NR 601 Week 5
Hector Ramirez is a physically active 76-year-old male with history of hypertension, type
II diabetes mellitus, hyperlipidemia, and history of myocardial infarction 2 years prior,
now presenting to establish care with you. He comes into your clinic with a man he
introduces as his roommate. Hector has no acute complaints. He reports his health is
robust and he is independent in his activities of daily living (ADLs) and instrumental
ADLs (IADLs). He walks independently without an assistive device and denies any
recent falls. He still does some part-time work as a lawyer. For leisure, he enjoys
swimming in the morning and walking his dog throughout the day. He denies hearing or
vision issues and reports he is up to date on routine vaccinations. - answerHe continues
answering your questions, denying any substance use, and reporting that he is currently
sexually active with men only. He then pauses, grasping the hand of his roommate. He
endorses that he has never told any health provider about his sexuality before because
no one had ever cared to ask if he had sex with men. He reports he has been with his
roommate for 35 years and self-identifies as gay.
1) What additional information would be helpful for determining his care needs and
appropriate laboratory testing? sexual history and depression screening
2) What may be additional healthcare considerations in care for this older gay male?
Advanced care planning
With an open discussion, you screen Hector for depression, which he currently denies,
although he states he has been treated for depression in the past. He reflects that he is
well supported by his roommate, Roy. At this time, your patient seems a bit worried and
asks you what would be appropriate preventative healthcare screening for him today.
He states that he has heard of anal Pap smears from friends and would be open to
scheduling an appointment for testing. He understands that if he has positive results, he
may need to undergo further testing.
You ask him about his sexual habits, and he states he has had multiple sexual partners
in the last year and is versatile, both bottoming (or receptive anal intercourse) and
topping (insertive anal intercourse) with multiple men. He rarely uses barrier protection
and has at least three sexual partners. - answerYou offer him rectal, oral, and urine
testing for gonorrhea and chlamydia, in addition to syphilis testing and HIV testing. You
counsel him on using protection as well, given he has multiple sexual partners. Finally,
you have some time left in your visit today. You ask open-ended questions about who
would make decisions for him in emergencies or care for him if he was unable to care
for himself. He reports it would be his roommate, Roy. You ask him if Roy is his partner
and if they have any legal documentation showing these are his care preferences. He
reports he does not have any legal documentation or license showing Roy is his
surrogate decision maker and partner.
,1) What are important advanced care planning considerations in the LGBT community?
whether paperwork has been completed. Are they married
2) What social structures do LGBT adults rely on
Families of choice
After speaking with Hector, you clarify that his primary surrogate decision maker would
be his roommate, Roy, with a secondary surrogate his close lifelong friend, Martha. You
firmly tell Hector that he will need to file advance directive paperwork to recognize his
chosen individuals as surrogate decision makers. You arrange for follow-up in 4 weeks
to continue your goals of care discussion. You have given Hector several items to think
about, and he is excited to continue his healthcare with you. - answerAfter speaking
with Hector, you clarify that his primary surrogate decision maker would be his
roommate, Roy, with a secondary surrogate his close lifelong friend, Martha. You firmly
tell Hector that he will need to file advance directive paperwork to recognize his chosen
individuals as surrogate decision makers. You arrange for follow-up in 4 weeks to
continue your goals of care discussion. You have given Hector several items to think
about, and he is excited to continue his healthcare with you.
Margaret is a 74-year-old female with a history of hypertension, prior smoking, and high
cholesterol who is presenting to establish care with you after she moved into assisted
living. You greet Margaret and see she looks noticeably uncomfortable. You go through
your routine interview—touching on past medical history and medications—and note
that Margaret has been on long-term estrogen therapy and has had a vaginoplasty.
Knowing this information, you pause and ask Margaret what pronouns and names she
prefers to use. - answerShe endorses her pronouns as "she/her/hers" and states her
preferred name is in fact Margaret. She breathes a sigh of relief and reveals that she
has jumped from provider to provider because of not feeling accepted as a transgender
woman and has deferred much of her medical care because of not feeling safe with her
last provider. When you ask what her chief concern is today, she reveals that she seeks
a refill of her estrogen as she is about to run out.She specifically asks you if she can
continue using her estrogen therapy and if you would provide the refill. She has been
using the same dose of estrogen patch for the last 30 years.
1) What are issues specific to the care of transgender women and men and how do we
effectively manage these concerns?
