Immunizations

Since I’m seeing Barry in November, I would advise he got the flu shot and the TDAP shot. Since he’s in his 30’s the DTAP shot he got when he was younger may have worn off and it’s safer to give him the TDAP than to not. This might be the only time I get to meet up with him. Since he has admitted to me that he’s had sex with other men and is an avid drug user I would also advise he got the Hep A and Hep B shots as a precaution.

Screenings

            I would firstly screen Barry for hypertension, tobacco use and cessation and for a possible HIV infection (due to his having sex with other men). I would also screen him for alcohol misuse, depression and both Hep B and Hep C viral infections. Since he is an IV drug user and does have sex for drugs, I would screen him for a possible TB infection and for any STIs including chlamydia, gonorrhea and syphilis. Lastly, I would definitely screen him for his heroin drug use. Since he does have diffused crackles bilaterally, I would try to see what was going on with at least a CXR and take it from there.

Preventions/Harm Reduction

            Since Barry has admitted to having sex with other men for money, after the HIV screening I would try to put him on PrEP. It’ll hopefully lessen the chances he gets an infection if he doesn’t have a condom with him. I would advise Barry to stop drinking altogether. I would also advise he quit smoking, even if it’s just 4-5 cigarettes daily. The smoking is a gateway to the harder drugs he’s gotten accustomed to. Getting to stop doing heroin is no easy feat. Barry has used clean syringes where ever he can find them, so he’s trying his best to be as safe as possible, especially in his situation. As for a harm reduction initiative I would give him some clean syringes to use whenever he has run out of the other ones he’s used. As for injury prevention I would suggest traffic safety as he is homeless and he does need to look out for himself. I would also have a brief intervention with him about his heroin use and possible cessation of it.

Diet

            Barry’s diet is exactly that – a diet. He’s 6’1” and weighs 120lbs with his clothing hanging off of him like he’s a clothes hanger. His other vitals are great, but he’s severely malnourished. He eats as well as he can, but he needs to change a couple of things up. I would try to have Barry spend some of his money that he gets on his jobs on fruits and vegetables, canned tuna, peanuts and other nuts, and possible leaner meats. Being homeless doesn’t help his situation, but trying to change little things can help. For breakfast he can have a cup of coffee with some butter and toast. For lunch he can grab a made salad from a deli. For dinner some grilled chicken with a vegetable or a tuna salad sandwich.

Exercise

            Barry’s exercise regimen isn’t anything too crazy, but he isn’t obese. His smaller frame needs more muscle tone so I would recommend to him that he gets some exercise for about 10 minutes each day until he can work up to 150 mins per week of moderate exercise. When he’s in a groove with that I would advise he tries to step up his regimen to 75 mins per week of vigorous exercise. Barry does enjoy singing, so I would ask him to move around to get money from people while singing. That would also bring in some moderate exercise to the equation.

Brief Intervention

            As a brief intervention I would talk to Barry about his heroin use. I would use the motivational interview techniques we’ve used in class. I would firstly ask for permission to about his heroin use. I would ask, “Barry, can we talk about your heroin use?” I would hope he opened up to me about his use and everything that was good and bad about it. I would then try to elicit some change talk to see if I can get him to think about possibly changing his behaviors. I would ask questions like, “What do you think would happen if you didn’t stop using heroin?” and “What do you think your life would look like, even 6 months from now, if you stopped your heroin use?” I would further the conversation by using open-ended questions to get a more detailed and involved conversation with Barry. It’ll allow him to tell his story to the fullest detail and think about what he’s doing to himself more deeply. I would hope Barry talking about the ups and downs of his heroin use can open his mind up to change. I would then use the readiness to change criteria to see how far along he was ready to give his addiction a change.