CHAPTER 15

CASE STUDY 15-1

A 52-year-old man went to his physician for a physical examination. The patient had
been a district manager for an automobile insurance company for the past 10 years and
was 24 pounds overweight. He had missed his last two appointments with the physician
because of business. The urinalysis dipstick finding was not remarkable. His blood
pressure was elevated. The blood chemistry results are listed in Case Study Table 15-
1.1.

CASE STUDY TABLE 15-1.1

LABORATORY RESULTS
ANALYTE PATIENT VALUE REFERENCE RANGE
Na+ 151 135-143 mmol/L
K+ 4.5 3.0-5.0 mmol/L
Cl- 106 98-103 mmol/L
CO2 content 13 22-27 mmol/L
Total protein 5.7 6.5-8.0 g/dL
Albumin 1.6 3.5-5.0 g/dL
Ca2+ 7.9 9.0-10.5 mg/dL
Cholesterol 210 140-200 mg/dL
Uric acid 6.2 3.5-7.9 mg/dL
Creatinine 2.5 0.5-1.2 mg/dL
BUN 95 7-25 mg/dL
Glucose 88 75-105 mg/dL
Total bilirubin 1.2 0.2-1.0 mg/dL
Alkaline phosphatase 27 7-59 IU/L
Lactate dehydrogenase 202 90-190 IU/L
Aspartate transaminase 39 8-40 IU/L
Amylase 152 76-375 IU/L

Questions:

1. Given the abnormal tests, what additional information would you like to have?
Ans. Abnormal test of K, Cl, total protein, calcium, cholesterol, BUN, total
bilirubin, lactate dehydrogenase are observed. Given the very high BUN value,
and low total protein and albumin values, it can be suggested that the high BUN
 value of the patient is not due to a very high protein intake in their diet. The
bilirubin values are slightly high the normal, which maybe due to fasting. Thus, it
has to be mentioned if the patient had taken the test in or without a fasting
condition. A GFR test is required to be done along with the above in order to
check for the kidney function test.

2. If this patient had triglycerides of 100 mg/dl (1.1 mmol/L) and an HDL-C of 23
mg/dL (0.6 mmol/L). What would be his calculated LDL-C value?
Ans. The calculated LDL-C value is 167 mg/dl.

Given: TC = 210mg/dL Formula: LDL= TC- HDL-VLDL VLDL= TAG/5

TAG = 100mg/dL
HDL = 23 mg/dL

Solving:
VLDL = TAG/5
= 100mg/dL / 5
VLDL = 20mg/dL

LDL = TC-HDL-VLDL
= 210mg/dL- 23mg/dL- 20mg/dL
LDL = 167mg/dL

3. If, however, his triglycerides were 476 mg/dL (5.4 mmol/L), with an HDL-C of 23
mg/dL (0.6 mmol/L). What would be his calculated LDL-C value?
Ans. The calculated LDL-C value is 91.8mg/dL

Given: TC = 210mg/dL Formula: LDL= TC- HDL-VLDL VLDL= TAG/5

TAG = 476mg/dL
HDL = 23 mg/dL

Solving:
VLDL = TAG/5
= 476mg/dL / 5
VLDL = 95.2 mg/dL

LDL = TC-HDL-VLDL
= 210mg/dL- 23mg/dL- 95.2mg/dL
LDL = 91.8mg/dL
CASE STUDY 15-3
A 43-year-old white man was diagnosed with hyperlipidemia at age 13 years, when his
father died of a myocardial infarction at age 34 years. The man's grandfather had died
at age 43 years, also of a myocardial infarction. Currently, the man is active
and asymptomatic with regard to CHD. He is taking 40 mg of lovastatin (Mevacor), 2
times/d (maximum dose). He had previously taken niacin but could not tolerate it
because of flushing and gastrointestinal distress, nor could he tolerate cholestyramine
resin (Questran). His physical examination is remarkable for bilateral Achilles tendon
thickening/xanthomas and a right carotid bruit (Case Study Table 15-3.1).

CASE STUDY TABLE 15-1.1

LABORATORY RESULTS
Triglycerides 91 mg/dL
Total Cholesterol 269 mg/dL
HDL-C 47 mg/dL
LDL-C 204 mg/dL
Aspartate aminotransferase 34 U/L
Alkaline aminotransferase 36 U/L
Alkaline phosphatase 53 U/L
Electrolytes and fasting glucose Normal

Questions:
1. What is his diagnosis?
Ans. His diagnosis is Hypercholesterolemia.
2. Does he need further workup?
Ans. Yes, people with hypercholesterolemia are advised to exercise regularly to
make the heart stronger and it is powerful way to lower your LDL (bad
cholesterol) and will boost your HDL (good cholesterol). Also, having proper and
balance diet can also be a good help for lowering the cholesterol levels.

3. What other laboratory tests should be done?

Ans. - A cardiac biomarker test should be done to evaluate heart function, since
hypercholesterolemia is prone to a cardiovascular disease.
- Lipid test should be also done that will measure the amount of LDL-C in
the blood.
4. Does he need further drug treatment? If so, what?
Ans. Statin therapy is best used as a drug treatment for his condition. It helps to
lower the cholesterol level and through the help of statins, body reabsorb
cholesterol that has built up in plaques on the artery walls, preventing further
blockage in the blood vessels and heart attacks.
CASE STUDY 15-5
A 49-year-old woman was referred for a lipid evaluation by her dermatologist
after she developed a papular rash over her trunk and arms. The rash consisted
of multiple, red, raised lesions with yellow centers. She had no previous history of
such a rash and no family history of lipid disorders or CHD. She is
postmenopausal, on standard estrogen replacement therapy, and otherwise
healthy (Case Study Table 15-5.1).

CASE STUDY TABLE 15-1.1

LABORATORY RESULTS
SERUM GROSSLY LIPEMIC
Triglycerides 6,200 mg/dL
Total Cholesterol 458 mg/dL
Fasting Glucose 160 mg/dL
Liver function tests and electrolytes Normal

Questions:
1. What is the rash? What is the cause of her rash?
Ans. The rash is due to her hypertriglyceridemia in which they can also spark the
eruption of itchy, pimple-like xanthomas) on the hands, feet.
2. Is her oral estrogen contributing?
Ans. Yes, since estrogen is used by women to help reduce vaginal symptoms
of menopause (such as vaginal dryness/burning/itching). Estrogens that are
taken by mouth, absorbed through the skin, or injected may have greater risks of
side effects due to more estrogen being absorbed. During menopause, hormonal
changes include a loss of estrogen. Estrogen is related to the production of
collagen, an essential building block of skin. The lack of collagen and natural
oils can cause your skin to become thin and itchy.
3. Is her glucose contributing?
Ans. Yes, because it affects how your cells responds to insulin. Longer duration
of estrogen use may relate to an increased risk of type 2 diabetes.
4. What treatments are warranted, and what is her most acute risk?
Ans. For the rashes, medical treatment and lifestyle changes can address the
underlying cause resulting in high fat levels, and to help the patient balance their
blood glucose level: insulin, metformin (Glucophage), glipizide (Glucotrol),
pramlintide (SymlinPen). Her most acute risk is Coronary Heart Disease (CHD)
considering her lipid profile is high.