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Clinical Cases: Part III

Case One: Mark Guttman is a 39 year old white male living in Stamford, Connecticut. Mr. Guttman is here to see you for a follow up to an initial routine health care maintenance exam.

Question 7:

Which one of the following includes the determinants used in the NCEP ATP III's assessment tool to quickly calculate 10-year risk for developing coronary heart disease?

  1. Cigarette smoking, blood pressure, HDL, gender, and age.
  2. Waist circumference, HDL, triglycerides, and fasting glucose.
  3. The presence of metabolic syndrome, hypertriglyceridemia, diabetes, and previous coronary events.
  4. Decreased physical activity, fasting glucose, total cholesterol, blood pressure.
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The correct answer is A.  Cigarette smoking, blood pressure, low HDL, gender, and age.

Question 8

At a subsequent follow up appointment 3 months later, Mr. Guttman’s LDL is 167 despite a good effort on TLC. He is reluctant to start a statin medication because he feels he needs more time on his diet and exercise. He also wants to try garlic supplements, fish oils, and Chinese herbs to help his cholesterol first. How would you approach Mr. Guttman?

Link to submission form for Question 8

Case Two: Maria De Los Santos is a 67 year old Dominican female living in Washington Heights. She has been your patient for 8 years and is here to discuss the results of her fasting lipid panel.

Question 9:

Which one of the following represents metabolic syndrome?

  1. Abdominal obesity, low blood pressure, high triglycerides, low HDL cholesterol, and high plasma glucose.
  2. Abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, and low plasma glucose.
  3. Abdominal obesity, high blood pressure, low triglycerides, low HDL cholesterol, and low plasma glucose.
  4. Abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, and high plasma glucose.
  5. Abdominal obesity, high blood pressure, high triglycerides, high HDL cholesterol, and low plasma glucose
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The correct answer is D.  Abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, and high plasma glucose represent metabolic syndrome. The presence of any three clinically identifies metabolic syndrome.

Question 10:
You discussed the findings with Mrs. De Los Santos and you both agree to start a statin in addition to maintaining her therapeutic lifestyle changes. Two months later she returns and admits that she did not start the statin. Upon further discussion, she tells you that she recently heard a Spanish language radio show and they said that “Esas medicinas matan el higado” (“Those medicines kill the liver”). How would you approach Mrs. De Los Santos?

Link to submission form for Question 10

Case Three: Nelson Nguyen is a 43 year old Vietnamese male living in Castro Valley, CA. He has been your patient for 5 years and is here to discuss the results of his fasting lipid panel. He had been lost to follow up to your practice for 2 years. He was taking only hydrochlorathizide (was buying it on own over past 2 years – you added a second hypertension med at the last visit)

Question 11:

Which one of the following is not true concerning the Therapeutic Lifestyle Changes diet?

  1. A diet low in saturated fat, transfatty acids, and cholesterol and that contains soy protein and plant sterols/stanols can be just as effective as a statin at decreasing serum total cholesterol and LDL level
  2. For every 1% increase in calories from saturated fatty acids as a percent of total energy, serum LDL rises about 2%.
  3. Total fat consumed is a primary target.
  4. Substitution of low-fiber carbohydrates for saturated fatty acids can decrease HDL and increase triglycerides.
  5. Increased viscous soluble fiber is recommended.
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The correct answer is C.  A diet low in saturated fat, transfatty acids, and cholesterol and that contains soy protein and plant sterols/stanols can be just as effective as a statin at decreasing serum total cholesterol and LDL levels. Substitution of low-fiber carbohydrates for saturated fatty acids can decrease HDL and increase triglycerides. For every 1% increase in calories from saturated fatty acids as a percent of total energy, serum LDL rises about 2%. Increased soluble fiber in the diet is part of the recommendations. The total fat consumed is not the primary target.

Question 12:

After you counsel Mr. Nguyen on treatment strategies, he tells you that he may not be able to return for care. He cannot afford to take time off from work because of his illness; he is the sole wage earner for his two children going to college, his wife, and his mother-in-law. Besides this, he has avoided medical attention for the past years for fear of a catastrophic diagnosis that would prevent him from supporting his family in the future. He says he can’t afford a gym, buy expensive “health” foods, and pay for expensive medications. How would you approach Mr. Nguyen?

Link to submission form for Question 12

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