think triggered the change?”

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