Question of the Week# 483

A 50-year-old previously healthy man comes to his physician for a scheduled follow-up examination. He works as an electrician, which involves a significant amount of physical activity when working. He says he also runs 5 miles twice a week and is on a low-fat, low-cholesterol diet. His father died of a ‘heart attack’ at the age of 54, and he has smoked one pack of cigarettes daily for the past 25 years. He denies alcohol or illicit drug use. He says he leads a low-stress lifestyle and has no complaints. His current medication include lisinopril. On presentation, his blood pressure is 135/85 mm Hg. Laboratory studies from a week ago show:

Total cholesterol     287 mg/dL

HDL                        65 mg/dL

LDL                        180 mg/dL

Which of the following is the best next step in patient care?

A Initiate drug therapy for control of his hyperlipidemia
B Educate the patient about diet and exercise and repeat the tests within 4 weeks
C Educate the patient about diet and exercise and repeat the tests within a year
D Initiate a mandatory low-fat diet for the patient
E No intervention is indicated

 

Question of the Week # 399

399)  A 65 year old man with history of diabetes mellitus is evaluated in your office during a routine follow-up visit. He does not have any complaints. He uses Glyburide and Metformin for his diabetes and Atorvastatin 80mg/day and Omega-3 Fatty Acids  for his dyslipidemia. He is compliant with diet and exercise. His weight has been stable. He does not smoke or consume alcohol. His most recent HgbA1C was 6.0% and a fasting lipid panel a month ago showed Total cholesterol of 125 mg%, LDL-C 70mg%, Triglycerides 100mg% and HDL-C 35mg%. You discuss with him that his lipid panel meets the recommendations with regard to LDL cholesterol and Non-HDL cholesterol goals. However, he insists that he be treated for his low HDL-cholesterol. You offer adding Niacin but after he heard about it’s side effects he refuses it and seeks alternatives.  Which of the following is the most appropriate recommendation for him?

A) Change Atorvastatin to Rosuvastatin

B) Add Cholestyramine

C) No further therapy

D) Discontinue Omega-3 Fatty Acids

E) Increase Atorvastatin

Question of the Week # 398

398)  A 45 year old man with well-controlled diabetes presents to your office with complaints of troublesome flushing of his face and trunk for the past one week. Frequently, the flushing is severe and causes stinging sensations. His past medical history is significant for dyslipidemia with an isolated low HDL cholesterol for which he was started on Niacin one week ago. On examination, his blood pressure is 120/88 mm Hg.  His face and trunk have flushed appearance. Reminder of physical examination is unremarkable. Which of the following is the most appropriate recommendation for him at this time?

A) Discontinue Niacin

B) Take Niacin with food

C) Diphenhydramine as needed

D) Take Aspirin before Niacin

E) Re-assure symptoms will bate in one week

Question of the Week # 397

397)  A 65 year old man with past medical history of Hypertension presents to your office to discuss his lipid profile results which were obtained two weeks ago.  He takes Losartan for his high blood pressure and is compliant with 2gm sodium diet. He smoked about 1 pack per day for the past 35 years. On examination, his blood pressure is 140/88 mm Hg. Reminder of physical examination is unremarkable. His fasting lipid panel reveals Total cholesterol 220 mg%, LDL-C 150mg%, Triglycerides 150mg%, HDL-C 40mg%. Which of the following is the most appropriate initial step?

A) Diet and lifestyle modifications alone

B) Diet, Lifestyle modification and Statin therapy

C) No Intervention

D) Omega 3 Fatty Acids

E) Repeat Lipid Panel in 3 months

Question of the Week # 396

396)  A 45 year old woman presents to your office for annual physical examination. She reports that she has had a fasting lipid panel done 6 months ago and her HDL – C was low at 25 mg%. She requests to be treated for this. She started healthy diet rich in fruits and vegetables. She used to smoke about 4 cigarettes/ day earlier but quit smoking after she came to know about her lipid results. She occasionally uses red wine in moderate amounts. She has also started aerobic exercises at least 3 days per week. Physical examination is unremarkable. A repeat lipid panel reveals Total cholesterol 128 mg%, LDL-C 80mg%, Triglycerides 100mg%, HDL-C 28mg%. Which of the following is the most appropriate next step?

A) Fenofibrate

B) Niacin

C) Ezetemibe

D) Atorvastatin

E) Omega-3-Fatty Acids

Question of the Week # 395

395)  A 65 year old man with history of Hypertension, Peripheral Artery disease and Dyslipidemia is seen during a follow-up office visit. His medications include Atorvastatin 80mg, Enalapril 20mg and Clopidogrel 75 mg/ day.  He does not have any new complaints and tolerating his medications well. He still smokes about 1 pack per day despite repeated counselling however, he has been strictly compliant with low-fat diet. On examination, his vitals are stable. Lower extremity dorsalis pedis are slightly diminished bilaterally. Reminder of the examination is unremarkable. A fasting lipid profile obtained a week ago showed :  Total Cholesterol : 205 mg% LDL cholesterol (calculated) 90mg%, HDL – cholesterol 45 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limits. Which of the following is the most appropriate next step?

A) Add Fenofibrate

B) Add Niacin

C) Add Cholestyramine

D) Change Atorvastatin to Rosuvastatin

E) Increase the dose of Atorvastatin

Question of the Week # 394

394)  A 36 year old woman with Type I diabetes mellitus presents to your office because she just learned that she is pregnant. She is excited and seeks your advise. Her home blood sugars are well controlled on a basal-bolus regimen of Glargine and Lispro insulin. Her other medications include Atorvastatin and aspirin. Her most recent HgbA1C was 6.0%. Her records also reveal that her most recent fasting lipid profile met the therapeutic goals at LDL of 80mg% and Non-HDL cholesterol of 100mg%. On examination, she is comfortable. Vitals are stable and reminder of the examination is unremarkable. An office based serum pregnancy test is positive. A repeat fasting lipid profile reveals Total Cholesterol : 250 mg% LDL cholesterol (calculated) 140mg%, HDL – cholesterol 40 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limitsWhich of the following is the most appropriate next step?

A) Therapeutic Abortion

B) Add Niacin to her Lipid Regimen

C) Discontinue Statin and Start Niacin

D) Discontinue Statin and advise Diet modification alone

E) Increase Atorvastatin

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