1、Eric E. Gish, D.O. Associate Dean of Clinical Education Liberty University College of osteopathic Medicine (Proposed),The Many Faces of Hyperlipidemia,Case #1,43 year old male presents because of a tan discoloration of his eyelids. He states that they started off as small “spots” and have enlarged o
2、ver the last year. They do not affect his vision and he denies any trauma to the area. He states that his father had similar “spots” on his eyelids as well.,43岁男性，因为眼睑有黄褐色样变来诊所看病。 开始为小点, 在过去的一年开始扩大。 不影视力,否认任何损伤。 他父亲的眼睑有相似的“斑点”。,Case #1 Continued,Past Medical History Type II diabetes diagnosed 2003 H
3、ypertension diagnosed 2007Past Surgical History: NoneMedications Lisinopril奈落普利 40 mg orally daily Metformin 1000 mg orally twice daily,Case #1 Continued,Family History Father: Type II Diabetes, MI, HTN Mother: Hypercholesterolemia Social History Smokes 1pack of cigarettes per day for 25 years Denie
4、s illicit非法 drug use Drinks 2 to 3 alcoholic beverages a day on average Allergies: No known drug or food allergies,Case #1 Continued,Review of Systems Constitution: Denies fever, chills, or weakness. Admits to fatigue. Endocrine: States glucose is well controlled, Last Hg A1C was 6.8% approximately
5、9 months ago Rheumatology: Denies any joint aches, swelling, inflammation, or morning stiffness. Hematology: Denies any unusual bleeding, bruising, noticeably enlarged lymph nodes.,系统回顾 否认发热，寒颤，虚弱。但有疲乏感。 内分泌：血糖控制好，9月前HBA1C6.8% 风湿学：无关节痛，肿胀，炎症，晨僵 血液学：无出血，外伤，无淋巴结肿大,Case # 1 Continued,Review of Systems
6、(Continued) Cardiovascular: Denies chest tightness, cyanosis of the extremities, diaphoresis, dyspnea on exertion, claudication symptoms Pulmonary: Denies coughing, wheezing, hemoptysis Gastrointestinal: Denies dyspepsia, stomachache, hematemesis, melena, hematochezia, or diarrhea. Admits to intermi
7、ttent constipation which is becoming more frequent.,心血管系统：否认胸闷、脸色惨白、出汗、呼吸困难,跛行症状 呼吸系统：无开始，气喘、咳血 胃肠道：否认消化不良、腹痛、呕血、黑粪症,便血,或腹泻。承认间歇便秘，而且正变得越来越频繁。,Case #1 Continued,Review of Systems (Continued) Musculoskeletal: Denies any muscular weakness, stumbling, backache. Admits to feeling a mass in the front of
8、his neck just above his breastbone. Neurologic: Admits to occasional numbness and tingling in toes bilaterally. Denies radicular symptoms, incontinence of bowel/bladder, vertigo, or loss of consicousness. Integument: Admits to easily chipping fingernails, skin feels dry.,肌肉骨骼系统：否认有任何肌肉无力,步履蹒跚,背痛。感觉脖
9、子前面略高于他的胸骨处有压迫感。 神经系统：承认偶尔脚趾双边麻木和刺痛。否认神经性症状,尿失禁肠/膀胱,眩晕,或者意识损失。体表：术容易指甲脱屑，皮肤干燥,Case #1 Continued,Physical Examination Vital Signs: BP 127/83 Pulse 81 RR 10 Afebrile Wt. 84.82 kg (187#) Ht. 172.72 cm (5 8”) BMI 28.4 Skin: well circumscribed tan colored plaques measuring 2 mm in diameter OD and 3 mm di
10、ameter OS noted at the inner canthus of the eyelids. Hair is course and dry, eyebrows appear somewhat sparse, finger and toe nails with multiple cracks and chips.,PE: BP 127/83 Pulse 81 RR 10 Afebrile Wt. 84.82 kg (187#) Ht. 172.72 cm (5 8”) BMI 28.4 皮肤：明显的棕褐色彩色斑块，测量2毫米X 3毫米，在眼角的内部。头发干燥,眉毛看起来有些稀疏,手指
