Jessica Anderson
KINS 7310
Frequent Flyer Roy
Narrative:
Roy is a 58-year-old male, 5’11” and weighs 220 lbs. He absolutely loves life but has always struggled with adherence to proper diet and exercise. He is a career driven and is willing to do anything to meet the needs of his family (a wife, daughter and son). Roy is an engineer and travels frequently for work. At the age of 43 he was diagnosed with cardiovascular disease and underwent a triple bypass surgery. Prior to this surgery, he had a stent placement in his LAD. Roy completed cardiac rehab sessions after each stent placement; however, he was non-compliant to his prescribed diet and exercise programs. Just last year Roy experienced throat tightness and resulted in two stent placements in his proximal circumflex and proximal to mid-circumflex. Due to sign/symptoms that emerged, Roy was referred to our exercise physiology facility for a GxT. Roy was able to complete the GxT—demonstrating a normal cardiovascular response to exercise with an increase in intensity. Since the most recent progression of his disease and diagnosis of LPa, there has been increased compliance with both diet and exercise. He currently is experiencing no signs/symptoms of CV risk. Just last year, Roy lost 39 lbs but gained 20 lbs back caused by loss of adherence to his prescribed exercise program. Roy has stated that he is ready to make a change for the long haul but needs some assistance in increasing adherence due to the drastic lifestyle change it requires. Having lived in California growing up, he loves to be outdoors—going for bike rides and walks, but finds it near to impossible having moved to Ohio. However, Roy just recently bought a gym membership to a location 2 miles from his home and is ready to get going. In moving forward, he would like to make a long-term exercise goal to help him stay on track. He has set a personal weight goal of 195-200 lbs and would like to live a long and healthy life to be with his family and experience his children’s life-milestones. He is very much goal oriented and does best when he has something to work towards. He has stated he would like to work towards participating in “Pedal to the Pointe”—bike riding from Cleveland, Ohio to Cedar Pointe, this coming summer. Roy’s family is very supportive and would like to join in on enhancing their diet, physical activity and exercise regimen with him. Roy does not have a family history of cardiovascular disease risk. Below are the doctor’s orders:
Doctor’s orders:
à Lower cholesterol as low as possible; LDL <50 by targeting Lpa (ZETIA), TC <100 (unless HDL)
à Lose weight: 185lbs
à Exercise: 3-5x/wk, 45min/d, cardio (target HR 110 bpm) *trouble getting to target HR tropolol (age-predicted HRmax: 220-58 = 162 HRmax without medication interference)
à Frequency of monitoring: every 6 months (blood work); GxT ordered only if symptoms/signs emerge
*NO ACE-inhibitor: coughing
à Prescribed ARB (angioretensive blocker)
SOAP Note
S: Subjective Assessment
Patient Statements:
· Stated Lifestyle Barrier: “My job is so demanding and requires quite a bit of traveling that I don’t have the time for exercise.”
· Stated Lifestyle Barrier: “I carry much stress related to my job and providing for my family. On top of that, the thought of a total lifestyle change in regards to diet and exercise makes me feel very overwhelmed.”
· Stated Exercise Barrier: “Incorporating an exercise program and eating a healthy diet requires a total lifestyle change. I find it stressful and difficult to sustain a healthy diet and exercise regimen since “life” keeps getting in the way.”
· Stated Climate Barrier: “It’s not a matter of liking or disliking exercise. I like to exercise. I used to run 3 miles a day and loved windsurfing when I lived in California. I love exercising outside, but it’s near to impossible with the weather being so unpredictable and the long winter season that we experience each year”.
· Stated Lifestyle Barrier: “I lost 39 lbs this past year (2014) but gained 21 lbs back because I stopped logging my food in MyFitnessPal and stopped exercising regularly. I got so caught up with life. I need to get back on the “wagon”. It’s “wagon time”.
· Stated Nutrition Barrier: “I think nutrition is so hard to keep up due to eating being such a social event. It’s hard to be consistent with “life” getting in the way. Especially now, choices and accessibility to food is almost too much. It’s hard not to indulge since it’s the holiday season”.
· Stated Goal Weight: “My self-desired goal weight is 195-200 lbs.”
· Stated Goal: “I want to witness and experience all the milestones of my son and daughter. Really, I just want to stay alive and as healthy as I can.”
· Stated PA Goal: “Without working towards an exercise goal, I think that’s why I keep falling off the “wagon”. In starting a new exercise program, I’d like to work towards some kind of organized exercise event, such as Pedal to the Pointe. I love biking”.
· Stated Goal: “ I want to feel good about my body weight and body image, be healthy for my family and enjoy life to the fullest”.
