John Liou

John Liou is a 75 year old retired construction worker with a history of hypertension, benign prostatic hypertrophy, COPD, GERD, and he was recently diagnosed with Parkinson’s Disease. He has exhibited a slow decline in physical function over the past five years. He has lost some weight (about 10 pounds in 5 years), but would still be considered overweight. He is generally de-conditioned, and is having difficulty standing and walking for any length of time. He will lean against a wall if the need for standing is more than a few minutes. He is complaining of some hip and back pain and has been having trouble with tripping more often (a common early symptom of Parkinson’s) which is making him more fearful of walking. He tends to sit when at home, and is in general quite sedentary. He is able to navigate stairs within the home with some difficulty and until very recently was able to manage some light gardening and home maintenance chores.

He lives with his wife of 54 years in a small, two-story house in Flushing. His wife is concerned about their future and how long John can manage at home. She would like to move to an apartment, so that John will no longer need to worry about raking the leaves, and managing all the home tasks he has always performed in the past, but John is resistant to this idea. You have discussed this idea with him in light of his recent diagnosis, but he says that he wants to stay in the home he and his wife have lived in for many years. He asks you if there isn’t some way you can help him get stronger so they can continue to do so.

His past medical history is noted above. His immunization records indicate that he has not received any vaccines since his last tetanus (Td) vaccination 10 years ago. He was offered the flu vaccine last year, but declined it saying that he heard you could get the flu from it.
His family history is vague – he left China as a very young man and has not been in touch with his family since. He knows that his parents died in an earthquake after he left, but he knows little about their health concerns. He has one sister who lives in California, but he hasn’t been in very close touch with her either. He thinks she had some “woman’s trouble” at some point and had surgery, but he doesn’t know the details. He has three children, all alive. His son has

hypertension and one daughter had a congenital heart condition, but that was taken care of with surgery when she was young. His grandchildren are all alive and well.
John has been a smoker all his life. He has cut down some, but is still smoking one pack a day (total 80 pack-years) and is taking 15 different medications. He was recently prescribed a new medication for his GERD symptoms which brought on intense dizziness to the extent that he could not walk without leaning against the wall. He discontinued the medication and the symptoms faded over a 24 hour period.

His diet is a traditional Chinese one, prepared by his wife mostly. He eats a fair amount of vegetables and not too much meat. His diet is fairly high in salt, but he says that his wife has been resistant to changing her way of cooking “after all these years”. He confesses that he does enjoy sweets and agrees that perhaps he eats them too often, “But it’s one of my few pleasures these days”.

Other information:
BP 120/70, seated T 98.7 R 20 P 84, regular Hgt 5 ft. 6 in. Wgt 170 lbs.
Medications:

• Hydrochlorthiazide 25mg daily
• Enalapril 2.5 mg twice daily
• Nifedipine XR 30 mg daily
• Potassium Chloride 20 meq daily
• Tiotropium inhaler 2 puffs daily
• Albuterol inhaler 2 puffs daily
• Omeprazole 40 mg daily
• Cimetadine 400 mg at bedtime (now discontinued after dizziness)
• Carbidopa/Levodopa (25/100) 3 times daily
• Naproxen sodium 200 mg 3 times daily
• Tylenol 350 mg – two tablets twice a day as needed
• Ferrous sulfate 300 mg daily
• Docusate sodium 100 mg daily
• Hydrocortisone cream 1% to scalp prn flaking and itching
• Calcium carbonate 500 mg – two tablets twice daily
• Sennokot (an over the counter laxative) as needed for constipationGen: Alert, oriented, with a somewhat increased AP diameter of his chest. Breathing with soft, but audible grunting sounds at times when he exerts himself. His facial expression is flat, though he smiles broadly when he makes a joke.

Primary care visit

J.L is a 75yo M with HTN, COPD, GERD, benign prostatic hypertrophy, Parkinson’s disease. Stopped GERD medication due to dizziness. Current smoker with 80 pack year. BMI of 27.4 with high salt diet and likes to eat “many” sweets. Sedentary, has trouble walking and standing at the same time and is tripping more due to Parkinson’s. Lives in two story house with wife. He doesn’t want to move. He wants to get stronger. Vitals all WNL. On BP medication and calcium channel blocker with BP and HR WNL.

