Download Clinical Scenario 2 What factors found in the medical and social

Clinical Scenario 2
1. What factors found in the medical and social history are pertinent for determining Mr. Gates’
Coronary Heart Disease (CHD) risk category? (include anthropometric, biochemical, clinical, and
dietary risk factors)
Mr. Gates has many factors that are pertinent to determining his risk category for coronary
heart disease. Among these factors are his triglyceride and cholesterol levels (increased LDL
cholesterol at 210 and decreased HDL cholesterol at 30) , his high blood pressure, indicating
hypertension (200/109), his smoking habit (1 pack/day for 30 years), his BMI (32.3), indicating
obesity, his sedentary lifestyle, and a diet high in saturated fats and cholesterol (bacon,
hamburger, cake, potato chips).
http://www.nhlbi.nih.gov/health/health-topics/topics/hd/
2. What is the patients’ BMI, and how would you interpret its significance?
Mr. Gates’ BMI is 32.3. This was determined by using the equation wt(kg)/ht(m)squared. This
BMI, or a BMI of 30 or greater, is indicative of obesity. Obesity is a very important risk factor for
coronary heart disease. As a person’s BMI increases over 25, entering the overweight and obese
categories, their risk for disease and mortality increases significantly. The increased levels of
lipids in the blood, contributed to by increased body mass, can lead to atherosclerosis and
coronary heart disease.
3. Compare the following normal blood levels (find the guideline from American Heart Association
instead of using the normal values from the chart) with the values obtained in Mr. Gates’ initial
lipid profile. Which ones are abnormal? Interpret Mr. Gates’ risks for cardiovascular disease
based on his lipid profile.
Parameter
Normal value (include the units)
Patient’s value
Cholesterol
<200 mg/dL
270
HDL-C
>60 mg/dL (optimal)
30
LDL-C
<100 mg/dL (optimal)
210
LDL/HDL ratio
<3.55 mg/dL
7.0
Apo A
94-178 mg/dL
75
Apo B
63-133 mg/dL
140
Triglyceride
<150 mg/dL
150
Mr. Gates’ Cholesterol levels are very high, HDL levels are far below optimal, LDL levels are more
than twice the optimal levels, LDL/HDL ratio is nearly twice the optimal level, Apo A level is far
below normal, Apo B level is above normal, and triglyceride levels are normal, but in the high
end of normal. All of these abnormalities are indicative of cardiovascular disease. High levels of
lipids circulating in the blood can lead to the hardening of arteries and coronary heart disease.
Low levels of HDL are indicative of a weakened protective mechanism against coronary heart
disease, as high levels of HDLs help to prevent the onset of CHD.
http://www.heart.org/HEARTORG/GettingHealthy/FatsAndOils/Fats101/Levels-ofCholesterol_UCM_305051_Article.jsp
Mr. Gate’s physician has decided to prescribe an ACE inhibitor and a HMG COA reductase inhibitor
(Zocor).
4. How does an ACE inhibitor work to lower blood pressure?
ACE inhibitors work by relaxing blood vessels. ACE inhibitors stop an enzyme in the body from
making angiotensin II. Angiotensin II narrows blood vessels and releases hormones that can
potentially raise blood pressure. The consequence of this is high blood pressure and narrowed
arteries, two contributing factors to CHD.
http://www.mayoclinic.com/health/ace-inhibitors/HI00060
5. How does a HMG COA reductase inhibitor work to lower serum lipid?
HMG COA reductase inhibitors block the rate-limiting step in the production of cholesterol. This
consequently lowers the rate of production and leads to lower levels of total cholesterol, LDLs,
and triglycerides
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0008779/
6. What changes can be expected in his lipid profile (specifically) as a result of taking these
medications? What are the pertinent drug-nutrient interactions and medical side effects for
each medication?
HMG COA reductase is responsible for lowering LDLs, total cholesterol, and triglycerides. They
also slightly raise HDL levels. Mr. Gate’s blood pressure should also drop to more normal levels.
ACE- Inhibitors: avoid salt, calcium, and natural licorice. High fat meals decrease absorption of
some ACE inhibitors.
HMG COA reductase: Avoid grapefruit and related citrus. Avoid alcohol and St. John’s Wort.
Decrease dietary fat and cholesterol. Take medication with evening meal to increase absorption.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0008779/
http://www.ext.colostate.edu/pubs/foodnut/09361.html
7. Identify the major sources of saturated fat and cholesterol in Mr. Gates’ diet. What suggestions
would you make for substitutions and/or other changes that would help Mr. Gates reach his
medical nutrition therapy goals?
The major sources of saturated fat and cholesterol in Mr. Gates’ diet are bacon, eggs, butter,
hamburger, potato chips, meat, sour cream and butter. The first suggestion I would make to Mr.
Gates is to consume fewer meals in restaurants. It is easier to make healthful choices when not
faced with a plethora of delicious, but unhealthful, options. Also, portions tend to be larger in
restaurants. Mr. Gates could substitute bacon for turkey bacon, choose a yogurt-based spread
instead of butter, have a grilled chicken sandwich or turkey sandwich instead of a hamburger, and
eat a salad instead of potato chips. He could also have grilled chicken or fish for dinner instead of
red meat, have a green vegetable instead of corn, and limit his bread intake to 1 piece instead of
two. Also, we could have a piece of fruit instead of a fruit pi rot cake. Mr. Gates should also quit
smoking and begin to exercise regularly. He could start with going on a 30-minute walk every day. A
way to ensure compliance and foster support is to encourage his wife to join him on his walks.