• • Conduct a Patient-centered interview with a brief intervention for mental health and smoking cessation.
  • Provide information on Diet modification and Exercise intervention.
  • Perform Clinician Center interview and Physical exam.
  • Indicate Immunizations and screenings.
  • Injury Prevention and Harm Reduction

• • • MMR
    • Varicella
    • Tdap
    • HPV
    • Hepatitis B
    • Hepatitis A
    • Inactivated Poliovirus
    • Meningococcal

• • • Influenza
    • Tdap booster (if not received in the past 10 yrs)
    • Zoster
    • Pneumococcal (indicated for smokers)

• • • Blood glucose
    • Hypertension
    • Hyperlipidemia
    • Mammography
    • Colonoscopy
    • Cervical cancer screening (if not done in the last 3 years)
    • Hepatitis C screening
    • HIV screening
    • STI screening
    • Depression screen by asking questions
    • Drug use screen by asking questions
    • Breast Cancer risk assessment screening tool

• • • Falls prevention
      • due to her age

• • • Poisoning Prevention
      • due to where she works even though non-toxic agents

• • • Firearms safety
      • due to prevalence of firearms in homes albeit illegal

• • • Traffic Safety
      • due to living in urban area

• • Patient did not share any specific food she eats more often then others but only expressed she “loves to cook and loves to eat” Puerto Rican food. She did express her inability and difficulty in losing weight. To help her with this, I outline below some ways she can use her cooking skills to create healthier meals with Puerto Rican food elements/seasoning.

• • Patient has specific health issues to consider for diet recommendations: Obesity (BMI >30, Waist 40”) and borderline Hypertension.

DASH diet recommendations – for both weight loss and Hypertension prevention:

• • Reduce sodium
    • intake to 2.3mg sodium/day = 1 teaspoon salt
    • Buy low sodium options when available
    • Buy no salt seasonings
    • Buy fresh whole foods/fruits and avoid processed prepacked foods

• • Limit red meat
    • Try chicken or turkey as alternative
    • Fish as ‘meat’ alternative
    • Choose leaner cuts of red meat (top sirloin steak, low % fat ground beef)

• • Avoid Trans Fats
    • Avoid items with “partially hydrogenated” oil in ingredients list

• • Limit Saturated Fats
    • Check food labels for serving size and aim to consume no more than 2-3 servings per day
    • Limit fried foods, choose baked or steamed instead
    • Use oil (olive oil, peanut oil) instead of solid fats (margarine, shortening, butter)
    • Consume more polyunsaturated fats (fish, flax seed, nuts, avocados)

• • Limit Sugar
    • Limit added sugar to 6 teaspoons per day = 25g or 100 calories
    • Avoid soda and fruit drinks
    • Do not add sugar to tea or coffee

Example Diet plan to address weight loss and hypertension prevention:

Advise patient about portion control and importance of calorie deficit in weight loss. Encourage patient to obtain a smaller dinner plate that will help with decreasing portion size.

Encourage patient to drink water before meals and drink at least 6 cups of water a day.

Breakfast

• • Fresh eggs with spinach and fresh herb with 1 slice of whole grain toast.

• • Muesli with milk or yogurt. Can add fresh fruit of choice.

Lunch

• • Avocado, chicken, cucumber, tomatoes, baby kale/spinach, couscous wrap with natural/homemade balsamic vinaigrette (or homemade dressing of choice)

• • Tuna salad with onions, celery, shredded carrots and radish. Light on mayo. Eaten on top of arugula, baby kale and baby spinach greens.

Dinner

• • Lean choice of meat, swap white rice for steamed/boiled brown or basmati rice, add peppers, onions, peas and chives to rice and any traditional no salt Puerto Rican seasoning.

• • Reduced sodium beans (or fresh beans), baked plantains and vegetables of choice on the side with either baked chicken or fish.

CDC guidelines recommend 150 minutes of moderate intensity activity or 75 minute of vigorous intensity activity per week and 2 days of muscle strengthening activities that work all the major muscle groups.

Although the patient is not completely inactive, she is can use some more physical activity according to the CDC guidelines.

Plan: (for both weight loss and hypertension prevention)

Aerobic Activity

• • Encourage patient to walk a longer distance for 30 minutes at a brisk pace when out with her dogs on an evening/morning walk. Do this 5 day a week.

• • Encourage patient to attend a virtual Zumba/dance class in her house that is 1 hour long two times a week and supplement with two 20-minute brisk walks with her dogs on the other two days.

Muscle Strengthening

• • Perform body weight resistance exercises with or without resistance bands twice a week doing 8-12 repetitions. (plank, pushups, sit ups, leg raises)

• • Gardening if in season two times a week. (weeding, planting)

• • Replace tobacco with smokeless nicotine alternatives
•  
  • Encourage whole foods and healthy eating choices as mentioned above

Mental health intervention

• • In the past 2 months, have you had little interest or pleasure in doing things you usual enjoyed?

• • In the past 2 months, have you had feelings of hopelessness, depression or feeling down?

• • In the past 2 months, how often have you had trouble staying asleep or sleeping too much?

• • In the past 2 months, have you started taking medication that was not prescribed to you?

Smoking Cessation intervention

• • Ask about Tobacco use
    • Ms. Negron do you smoke or use tobacco?

• • • How many cigarettes/packs do you smoke a day?

• • Assess readiness to change, health status and dependence on tobacco
    • You mentioned you tried to quit twice, are you will to try to quit smoking again? What happened the last time when you tried to quit?

• • • On a scale of 1-10, how ready are you to quit smoking? Why did you say that number?

• • • How long after you wake up do you have your first cigarette? Is this your daily routine?

• • Advise about risks, benefits, resources available
    • I can imagine how difficult this may be for you. I am here to help and would like to come up with a plan with you. Can I share some approaches that may make you more successful?

• • • Would you like to hear about some benefits of quitting smoking and how quitting will improve your health?

• • • Did you know that there is prescription medication that can help reduce your cravings to help you quit smoking?

• • Arrange for a plan to quit smoking and support
    • Do you have a date in mind as to when you would like to quit?

• • • Would you like to take some time to think about it and come back to discuss your options/plan further?

• • • Would like me to provide you with some more information on the medication available so you can take home and read over it?

• • Assure – call in to check on patient and schedule follow up visit
    • When would be a good time for you to come back two weeks from now so we can discuss this further/put the plan into action?

1. https://www.nia.nih.gov/health/four-types-exercise-can-improve-your-health-and-physical-ability
2. https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/shaking-the-salt-habit-to-lower-high-blood-pressure
3. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/cuts-of-beef/art-20043833
4. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fat/art-20045550
5. https://www.cdc.gov/physicalactivity/basics/adults/index.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fphysicalactivity%2Feveryone%2Fguidelines%2Fadults.html