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    Case Study

    Mr. Barry Anderson

    BMI 15.8 (underweight)

    He has not had regular medical care in 10 years

     

    Immunizations

    • Influenza, 1 dose annually
    • Td, 1 dose every 10 years
    • Pneumonia, PSV23, 1 dose due to alcohol and cigarette smoking.
    • Hep A, MSM and IV drug use, homelessness
    • Hep B, MSM, unprotected sex, and IV drug use

    Screening

    As per USPSTF the patient should be screened for:

    • Depression
    • Alcohol use-follow up
    • HIV-admits reusing needles and unprotected sex
    • Hypertension-130/80 today
    • Tobacco –follow up
    • Hep B
    • Syphillis
    • Tuberculosis
    • Chlamydia and Gonorrhea
    • Hep C

     

    Health Promotion/Disease Prevention Concerns

                Injury Prevention

    • Fire safety and burn prevention
    • Traffic safety and being aware of traffic when he walks around and being aware of traffic where he settles down each night.

    Diet

    • His BMI is 15.8 classifying Mr. Anderson as underweight.
    • He admits to weight loss over the past year and his clothes do not fit as well as they used to but he does not tell us about his diet.
    • Due to Mr. Anderson’s lack of consistent income we can infer that he is unable to have consistent meals with adequate nutrients causing him to lose weight. His drug use and unstable living situation could also contribute to his poor diet. His income and lifestyle limit his ability to consume healthy options.
    • It is important for him to have access to and consume food to maintain a healthy weight and BMI. Meal prep may be difficult for the patient because he does not have a consistent home. I would suggest dietary supplements such as shakes and smoothies for 2 meals a day as these will make sure he is consuming an adequate number of calories and nutrients. I would educate about HHS Dietary Guidelines for Americans: balance calories with physical activity, consume more: fruits/vegetables/whole grains/seafood/low fat diary, and consume less: salt/saturated and trans fats/sugars/refined grains. The Mayo Clinic suggests the following strategies for underweight people: eat more frequently (5-6 smaller meals throughout the day), eat nutrient rich foods, use liquid meal replacement smoothies & shakes, monitor when you drink liquids as they may curb appetite before a meal, eat nutrient rich snacks, add extra calories to dishes, eat occasional treats, exercise regularly to build muscle and stimulate appetite.
    • In order to help Mr. Anderson gain access to food I will refer him to food assistance programs as per this link: https://www.nutrition.gov/food-assistance-programs These programs will show him how to gain access to healthy food options. I would also give him the following brochure: https://fns-prod.azureedge.net/sites/default/files/ConsumerBrochure.pdf this brochure goes over which food assistance programs are available for each population. For Mr. Anderson I would refer him to page 2 where it discusses SNAP benefits for people with low incomes and TEFAP.
    • Plan: Due to Mr. Anderson’s weight loss I would suggest to focus on intake of adequate calories and nutrients. The plan includes regular intake of dietary supplements and information for food assistance programs such as SNAP. A typical day’s diet: Breakfast-fruit, whole grain toast. Lunch-supplementary shake with salad. Dinner-Supplementary shake and/or grilled chicken/steamed fish with whole grain rice and vegetables. Snacks throughout the day such as nuts, cheese, fruits, dried fruits, vegetables.

    Exercise

    • Anderson does not tell us any information about exercise habits however admits to living on the street and is losing weight, we can infer that he walks often but is unlikely to meet the guidelines. It is unlikely that he is meeting the CDC guidelines for physical activity (150 minutes per week of moderate aerobic activity or 75 minutes per week of intense aerobic activity and muscle strengthening 2x per week)
    • Plan: Mr. Anderson is active due to his lifestyle but he is not meeting the recommended levels of activity. I recommend that he gradually increase moderate aerobic activity to 150 minutes per week as well as muscle strengthening 2x per week. His heart rate goal during moderate exercise is 95-133 bpm.
    • The moderate aerobic exercise goal should be easy to meet by walking, however it may be difficult for him to find the resources for strength training due to his lack of income and living situation. He can work strength training into his daily activities such as when working at the local garage. Exercise can help to improve his cough as well as to increase his weight by building muscle and may help to stimulate his appetite.

    Harm Reduction

    • Relevant harm reduction for Mr. Anderson includes needle exchange programs and safe sex practices. It would be preferable if Mr. Anderson ceased the use of needles and heroin, however if he is to continue to use heroin he should have access to clean needles and access to a place to dispose of used needles. He currently uses some form of needle exchange irregularly; I would stress the importance of utilizing needle exchange more regularly. Mr. Anderson admits to being sexually active with both men and women in exchange for money and does not always use barrier protection. It would be preferable for Mr. Anderson to limit his sexual partners, however if that is not possible then a plan for harm reduction includes access to condoms and education on proper use and safe sex practices.

    Brief Intervention

                Substance use and smoking cessation

    • I would conduct similar brief interventions for substance use as well as for smoking cessation. Mr. Anderson admits to injecting heroin at least twice daily for 10 years and occasional alcohol use. His alcohol use is less than 5 drinks per day and as such does not qualify as risky behavior. Mr. Anderson admits to smoking 4-5 cigarettes per day or, “however many I can bum on the street.”
    • Based on his history of IV drug use, his NIDA assessment would put him in the high risk category with a score greater than 27 and as such I would provide him feedback on his score, offer continuing support, advise, assess, assist, and arrange a referral.
    • Ask 5 A’s:
      • Ask-ask questions about his substance use and seek permission to discuss problem (ask individually for IV drug use, alcohol use, tobacco smoking). “Are you concerned about your substance use and do you want to discuss it?”
      • Advise-ask permission to offer advise for a clinical management plan and advise patient to cut down or stop drug use.
      • Assess-assess the patient’s willingness to make a change or quit drug use. “ On a scale from 1-10 how ready you are to quit?”
      • Assist-Assist the patient to change if they are ready by identifying and addressing barriers to achieving the treatment plan. “What do you think is holding you back from making a change?”
      • Arrange-Arrange further evaluations and treatment. This can also include referral to drug treatment programs.
    • CAGE questionnaire:
      • Have you ever wanted or felt a need to cut down on drug use?
      • Have you ever been annoyed by other people asking about drug use?
      • Have you ever felt guilty about your drug use?
      • Do you ever feel that you need to shoot up first thing when you wake up in the morning? (eye opener)
    • Express concern if screening is positive, while also assessing Mr. Anderson’s understanding of his situation and readiness to change. We will discuss benefits of quitting drugs, alcohol, and tobacco and discuss treatment options such as methadone and buprenorphine. We will assess his prior attempts at quitting and assess what lead to success or failure. The plan will have achievable goals and I will refer him to mutual help groups such as AA for peer support.

     

    Items to address in order of importance

    1. Insurance-It does not appear that Mr. Anderson currently has any form of health insurance. I would recommend that he sign up for some form of insurance (Medicaid or private insurance options) to ease his access to healthcare and help to remove financial barriers to care. I will provide resources and pamphlets to aid him.
    2. Substance use – heroin
    3. Diet – increase weight and maintain healthy BMI
    4. Screening: as listed above
    5. Immunizations-as listed above
    6. Smoking cessation
    7. Exercise – increase to meet guidelines

     

     

     

     

    References:

     

     

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