Case Study – John Liou 

 

Immunizations  

Vaccination	Recommendation
Influenza	I would recommend the influenza vaccination and provide Mr. Liou with some information supporting the vaccination since he seems to be skeptical about it. To address his concerns, I would inform him that he could develop some mild flu-like symptoms (low-grade fever, soreness at injection site, headache, and muscle aches) for 24-48 hours after the vaccination. Getting the vaccine would help protect both himself and his family during flu season.
Tetanus, Diptheria, Pertussis (Td/Tdap)	I would recommend a Td booster since it has been 10 years since Mr. Liou’s last booster.
Varicella	I would not give Mr. Liou the Varicella vaccine because he likely received it in his childhood immunizations and should instead receive the Zoster vaccination due to his age.
Zoster	I would recommend the zoster vaccination since Mr. Liou is over 60 years old and has not received it yet according to his immunization records. Due to this, he would receive the Zoster vaccination instead of the Varicella vaccination.
Measles, Mumps, Rubella (MMR)	I would not give Mr. Liou the MMR vaccination because he was born before 1957 and is therefore considered immune.
Pneumococcal 23-Valent Polysaccharide (PPSV23)	I would recommend the PPSV23 vaccine because Mr. Liou is over the age of 65.
Pneumococcal 13-Valent Conjugate (PCV13)	I would instruct Mr. Liou to return for the PCV13 vaccine 1 year after receiving the PPSV23 (next November) because he is over the age of 65.
Hepatitis A	I would not recommend the Hepatitis A vaccination because Mr. Liou is not at increased risk.
Hepatitis B	I would not recommend the Hepatitis B vaccination because Mr. Liou is not at increased risk.
Meningococcal 4-Valent Conjugate (MenACWY) or Polysaccharide (MPSV4)	I would not recommend the MenACWY or MPSV4 vaccinations because Mr. Liou is not at increased risk.
Meningococcal B (MenB)	I would not recommend the MenB vaccination because Mr. Liou is not at increased risk.
Haemophilus Influenzae Type B (Hib)	I would not recommend the Hib vaccination because Mr. Liou is not at increased risk.

 

Screening  

Screening	Recommendation
Alcohol Misuse	I would screen Mr. Liou for alcohol misuse because it is recommended for all patients above the age of 18.
Depression	I would screen Mr. Liou for alcohol misuse because it is recommended for all patients above the age of 18.
Hypertension	I would screen Mr. Liou for hypertension because it is recommended for all patients above the age of 18.
Obesity	I would screen Mr. Liou for obesity because it is recommended for all patients above the age of 18.
Tobacco Use and Cessation	I would screen Mr. Liou for tobacco use and cessation because it is recommended for all patients above the age of 18.
HIV Infection	I would not screen Mr. Liou for HIV infection because he is not at increased risk and he is above the age of recommendation.
Hepatitis B Virus Infection	I would not screen Mr. Liou for Hepatitis B virus infection because he is not at increased risk.
Syphilis	I would not screen Mr. Liou for syphilis because he is not at increased risk.
Lipid Disorder	I would screen Mr. Liou for a lipid disorder because it is recommended for all men above the age of 35 to be screened.
Hepatitis C Virus Infection	I would not screen Mr. Liou for Hepatitis C virus infection because he is not at increased risk.
Colorectal Cancer	I would screen Mr. Liou for colorectal cancer because screening is recommended for men between the ages of 50 and 75.
Lung Cancer	I would screen Mr. Liou for lung cancer because he is an 80 pack-year current smoker.
Abdominal Aortic Aneurysm	I would screen Mr. Liou for an abdominal aortic aneurysm because he is a male between the age of 65 and 75 who is a smoker.
Aspirin for Cardiovascular Risk	I would screen Mr. Liou for aspirin use to minimize cardiovascular risk because he is an older male with increased risk for stroke due to his hypertension and smoking history.
Fall Prevention (Vitamin D)	I would screen Mr. Liou for fall prevention due to his age and recent Parkinson’s Disease diagnosis and decline in physical condition.
Sexually Transmitted Infection Prevention	I would not screen Mr. Liou for STI prevention because he is not at increased risk.
Diet/Activity for CVD Prevention	I screen Mr. Liou for diet/activity for CVD prevention because he is slightly overweight and a smoker, increasing his risk for CVD.