· “I’m currently not experiencing any signs/symptoms of heart problems”.
· Orthopedic Limitations: previous sprained ankle and right wrist limitations related to previous break.
· Support System: “I’m lucky to have a wife who is a heart nurse at the Cleveland Clinic and a daughter who has a passion for exercise and nutrition. I have the most amazing support system”.
Subjective Analysis:
Stated Problem: Patient states wants to stay alive and well for his family.
Stated PA goal: Patient wants to participate in an exercise program that he enjoys doing. Patient states they are ready for a lifestyle change. Patient wants to work towards an organized exercise event, such as Pedal to the Pointe (biking from Cleveland to Cedar Pointe).
Current PA: Little to none. Inconsistent.
Dietary Specifics and Supplement Use: CV Dietitian prescribed for patient to follow the Mediterranean diet. No current supplement use.
Orthopedic Limitations: Previous sprained ankle. Patient states slight difficulty with ankle when running. Previous broken wrist. Patient states slight discomfort of wrist when lifting and exercising.
Social/Environment: Patients states he has a great family support system—his wife being a CV nurse and his daughter studying nutrition and exercise. Patient states he has many family members within a 10-mile radius. Patient states his work requires a huge time commitment due to travel and a recent promotion. Patient states difficulty maintaining a nutrition program due to eating being a “social event”.
O: Objective Assessment
· Demographics
o Gender: Male
o Age: 58 yrs old
· Anthropometrics
o Ht: 5’11” (71” or 180.34 cm)
o Wt: 220 lbs (100 kg)
o BMI: 30.86 kg/m2
§ Calculation: 100 kg/ (1.8034 cm)2
o BMI Classification: Obesity Class I
§ Obesity Class I = 30.0 kg/m2 – 34.9 kg/m2
o Waist Circumference: 38”
o Waist Classification: Low risk
§ Low risk: 31.5-39.0”
· Blood Work Results
o 2 x BP (rest): 120/80 mmHg
o 2 x HR (rest): 54 bpm
· Cholesterol Levels
o TC: 99 mg/dL
o LDL-C: 42 mg/dL
o HDL-C: 35 mg/dL
o VLDL-C: 22 mg/dL
o TG: 109 mg/dL
o TC/HDL ratio: 2.83
o LDL/HDL ratio: 1.20
o Non-HDL 64 mg/dL
o LPa-C: 100 mg/dL
· Fasting Blood Glucose
o IFG: 102 mg/dL
· Medications
o isosorbide mononitrate ER (IMDUR) 60mg 24hr tablet (dilate blood vessels; Beta-blocker and lowers BP; prevent angina attacks)
o fluticasone (FLONASE) 50mg/actuation nasal spray (allergies)
o clopidogrel (PLAVIX) 75mg (blood thinner so don’t occlude or block the stents; Lpa – kept on them will help that too likely indirectly; keep platelet from sticking together; prevention of MI and CVD signs/symptoms)
o fexofenadine (ALLEGRA) 180mg tablet (allergies)
o metoprolol succinate ER (TOPROL XL) 200mg 24hr tablet (beta-blocker; keeps blood pressure from getting high; keeps HR down; helps pump more efficiently; treat angina and HTN; prevents heart attack)
o Valsartan-Hydrochlorothiazide (ARB) 160-25 mg tablet (two part drug: 1. Diuretic, 2. Angiotension II receptor blocker—relaxing blood vessels)
o ezetimibe (ZETIA) 10mg tablet (lowers LDL, TC and Non-HDL; started about 1yr ago post-stent placement; discovered high Lpa, no direct treatment for it)
o nitroglycerin sublingual (NITROSTAT) 0.4 mg SL tablet (as needed, chest pain/angina would take it; dilates large epicardial coronary arteries and dilation of post-capillary vessels)
o Asprin 81 mg tablet (blood thinner)
o atorvastatin (LIPITOR) 80 mg tablet (statin, reduce LDL and TG in the blood; cholesterol drug)
*No current signs/symptoms present of CVD (managed with medications and bi-annual appointment follow-ups with cardiologist)
A: Assessment
Risk Stratification Assessment:
* = Positive Risk Factor
1. * Age: 58-year-old male
2. No family Hx of CV, metabolic or pulmonary disease
3. Has never been a cigarette smoker
4. *Sedentary: participates in exercise < 30 min of moderate exercise on 3d/wk for at least 3 mo (each time discharged from cardiac rehab); inconsistent activity
5. *BMI: 30.86 Obese classification I
6. *HTN: medications: metoprolol succinate ER (TOPROL XL) and isosorbide mononitrate ER (IMDUR) to keep blood pressure down
7. *Dyslipidemia: LDL 42 mg/dL; TC 99 mg/dL; medications atorvastatin (LIPITOR) and ezetimibe (ZETIA)—doctor referral for use in management of lipids
8. *Pre-Diabetes: IFG 102 mg/dL
Negative risk factor
1. HDL: 35 mg/dL (not considered, less than 60 mg/dL)
Total Risk Factors: 6 of 8
1. Age
2. Sedentary
3. Obesity
4. HTN medications
5. Dyslipidemia medications
6. Pre-Diabetes: IFG >/= 100 mg/dL
*Diagnosed CVD
Patient had a stent placement in 2000 related to the LAD. Patient had triple bypass surgery in 2001. Patient had 2 stent placements in 2014 associated with diagnosis of high levels of LPa (January and November). Stent was placed in the proximal circumflex in January and within the Proximal mid-circumflex (reopening the stent from January and overlapping) in November of 2014.