11、和脚趾的指甲见多个裂缝和增厚。,Case #1 Continued,Physical Examination Continued HEENT: Dense nodular mass anterior neck at the level of the thyroid, no bruits to auscultation over thyroid or carotid arteries. PEERLA, EOMI, Visual Acuity is 20/20 with corrective lenses, peripheral vision approximately 85 degrees bi
12、laterally. Bilateral plaques on inner canthus of eyelids as noted on integument exam. Fundiscopic examination is negative.,五官:可触及颈前部甲状腺结节，甲状腺听诊无杂音。 视力是20/20，矫正镜片,周边视觉大约85度双边。Fundiscopic（内窥镜）检测正常。,Case #1 Questions,What is/are the patients likely diagnosis/diagnoses? Are there any potentially confoun
13、ding comorbidities? What additional studies you would like to perform? What additional information from the patient would you obtain? How would you medically manage this patient?,If the patients hypertension became uncontrolled and necessitated a second medication, what class would you consider? Wha
14、t education would you provide to the patient for self care and prevention? What comorbidities are likely with this patient and how would you refine your future examinations?,Question #1,What is/are the patients likely diagnosis/diagnoses?Answer: The patients presenting diagnosis is xanthoma of the e
15、yelids. However, this diagnosis is likely a symptom of another underlying disease, hyperlipidemia. 病人的初步诊断是眼睑的黄色瘤。但是不能忽视背后隐藏的另一个潜在疾病，高血脂。,Question #2,Are there any potentially confounding comorbidities?Answer: There is likely an underlying comorbidity of hypothyroidism as evidenced by the nodular an
16、terior neck mass, dry skin and fingernails, course hair, sparse eyebrows, and constipation. Additionally, there is likely an underlying comorbidity of hyperlipidemia. Along with the history of hypertension and diabetes, the patient may have metabolic syndrome.,可能有其他易混淆的合并症吗？答:有可能存在潜在的甲状腺功能减退，如前颈部肿瘤结
17、节,干性皮肤和指甲,头发,稀疏的眉毛和便秘。 此外,有可能是潜在疾病的高脂血症。由于有高血压和糖尿病病史,患者可能有代谢综合征。,Question #3,What additional studies you would like to perform? 你需要哪些其他的检查?Answer: Comprehensive Metabolic Profile (CMP), serum creatine kinase, lipid profile, TSH CMP综合代谢指标，血肌酐，血脂，TSH(促甲状腺激素),Patients Lab Results,Total Cholesterol: 289
18、 mg/dl -7.5 （2.86.0 mmol/L） LDL Cholesterol: 236 mg/dl HDL Cholesterol: 41 mg/dl Triglycerides: 189 mg/dl-2.08（0.231.24 mmol/L）TSH: 10 mIU/LCMP All Values within normal limits Serum Creatine Kinase within normal limits,National Cholesterol Education Program,Total Cholesterol Levels Desirable: Less t
19、han 200 mg/dL (5.18 mmol/L) Borderline high: 200-239 mg/dL (5.18 to 6.18 mmol/L) High: 240 mg/dL (6.22 mmol/L) or higher,National Cholesterol Education Program,LDL Cholesterol Levels Optimal: Less than 100 mg/dL (2.59 mmol/L) Near/above optimal: 100-129 mg/dL (2.59-3.34 mmol/L) Borderline high: 130-
20、159 mg/dL (3.37-4.12 mmol/L) High: 160-189 mg/dL (4.15-4.90 mmol/L) Very high: Greater than 190 mg/dL (4.90 mmol/L),National Cholesterol Education Program,HDL Cholesterol Levels Low level, increased risk: Men: Less than 40 mg/dL (1.0 mmol/L) Women: Less than 50 mg/dL (1.3 mmol/L) Average level, aver