2) What risk factors may transgender patients have for osteoporosis?
Talking with Margaret, you learn she is independent in all her ADLs, although for her
IADLs she no longer drives or goes grocery shopping on her own. She reports with the
loss of some of her night vision and slower reaction speed, she simply did not feel safe
behind the wheel anymore. She enjoys assisted living and getting help with cleaning
and her meals. Otherwise, she reports no recent falls and denies depression. Asking
about her advanced care planning, Margaret does tear up and states her surrogate
decision maker is her friend, Anne, after her partner of 10 years had passed away. She
provides her advanced directive showing Anne as her primary healthcare surrogate.
,You then ask her if she is sexually active with men, women, or both. She notes that she
is currently sexually active with both men and women. - answerTalking with Margaret,
you learn she is independent in all her ADLs, although for her IADLs she no longer
drives or goes grocery shopping on her own. She reports with the loss of some of her
night vision and slower reaction speed, she simply did not feel safe behind the wheel
anymore. She enjoys assisted living and getting help with cleaning and her meals.
Otherwise, she reports no recent falls and denies depression. Asking about her
advanced care planning, Margaret does tear up and states her surrogate decision
maker is her friend, Anne, after her partner of 10 years had passed away. She provides
her advanced directive showing Anne as her primary healthcare surrogate.
You then ask her if she is sexually active with men, women, or both. She notes that she
is currently sexually active with both men and women.
You conclude your visit offering her STI testing, offering her mammogram screening,
and letting her know you are here to support her. You will refill her estrogen prescription
at this time, after discussing the long-term risks of estrogen use, including DVT risk and
screening her for smoking. However, you wish to hold an ongoing discussion about her
estrogen use and referral to one of your colleagues who specializes in transgender
health. She smiles and shakes your hand before you leave the room. - answerYou
conclude your visit offering her STI testing, offering her mammogram screening, and
letting her know you are here to support her. You will refill her estrogen prescription at
this time, after discussing the long-term risks of estrogen use, including DVT risk and
screening her for smoking. However, you wish to hold an ongoing discussion about her
estrogen use and referral to one of your colleagues who specializes in transgender
health. She smiles and shakes your hand before you leave the room.
LGBTQI - answerUmbrella term to describe the community of lesbian gay, bisexual,
transgender community and etc.
Sexual orientation - answerEmotional, sexual, or romantic fluid attraction
MSM - answermen who have sex with men
WSW - answerwomen who have sex with women
Gay - answeridentity for sexual orientation of individuals who have sex with the same
gender
Lesbian - answerwomen who have the sexual orientation towards women
Bisexual - answerPrimary sexual orientation and emotional orientation for both genders
Transgender - answerA person who identifies as a gender that is not their gender at
birth.
Genderqueer and does not identify within to gender binary.
, Queer - answerTerm to include younger LGBTQI members who do not identify with
other genders or sexual identities yet or ever.
Gender dysphoria - answerDistress that is caused by a discrepancy between a person's
gender identity and that person's sex assigned at birth. This distress may also be from
the associated gender role or attributed sex characteristics.
Gender identity - answerA person's intrinsic sense of being male, female, or an
alternative gender
Sex - answerSex is assigned at birth as male or female, usually based on the
appearance of the external genitalia. Natal gender.
Gender expression - answerThe way an individual socially expresses gender, such as
style of clothing, speech, and mannerisms. Gender identity and gender expression may
differ. There may also be people who do not present in the binary or masculine or
feminine roles, presenting as an alternate gender, such as genderqueer.
How can a PCP facilitate sexual, and gender identity disclosure? - answerAsk this
question in intake paperwork
How to ask for a patient's sexual and gender identity - answeruse of standardized
questions with open-ended responses in a nonjudgmental manner
Example: What is your pronouns?
Do you have sex with women, men, or both?
Do you identify as gay, lesbian, or bisexual?
What is minority stress? - answerLGBT older adults have experienced a hostile social
environment filled with discrimination and stigma that creates stress within the person.
For example, persons may be increasingly vigilant of their actions, expecting rejection
regardless of the situation or even hide their identity for fear of harm, making them less
likely to come out
What is internalized homophobia? - answerAn individual who has experienced societal
stigma is now internalized
Minority stress and internalized homophobia contributes to... - answerstress which leads
to higher rates of mental disorders and may be connected to physical injury.
