[Solved]: VII

VII. Smoking Cessation Complaint: “I think I want to quit smoking.” History A 42-year-old male presents to clinic for a blood pressure check. A nurse at a mall health screening had told him that his blood pressure was a little elevated. He denies any other physical complaints. He also mentions that the nurse told him that if he quits smoking, his blood pressure might go down. He has been a patient at the clinic for 8 years but is seen on average every 18 months for minor acute problems, the last visit being 2 years ago (for bronchitis). He has never had an elevated blood pressure in the clinic. The chart reveals that tobacco cessation has been addressed previously, but he was not ready to quit. The patient reports that he began smoking when he was 15 years old and became a regular 1.5 pack per day smoker when he was 19 or 20 (35 pack year history). He at first denies any physical symptoms from smoking but does admit to a morning cough and shortness of breath during moderate exercise. He did try to quit cold turkey in his late 20s and again in his mid-30s but was unsuccessful. He is interested in the “pill” that helps people stop smoking, and he also saw an ad on television for “the patch.” His wife is a nonsmoker and he has two teenage children. Assessment The patient is well nourished and well developed. His blood pressure (BP) is 132/90 mm Hg at the beginning of the visit; when retaken at the end of the visit, it was 128/88 mm Hg. The rest of his vital signs are within normal limits (WNL). Upon physical examination, he is noted to have a cough with deep inspiration and no clubbing or cyanosis noted. Breath sounds are clear. The rest of the examination is WNL. He denies any symptoms of depression. The provider assesses the patient’s smoking habit and determines that he smokes the most in the morning before work (usually three to four cigarettes between arising and getting to work) and in the evening. Smoking is not allowed at work, and he only gets 30 minutes for lunch, allowing one or two cigarettes at lunch and one at each of his two breaks. After work, he begins smoking n the car on the way home and has an average of two to three cigarettes per hour until bed. The patient considers himself to be highly dependent on cigarettes and readily admits to nicotine withdrawal symptoms if he is not able to have his early morning cigarettes. 1. What would be the initial management plan? 2. What education would the patient need regarding starting smoking cessation therapy?