Yusuf Khoury is a 57 year old accountant with a history of Type 2 diabetes and moderate to severe depression somewhat controlled by medication. He comes to see you today with a complaint of shoulder and left hand pain when he walks his dog and left wrist pain when us uses his computer. He is concerned that the pain may be caused by his heart because he has been told that left arm pain can be a symptom of heart attack, however you’re not so persuaded. He describes the pain in his shoulder as aching, but not worse at the end of the dog walk than it was at the beginning. It is located mostly in the shoulder and upper arm and is not accompanied by chest or jaw pain, shortness of breath, nausea, palpitations or discomfort anywhere else. It resolves when he stops walking the dog and does not occur when he walks at any other time. The wrist pain is located mostly in the ventral surface of his wrist and gets progressively worse while he’s at work, sometimes accompanied by numbness and tingling in his thumb and first finger. The wrist pain occasionally also bothers him at night. He has taken ibuprofen 400 mg. for this pain which does help some – relieving at the end of the day from 6/10 to about 3/10. Over the weekends, the wrist pain doesn’t bother him at all and his arm only bothers him when he walks the dog
His desk job requires many hours of sitting at his computer and very little walking during his typical work day. He commutes to work via subway which is one block from his home and leaves him one block from his office. Apart from walking the dog, he gets no regular exercise. In fact he says, “I’m allergic to exercise”.
He typically buys breakfast at the shop in the ground floor of his office building – usually a buttered roll and large coffee with half and half and Equal. “Sometimes I get a piece of fruit too from the guy with the stand on the corner”. He usually orders in for lunch from one of the local restaurants – a sandwich or sometimes soup with a bag of chips. He admits that his office mates usually have a big plate of cookies or other sweets in the break room and that he has a hard time resisting them.
His family history is significant for a father who also had Type 2 diabetes and prostate cancer at age 70. His mother had hypertension and a stroke at age 68. He has one sister who is alive and well and a brother who has macular degeneration.
He lives with his wife and their dog in an apartment building with an elevator. He spends most of his weekends at home, sleeping for long periods of time. He rarely leaves his apartment on weekends and has very little social life, though his wife is very involved in the local mosque and frequently tries to get him to join her there. He says, “It just seems like too much effort”.
Yusef does monitor his blood sugar and blood pressure regularly and keeps a log of his measurements. Lately his glucometer readings have been in the 180-200 range fairly often. His blood pressure readings have been under 140/90 on his current medication. You are considering whether he needs to be started on insulin, but so far he has resisted this suggestion.
Other information:
BP 142/86 P 72 R16 T 99
Hgt 5ft 11.5 in Wgt 190 Waist circumference 43
Finger stick glucose this morning (fasting) 160
Hgb A1C 9.0
Medications:
- Metformin 500 mg twice daily
- Glyburide 5 mg twice daily
- Paroxetine 20 mg twice daily
- Enalopril 5 mg twice daily
IMMUNIZATIONS:
Given that the pt has had his childhood vaccines and considering his history of diabetes.. recommend influenza, Tdap booster, PPSV23 (pneumococcal polysaccharide), RZV (2 doses)
SCREENING:
Visual acuity (given brother hx of macular degeneration)
Prostate CA (PSA) – Given age, will be up to the patient. Discuss the benefits and risks of screening.
Colorectal cancer – colonoscopy
Hep C (pt born between 1945-1965)
Total cholesterol, HDL (also maybe LDL)
ECG (due to high risk of CVD with BMI 26.1 and high waist circumference >40 in, hx of DM)
HEALTH PROMOTION/DISEASE PREVENTION CONCERNS:
Injury Prevention:
Traffic safety – pt uses the subway to commute to work, but discuss traffic safety in case he uses a car to drive to other places on occasion.
Exercise:
Mr. Khoury is NOT getting adequate exercise. (It does not seem like he is getting 150 minutes per week of moderate-intensity aerobic exercise. And he is not doing muscle strengthening exercise).
Commend the patient for walking his dog (we are not sure how long he does this) despite the shoulder and hand pain.
Take the stairs up to apartment, don’t use escalator.
Prolonged sitting is an independent risk factor. Encourage 10-minute bursts of activity while on break at work. Try to get off of the subway 1 stop early on the way to work and on the way home, and walk the rest of the way.
Lack of social life, staying at home, and long sleep periods all likely secondary to depression. Refer to psychiatry for better management? Better control may help with motivation to be more active and get more exercise.
Will gradually build up exercise regimen to meet the guidelines stated above.
Diet:
Aim for a low glycemic diet – which will help decrease HgA1c and will help with weight loss.
Get decaf coffee instead.
Commend patient for eating fruit. Encourage more fruits and non-starchy vegetables (spinach, broccoli, etc) into diet.
Restaurant soups will often have high sodium content. Recommend preparing soup at home, preferably vegetable-based soups, soups with chicken or beef broth, and tomato soups (without cream), to maintain satiety.
Substitute the bag of chips with a side of whole grains (such as brown rice, whole wheat bread/pasta, or popcorn). This will help keep you full and will decrease your desire to have sweets in the office break room.
BRIEF INTERVENTION:
Obesity–
Ask: “Do you mind discussing your weight and the effects it may be having on your health?” “Have you ever tried to lose weight before?” “What weight would you like to be?” “What has gotten in your way?” etc..
Assess: Patient is overweight. BMI ~26.1, high waist circumference >40 in. Lifestyle management/intervention is indicated due to BMI >25 with risk factors. Ask for PMHx. “How has being overweight affected your life?” Assess for effects on psychosocial functioning.
Advise: “can we come up with a plan to improve things?”
Agree: “Yes, about 20 lbs weight loss is a realistic goal.”
If patient is willing to talk about weight and is motivated to lose weight, recommend 10% weight loss (19 lbs). Likely benefits of losing 10-15% of your weight include decrease in blood glucose levels and decrease in risk of depression.
Assist: “what motivates you to lose weight?” “What has gotten in your way?”
Smoking: Patient did not mention smoking history, but we should ask if he does smoke.
Substance Use: Patient did not mention substance use, but we should ask if he does use
****Order in which items/issues may be addressed****
- Patient’s chief complaint is left upper extremity pain. First address this and provide treatment/referral.
- Diet – pt’s HgA1c is quite high (9.0), along with fasting blood glucose.
- Exercise – this will also help patient’s diabetes. Will also decrease risk of CHD, of which he is already at risk of due to family history and personal hx of DM.
- Obesity brief intervention.
- Screening. Include smoking and substance use screening here.
- Vaccinations.
- Injury prevention