Immunizations recommendations:

1. Tetanus shot (Tdap)
   o It has been over 10 years and this vaccine is recommended every 10 years
2. Influenza inactivated (IIV)
   o This vaccine is recommended every year and is appropriate for those age >65
3. Zoster recombinant (RZV)
   o This is the preferred vaccine for ages >65, patient has not gotten any vaccine in>10 years
4. Pneumococcal polysaccharide (PPSV23)o This is the recommended vaccine for ages >65, patient has not gotten any vaccine in >10 years

Screening:
1. Smoking cession

a. Discuss his risk of lung cancer due to smoking, bring up if he has ever tried to stop and what might have stopped him and if he is willing to try again. Along with screening provide behavior therapy and U.S. Food and Drug Administration–approved intervention therapy for cessation.

2. Lung cancer screening
a. Recommendations are to screen annually with low-dose computed tomography

for individuals 55 to 80 years of age with a 30-pack-year history; he has a 80 year

pack history 3. Depression

a. This patient is dealing with a terminal illness and his refusal to move from a two- story home may be signs of denial in how this disease is affecting his diet

4. Diabetes/lipid screening
   1. CBC and CMP should show random glucose and total cholesterol, LDL,triglycerides adequate enough for screening purposes
   2. This would help to better access his cardiovascular risks
5. Colorectal cancer

a. Discuss if patient has been screened from ages 50 to now and if not recommend

fecal occult blood (or immunochemical) test, sigmoidoscopy, colonoscopy, computed tomography colonography, or multitargeted stool DNA test

Interventions/education

1. Injury prevention
o Discuss permanently relocating to floor-level of the two-story home. Discuss

this disease process in Parkinson’s and the risk of injury without adapting and to his changing needs before it’s too late. Discuss possible referrals for physical therapy and equipment such as a walker. Discuss the fall risk when doing house chores and should see if he can get a neighbor or one of his children to help. Discuss with patient that a fall could lead to broken bones, prolonged hospitalization, worsening mobility or even death.

2. Vaccine education
o Would discuss how the flu vaccine does not give you the flu but that when

you get the flu, it triggers you to make antibodies and some people can feel mild symptoms such as chill, fever and fatigue that go away with 48-72 hours. Discuss the risk of him getting the flu or pneumonia with his increased age. Also discuss the risks of not getting tetanus and zoster.

3. Smoking cession and Lung cancer screening
o Would talk about the relevance of his condition and the risks continuation

could have and have some of the rewards could be. I would also discuss some roadblocks and potential barriers.

§ Ask him patient about tobacco use
§ Advise him of risks, benefits, helps available
§ Assess readiness to change, health status and level of tobacco

dependence (HSI)
§ Arrange for a quit plan and supports
§ Assure – Call soon after quit date & visit within 1 month

o Would help set up the appointment and again emphasis the importance and need for him to do a CT scan to screen for lung cancer due to his age and pack years

4. Nutrition and Exercise
o Discuss the benefit on his overall well-being from mental to cardiology in

reducing salt and sugar
o If patient agrees to home visits with physical therapy they can do chair

exercises and maybe walker exercises to safely strengthen his muscles o The physical therapy may also help with the hip and back pain that he is

having
o Would help set up the appointment and again emphasis the importance and

need for him to do a CT scan to screen for lung cancer due to his age and

pack years
5. Medication compliance

o I would also briefly ask if he has stopped any other medications due to side effects. Would also ask how he remembers to take each medication since he has so many

o Would reinforce the important of taking them and discuss any questions he had about why he takes any of them

End of appointment referrals

• Radiology for low-dose computed tomography and possibly colonoscopy
• Physical therapyFollow up: One month

• Follow-up scheduled in one month to discuss results of CBC, CMP and to discuss results of CT Scan and/or colonoscopy as well as see how physical therapy is going and any barriers he is facing.

Resources

•

• Olson EC, Van Wye G, Kerker B, Thorpe L, Frieden TR. “Take Care of Jamaica”. New York City Community Health Profiles, 2nd Edition; 2006; 36(42): pg 6.
• Tran, N. Treating Tobacco Addiction. “City Health Information”. 2008; 27(1):1-8 •
• United States Preventive Services Taskforce. (2013, December 13). Recommendation: Lung Cancer: Screening | United States Preventive Services Taskforce. United States Preventive Services Taskforce: Lung Cancer Screening Recommendation. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer- screening