NMS Q&A Family Medicine

238 NMS Q&A Family MedicineExamination Answers1. The answer is E. That is, the incorrect statement is thata side effect of xenical (Orlistat) is reduction of HDL-C.This weight loss drug functions by inhibiting lipase, thusrendering exogenous triglycerides unabsorbable. To theextent weight loss is achieved, lipids are improved onaverage, and thus, HDL-C is increased. As exogenous triglycerideswould be less absorbed, diarrhea would beexpected to occur; hypoglycemia, as expected, is morelikely when the drug is combined with antidiabetic agents.Cholelithiasis may be a side effect of any aggressive weightloss program.2. The answer is C. Amoxicillin is not listed among thosedrugs that increase the risk of rhabdomyolysis. However, calciumchannel blockers, erythromycin, amiodarone, and niacindo increase the risk of rhabdomyolysis in patients takingHMG-CoA inhibitors. Diabetes, renal insufficiency, age, andsmall frame are indeed risk factors, the latter perhaps relatedto the fact that a given dosage is increased per unit weight ofthe patient in a smaller person.3. The answer is D. The definition of rhabdomyolysis ina patient who is taking a statin is 10-fold elevation of CKlevels. Myalgias may occur, but in the absence of elevationof CK, 10 times normal, the drug need not be discontinued.It occurs in less than 1% of cases. When rhabdomyolysisoccurs, it may take place early in the course butusually after the patient has been on the drug for an averageof 6 months, but that period does not define the syndrome.It will subside over a course of several days. Acuterenal failure occurs due to myoglobinuria. If acted uponpromptly, rhabdomyolysis rarely will result in acute renalfailure.4. The answer is B. The patient is within 5 lb (2.27 kg) ofhis ideal weight (at 69 in. or 1.75 m, ideal weight is 106 6 lb for each inch over 5 feet in height 160 lb, or 72.5kg). Therefore, even if the patient were very sensitive tothe relationship between weight and hypertension, dyslipidemia,and prediabetes (metabolic syndrome), thisman cannot be expected to change his vascular risk profileto a significant degree by losing less than 5% of hispresent weight. Thus, specific methods of weight loss,such as low carbohydrate or low fat, are equally inapplicableat this time, although low-fat maintenance is alwaysadvisable. Most authorities have moved to the position ofadvising pharmacologic therapy for virtually anyone withpreexisting heart disease or with strong family history ofatherosclerotic vascular disease and present significantrisk factors, including a significant recent history ofsmoking.5. The answer is D. Of all the agents presented, an HMG-CoA inhibitor (“statin”) addresses this patient’s profilethe best. The patient has abnormally elevated TC andLDL-C levels, and the ratio of TC to HDL-C is 6.5; formen, an acceptable ratio is 4.5 or lower. In addition, histriglyceride level is markedly elevated. Statins reduce TCand LDL-C levels as well as triglyceride levels, and theyelevate HDL-C. Metformin is an excellent drug for reducinginsulin resistance and, as such, improves lipids in theface of insulin resistance. However, it is not establishedthat this patient has insulin resistance. In any event, metformin’seffect is modest compared with that of the statindrugs in this type of case.6. The answer is A. The only risk factor known to thispatient is obesity in his parents. The fact that neither parenthas diabetes may mean that both his parents had hip–thigh obesity rather than the central obesity that isassociated with the metabolic syndrome. Obesity isdefined as a weight 20% above ideal. This patient’s weightof 180 lb (81.5 kg) at a height of 70 in. (1.78 m) is calculatedas a BMI of 25.8, which is overweight but not obese(top normal limit for men is 24 kg/m 2 ). Because his lipidsare within normal limits for a man (TC to HDLC ratio is4.5), there is no evidence that his overweight status is inhis case a risk factor. Thus, the diet, although well designedfor weight loss, is not clinically indicated nor certainly theradical VLCD. Sibutramine (Meridia) is an appetite suppressantand by definition of limited value for long-rangecontrol of weight.7. The answer is C. Obesity in early childhood conveys arisk of obesity in adulthood with all the attendant risks ofdiabetes, hypertension, dyslipidemia, and vascular disease,as well as osteoarthritis. In addition, there is an associationbetween childhood obesity not only with the adultorganic health risks mentioned but also with poor psychologicalhealth and decreased economic well-being. Fora child to be neurologically equipped for participation ina weight-loss program, he or she must have attained theage of 2 years.8. The answer is E. Enroll the patient in a commercialweight loss program. The most well-known commercialprograms are Weight Watchers, Jenny Craig, and Nutrisystems.This is a good approach for a patient who appears toneed social support. Nevertheless, weight regain is commonif patients are followed for years after a commercial programwas instituted. Nutritional assessment and program modificationscan be done by the physician, trained nursing staff, ora dietitian. Patients typically lose 11 to 22 pounds, but