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16 Aug 2019

Lassie’s resting metabolic rate was determined to be 358 mL min-1 with a respiratory exchange ratio of 0.77, with light exercise (walking) Lassie’s metabolic rate increased to 662 mL min-1 with a respiratory exchange ratio of 0.83, and for a brief period of time, Lassie’s metabolic rate was maximal at 3550 mL min-1 with a respiratory exchange ratio of 1.36 while he was running up a steep gradient. How much CO2 was Lassie excreting at each of these three time points? Consider one day (24 hours) in which 60% of the time Lassie was at his basal (resting) metabolic rate, 39% of his time was at light exercise (662 mL min-1) and the remaining 1% of his time was at maximal exertion (3550 mL min-1). Assuming Lassie’s been eating a dogfood diet composed of 45% protein, 30% fat, and 25% carbohydrates, how much energy did he expend in that day?

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Reid Wolff
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17 Aug 2019

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Related questions

Medical History and Physycal E x a m i n a t i o n:
At age 7, Mr. AT suffered a series of seizures, and after a physical e x a m, lab tests, and electroencephalography, he was diagnosed with epilepsy and put on epileptic medication. He has gained 25 lb (11 kg) over the last 2 yr. He complains about excessive postural sway and loss of balance while walking and therefore uses his father’s cane. He has no history of smoking or alcohol consumption, but he has a familial history of diabetes. At a recent physical e x a m his low-density lipoprotein cholesterol (LDL-C) was 178 mg · dl−1, high-density lipoprotein (HDL) was 61 mg · dl−1, fasting glucose was 88 mg · dl−1, and waist circumference was 42 in. (107 cm). He is currently on Carbatrol (carbamazepine) and baclofen.

Diagnosis:
Mr. AT, now 28 yr old, was born prematurely along with his twin sister at 34 wk. His mother experienced a severe infection early in her pregnancy and was hospitalized for several days; upon birth he had an Apgar score of 4. At age 1 he was diagnosed with spastic hemiplegia.

Exercise Test Results:
Because Mr. AT is ambulatory but has balance difficulties, leg cycle ergometry was chosen as the method of aerobic exercise testing. His resting blood pressure and heart rate in a seated position were 134/80 mmHg and 82 beats · min−1, respectively. A small face mask was used to provide an adequate seal. A toe clip on his right side was used to maintain proper foot positioning on the pedals, and an adaptive glove was used to help his right hand grip the handlebar throughout the test. Mr. AT performed a 2 min warm-up without resistance. The leg cycle ergometry test began at 25 W at a cadence of 50 to 60 rpm. The protocol consisted of 2 min stages with an increase of 15 W per stage. The following data were collected during the exercise test.
The exercise test was terminated at 5:15 because of increased hip adductor spasticity and inability to maintain speed of 50 rpm, and by request of the participant because of shortness of breath. No signs of electrocardiogram abnormalities were present during the test. His V.O2 at 5:00 was 16 ml · kg−1 · min−1. The RER was <1.00 and the heart rate and V.O2 failed to reach peak. This was not a valid peak V.O2 test.
Because of the termination of the clinical leg cycle ergometry test, a more functional approach was chosen. The Timed Get Up and Go test was used as a baseline measure. This test used the following protocol.
Test Instructions
1. Starting position: Sit upright against the chair.
2. Stand up from the chair (time start).
3. Move quickly along the line toward the opposite end.
4. Touch the end and pivot back toward the chair.
5. Move quickly all the way back to the chair.
6. Pivot.
7. Sit back down (time end).
The total distance was 10 ft (3.05 m). The test was performed three times. Mr. AT’s scores were 42 s, 38 s, and 40 s. (A score over 30 s suggests a higher risk of falls.) Mr. AT used his assistive device during all testing.

Exercise Prescription:
Using the information presented in the medical history and exercise testing sections and in tables 27.9 through 27.11, develop an exercise prescription that encompasses aerobic, strength, flexibility, and neuromuscular training. Consider the different modes for each of the exercise training domains and the frequency, duration, intensity, and progression of each.

Questions:
1. How would the clinical exercise physiologist best determine the appropriate resistance levels to prescribe for this person?

2. What factors represented in the ICF model should the clinical exercise physiologist take into consideration to increase the adherence level and success of this client?

3. What fall prevention strategies should be incorporated into the exercise prescription for an individual who is at increased risk for falls?

