Thanks to David Williams for suggesting this Case.
A serum sample from a 47 year old male attending a medical outpatient
clinic produces the following results. Clinical information given is 'on
simvastatin'.
Cholesterol: 20.7 mmol/L
Triglycerides: >37 mmol/L
Urea and electrolytes, and liver function tests are within reference limits
apart from a sodium of 130 mmol/L.
Three months earlier, cholesterol was 4.7 mmol/L and triglycerides 1.5
mmol/L; and three months prior to that, cholesterol was 15.2 mmol/L and
triglycerides 33.2 mmol/L.
This Case attracted 24 participants.
11 would discuss clinical and therapeutic history with the requesting
clinician;[1.0]
3 would suggest referral to the Lipid Clinic.[0.8]
2 participants would check the current sample's appearance and ID;[1.0]
3 would query the validity of the previous results.[0.8]
3 pointed out the very high triglycerides (associated with a risk of
pancreatitis);[1.5]
2 stated 'Type III hyperlipidaemia'.[-1.0]
13 queried alcoholism;[1.8]
10 queried compliance with therapy or a change in therapy;[1.0]
9 queried diabetes;[1.3]
5 queried drug use other than Simvastatin;[0.3]
3 queried inappropriate diet and/or obesity;[0.3]
2 queried a family history of premature IHD;[-0.3]
1 queried analytical interference.[0]
8 thought the high lipids were likely to cause pseudohyponatraemia;[1.3]
1 each thought possible that the low sodium could be
through diarrhoea;[-0.5]
associated with decompensated diabetes.[0.5]
7 participants queried the appropriateness of Simvastatin therapy;[1.0]
3 suggested that a fibrate would be more appropriate.[0.8]
6 participants would measure glucose;[1.3]
4 would measure TSH/ thyroid function tests;[0]
3 each would measure
gamma-GT;[1.3]
apo-E genotype;[0.5]
2 each would measure
urate;[-0.3]
amylase;[-0.3]
ethanol [0]
1 each would
check MCV;[1.0]
carry out lipoprotein electrophoresis.[0.8]
David Williams comments that this was a 'binge alcoholic' who was also
thought not to be particularly compliant with Simvastatin therapy. A very
similar pattern of high lipids followed by normal lipids had been obtained
in the previous year.
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