Case Study- Barry Anderson

Immunizations

• Flu Vaccine
  • As is the standard for any individual who has large gaps in their medical history
• TB vaccine
  • Due to lack of history & the knowledge that Mr. Anderson sometimes tends to live in close quarters with other drug users or homeless individuals.
• Hepatitis A Vaccine
  • Due to lack of history & the knowledge that Mr. Anderson is an IV drug user, homeless, and occasionally has sex with other men.
• Hepatitis B Vaccine
  • Due to lack of history & the knowledge that Mr. Anderson is an IV drug user, homeless, and occasionally has sex with other men.
• Hepatitis C Vaccine
  • Due to lack of history & the knowledge that Mr. Anderson is an IV drug user, homeless, and occasionally has sex with other men.
• Tdap Vaccine
  • Due to lack of history & the knowledge that Mr. Anderson is an IV drug user, homeless, and sometimes tends to live in close quarters with other homeless individuals.

The instruction outline says to assume we will see our patient again in November, however this particular case study surrounds a somewhat nomadic, homeless man who has a history of neglecting regular medical visits. As such, we operate under the assumption that we will not see Mr. Anderson again after this visit. Some of these vaccines are given in 2 doses, I recommend these vaccinations with the understanding that even one dose provides some protection compared to not being vaccinated at all.

Screening

• Alcohol Misuse
  • Self-reported, but we should investigate just how severe the alcohol abuse is. Provide pamphlet/information on support groups should Mr. Anderson be interested in quitting.
• Drug Abuse
  • Self-reported, but we should investigate just how severe the drug abuse is. Provide pamphlet/information on support groups, affordable/free rehabilitation centers should Mr. Anderson be interested in quitting.
• Tobacco Use
  • Self-reported, but we should investigate just how severe the tobacco use is. Provide pamphlet/information on smoking alternatives & support groups should Mr. Anderson be interested in quitting.
• Depression
  • Due to the knowledge that Mr. Anderson is going through major difficulties in his life. Depending on screening results, provide Mr. Anderson with pamphlet for affordable/free therapy clinics/ psychiatric professionals.

• HIV
  • Due to the knowledge that Mr. Anderson is an IV drug user and occasionally has sex with other men.
• Hepatitis A/B/C
  • Due to the knowledge that Mr. Anderson is an IV drug user, homeless, and occasionally has sex with other men.
• STI Screening (particularly syphilis)
  • Due to the knowledge that Mr. Anderson is sexually active and does not always have access to condoms.
• Lung Cancer

• Due to smoking history, reported weight loss, rales upon osculation, productive cough w/ green phlegm. 
• Since we are operating out of a van, we clearly cannot perform a CT scan. However, after tactfully explaining the risks associated with smoking and their relationship to his reported symptoms, we can provide Mr. Anderson with resources to a more widely equipped affordable healthcare clinic that can screen him more in depth.

Health Promotion/Disease Prevention Concerns – please address all that are relevant for this patient:

• Injury Prevention
  • Traffic Safety
    • Mr. Anderson does not specific if he has a car or a license, but we cannot assume that he doesn’t have access to a vehicle that he knows how to operate.
  • Firearm Safety
    • Based on the population Mr. Anderson may sometimes be surrounded by, there is a higher chance he may encounter a deadly weapon.
• Diet

• Mr. Anderson’s homelessness is a barrier to a healthy diet. Provide him with pamphlets for local food pantries and hot food kitchens.
• Educate Mr. Anderson on the importance of making good food choices, this includes picking the better option whenever available, even when eating cheap & easy fast-food.
• Exercise
  • Mr. Anderson is homeless, nomadic (so he’s likely to be on foot often), and works odd jobs (usually these types of jobs are physical in nature.) Given this background & his reported weight loss, I would not be immediately concerned about his exercise habits. I would be more inclined to focus on his dietary habits.
  • For the sake of following CDC guidelines, I would note that Mr. Anderson is not likely to be meeting the recommended 150 min of moderate exercise each week. Since his weight and exercise habits are not my main concern & I understand I am not likely to see him again, aside from encouraging the typical daily exercise (perhaps walking or jogging), I would not go into detail about an exercise plan in favor of utilizing our time together to discuss more pressing health concerns.
• Harm Reduction
  • Provide pamphlets for overdose protection programs in the area
  • Provide pamphlets for needle exchange programs in the area
    • Provide Mr. Anderson with clean, unused syringes as well as a small sharps disposal container for safe keeping until he can exchange his needles elsewhere.
  • Provide information on smokeless nicotine alternatives
    • This one is a tricky one. We know Mr. Anderson is homeless and works odd jobs to get by, and smokeless alternatives may be expensive and therefore not a viable option for him right now. However, with the knowledge that we may not see him again after this visit due to his nomadic nature, it may be prudent to provide him with any information that can educate him and maybe someday empower him to take the steps necessary to seek help. 

Brief Intervention – where relevant to your chosen patient, please explain how you would conduct a brief intervention for:

• Obesity
  • N/A
• Smoking Cessation & Substance use
  • Use the 5 A’s
    • Ask: “Mr. Anderson, are you currently smoking/using?” “How many cigarettes a day do you smoke/ how often a day do you use?” “On a scale of 1-10, how ready would you say you are to take steps toward quitting?”
    • Advise: “Would it be alright if I provided you with some information on quitting?” If yes, go on to provide smoking cessation/rehabilitation information as detailed previously in the case study. If no, provide Mr. Anderson with a pamphlet that he can “read whenever you are ready.”
    • Assess:  Determine what motivating factors may exist. “Mr. Anderson, is there anyone in your life that might be happy to learn that you’ve quit smoking/using?” “Mr. Anderson, what aspirations do you have for your life and health?”
    • Agree: “Mr. Anderson, it’s fantastic that you’re committing to taking steps toward quitting. Here is some information on behavioral changes that might help you make the transition.”
      • Since Mr. Anderson is not likely to come back to the van, setting up a plan/ check-in dates or even setting a quit date that he cannot be held accountable for may not be the most effective method. Instead, educating him on healthy habits, behavioral changes, and smoking alternatives will better equip him with what he needs to enact change in himself. 
    • Arrange/Assist: Since we are not likely to see Mr. Anderson again, providing him information on support groups, affordable/free rehabilitation centers. Affordable/free psychotherapy clinics, affordable/free smoking alternatives, etc. will play a key role in his feeling prepared enough to take on his addictions. In this stage we would typically arrange a follow-up appointment. We can go ahead and do so if Mr. Anderson is willing, but understand he is not likely to return.