4. Is the assistive device described in this case study appropriate for use by Mr. AT?

5. How should the clinical exercise physiologist incorporate weight loss strategies into the goals for this client?

Medical History:
A 31 yr old man, a two pack per day smoker, presented to the emergency department complaining of sudden-onset, 10/10 crushing substernal chest pain associated with shortness of breath and diaphoresis that began 30 min prior to arrival. He had no previous history of cardiovascular disease.
Physical exam: Height 192 cm, weight 153.8 kg, BMI 41.6 kg · m–2 (class III obesity); blood pressure 178/101 mmHg, pulse 75 beats · min–1, respiratory rate 20 breaths · min–1, temperature 36.7 ∞C; normal heart sounds, lungs clear to auscultation, normal peripheral pulses
Electrocardiogram: Normal sinus rhythm, rate 72 beats · min–1; ST-segment elevation V1-V4
Chest radiograph: Normal Blood work: Elevated cTn and CK-MB; glucose normal; blood lipids: total cholesterol 200 mg · dl–1, HDL-C 45 mg · dl–1, LDL-C 134 mg · dl–1, triglycerides 104 mg · dl–1
Chest CT: No evidence of aortic dissection Echocardiogram: Left ventricular ejection fraction 45%, hypokinesis of the anteroseptal wall, borderline left ventricular enlargement, normal diastolic function, normal cardiac valves

Diagnosis:
Acute anterior wall STEMI.

Treatment:
1. Emergent cardiac catheterization (began 46 min after initial presentation to the hospital): total occlusion of the proximal left anterior descending (LAD) coronary artery, mild diffuse narrowing of the circumflex and right coronary arteries. The LAD occlusion was treated with thrombectomy, percutaneous coronary angioplasty, and placement of a drug-eluding stent, with good result.
2. Medical treatment: Aspirin, heparin, intravenous nitroglycerin, clopidogrel, abciximab, atorvastatin, carvedilol, lisinopril, nicotine patch.
3. Nicotine dependence consultation.
4. Referral to outpatient cardiac rehabilitation. Complications: None Hospital dismissal: Occurred approximately 48 h after admission; appointments made to see primary physician and to begin outpatient cardiac rehabilitation program in 5 d; follow-up blood work, ECG, and cardiology appointment in 8 wk Dismissal medications: Carvedilol, aspirin, clopidogrel, lisinopril, nicotine patch, simvastatin

Outpatient Exercise Test Results (Performed 8 D after Hospital Dismissal)
8.0 min duration (treadmill), normal blood pressure and electrocardiographic responses, peak heart rate 164 beats · min–1, V.O2peak = 3.04 L · min−1 (20.8 ml ∑ kg−1 ∑ min−1; 47% of expected), no angina reported
Exercise Prescription:
Outpatient cardiac rehabilitation program: Began 5 d after hospital dismissal; initial evaluations included assessments of neuromuscular function (normal), depression (normal), and potential sleep apnea (abnormalBerlin questionnaire, abnormal overnight oximetry resulted in referral for a sleep consultation); meeting with registered dietitian.
Exercise prescription: Goals included weight loss, increased aerobic and muscular fitness; frequency of three supervised sessions per week in cardiac rehabilitation facility plus three or four independent sessions per week (total frequency of six or seven sessions each week); average intensity using target heart rate 130 to 140 beats · min–1 (60-70% heart rate reserve), RPE 12 to 14; high-intensity intervals (to begin 2 wk after starting cardiac rehabilitation) using RPE 17, heart rate <160 beats · min–1; duration initially set at 10 to 15 min (not including warm-up, cool-down, strength training), gradually increasing to 45 to 60 min per session; types of exercise to include outdoor or treadmill walking, elliptical trainer; resistance training (to begin 2 wk after starting cardiac rehabilitation) using free weights and weight machines, initially one set of 8 to 15 slow repetitions, exercises for the major muscle groups, two or three sessions per week; lifestyle or general physical activity including walking short distances during the day, yard work, physical activity at work (return to work as restaurant equipment installer 4 wk after myocardial infarction).

Outcomes from 11 WK of Cardiac Rehabilitation Program
Medication compliance: Excellent (self-report) Exercise training: Frequency six or seven sessions per week (two or three supervised sessions per week); aerobic exercise duration 50 to 60 min per session; aerobic interval training two or three sessions per week (initially treadmill grade walking for 30 s progressing to slow jogging on treadmill for up to 4 min, three to five high-intensity intervals per session); resistance training two or three sessions per week, two or three sets of 8 to 15 repetitions, major muscle groups. Body weight: Stopped eating fast food and desserts, had more fruit, vegetables, poultry, fish; weight loss = 20.8 kg (BMI still excessive, 33.8 kg · m–2). Repeat cardiopulmonary exercise test: 10.5 min duration (treadmill), normal blood pressure and electrocardiographic responses, peak heart rate 162 beats · min–1, V.O2peak = 4.16 L · min−1 (31.2 ml ∑ kg−1 ∑ min−1; 71% of expected), 37% increase in V.O2peak (L · min−1), no angina reported. Tobacco use: One or two cigarettes daily. Blood pressure: 126/80 mmHg. Blood lipids: Total cholesterol 126 mg · dl–1, HDL-C 33 mg · dl–1, LDL-C 80 mg · dl–1, triglycerides 65 mg · dl–1. Recommendations: Stop smoking; continue medications, exercise program, and heart-healthy eating habits; continue efforts for weight loss; return appointment with cardiac rehabilitation team in 3 mo.

