Tabitha Moe, MD August 2010 Ambulatory A

1. A 21 year old medical student comes to you in July. You are a new intern and excited about imparting your new font of knowledge. The medical student excitedly begins telling you about this new great diet. Its better than any of those other beachy diets. She says. It is a completely no fat diet. I have already lost weight since yesterday. You decide to review your physiology prior to giving her any advice and you remember that fat is an essential dietary component. Which of the following dietary evaluations is false: A. B. C. D. E. Only 25 g of fat per day are necessary to meet the requirements for physiologic function 30% of daily calories should come from fat Dietary fats are necessary to incorporate soluble vitamins Omega-3 and Omega-6 fatty acids are made endogenously Diets that eliminate cholesterol may be safe in closely monitored high-risk patients

Key Concept/Objective: To demonstrate knowledge of dietary fat metabolism Answer: D- Omega-3 and Omega-6 fatty acids are made endogenously Omega-3 and omega-6 fatty acids can not be synthesized endogenously and require dietary intake of fatty acids. Although all dietary fats have the same caloric value 9cal/gram, not all fats are created equal. The American Heart Association (AHA) guidelines for healthy adults state that no more than 30% of calories should come from fat, less than 10% saturated fat and the remainder from unsaturated fat in vegetables, fish, and nuts. At a minimum15-25 grams of dietary fat are required daily to construct bilipid cellular membranes, and absorb soluble vitamins. In the true absence of dietary fats soluble vitamins such as A, D, E, and K are not able to be utilized and may result in significant dysmetabolic syndromes. However, patients who are high risk: diabetics; those with cardiovascular disease, and morbid obesity, may benefit from a very low or no cholesterol diet under close monitoring. The recommended daily cholesterol intake for the average healthy adult is 300mg. Diets with less than 200mg/day can be maintained without close monitoring. However, the absence of dietary cholesterol can not and should not exclude dietary fats. 2. Your co-intern Dr. K has been acting rather oddly. He has no past medical history. He has become progressively withdrawn throughout the year. His patients seem to like him, he always has his work done and is conscientious about staying over to help his colleagues out. When asked how things are going, he says, fine. He does not socialize, he looks as though he has lost weight and one morning simply does not show up for work. When he can not be reached by pager or cell phone the Chief Resident decides to drop by his apartment and finds him passed out on the floor. The are empty liquor bottles piled around him and stacks of gum and breath fresheners on every surface. Going through his lab coat pockets, there is a flask with clear, odorless fluid.

Which of the following complete blood counts is likely consistent with Dr. K: A. B. C. D. WBC 4.0; Hgb 10.1, Hct 33, Plt 115 MCV 105 WBC 5.5, Hgb 13.2, Hct 40, Plt 200, MCV 90 WBC 6.0, Hgb 6.0, Hct 28, Plt 32, MCV 78 WBC 4.0, Hgb 14, Hct 45, Plt 215, MCV 88

Key Concept/Objective: To demonstrate knowledge of downstream effects of dietary insufficiencies Answer: A- WBC 4.0; Hgb 10.1, Hct 33, Plt 115 MCV 105 Alcoholism is often found to coexist in the setting of Vitamin B-12 and folate deficiencies. Deficiencies of these particular vitamins lead to the appearance of a megaloblastic anemia over time. Red cells are large and pale leading to an modestly increased MCV in the range of 95-105. Seldom will solitary dietary insufficiency increase the MCV to greater than 105, if the MCv is greater than 105 consider malignancy. A bone marrow suppression caused by chronic alcoholism prior to the onset of hepatic cirrhosis can cause all cell lines to be suppressed. It is not uncommon for alcoholics to have comorbid leucopenia as well as thrombocytopenia. CBCs for answers B and D are essentially normal for a male. The CBC listed as C would be more likely a mixed picture. The MCV of less than 80 is consistent with iron deficiency, and a Hgb of 6 is inconsistent with an otherwise healthy male who does not have any history of bleeding. 3. After a stint on the night float team you are now attempting to transition back to days but are having a difficult time. You have been stopping by Starbucks for the double espresso shot on the way in every morning and essentially chain-drinking caffeine all day just to stay awake. On your third day of the switchover you are awakened with palpitations but are somehow able to ignore them until after morning rounds. You convince one of your colleagues to perform an EKG and interpret the results yourself. You decide that you are in SVT and are able to resolve this spell with Valsalva maneuvers. Which of the following are not proven effects of caffiene: A. Susceptible individuals are likely to have an decreased threshold for migraines B. Decreasing caffeine intake will decrease spontaneous premature ventricular contractions C. Should not be drunk within 6 hours of sleep as it may disrupt sleep and cause sleeplessness D. Increased risks of cancers Key Concept/Objective: To demonstrate knowledge of caffeine effects Answer: B. Decreasing caffeine intake will decrease spontaneous premature ventricular contractions