21、age risk: Men: 40-50 mg/dL (1.0-1.3 mmol/L) Women: 50-59 mg/dl (1.3-1.5 mmol/L) High level, less than average risk: 60 mg/dL (1.55 mmol/L) or higher for both men and women,National Cholesterol Education Program,Fasting Triglycerides: Desirable: Less than 150 mg/dL (1.70 mmol/L) Borderline high: 150-
22、199 mg/dL(1.7-2.2 mmol/L) High: 200-499 mg/dL (2.3-5.6 mmol/L) Very high: Greater than 500 mg/dL (5.6 mmol/L),Question #4,What additional information from the patient would you obtain? 需要了解更多地病人资料吗？ Answer: Further information to be considered would be dietary and exercise habits. 饮食习惯，运动习惯,Question
23、 #5,How would you medically manage this patient?Answer: Consideration should be given to initiating L-thyroxin to address the hypothyroidism in addition to starting an HMG Co-A Reductase Inhibitor (“statin”) medication. By addressing the thyroid condition, the physician may utilize a lower dose of t
24、he “statin” medication and reduce the risk potential risk of rhabdomyolysis.,如何管理病人 答: 应考虑开始使用左旋甲状腺素，解决甲状腺功能减退。 使用还原酶抑制剂(他汀类)药物。 通过解决甲状腺疾病,会降低“他汀”药的剂量物治疗，和减少潜在横纹肌溶解的风险。,Factors that may increase the risk of statin induced myopathy导致他丁类药物所致肌溶解的危险因素,Advanced age (80 years old) Female sex Low body mass
25、 index Multisystem diseases (for example, diabetes mellitus) Diseases affecting kidney or liver function Hypothyroidism (untreated) Drug interactions, especially with drugs that are inhibitors or substrates of the cytochrome P450 pathway (for example, fibrates, nicotinic acid, calcium channel blocke
26、rs, ciclosporin, amiodarone, thiazolidinediones, macrolide antibiotics, azole antifungals, protease inhibitors, warfarin) Vigorous exercise Excess alcohol Intercurrent infections Major surgery or trauma Diet (excessive grapefruit or cranberry juice) Genetic factors (for example, polymorphisms of the
27、 cytochrome P450 isoenzymes or drug transporters, inherited defects of muscle metabolism, traits that affect oxidative metabolism of fatty acids),高龄(80 years old) 女性 较低的体重指数 多系统疾病（如糖尿病） 影响肝肾功能的疾病 未经处理的甲减 药物相互作用 高强度的运动 酗酒 并发感染 大手术或外伤 不良的饮食习惯（过度的葡萄柚或酸果蔓汁） 遗传因素,Source: BMJ 2008;337:a2286,Question #6,If
28、 the patients hypertension became uncontrolled and necessitated a second medication, what class would you consider? 病人的高血压控制不了，需要第二种降高血压药物，你选择哪一类？ ACEI ARB 慎用受体阻滞剂和噻嗪类利尿剂,Question #7,What education would you provide to the patient for self care and prevention?Answer: Dietary, exercise, smoking cessa
29、tion recommendations.Patient education related to poor control of lipids and glucose leading to delayed wound healing, atherosclerosis, coronary artery disease, blindness, peripheral neuropathy, stroke, and renal insufficiency.,如何病人教育：答：低盐低脂节食，运动，戒烟病人教育很重要，会直接导致脂类和葡萄糖控制欠佳，引起延迟伤口愈合、动脉粥样硬化、冠状动脉疾病、失明、周
30、围神经病变、中风和肾功能不全。,Question #8,What comorbidities are likely with this patient and how would you refine your future examinations?Diabetic neuropathy Coronary Artery Disease Retinopathy Renal Insufficiency Thyroid: Repeat TSH in 3 months interval until euthyroid, then repeat annually. Liver function: re