  

Health Promotion/Disease Prevention Concerns  

Injury Prevention 

• I would address whether Mr. Liou drives or ever rides in a car. If he answers either affirmatively, I would determine whether he wears a seatbelt in the car and recommend that he always wear a seat belt when in a vehicle. 
• In regard to Mr. Liou’s report that he has experienced a slow decline in physical function and instability when walking since his Parkinson’s Disease diagnosis I would recommend that he begin using a cane or walker for ambulation. I would also recommend that he consider his wife’s request to move to an apartment where he would not have to climb as many stairs or do physically challenging home tasks to minimize his risk for falls and injury. 

Diet 

• Mr. Liou has an overweight BMI of 27.4, so I would address a diet and exercise plan for him to get to a normal, healthy BMI of 24.9. He would have to lose 16 pounds to achieve this, which is just under 10% of his total body weight. Therefore, it would be most advantageous to Mr. Liou to spread this out over a year, perhaps aiming to lose 1-2 pounds each month. Getting to a normal BMI will help lower Mr. Liou’s risk for heart disease since he has multiple additional risk factors (hypertension and current smoker). 
• Since Mr. Liou has hypertension and reports that his diet is high in salt, I would recommend cutting down on his salt intake. He mentioned that his wife is resistant to changing how she cooks, so I would perhaps recommend that she come with him to the next appointment and address the issue with her. Perhaps a solution could be to add less salt cooked into the food and supplement salt on top of her portion as needed to satisfy her taste. 

• I would recommend that Mr. Liou drink 6-8 glasses of water daily. This will help balance out his salt intake so he can flush more of it out of his system and help manage his hypertension, as well as help with the constipation that he sometimes takes Sennokot for and can be a result of his recently diagnosed Parkinson’s Disease. 
• Mr. Liou also suffers from GERD, so I would work with him to outline what foods he should eat and what to avoid. This will be a key point in managing this condition, as he experienced some bad side effects from the medication he took to minimize his GERD symptoms. He should eat a diet rich in vegetables because they have low fat and sugar contents, which will reduce the production of stomach acid that contributes to GERD symptoms. He should also eat whole grains because they will help absorb excess stomach acid and reduce his symptoms. To incorporate this into his wife’s traditional Chinese cooking, she can cook with whole grain rice. 
• He should fill his diet with lean meats like chicken, turkey, and seafood and avoid fried foods. This will have benefits for weight loss as it follows guidelines for a low fat diet, help manage his GERD symptoms, and be beneficial for his Parkinson’s Disease diagnosis because the protein will be key in strengthening Mr. Liou’s muscles and the low fat aspect of the plan is linked to delayed progression of the disease, since high fat diets have been associated with increased Parkinson’s Disease symptoms.  
• Mr. Liou should incorporate lots of antioxidants into his diet, like blueberries, pecans, raspberries, kale, and spinach, as they have been linked to neuroprotective effects in Parkinson’s Disease. Dark chocolate is also rich in antioxidants, but should be eaten sparingly as a “treat,” as dark chocolate can exacerbate his GERD symptoms.  
• Mr. Liou admits to eating a lot of sweets and agrees that he eats them too often. He can cut down on his sugar intake by avoiding traditional desserts like cakes and cookies and instead incorporating naturally sweet fruits into his diet when he wants something sweet. He should avoid citrus fruits, however, to keep his GERD under control. Blueberries, while acidic, are a great option because they are very sweet, antioxidant rich, and can be incorporated into dairy products to neutralize their acid. 

• I would create an example of a good meal plan for a typical day for Mr. Liou, as follows: 

Breakfast options: 

Whole grain oatmeal with fresh fruit mixed in (banana slices, blueberries, apple slices, or pear slices) with a hard–boiled egg and tea or low–fat milk 

An egg-white omelet with vegetables (green peppers, onion, and spinach), fresh fruit, and tea or low–fat milk 

Lunch options: 

Grilled chicken sandwich on multigrain bread with a spinach or kale salad 

Whole grain fried rice (using low sodium soy sauce) with shrimp or lean beef 

Dinner options: 

Chicken or shrimp stir fry with broccoli, carrots, onion, cabbage, and bell peppers with whole grain rice 

