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A 49-year-old man comes to his physician for follow-up of a previous fasting total serum cholesterol level of 299 mg/dL. The patient is otherwise well, with only mild hypertension that he is attempting to control with exercise and a low-fat, low cholesterol diet. He has a family history of ischemic heart disease on his father's side, and he smokes a pack of cigarettes daily. The patient is a plant manager and is happy with his job and reports no home-life issues with his wife or three sons. A lipid profile was drawn at his last visit, and he presents today for review of those results, which are as follows:

Total cholesterol 230 mg/dL

HDL 45 mg/dL

LDL 100 mg/dL

Which of the following is the most appropriate intervention at this time?

A. No intervention is indicated
B. Educate the patient about diet and exercise
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. Initiate drug therapy for control of his hyperlipidemia

The correct answer is C. This patient has two risk factors (family history and tobacco) but has an LDL less than 130 mg/dL and a total cholesterol less than 239 mg/dL. He can therefore be managed by diet and exercise with a follow up profile being drawn in 1 year.

ok, this question is from Kaplan Qbank, and this is the explanation for the answer. However, I have another question, as the case has made me curious about something:

what are the guidelines for lipid management during follow-up visits?

i.e. I know the guidelines following first visit : in pt w/ 2 or more risk factors, diet mod when LDL 130-159, start meds when LDL > 160. But I'm not sure how management should be adjusted on subsequent visits.

For example, in the pt above,

1) should meds be started on second visit if LDL is still >130, but <160? Or continue with diet management?

2) What is the optimal lipid profile you want to achieve for this pt? Total chol < 200? LDL < 130? LDL <100?

Been trying to look around for guidelines, but just about everyone talks about screening guidelines rather than how you follow the lipids afterwards. Any insight would be appreciated. And sorry for the long post.


Before going to your questions lets review:
Non Mod & Modifiable risk factors for this pt.:
1. age( >45)
2. male
4. (+) FHx. IHD
5.Total Chol. 299 went to 230
6. LDL 100

ISt question: Sholud meds. be started if LDL is still
>130 but <160? Since pt. is on low fat diet & it's working he shld. continue to do that for several mos. in addition to wt. loss & exercise!

2nd Question: Fo r this pt. LDL less than 130mg/dl is the goal since he does not have CHD but w/ 2 or more risk factors.

Most Importantly, let me remind you that RISK FACTORS ARE NOT AS IMPT. as INDIVIDUAL PRESENTATION.

SOURCE:Manual of Family Practice byRobert Taylor & my favorite lecturer in Kaplan


I think start pt on statins as pt has hist of IHD with other modif risk factor if chol more than 130

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