31、peat 2-4 weeks after starting “statin” and after any dosage adjustment, then annually.,这类病人最可能发展什么并发症，如何制定远期随访检查？糖尿病神经病变 冠状动脉疾病 视网膜病变 肾功能不全 甲状腺:在3个月内重复检查TSH,直到正常，然后每年重复一次。 肝脏功能:开始使用“他汀”和之后的任何剂量调整,要每隔3周复查一次肝功能，然后每年复查一次。,中国血脂异常防治建议,高脂血症的分类一、从临床上，可以简单地分为以下四类：高胆固醇血症：血清TC水平增高混合型高脂血症：血清TC与TG水平均增高高甘油三酯血症：血
32、清TG水平增高低高密度脂蛋白血症：血清HDL-C水平减低 二、按病因高脂血症可分为：原发性高脂血症继发性高脂血症：常见的病因为：糖尿病、甲状 腺机能低下、 肾病综合症,中华心血管病杂志 1997;25;.,血脂异常的临床分型,降低,低高密度脂蛋白血症,b、 、,增高,增高,混合型高脂血症,、,增高,高甘油三酯血症,a,增高,高胆固醇血症,WHO表型,HDL-C,TG,TC,分型,我国人群的血脂合适水平,40,1.04,降低,200,2.26,60,1.55,160,4.14,240,6.19,升高,150-199,1.7-2.26,130-159,3.37-4.14,200-239,5.18-
33、6.19,边缘升高,150,1.76,130,3.37,200,5.18,合适范围,TG mg/dL,TG mmol/L,HDL-C mg/dL,HDL-C mmol/L,LDL-C mg/dL,LDL-C mmol/L,TC mg/dL,TC mmol/L,代谢综合征,具备以下的三项或更多即可作出诊断 腹部肥胖:男性腰围90cm，女性85cm 血甘油三酯：1.7mmol/L（150mg/dL） 血HDLC：1.04mmol/L（40mg/dL） 血压：130/ 85mmHg 空腹血糖100mg/dL或餐后2小时血糖140mg/dL；糖尿病,中国血脂异常防治建议 高脂血症患者开始治疗标准值及治
34、疗目标值,饮食疗法开始标准,药物疗法开始标准,治疗目标值,动脉粥样,c,(-),其它危险,因子,(-),TC,5.72mmol/L,(220,mg/dL,),LDL-C,3.64,mmol/L,(140 mg/,dL),TC,6.24,mmol/L,(240,mg/dL,),LDL-C,4.16,mmol/L,(160 mg/,dL),TC,5.72mmol/L,(220,mg/dL,),LDL-C,3.64,mmol/L,(140 mg/,dL),动脉粥样,硬化病,(-),其它危险,因子,(+),TC,5.20mmol/L,(200,mg/dL,),LDL-C,3.12,mmol/L,(12
35、0 mg/,dL),TC,5.72mmol/L,(220,mg/dL,),LDL-C,3.64,mmol/L,(140 mg/,dL),TC,5.20mmol/L,(200,mg/dL,),LDL-C,3.12,mmol/L,(120 mg/,dL),动脉粥样,硬化病,(+),TC,4.68,mmol/L,(,180mg/dL,),LDL-C,2.60,mmol/L,(100 mg/,dL),TC,5.20mmol/L,(200,mg/dL,),LDL-C,3.12,mmol/L,(120 mg/,dL),TC,4.68,mmol/L,(,180mg/dL,),LDL-C,2.60,mmol/
36、L,(100 mg/,dL),调脂药物治疗,他汀类贝特类烟酸类胆酸螯合剂胆固醇吸收抑制剂其他: 普罗布考, -3脂肪酸,他汀类药物常用剂量和最大剂量,常用剂量 （mg/日）最大剂量* （mg/日）,阿托伐他汀 辛伐他汀 洛伐他汀 普伐他汀 氟伐他汀 瑞舒伐他汀,10 20 20 10-20 40 5-10,80 80 80 40 80 20,国产血脂康：1.2g/日（含洛伐他汀10mg) *根据我国SFDA批准的各产品说明书,Case #2,Case #2,32 year old female presents to the emergency department with severe l
37、eft upper quadrant abdominal pain of 1 hour duration. The pain is described as a deep, sharp, boring pain with radiations to the left side of the back just below the scapula.,32岁的女性，因左上腹腹痛1小时到急诊就诊。 疼痛为较深部疼痛,锐利,钻痛；并放射到左肩胛骨下方。,Case #2 Continued,Past Medical History: Non-Contributory Past Surgical Hist
38、ory: None Family History: Father with Hypertriglyceridemia Social History: 6-8 alcoholic beverages per month, Non-smoker, No illicit drug use. Eats out at restaurants 5-10 times per week. Medications: None Allergies: No Know Drug or Food Allergies,既往史:无特殊 过去外科历史:无 家族史:父亲有高甘油三酯血症 社会史:每月6 8次饮酒,不吸烟,不使用
39、毒品。在饭店吃每周5 10次。 药物史:没有 过敏史:不知道药物或食物过敏,Case #2 Continued,Review of Systems Abbreviated due to patient discomfort Gastrointestinal: Admits to constipation, nausea and vomiting. Pain was of sudden onset within the last hour but felt uncomfortable for several hours prior. No changes in stool color or co
40、nsistency. No RUQ pain or lower CVA pain. No history of reflux or peptic ulcer disease. No history of gallstones or cholecystitis.,系统回顾 由于病人不适，简略。 胃肠道:承认便秘、恶心和呕吐。感觉不适有几小时，最近的一小时疼痛发作突然。 大便颜色及形态正常。 无返流疾病历史，无消化性疾病病史。 无胆结石或胆囊炎病史。,Case #2 Continued,Review of Systems Continued Genitourinary: No hematuria.