Alternatively, use iceberg lettuce as lettuce cups to cut the rice out of the dish 

Dessert options: 

Low fat yogurt with honey, berries, or whole grain granola 

Baked apple or pear slices with cinnamon  

Fresh fruit with low fat whipped cream 

Exercise 

• Mr. Liou is generally sedentary and also has some problems ambulating recently as a result of his Parkinson’s Disease, so it is important to incorporate some exercise into his lifestyle so he can delay the effects of the disease for as long as possible. Exercise in conjunction with a healthy diet will also help him get to a healthy BMI. 
• Mr. Liou should ideally undergo between 30-60 minutes of exercise 4 or 5 times weekly. Being that he has largely been sedentary until now and has some movement problems, he can start at 30 minutes a couple of times each week and work his way up, perhaps doing 10 extra minutes and an extra day every week or two. 
• Aerobic and learning-based exercised have recently been linked with neuroprotective effects in patients with neurodegenerative diseases like Parkinson’s Disease, so walking at a slow pace, swimming in a local pool, yoga, or tai chi would all be great options.  

• Walking on a treadmill where Mr. Liou could have more support would be best because it would reduce the risk of falls. 
• Swimming is a good, repetitive exercise that can help strengthen Mr. Liou’s coordinated movements, but caution should be taken since he has COPD and may experience trouble breathing. 

• It is important to emphasize the Mr. Liou should exercise in a supervised setting to promote his own safety 

• Alternatively, Mr. Liou can take a 30–minute walk with his wife after dinner each night using a cane or walker 

 

Brief Intervention 

Smoking Cessation 

• Mr. Liou has been smoking for most of his life and is an 80 pack-year smoker. While he has cut down on his smoking recently, he still smokes 1 pack a day. 
• I would use the 5 A’s to conduct a brief intervention 

• I would ask about his current smoking habits and willingness to quit 
• I would advise him about the health risks of smoking and the benefits he would experience if he quit smoking. 

• Smoking puts him at increased risk of heart disease, stroke, abdominal aortic aneurysm, and lung cancer, among other risks. 
• Quitting will have many short-term and long-term benefits, including improvement of COPD symptoms. 

• I would assess his addiction to nicotine using the Heavy Smoking Index (HIS). 
• I would acknowledge his efforts to cut down on is smoking and work so that we could agree on a specific plan to help him quit 

• Chantix would be a good option for Mr. Liou, as it will help cut down his nicotine cravings and make it easier for him to quit. 

• He would need to start this intervention 1 week before his quit date so he can build up the level of the drug in his system. 

• If he does not want to take a medication since he already takes so many, I would recommend using the nicotine patch or gum so he can still manage his nicotine cravings without the added risks of smoking cigarettes. 

• I would assist him in getting started on the agreed upon plan and set up a follow up appointment . 

• Follow up 1 week after his quit date initially, then after 1 month. 
• Make sure he understands that the first month will be difficult for him, but it will improve after. 

 

Sources: 

 Immunizations: 

• CDC Recommendations for Immunizations 

• https://www.cdc.gov/flu/about/qa/flushot.htm 

Screenings: 

• USPSTF Screening in Adults 

• Class notes on cancer screening 

 Injury Prevention 

• http://www.health.ri.gov/materialbyothers/fallsprevention/ScreeningToolsFallsPreventionAmongOlderAdults.pdf 

• https://www.parkinson.org/Understanding-Parkinsons/Symptoms/Movement-Symptoms/Trouble-Moving-or-Walking 

Diet 

• https://www.healthline.com/health/gerd/diet-nutrition#helpful-foods 

• https://www.michaeljfox.org/understanding-parkinsons/living-with-pd/topic.php?nutrition 

• https://www.parkinson.org/Living-with-Parkinsons/Managing-Parkinsons/Diet-and-Nutrition 

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945400/ 

• https://www.healthline.com/nutrition/foods-high-in-antioxidants#section6 

Exercise 

• http://pdcenter.neurology.ucsf.edu/patients-guide/exercise-and-physical-therapy 

Smoking Cessation 

• Week 9 Class Notes 

• https://tobaccocontrol.bmj.com/content/13/2/123 

• CDC “What to Tell Your Patients About Smoking and Chronic Diseases”