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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify patients who require treatment for dyslipidemia.

  • Stratify individual patients for risk of coronary heart disease (CHD) and stroke.

  • Determine appropriate LDL and non-HDL goals based on individual risk factors.

  • Recommend a cholesterol management strategy that includes therapeutic lifestyle changes (TLC), drug therapy, patient education, and monitoring parameters.

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PATIENT PRESENTATION

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Chief Complaint

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“I need refills.”

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HPI

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Felecia A. Thorngrass is a 56-year-old woman who presents to pharmacotherapy clinic for intake. She has recently moved to your area, and states she has not seen her primary care provider for the last 11 months. Her prescriptions have expired, and she is coming to you for “refills.”

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PMH

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  • Obesity (BMI 31.5 kg/m2)

  • Dyslipidemia × 4 years

  • HTN × 15 years

  • Postmenopausal—has not had GYN screening since onset of menopause (14 years ago)

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FH

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  • Father: age 74 with extensive cardiovascular history, most notably first MI at age 42.

  • Mother: died at age 61 from MVA, medical history unknown.

  • Patient has one older sister with HTN and history of “mini-strokes” and one younger sister with HTN only.

  • Her children’s medical conditions are noncontributory.

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SH

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  • Patient is married with three children, all of whom live out of state.

  • College graduate, works as librarian.

  • Admits to “social” alcohol and tobacco use, and to previous marijuana use when she visited her children.

  • Began sporadic exercise regimen when diagnosed with dyslipidemia.

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Meds (Per Patient History; She Did Not Bring Records)

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  • Metoprolol tartrate 50 mg PO BID

  • Ezetimibe 10 mg PO once daily

  • Aspirin 81 mg PO once daily

  • Ibuprofen 200 mg, four tablets PO PRN leg cramps

  • Naproxen 220 mg, two tablets PO PRN leg cramps

  • Garlic capsules

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All

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“Statin” drugs—states she had occasional leg cramps after starting atorvastatin.

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ROS

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Patient states that she just needs refills. She is argumentative about getting labs done and cannot understand why you would not just refill her medications. She denies any acute changes in health. She denies unilateral weakness, numbness/tingling, or changes in vision. She denies CP, and only has SOB when she walks in the park. With further questioning you find that she rarely exercises, but when she does go for a walk she typically overdoes it. She denies changes in bowel or urinary habits and states she does not need to have GYN follow-ups anymore, because she has gone through “the change.” She denies any lower extremity edema.

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Physical Examination

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Gen
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Obese, somewhat agitated Caucasian woman

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VS
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