Case study: Mr. Yusuf Khoury

 

Immunizations (November):

Pt is a 57-year-old male and assuming that he had all his childhood vaccination he should now receive:

1. Td booster (if not done in the last 10 years)
2. Inactivated influenza or recombinant influenza shot
3. Zoster recombinant

Screening:

Based on Fhx and Presentation (Screening):

1. Following the USPTF recommendations, because Mr. Khoury is a male and above 55 y/o with a Fhx of prostate cancer, I would recommend screening for prostate cancer to the patient. However, it is an individual choice so it will be up to the patient to decide but I would counsel the patient on the risk and benefits of screening especially since he had a father diagnosed with prostate cancer at 70.

Depression:

• Although Mr. Khoury seems to have already been diagnosed with depression, I would like to screen him again just to see if there have been any changes to his mood and welfare since his last visit.

Assessment for other risk factors:

1. Although the prompt states that the patient’s BP readings have been under 140/90 with medication it appears his current reading is 142/86 which may indicate that Mr. Khoury now has Hypertension (assuming a double reading was done).
2. Having a PMhx of type 2 diabetes, high BP, an unhealthy diet, physical inactivity, and a fhx of hypertension and stroke. I am concerned that Mr. Khoury is at an increased risk for a stroke later on if necessary, changes are not made.
3. Mr. Khoury may also be at risk for macular degeneration later down the line as well based on Fhx of macular degeneration, his PMhx of diabetes, and his age.

Differential dx for Chief complaint:

-Pt most likely has carpal tunnel syndrome because it is associated with tingling and numbness in his thumb and finger. Pain in the left wrist left arm and shoulder is also exacerbated by dog walking or strain during work. 

Tx: resting his wrist and arm (limit dog walking for a month), apply ice, wrist splint if deemed necessary and continuation of the ibuprofen for the pain since it does relieve the pain.

-R/o myocardial infarction, because pain is localized to the left arm, shoulder, and wrist and the pt. does not have other accompanying sxs like chest or jaw pain, s.o.b, nausea, or palpitations.

Health Promotion/Disease Prevention Concerns 

Mr. Khoury does a good job of regularly monitoring his blood sugar and blood pressure; however, his diet and physical activity levels are not the best at the time. His Hgb A1C is currently 9.0 which is quite high. According to the American Diabetes Association, the goal for most adults with diabetes is an A1C of less than 7% but the goal can vary from patient to patient. Considering where the patient is currently at and following the recommendation from “endocrine web” I would set a preliminary target HgA1c of 7-8% for Mr. Khoury.

Since Mr. Khoury is already on an ACE inhibitor for his blood pressure management I would like to focus on some dietary and physical exercise changes.

1. Diet
2. I would suggest that Mr. Khoury consider opting for plain oatmeal with some skimmed milk and a piece of fruit for his breakfast rather than a buttered roll. And if he chooses to get a roll, I recommend not adding any butter of sweetened additives to it.
3. I would also recommend a medium coffee instead, with his half and half milk but without the equal sweetener or sugar.
4. For his lunch, I would recommend a healthier choice for his sandwich (avoiding things like excessive cheese and meats) and would suggest that instead of a bag of chips Mr. Khoury should maybe opt for a chicken salad with little dressing (olive oil and vinegar for example) and a glass of water with his meals.
5. I would most of all like to recommend that Mr. Khoury avoid eating the cookies and sweets in the breakroom. I would maybe suggest that if he is comfortable doing so, maybe he can involve his colleagues to help be mindful of having so many sugar snacks and food around him. He can have a treat once in a while, but it should not be often and not every day. Maybe a piece for dessert once a week to start with.
6. Because Mr. Khoury is diabetic, hypertensive, slightly overweight (BMI of 26.1), and has a waist circumference of 43 he is at increased risk for metabolic syndrome and at risk for heart disease, and stroke. Making these dietary changes may help reduce his risk for sooner complications.

These are a few dietary recommendations I would make to start the process of helping Mr. Khoury work towards the HBA1C goal.

• Exercise

It appears that Mr. Khoury does not get much physical activity since his work is mostly sedentary, he does not work out except for when he goes dog walking, he is not very social and spends his weekends sleeping for long periods.

Obesity: Mr. Khoury is not obese and is slightly overweight, however, he does have a fairly large waist circumference which brings up concerns for metabolic issues. Because Mr. Khoury Is on medication for his diabetes and blood pressure, I would mostly focus on improving his diet and physical activity and see if we can get him in shape again.

• To improve his physical activity levels, I would suggest that Mr. Khoury consider walking to work (especially if it is within walking distance).
• I would also recommend that depending on what floor Mr. Khoury lives on, maybe he can consider walking down the stairs on his way out instead of taking the elevator.
• I would recommend that Mr. Khoury engages in activities with his wife such as going to the mosque even if it is once in a while to keep him more active and engaged.
• Since Mr. Khoury enjoys walking the dog, I would recommend that he continue doing so but after his wrist and arm pain have been treated. He can use his other hand as well as long as it doesn’t bring on any pain.
• I would recommend that Mr. Khoury aim for at least 30 minutes/day of moderate aerobic physical activity and for 5 days a week.

Harm Reduction

• Because Mr. Khoury is resistant to starting insulin I would either counsel him on the benefits and advantages of using insulin (if not already done) and if it is met with resistance again, I would roll with the resistance and try to encourage him to begin the lifestyle and dietary changes instead and we can follow up and decide what next based on how things work out.

Sources:

1. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
2. https://www.diabetes.org/a1c
3. https://www.endocrineweb.com/professional/diabetes-complications/type-2-diabetes-less-intensive-hba1c-goals-promise-less-harm

Disclaimer: This is a fictional character that was created for the purpose of this assignment.