Classification of Risk à HIGH RISK
Experienced Exercise Tests
Stress Tests (GxT)
· Performed when the patient develops signs and symptoms associated with CV risk
· Last test performed November 2014 related to tightness in throat
Recommended Tests
Bod-Pod OR DXA-Scan
· Determine FM versus FFM
· Determine current bone density
Patient Interests:
· Walking outside, bike riding, being outdoors, running, rowing, windsurfing
Patient Logistics
· Has access to gym and clearance to participate in the fitness center
· Group classes are offered at the fitness center (i.e. spinning, boot-camp, cardio-kick boxing, yoga etc.)
· Has side walk accessibility in the neighborhood for walking
· Lives in a safe suburb where he can walk and bike without caution
· Has access to fresh foods and groceries within a 2 mile radius
· Has access to a bike and multiple routes of transportation
· Has a company car that pays for gas
Patient Support System
· Has an encouraging family around who can help motivate him to stay active and healthy
· Has a family who has a great interest in eating well and being active
· Has family members that would like to go to the gym and workout with him
Recommendations for Roy
· Review dietitian material received about the Mediterranean diet.
o Refresh and self-educate on the materials presented from patient meeting with dietitian.
· Seek dietitian for additional advice and support in helping to make a smoother transition into a nutrition lifestyle change (i.e. making food ahead of time for the week, portion control, recipes, easy snack foods to pack while on-the-go etc.).
o This will be of assistance in creating a menu that best-fits the individualized needs and lifestyle of the patient. This will also help to review and answer any questions the patient may have that will help with greater patient adherence to the Mediterranean diet.
· Continue to meet with cardiologist every 6 months for CV assessment via blood work and anthropometric measures.
o For preventative measures and close monitoring of the patients LPa-C and other factors associated with onset of a CV event.
· Contact cardiologist for referral to physiologist for a GxT (or other type of exercise testing) if patient experiences signs/symptoms related to CV risk.
*GxT is unneeded at this time due to no signs or symptoms being present. The patient has recently undergone a GxT (November 2014) and entered cardiac rehab. However, adherence to the exercise program was not maintained, but the patient demonstrates an eagerness and readiness (preparation phase) to enter back into his recommended exercise program. It is recommended for the patient to contact and meet with his exercise physiologist to best create and revise the current exercise program to increase patient adherence. The plan is as follows:
P: Plan
*To decrease periods of physical inactivity in addition to an increase in physical activity and exercise.
*Warm-up and cool-down, stretching exercises and gradual progression of volume and intensity
*Weight bearing to maintain bone health
1. Initial ExRx—FITT Principle for all components
Includes:
Warm-up: at least 5-10 min of light-to-moderate intensity Cardiorespiratory activities
Conditioning: 20-60 min of aerobic, resistance, and neuromotor activities (exercise bouts of 10 min are acceptable if the individual accumulates at least 20-60 min/d a daily exercise)
Cool-Down: at least 5-10 min of light-to-moderate intensity Cardiorespiratory and muscular endurance activities
Stretching: at least 10 min of stretching exercises performed after the warm-up or cool- down phase
· Aerobic Exercise
o 3-4 x a week for 30-60 min each, light-to-moderate intensity (~35-60% HRR [difficult to determine due to medications interfering with HR] or <4-6 METs)
§ *On one of the days performing aerobic exercise, perform interval training at least 1 x a week for 20 min of moderate-to-vigorous intensity (60-<90% HRR [medications interfere] or 6-8.5 METs)—2 min vigorous bout followed by 2 min recovery bout.
§ *Recommended for patient to workout at an intensity that makes it slightly difficult to hold a conversation.