A 42-year-old man comes to the office for further evaluation after a high blood pressure reading on an automated machine at a supermarket. He has no chronic medical problems and takes no medications. The patient has felt fatigued lately, which he attributes to stress at work. He also reports constipation and a 4.5-kg (10-lb) weight gain since he stopped exercising 9 months ago. The patient smoked cigarettes for a few years in college but has not smoked for the last 20 years. He does not use alcohol or illicit drugs. The patient lives with his girlfriend and has no children.
Blood pressure is 145/95 mm Hg and pulse is 66/min. Repeat blood pressure after 10 minutes is 135/85 mm Hg. BMI is 31 kg/m². The patient appears mildly obese, but the remainder of the examination is normal.
Fasting laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient's metabolic abnormalities?

Question

A 42-year-old man comes to the office for further evaluation after a high blood pressure reading on an automated machine at a supermarket. He has no chronic medical problems and takes no medications. The patient has felt fatigued lately, which he attributes to stress at work. He also reports constipation and a 4.5-kg (10-lb) weight gain since he stopped exercising 9 months ago. The patient smoked cigarettes for a few years in college but has not smoked for the last 20 years. He does not use alcohol or illicit drugs. The patient lives with his girlfriend and has no children.
Blood pressure is 145/95 mm Hg and pulse is 66/min. Repeat blood pressure after 10 minutes is 135/85 mm Hg. BMI is 31 kg/m². The patient appears mildly obese, but the remainder of the examination is normal.
Fasting laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient's metabolic abnormalities?

Quizplus · Accepted Answer

11ec193a_97d1_f6ea_853d_95e937c3eed3_MD0002_00 This patient has mild hypertriglyceridemia and suboptimal levels of total cholesterol, LDL, and HDL. In addition, he has other features (ie, fatigue, weight gain, constipation) that suggest undiagnosed hypothyroidism. Hypothyroidism is a common cause of dyslipidemia and is associated with an increased risk for coronary events. Patients can also have hypertension, elevated hepatic transminases, and nonalcoholic fatty liver disease (due to defective hepatic lipoprotein clearance). Current guidelines recommend screening for thyroid disorders with serum TSH in all patients with newly diagnosed dyslipidemia, particularly if they have findings suggestive of hypothyroidism. In addition, if not previously checked, TSH should be measured prior to initiation of statin therapy, as untreated hypothyroidism increases the risk of statin-induced myopathy (Choice C). The dyslipidemia in hypothyroidism improves with levothyroxine therapy. (Choice A) Once this patient's hypothyroidism is corrected, any residual lipid abnormalities may be amenable to lifestyle changes (eg, exercise, weight loss). However, his lipids are likely to normalize once he achieves a euthyroid state. (Choice B) In addition to dyslipidemia, hypothyroidism can raise blood pressure due to increased systemic vascular resistance. However, the elevated blood pressure often improves with the treatment of hypothyroidism and may not require antihypertensive therapy. (Choice D) Apolipoprotein B100 is a structural component of LDL and functions as a ligand for the LDL receptor. Apolipoprotein B100 levels correlate with cardiovascular risk and can be used to assess residual risk in patients with dyslipidemia who have achieved optimal lipid levels. However, this test is rarely needed for clinical decision-making and is not necessary for this patient at this time. Educational objective: Hypothyroidism is a common cause of dyslipidemia. Patients with dyslipidemia should be screened for hypothyroidism with serum TSH. Dyslipidemia due to hypothyroidism improves with levothyroxine therapy. __________ References: Thyroid function testing in patients with newly diagnosed hyperlipidemia. (http://www.ncbi.nlm.nih.gov/pubmed/24217672) Secondary causes of dyslipidemia. (http://www.ncbi.nlm.nih.gov/pubmed/22658245)

A 42-Year-Old Man Comes to the Office for Further Evaluation