Studies have been unable to demonstrate that there is along term reduction in symptomatic premature ventricular contractions with the cessations of caffeine intake. As PVCs are likely multifactorial in nature, including electrolyte disturbances, irritable myocardium, and psychosomatic overlay, it is not conclusive that caffeine will decrease this occurrence. Caffeine Studies have failed to confirm a link between caffeine and hypertension, peptic ulcer disease, coronary artery disease, breast disease, or any type of cancer. Migraines may be triggered by caffeine in susceptible individuals. Caffeine withdrawal can precipitate headaches or depression in those who routinely ingest caffeine. Caffeine can cause gastroesophageal reflux, anxiety, and insomnia. Caffeine metabolism varies from individual to individual and may take up to 6 hours to completely metabolize. Therefore, it is strongly recommended that patients with previously diagnosed, or newly diagnosed sleep disturbances avoid caffeine intake. Brewed coffee can increase blood cholesterol levels, but filtered coffee does not. Caffeine effects on pregnancy are not well-understood and have not been well documented, however, it is widely discouraged by practitioners. 4. The Residency running club is getting started for the academic year and each of the residents comes to you asking what sort of screening evaluation is necessary to allow them to participate. The residents are over all a young and healthy group. Only one of which has Diabetes Type I. One of which also has exercise induced asthma and is beta-agonist dependent in order to exercise strenuously. Then, your dad calls and says he would like to get back into shape after having had a heart attack last year. He wants to join the running club too to spend more time with you. What recommendations can you make to these individuals regarding their exercise prescriptions?: A. Young and otherwise healthy individuals need no screening prior to initiating a moderate exercise program B. Exercise-induced asthma is often worsened by chlorine and these individuals should avoid swimming C. Repetitive isotonic exercise is the most widely recommended D. High-risk individuals should not exercise following a significant cardiovascular event E. Diabetics are at too high risk to allow for intense aerobic exercise Key Concept/Objective: Understanding how to write an exercise prescription Answer: C. Repetitive isotonic exercise is the most widely recommended Isotonic or aerobic exercise that involves large muscle groups in repetitive motions over time is the best form of exercise to attain, and maintain cardiovascular health. These activities include running, biking, skating, swimming, and cross-country skiing. Young, and otherwise healthy individuals can undergo screening prior to beginning an exercise program. It is highly debatable the extent to which screening is required. A CBC, and a urinalysis are reasonable in all athletes. However, the increased cost associated with more extensive testing has not been proven. The most important thing is a complete history and physical. Family history of sudden death, early cardiovascular disease, or stroke should be evaluated. Physical exam findings including hand

grip and Valsalva during cardiovascular exam may also be important. Asthmatics, particularly with reactive airways related to exercise benefit from improving their cardiovascular tolerance. They are most likely to succeed in something like swimming as the reactive pattern is often broken compared to jogging or biking. High-risk individuals increasingly have been proven to benefit from a cardiac rehabilitation program including reconditioning with mild to moderate aerobic exercise as tolerated. These programs often include telemetry, blood pressure, and glucose monitoring throughout their exercise program. Aerobic exercise improves glucose tolerance, improves fasting blood sugar and has been shown to decrease the need for increasing insulin doses over time. 5. The Geriatrics rotation has been your favorite so far, and you are now seriously considering a geriatric fellowship. You go to visit your great-grandmother for the weekend just to check on her. She has made her usual chocolate chip cookies and is waiting for you. As you hug her your physician senses kick in to over drive and you feel her ribs through her dress, and her heart is pounding against you after trying to get out of her easy chair. She tells you it took almost an entire day to make her special cookies because she kept having to rest. What is the role of exercise in the elderly?: A. B. C. D. E. Improves muscle tone Decreases glucose resistance Decreases risk of falls Improves risk of cognitive decline Improved stair climbing and gait velocity

Key Concept/Objective: Understanding Exercise Benefits in the Elderly Answer: All of the above Aging closely resembles the physiologic decline associated with a long-term sedentary lifestyle. Both circumstances result in decreases in cardiac output, glucose tolerance, and muscle mass. Similarly both scenarios lead to an increase in systolic blood pressure, body fat percentage and serum cholesterol levels. Regular exercise appears to combat this decline. Endurance training improves glucose tolerance and blunts the age-related decline in basal metabolism. Spontaneous physical activity in the elderly is increases functional status and decreases mortality. Exercise is safe in the elderly with a bit of planning and structured precautions. Even nursing home residents responded to resistance training with an increase in muscle mass and strength, as well as improved gait velocity, stair-climbing power, and spontaneous activity. Although more studies are needed, enough information is available to warrant recommendation of a planned exercise program for the elderly.