Based on the following hypothetical patient profile:
Damien Jackson
Damien, age 33, was adopted by a NYC couple after birth to a single mother in Tennessee. He has been a long-haul truck driver and sometimes bus driver for private companies. These jobs have not typically provided health coverage so even though he suffers from hypertension and gout, he has not been consistent about taking his medications for these conditions because he can’t always afford them. He had regular health care through his teens when he was still on his parents’ insurance, but he hasn’t had a regular health care provider since turning 18 and has mostly managed by going to urgent care centers when he needs new prescriptions or has an acute problem. He has just obtained a job in a UPS processing center which will mean that he’ll be on his feet all day rather than sitting and driving. It also means he now has regular health insurance so he has come to see you today for a “once over” and to get prescriptions for his blood pressure and gout.
Damien rarely drinks alcohol, except on special occasions. He smokes cigars “when I want to relax” with friends at a cigar bar. He estimates that he has about 4 cigars a week. He drinks up to a gallon of (full fat) milk a day which he sees as a healthy behavior, but he otherwise has a basically poor diet. He eats a good deal of meat, is trying to cut back on sugary drinks, has developed a “beer belly” in spite of the fact that he rarely drinks beer. He loves snack food and pastries and cakes of all kinds. He says he also loves edamame (fresh soy beans) and will enjoy salad but rarely chooses this in a restaurant, or buys it when shopping for food to bring home.
Damien loves to be active, but also seems to express fatigue when he has done relatively little. He says he’d like to get more exercise and have a healthier life style but does not seem to be able to really put together a plan for this. He doesn’t get any regular exercise now. He has been noted to enjoy the outdoors, his church community and basketball.
Damien lives with his girlfriend and their 4 year old son in a 3rd floor walk –up apartment in Bay Ridge Brooklyn. He says he can walk up the stairs without being uncomfortable except when his feet are bothering him when he has a gout flare up. He notes that he does get winded sometimes if he has to carry heavy groceries or his son’s tricycle up the stairs.
Other Information:
BP 140/88 P 72 R 18 T 98.6
Hgt 5 ft 10 in Wgt 200 lbs Waist circumference: 43 in
Gout: last episode of Right 1st toe pain was 6 months ago after having a lobster dinner with red wine and a cheese appetizer. He was given corticosteroids at an urgent care center and returned to baseline.
Regular meds (when he takes them): hydrochlorthiazide 25 mg daily, diltiazem 120mg daily, allopurinol (uric acid reducer) 100 mg daily
DAMIENJACKSON – MY EVALUATION FOLLOWS:
IMMUNIZATIONS
The following immunizations would be appropriate:
- Influenza
- Tdap booster
SCREENING
Screening should include:
- Alcohol Misuse (patient denies)
- Depression
- HTN
- Obesity (with current waist circ., BMI ~ 28.7)
- Tobacco use & cessation (promote cessation)
- HIV infection
DIET
“While it’s true milk is a good source of calcium, drinking an entire gallon of whole milk in a day is far too much. One gallon of whole fat milk contains nearly 200% of daily fat and approaches 300% of total daily recommended saturated fat alone.”
- Recommend gradual reduction in daily consumption and/or substitution with skim milk as he tapers down the habit..
“Meat is a good source of protein but, again, I would scale it back gradually. With your gout, a diet high in ‘purine rich foods’ such as red meat is risky. You don’t have to cut meat out of your diet entirely, but maybe set aside specific days where you give meat a break. That’s a place to start.”
- Patient loves edamame and enjoys salad. I would encourage him to indulge in these more frequently and, especially if he’s still hungry after eating meals, to make sure he drinks enough water with his meal as well as adding some whole grain bread. Fiber rich foods aren’t just good for regularity and cholesterol but help contribute to satiation as well.
Weight Loss:
At current estimated BMI, weight loss goal of 20 – 25 lbs is reasonable.
Explain benefits of this 10% – 15% reduction in weight including:
↓Blood Pressure – beneficial in conjunction with his current medications
↓Risk of arthritis on weight bearing joints – especially being on feet all day at new job
↓LDL/Triglycerides – he is already at risk for CVD with current diet and HTN
– as well as reduction in blood glucose, and risk of depression and sleep apnea
With his current BMI of ~ 28.7, he is deemed ‘high risk’ for diabetes mellitus II, exacerbating his hypertension, and developing cardiovascular disease (CVD).
Prevention of CVD:
As an African American male, he is twice as likely to develop CVD, and, as he approaches his mid 30s, it’s not a bad time to start making changes as middle age approaches.
While ethnicity, gender, and age are obviously not modifiable, there are several modifiable factors that he can choose to alter. One of these factors is his aforementioned poor diet and the other is exercise, discussed shortly. I would also make the following recommendations:
– Smoking cessation: cut out the cigars. Educate on cessation tools such as nicotine gum
– Cut back the sugary drinks and snacks, he is at risk for developing diabetes, which is itself a risk factor in developing CVD / Peripheral Artery Disease (PAD)
– Reestablishing his HTN meds and reiterating the importance of compliance
(as well as allopurinol compliance and diet considerations to prevent gout flare-ups)
- (On the topic of his meds, his BP is borderline condsidering where we would like it. If the elevation is not due to poor compliance, we could consider modifications to achieve a BP below 140/80)
If he chooses to lose weight, I would explain that diet is the most important factor, even above physical activity, although exercise can be key in long-term maintenance of a healthy weight.
EXERCISE
- Begin with a few minutes of physical activity per day
- Gradually increase to 30 minutes per day
- → Gradually increase to 150 min/ week of moderate intensity aerobic exercise + strength training 2 times per week
“This sounds daunting at first but remember it’s important take baby steps. You told me that you love to play basketball and, since you make it up those 3 flights of stairs just fine, I don’t see any harm in starting by playing a few minutes each day. You can even spend some time with your kids playing basketball! Eventually you can consider adding some more light activity exercise such as going for a walk or an easy-going bike ride.
I know you have a connection to the community at your church so if you know anyone groups of people who enjoy a sport or some form of exercise, try joining in. The social aspect can really help you stick with it and enjoy it even more.”
– differentiate between light/moderate/vigorous activity by ability to sing, converse, etc.
– explain exponential benefit increasing duration of exercise has in preventing CVD
INJURY PREVENTION
“Since you’ll be on your feet almost constantly at your new job, there is increased risk of developing lower back pain, leg swelling, and muscle pain. I would recommend making sure you have comfortable shoes with decent padding and support, as well as taking time when you can to walk around and change your position. Remember to take a seat occasionally, when possible, as well.
Now that you’ll be playing basketball a bit more, I would also recommend that you stretch properly before and after exercise, and make sure to drink plenty of water. Again, avoid sugary drinks in all cases and even limit “sports drinks” such as Gatorade. But if you love the stuff, some people find it useful to dilute sports drinks with some extra water. Like with most of my suggestions, making gradual changes is okay. Now that you have the opportunity for regular medical attention, I think we can start to make some really important changes in your life for the better. I’ll make sure we get these meds to your pharmacy and I feel good that if we stick to the plan this could be the start of a healthier, happier, ‘beer belly’ free future!”