41、 No history of nephrolithiasis. No urgency or frequency. No suprapubic tenderness. Cardiovascular: No history of vascular insufficiency or aortic aneurysm. No antecedent claudication symptoms. No prior history of coronary artery disease, angina, or valvular disease. Endocrine: No history of diabetes
42、 or hypothyroidism,泌尿生殖系:无血尿。没有历史的肾结石。无尿频尿急。 心血管:没有历史的血管机能不全或主动脉瘤。没有前期跛行症状。没有先前历史的冠心病、心绞痛或瓣膜病。 内分泌:没有历史的糖尿病或甲状腺机能减退,Case #2 Continued,Physical Examination Vital Signs: BP 156/91 HR 98 RR 14 Afebrile Ht. 160.0 cm (5 3”) Wt. 71.21 (157#) BMI 27.8 Constitutional: Awake, Alert, Oriented X 3, Moderate to
43、 severe outward distress in fetal position. Abdomen: Firm, Pain to palpation in LUQ, No Rebound, No Masses, No Bruits, Diminished bowel sounds globally, Guaiac negative. No Caput Medusae, Negative Murphy, No hepatomegaly to auscultation or palpation.,体检 生命体征:BP 156/91 HR 98 RR 14 Ht 160.0厘米(5 3”)重量。
44、71.21(157 #)体重指数27.8（24） 腹部:触诊肌紧，疼痛,没有反弹,未及包快、没有杂音,肠鸣音减弱。墨菲证阴性,听诊或触诊未及肝肿大。,Case #2 Continued,Physical Examination Continued Pulmonary: Lungs clear to auscultation bilaterally, No Wheezes, Crackles, Rubs Heart: Tachycardia, No ectopic beats, No murmurs, No rubs Musculoskeletal: No CVA tenderness, mus
45、cular tenderness inferior to the left scapula Extremities: Pulses full, capillary refill 2 seconds, no cyanosis, clubbing, or edema.,肺:肺部听诊无杂音,无踹鸣音。 心:心动过速,没有异位节拍,没有杂音,没有摩擦 肌肉骨骼:没有CVA的指证, 四肢:无发绀、杵状指、或水肿。,Case #2 Questions,What are the management considerations for the acute care of this patient? Wha
46、t additional history would you like to obtain? What additional workup would you like to obtain to confirm your diagnosis/diagnoses? What is your long term management plan for this patients acute condition and its underlying cause?,Case #2 Questions Continued,What lifestyle modifications would you re
47、commend in addition to her medical management? What comorbidities are likely with this patient and how would you refine your future examinations?,Question #1,What are the management considerations for the acute care of this patient?Answer: Fluids, bowel rest and pain control medications for the acut
48、e management. Discover likely underlying etiology for long term prevention and management.,对该病人的紧急处理？答: 液体、肠道休息和治疗急性疼痛 发现潜在的病因，进行为长期的预防和管理。,Question #2,What additional history would you like to obtain?Answer: It becomes important to identify the trigger of the attack to prevent future episodes. Addi
49、tionally, a more detailed history regarding family history of hyperlipidemia, dietary intake and alcohol use (i.e. are the 6-8 drinks per month all at once or divided fairly equally over the entire month).,还需要了解哪些病人的资料？答:重要的是，识别疼痛的诱发原因，预防出现更严重的后果。此外,要了解更详细的家族史，如高脂血症，酒精摄入量和使用。,Question #3,What additi
50、onal workup would you like to obtain to confirm your diagnosis/diagnoses?Answer: CMP, Amylase, Lipase, C-Reactive Protein Levels, Abdominal U/S of Pancreas, Gall Bladder, and Ducts, Lipid profile. (If the patient came in appearing intoxicated I would also consider adding a drug screen and alcohol level.),
