Patient John Liou, 75YOM

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Vaccines

Assuming Mr. Liou had all childhood immunizations and since it’s November, I would recommend:

1. Influenza: 1 dose annually, high-dose
   1. Mr. Liou has been hesitant to receive his flu vaccine in the past, so I would give him a thorough vaccine science education. I would clarify any questions he may have and remind him that a flu vaccine is especially important to prevent COPD complications secondary to respiratory infection.
2. COVID, initial dosing or booster
3. Tetanus, diphtheria, pertussis (Td/Tdap) booster
   1. Assuming he has already received his one time TDap, I would give Mr. Liou his recommended Td booster
4. Pneumonia vaccine
   1. Given that he is historically skeptical of vaccines, I would recommend the 1 dose schedule with PCV20. Again, I’d emphasize the importance of preventing respiratory disease in patients with COPD.

NOTE: If Mr. Liou’s vaccines were last updated 10 years ago, then he has most likely received a Zoster vaccine as recommended. If not, I would begin his 2 time dosing.

Screenings

I would screen Mr. Liou for:

1. Colorectal Cancer: Screening with a colonoscopy
   1. I’d consider that Mr. Liou is about to age out of this recommendation
2. Tobacco Smoking Cessation
3. Alcohol misuse
4. Unhealthy drug use
5. Depression
   1. Mr. Liou seems to be struggling to cope with his physical decline, so I think this is of particular importance.
6. Latent Tuberculosis Infection
   1. Mr. Liou is of increased risk of latent tuberculosis infection (LTBI) because he is from China, a country identified to have increased tuberculosis prevalence.
7. Lung Cancer with low-dose computed tomography (LDCT)
8. Abdominal Aortic Aneurysm
   1. Mr. Liou is about to age out of this recommendation, but being that it is a one-time screening that he qualifies for, I would highly recommend it. 
9. Osteoporosis
10. Falls Prevention in Community-Dwelling Older Adults
    1. Mr. Liou is a known fall risk patient, so I would want to discuss the details of that and harm reduction strategies to mitigate it, to be discussed further below.
11. Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors

I would consider screening Mr. Liou for:

1. Hepatitis C Virus Infection
   1. It’s a one-time screening for most adults, so if he has never undergone a HepC screening, I would want to move forward with it now.
2. Statin Use for the Primary Prevention of Cardiovascular Disease
   1. Mr. Liou is about to age out of this recommendation and already takes many medications, but given his cardiovascular risks of hypertension and smoking, I would consider this.

NOTE: Mr. Liou does not seem to be high-risk for HIV, HepB, or syphilis, but if he revealed himself to be, I would screen for those as well.

Injury Prevention

• Injury prevention concerns that should be discussed:
  • Traffic Safety
  • Falls prevention
  • Choking Prevention
• Injury Prevention Initiatives:
  • Given his fall risk and progressive Parkinson’s Disease, I would recommend that Mr. Liou begins initiatives to make his home more accessible. Since he insists on remaining in his home, he may wish to consider assistive mobility devices to keep him safer while walking, climbing stairs, and performing other difficult aspects of his activities of daily living. I would recommend that he begins carrying a fall notification system that he can press for help in case of emergency. I’d advise him to hire professionals for home maintenance. If he insists on doing it himself, he should incorporate the safety initiatives I mentioned above.
  • For choking prevention, I would recommend establishing care with a speech pathologist to ensure Mr. Liou is evaluated as his fine motor skills may deteriorate with his Parkinson’s.
  • As will be discussed  further below, I would recommend physical therapy in addition to aquatic and stationary exercises to increase Mr. Liou’s physical strength in order to decelerate his Parkinson’s and reduce his fall risk.
  • I would suggest Mr. Liou take initiative to lose weight. His heart, lungs, and musculoskeletal system have to work harder carrying extra weight. Studies show that all of his chronic conditions would benefit from a sustained decrease in body weight, which would require a combination of an improved diet with decreased caloric intake and increased exercise.

Diet

Relevant dietary issues to be discussed with Mr. Liou:

• Decrease sodium intake
  • Lowering sodium intake would improve blood pressure and CV health, which could also improve COPD symptoms
  • Focus on eating low-sodium meals for the meals that aren’t home-cooked by his wife
    • Eat low-sodium meals like whole fruits and grains for breakfast and lunch, then enjoy his wife’s cooking for dinner
    • I’d suggest low-sodium overnight oats as an easy and nutritious whole food option to prep ahead, and he could season them with sugar-free sweetener to help satisfy his sweet food preference, top them with antioxidant berries, etc 
• Lower intake of acidic foods to better manage GERD without medication
  • This would also be good for his COPD as many acidic foods cause gas or bloating that tend to make breathing more difficult.
    • Decrease intake of carbonated beverages, fried, greasy, or heavily spiced foods 
    • Be mindful of certain vegetables, fruits, and legumes that can cause gas
• Increase water and fiber intake
  • Staying well-hydrated will loosen respiratory mucus, which could improve COPD symptoms
  • Drinking 6-8 glasses of water and fiber-rich foods every day would improve constipation associated with Parkinson’s Disease
• Be conscious of protein intake
  • Mr. Liou’s medication levodopa is a protein building block, so it competes for absorption with other proteins and should not be taken in the same time-frame as high protein meals. Mr. Liou says he doesn’t eat much protein at meal-time, but he should be educated on why he should continue that.
• Decrease sugar intake
  • Sweets just once a day as a special treat
  • Sugar-free options like sugar-free candies would be best
• For COPD
  • Rest just before eating
  • Eat 4 to 6 small meals a day. This enables your diaphragm to move freely and lets your lungs fill with air and empty out more easily
• For Parkinson’s
  • Supplements like vitamin D for bone health
  • Anti-inflammatory supplements and foods
    • Berries, salmon, tuna, leafy green vegetables
  • Supplements and foods for brain health
    • Walnuts, cashews and other nuts

