Question

Subjective:

Mr. CB is a 46 yr old Caucasian male with known stage 3 CKD, secondary to his poorly controlled insulin dependent diabetes mellitus. He has hypertension and diabetic nephropathy, and a history of a prior stroke. His eGFR using the MDRD equation is 34.2 mL · min–1 · 1.73 m–2 BSA. His nephrologist recommends that Mr. CB needs to adopt some lifestyle behaviors to reduce his risk of dying prematurely from the complications associated with his disease. He is referred to the clinical exercise physiologist affiliated with the nephrology group. His current medications were clopidogrel 75 mg p.o. daily, irbesartan 150 mg p.o. daily, aspirin 81 mg p.o daily, Lantus insulin 75 units daily, Humalog sliding scale.

Objective and Laboratory Data:

Review of electronic heath record provides the following laboratory data: Variable Measured Value Weight (kg) 109.1 Waist (cm) 104.3 % Body fat (skinfolds) 19.1 Body mass index (kg · m–2) 34.2 Resting systolic blood pressure (mmHg) 123 Resting diastolic blood pressure (mmHg) 78 Resting heart rate (beats · min–1) 80 Low-density lipoprotein cholesterol (mg · dL–1) 84 High-density lipoprotein cholesterol (mg · dL–1) 34 Variable Measured Value Total cholesterol (mg · dL–1) 170 Triglycerides (mg · dL–1) 204 Fasting glucose (mg · dL–1) 231 Hemoglobin A1c (HbA1c) (%) 10.3

Because Mr. CB has diabetes, the clinical exercise physiologist recommended that he undergo a medically supervised graded exercise ECG stress test, during which his functional capacity was directly measured using open-circuit spirometry. The test was performed using the modified Bruce protocol, and the following data were collected:

• Peak oxygen uptake = 25.5 mL · kg−1 · min−1

• Mr. CB developed a 2 mm horizontal ST-segment depression, and the test was terminated during the fourth stage (2.5 mph, 12% grade); 1 mm of ST-segment depression was noted at an exercise heart rate of 114 beats · min–1. ST segments returned to baseline quickly during the recovery period.

• Heart rate and blood pressures all responded normally during the test.

• No symptoms of excessive shortness of breath or chest discomfort reported.

• There were no dysthymias noted either during the test or recovery period.

Assessment and Plan:

Mr. CB is a 46 yr old Caucasian male with known stage 3 CKD, referred to start a regular exercise program. He has a markedly reduced exercise tolerance, and his exercise stress test was consistent with silent exercise-induced myocardial ischemia.

Following the graded exercise test, the clinical exercise physiologist met with Mr. CB and reviewed the results of the exercise test with him and devised an exercise plan. He first educated Mr. CB that he would need to check his blood glucose levels before and after each exercise session to make sure the values are neither too high or too low. He was also warned that as the amount and intensity of his exercise training increases, he would need to consult with his endocrinologist to reduce his insulin dose to reduce the risk of experiencing a hypoglycemic event.

Because of the silent myocardial ischemia (evidenced by ST-segment depression without symptoms) observed during Mr. CB’s exercise test, the clinical exercise physiologist felt it necessary to have him supervised while performing moderate to vigorous physical activity. Therefore, he was scheduled to attend a facility-based supervised exercise program 3 d/wk, training at a heart rate not to exceed 104 beats · min–1. This upper heart rate value was determined because it is 10 beats · min–1 below the heart rate at which the ST-segment changes were initially observed (beats · min–1) during the exercise test.

During the initial exercise sessions there was to be a 5 min warm-up followed by 20-25 min of continuous aerobic exercise utilizing (depending on Mr. CB’s preference) the treadmill, cycle, or elliptical. Following completion of the 20-25 min, Mr. CB would then begin a 5 min cool-down period, after which a variety of static stretches (each repetition held for 20-30 s) would be given to Mr. CB. His blood glucose and blood pressures would both be re-measured to make sure that they were normal prior to him leaving the facility.

After the first 2 or 3 wk, if no problems are observed or reported, the duration of the aerobic sessions will be increased by 5 min per week until Mr. CB is able to exercise for 45 min continuously. After 6 sessions of aerobic training only, some resistance exercise will be introduced 2 times per week involving a whole body program of 1 set of 10-15 repetitions of 8- 10 different exercises. The resistances used in his weight training sessions will be gradually increased when he is easily able to complete 15 repetitions of a weight. Mr. CB would be also counseled to reduce sedentary time while at home by not sitting for more than 30 min at any given time by taking a stand-up and light activity break.

Case Study Discussion Questions:

4. How does this person’s functional capacity compare with a normal, healthy person free of clinically manifest disease who is of the same age and gender? What realistic improvement in his functional capacity can occur over 4 to 6 mo of training?

5. What are the major complications that the clinical exercise physiologist needs to be aware of while working with Mr. CB, and what precautions should be taken to ensure patient safety?

Answer 1

1)How does the patient functional capacity compare with normal?

This patient functional capacity is different from normal,because he is having hypertension and diabetics,heart disease,CKD, diabetic nephropathy.

Patient value.

Resting systolic and diastolic pressure ,heart rate are in normal range.

_Low lipoprotein cholesterol _84(normal is less than 70)

High lipoprotein cholesterol_34(normal60mg/dl)

Total cholesterol_170(normal)

Triglycerides_204(normal should be less than 150mg/dl)

Fasting glucose_231(normal_less than 170mg/dl)

Hemoglobin_10.3(normal is 13.8_17-2)

2) Healthy person free of clinically manifest disease compared to who is one of same age and gender?

A healthy person will be some what free from clinically manifest disease because he is having already diseases so it will cause to get the disease faster,his immunity also law because of disease condition.A healthy person can also will get clinically manifest disease but not like a disease person.

3)His functional capacity improved after the exacises?

Yes he improved a lot with exacises,after the exacises Bp and blood glucose was come to side of normal range,1st time he done aerobic exercise for 20_25 min,after 1 week he is able to do for 45 min.weight sessions of aerobic training gradually increased.

4)What are the major complications that the clinical exacises physiologist needs to be aware of?

(a)The patient glucose (hypoglycemia)and blood pressure should be checked prior to the exercise,

(b)Have to observe the heart rate and and for MI symptoms when doing physical exercise.

(c)Heart rate not to be exceed 104 beats / min

(d)Should give time to take rest between exercise.

Provide education regading the condition and to avoid the discomfort during exercise section.