Discussion:
This patient was extremely young and was fortunate to realize the importance of promptly seeking medical attention with the onset of symptoms. His hospital course included standard diagnostic testing for acute myocardial infarction with subsequent timely coronary angiography with PCI of the infarct-related artery. Fortunately he did not develop serious complications and was discharged from the hospital after only 2 d. He enrolled in outpatient cardiac rehabilitation 1 wk after his MI. Of concern, he was markedly obese and may have had obstructive sleep apnea based on his abnormal Berlin questionnaire; he was referred for further evaluation in the Sleep Clinic. His course during rehabilitation was very favorable, and he did not experience post-infarction angina. He was successful in exercise and weight loss and demonstrated a remarkable increase in aerobic capacity. His challenge will be to continue taking his medications, stop smoking completely, eat a healthy diet, maintain his exercise program, and control his other coronary risk factors.

Questions:
1. What were this patient’s coronary risk factors?

2. What clinical tests were used to make the diagnosis of an acute ST-segment elevation anterior wall myocardial infarction?

3. What classes of cardiovascular medications were prescribed for this patient?

4. Compare the two cardiopulmonary exercise tests for this patient. What were the similarities? What were the differences?

5. Review the patient’s exercise prescription and program. Were the established goals achieved? Would you alter the exercise program in any fashion?

6. How effective was the patient in controlling his coronary risk factors by the time he completed 11 wk in the outpatient cardiac rehabilitation program?

7. What is his most important remaining coronary risk factor?

8. What component of the recommendations given to him at the completion of 11 wk of cardiac rehabilitation will potentially help him in sustaining his efforts at secondary prevention?

Jim, A 19-year-old college student, was rock climbing when he fell 30 feet to the ground. Paramedics arriving at the scene found him lying in the supine position, unable to move any extremities and complaining of neck pain. He was awake, alert, and oriented to his current location, the date and day of the week, and the details of his fall. His responses to questioning were appropriate. He complained that he could not feel his arms and legs. His pupils were equal and reactive to light. He showed no other signs of injury except for several scrapes on his arms. His vital signs revealed a blood pressure of 110 / 72, heart rate of 82 beats per minute, respirations of 18 per minute. The paramedics applied a cervical collar, placed him on a back board, immobilized his head, and transported him to the trauma center by helicopter. Upon examination at the hospital, Jim had minimal biceps brachii stretch reflexes, but no triceps or wrist extensor reflexes. All other muscle stretch reflexes in the upper and lower extremities were absent. His perception of sensory stimuli ended bilaterally at an imaginary line drawn across his chest about 3 inches above the nipples (i.e. everything below felt numb). He had some sensation in his arms, but could not localize touch or describe texture with any consistency there. He was able to raise his shoulders and tighten his biceps brachii slightly in each arm, but could not raise either arm against gravity. His lower extremities were flaccid, despite attempts to move them. Vital signs were taken again at the hospital and were as follows: blood pressure=94 / 55; heart rate=64; respiratory rate=24 (with shallow breathing). X-rays taken upon arrival revealed a fractured vertebra at a particular location. A chest X-ray showed a decreased lung expansion upon inhalation. The neurosurgeons immobilized his neck by inserting tongs into the skull above the ears to hold his neck in a position so that no further injury could occur. Jim was transferred to intensive care and his condition was stabilized. A physical examination four days later revealed normal vital signs and no change in his arm strength or sensation, but also marked spasms and exaggerated stretch reflexes of the lower extremities. He also had urinary incontinence which required the placement of a Foley catheter connected to a urine collection bag.

Questions:

1. Why did Jim's heart rate and blood pressure fall in this time of emergency (i.e. at a time when you'd expect just the opposite homeostatic responses)?

2. Upon admission to the hospital, Jim's breathing was rapid and shallow. Can you explain why?

3. Why did he lose some sensation in his arms and all sensation from the upper trunk down?

4. What is the primary muscle of respiration? Which spinal nerves contribute to innervate this muscle? (It’s almost like this question is review…)

5. Based upon the physical exam findings, which vertebral bone do you think was fractured? Give reasons for your answer. (Life’s anatomy knowledge is cumulative…)

6. By four days after the injury, some of Jim's signs and symptoms had changed. His arm muscles were still flaccid, yet his leg muscles had become spastic and exhibited exaggerated stretch reflexes. How would you explain these findings?

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