General Preventative screening for LGBTQI - answerDepression and suicide risk
screening: translate minority stress into PCP
Hector Ramirez is a physically active 76-year-old male with history of hypertension, type
II diabetes mellitus, hyperlipidemia, and history of myocardial infarction 2 years prior,
now presenting to establish care with you. He comes into your clinic with a man he
introduces as his roommate. Hector has no acute complaints. He reports his health is
robust and he is independent in his activities of daily living (ADLs) and instrumental
ADLs (IADLs). He walks independently without an assistive device and denies any
recent falls. He still does some part-time work as a lawyer. For leisure, he enjoys
swimming in the morning and walking his dog throughout the day. He denies hearing or
vision issues and reports he is up to date on routine vaccinations. - answerHe continues
answering your questions, denying any substance use, and reporting that he is currently
sexually active with men only. He then pauses, grasping the hand of his roommate. He
endorses that he has never told any health provider about his sexuality before because
no one had ever cared to ask if he had sex with men. He reports he has been with his
roommate for 35 years and self-identifies as gay.
1) What additional information would be helpful for determining his care needs and
appropriate laboratory testing? sexual history and depression screening
2) What may be additional healthcare considerations in care for this older gay male?
Advanced care planning
With an open discussion, you screen Hector for depression, which he currently denies,
although he states he has been treated for depression in the past. He reflects that he is
well supported by his roommate, Roy. At this time, your patient seems a bit worried and
asks you what would be appropriate preventative healthcare screening for him today.
He states that he has heard of anal Pap smears from friends and would be open to
scheduling an appointment for testing. He understands that if he has positive results, he
may need to undergo further testing.
You ask him about his sexual habits, and he states he has had multiple sexual partners
in the last year and is versatile, both bottoming (or receptive anal intercourse) and
topping (insertive anal intercourse) with multiple men. He rarely uses barrier protection
and has at least three sexual partners. - answerYou offer him rectal, oral, and urine
testing for gonorrhea and chlamydia, in addition to syphilis testing and HIV testing. You
counsel him on using protection as well, given he has multiple sexual partners. Finally,
you have some time left in your visit today. You ask open-ended questions about who
would make decisions for him in emergencies or care for him if he was unable to care
for himself. He reports it would be his roommate, Roy. You ask him if Roy is his partner
and if they have any legal documentation showing these are his care preferences. He
reports he does not have any legal documentation or license showing Roy is his
surrogate decision maker and partner.
,1) What are important advanced care planning considerations in the LGBT community?
whether paperwork has been completed. Are they married
2) What social structures do LGBT adults rely on
Families of choice
After speaking with Hector, you clarify that his primary surrogate decision maker would
be his roommate, Roy, with a secondary surrogate his close lifelong friend, Martha. You
firmly tell Hector that he will need to file advance directive paperwork to recognize his
chosen individuals as surrogate decision makers. You arrange for follow-up in 4 weeks
to continue your goals of care discussion. You have given Hector several items to think
about, and he is excited to continue his healthcare with you. - answerAfter speaking
with Hector, you clarify that his primary surrogate decision maker would be his
roommate, Roy, with a secondary surrogate his close lifelong friend, Martha. You firmly
tell Hector that he will need to file advance directive paperwork to recognize his chosen
individuals as surrogate decision makers. You arrange for follow-up in 4 weeks to
continue your goals of care discussion. You have given Hector several items to think
about, and he is excited to continue his healthcare with you.
Margaret is a 74-year-old female with a history of hypertension, prior smoking, and high
cholesterol who is presenting to establish care with you after she moved into assisted
living. You greet Margaret and see she looks noticeably uncomfortable. You go through
your routine interview—touching on past medical history and medications—and note
that Margaret has been on long-term estrogen therapy and has had a vaginoplasty.
Knowing this information, you pause and ask Margaret what pronouns and names she
prefers to use. - answerShe endorses her pronouns as "she/her/hers" and states her
preferred name is in fact Margaret. She breathes a sigh of relief and reveals that she
has jumped from provider to provider because of not feeling accepted as a transgender
woman and has deferred much of her medical care because of not feeling safe with her
last provider. When you ask what her chief concern is today, she reveals that she seeks
a refill of her estrogen as she is about to run out.She specifically asks you if she can
continue using her estrogen therapy and if you would provide the refill. She has been
using the same dose of estrogen patch for the last 30 years.
1) What are issues specific to the care of transgender women and men and how do we
effectively manage these concerns?
2) What risk factors may transgender patients have for osteoporosis?