Exercise

CDC recommends 150 minutes of moderate-intensity exercise a week. Since Mr. Liou is currently sedentary, he is definitely not meeting that recommendation. Exercise would be beneficial for a variety of Mr. Liou’s chronic conditions, but it’s of particular interest while considering his developing Parkinson’s. The Parkinson’s Outcomes Project shows that people with PD who start exercising earlier in their disease course for a minimum of 150 minutes per week experience a slower decline in quality of life compared to those who start later. Mr. Liou has expressed particular interest in strengthening exercises.

• I would offer to help find local exercise classes specifically for those with Parkinson’s Disease, an option that is increasing in popularity
• I would recommend aquatic and recumbent bike exercise for strengthening to mitigate fall risk and and minimize impact on Mr. Liou’s joints and bones
• I would recommend that in a safe area modified with mobility assistance, he does simple movements like sit-to-stand and balance exercises at home on a daily basis. 
• I would also prescribe Mr. Liou physical therapy twice a week with a provider that specializes in Parkinson’s Disease.
• I would recommend that Mr. Liou begins by trying to fit in at least 20 minutes of activity at least 5 days a week for the next month, which will help it become a habit. I would want him to follow up in one month to reassess his lifestyle and health before recommending he work up to exercising 30 minutes, 5 days a week, which is the recommended weekly total of 150 minutes.

Brief Intervention:

Mr. Liou would benefit from quitting smoking. Both his COPD and CV conditions are exacerbated by smoking. I would intervene first with the 5As.

• Asking Mr. Liou about his current smoking habits and his readiness to change.
  • Do you currently smoke tobacco?
• From there, I would ask permission to advise before explaining the health risks of smoking and the benefits to quitting, in addition to the tools available to help with the cessation process.
  • May I offer advice on ways to quit smoking tobacco?
• Then, I would further assess Mr. Liou’s health status and addiction to nicotine, specifically inquiring whether other factors contribute to his reliance on nicotine
  • Are you willing to try to quit tobacco?
• From there, I would collaborate with Mr. Liou to agree on a quit date and formal action plan including any supplementary tools like medication or behavioral changes we think would most contribute to successful cessation
  • Do you agree that this plan to quit tobacco could be successful?
• Once we agreed on a plan, I would arrange/assist Mr. Liou with carrying out that plan, providing a prescription or referrals to resources if needed. I would also definitely arrange a follow-up.
  • Are you available to follow up with me in the office one week after the quit date we agreed on?
• If Mr. Liou were resistant to the 5As, I would shift to the 5Rs
  • I’d have Mr. Liou reflect on the relevance of quitting, asking what reasons might he have to quit.
  • Then, I’d remind Mr. Liou about the risks of continued smoking, especially on the impact of his current measures of health regarding his COPD.
  • I’d ask Mr. Liou if he can think of any rewards of quitting
  • I’d want to discuss the roadblocks Mr. Liou may face in his pathway to smoking cessation
  • I would repeat the above to gauge understanding and impact of the conversation

Regarding which issues/items should be addressed first, I would most highly prioritize speaking to John about injury prevention. He seems to be at a pivotal time in his physical deterioration where his current lifestyle is becoming extremely risky to his health and safety. He urgently needs to make some lifestyle changes to maintain his safety and health. It would also be very important to discuss smoking cessation. Quitting smoking could significantly improve Mr. Liou’s chronic symptoms and quality of life while decreasing his risk of mortality.  His diet and exercise, both of which would ideally require significant improvement, would also greatly benefit his health. It would be particularly important for him to become stronger, also as a means to prevent injury. Of course, vaccines are always important, especially vaccines to prevent respiratory infection in a patient with COPD. Screenings are paramount in primary care as well, but feel less urgent than some other aspects of Mr. Liou’s visit.

References

https://www.michaeljfox.org/news/diet-nutrition

https://www.parkinson.org/living-with-parkinsons/management/diet-nutrition

https://my.clevelandclinic.org/health/articles/9451-nutritional-guidelines-for-people-with-copd

https://www.hopkinsmedicine.org/health/wellness-and-prevention/fall-prevention-exercises