Talking with Margaret, you learn she is independent in all her ADLs, although for her
IADLs she no longer drives or goes grocery shopping on her own. She reports with the
loss of some of her night vision and slower reaction speed, she simply did not feel safe
behind the wheel anymore. She enjoys assisted living and getting help with cleaning
and her meals. Otherwise, she reports no recent falls and denies depression. Asking
about her advanced care planning, Margaret does tear up and states her surrogate
decision maker is her friend, Anne, after her partner of 10 years had passed away. She
provides her advanced directive showing Anne as her primary healthcare surrogate.
,You then ask her if she is sexually active with men, women, or both. She notes that she
is currently sexually active with both men and women. - answerTalking with Margaret,
you learn she is independent in all her ADLs, although for her IADLs she no longer
drives or goes grocery shopping on her own. She reports with the loss of some of her
night vision and slower reaction speed, she simply did not feel safe behind the wheel
anymore. She enjoys assisted living and getting help with cleaning and her meals.
Otherwise, she reports no recent falls and denies depression. Asking about her
advanced care planning, Margaret does tear up and states her surrogate decision
maker is her friend, Anne, after her partner of 10 years had passed away. She provides
her advanced directive showing Anne as her primary healthcare surrogate.
You then ask her if she is sexually active with men, women, or both. She notes that she
is currently sexually active with both men and women.
You conclude your visit offering her STI testing, offering her mammogram screening,
and letting her know you are here to support her. You will refill her estrogen prescription
at this time, after discussing the long-term risks of estrogen use, including DVT risk and
screening her for smoking. However, you wish to hold an ongoing discussion about her
estrogen use and referral to one of your colleagues who specializes in transgender
health. She smiles and shakes your hand before you leave the room. - answerYou
conclude your visit offering her STI testing, offering her mammogram screening, and
letting her know you are here to support her. You will refill her estrogen prescription at
this time, after discussing the long-term risks of estrogen use, including DVT risk and
screening her for smoking. However, you wish to hold an ongoing discussion about her
estrogen use and referral to one of your colleagues who specializes in transgender
health. She smiles and shakes your hand before you leave the room.
LGBTQI - answerUmbrella term to describe the community of lesbian gay, bisexual,
transgender community and etc.
Sexual orientation - answerEmotional, sexual, or romantic fluid attraction
MSM - answermen who have sex with men
WSW - answerwomen who have sex with women
Gay - answeridentity for sexual orientation of individuals who have sex with the same
gender
Lesbian - answerwomen who have the sexual orientation towards women
Bisexual - answerPrimary sexual orientation and emotional orientation for both genders
Transgender - answerA person who identifies as a gender that is not their gender at
birth.
Genderqueer and does not identify within to gender binary.
, Queer - answerTerm to include younger LGBTQI members who do not identify with
other genders or sexual identities yet or ever.
Gender dysphoria - answerDistress that is caused by a discrepancy between a person's
gender identity and that person's sex assigned at birth. This distress may also be from
the associated gender role or attributed sex characteristics.
Gender identity - answerA person's intrinsic sense of being male, female, or an
alternative gender
Sex - answerSex is assigned at birth as male or female, usually based on the
appearance of the external genitalia. Natal gender.
Gender expression - answerThe way an individual socially expresses gender, such as
style of clothing, speech, and mannerisms. Gender identity and gender expression may
differ. There may also be people who do not present in the binary or masculine or
feminine roles, presenting as an alternate gender, such as genderqueer.
How can a PCP facilitate sexual, and gender identity disclosure? - answerAsk this
question in intake paperwork
How to ask for a patient's sexual and gender identity - answeruse of standardized
questions with open-ended responses in a nonjudgmental manner
Example: What is your pronouns?
Do you have sex with women, men, or both?
Do you identify as gay, lesbian, or bisexual?
What is minority stress? - answerLGBT older adults have experienced a hostile social
environment filled with discrimination and stigma that creates stress within the person.
For example, persons may be increasingly vigilant of their actions, expecting rejection
regardless of the situation or even hide their identity for fear of harm, making them less
likely to come out
What is internalized homophobia? - answerAn individual who has experienced societal
stigma is now internalized
Minority stress and internalized homophobia contributes to... - answerstress which leads
to higher rates of mental disorders and may be connected to physical injury.
General Preventative screening for LGBTQI - answerDepression and suicide risk
screening: translate minority stress into PCP
