Medical Record Format for Dyslipidemia

1. PATIENT DEMOGRAPHICS

• Name, Age, Sex, Occupation
• Date of visit
• Referral source (self/physician/screening)

2. CHIEF COMPLAINT

• Reason for visit (routine screening, chest pain, fatigue, found incidentally on labs, family member diagnosed, etc.)
• Note: Most dyslipidemia is asymptomatic - many patients present only after cardiovascular events or routine blood work

3. HISTORY OF PRESENTING ILLNESS (HPI)

• When was dyslipidemia first diagnosed?
• How was it detected (incidental lab finding, screening, symptomatic event)?
• Any previous lipid values and trends?
• Any treatment already initiated (diet, drugs)?
• Compliance with current treatment, if any?

4. SYMPTOMS TO SCREEN FOR

• Chest pain or chest tightness (angina)
• Shortness of breath on exertion
• Palpitations
• Leg pain/claudication while walking (peripheral arterial disease)
• Prior stroke or TIA (transient ischemic attack) - slurred speech, facial droop, arm weakness

• Acute abdominal pain (epigastric, radiating to back)
• Nausea and vomiting

• Yellowish deposits around eyelids (xanthelasma)
• Lumps over tendons (Achilles, extensor tendons) - tendon xanthomas
• Yellow deposits on palms or elbows (xanthomas)
• Yellowish ring around the cornea (corneal arcus - especially if age <45)

5. PAST MEDICAL HISTORY

6. MEDICATION HISTORY

• Raise LDL / TG: Corticosteroids, isotretinoin, thiazide diuretics, beta-blockers (non-selective), cyclosporine, protease inhibitors (HIV drugs - especially ritonavir), estrogens (oral contraceptives), anabolic steroids
• Lower HDL: Beta-blockers, progestins, anabolic steroids
• Current lipid-lowering therapy: Statins, fibrates, ezetimibe, niacin, omega-3 - name, dose, duration, compliance, side effects (muscle pain with statins?)
• Supplements: Fish oil, red yeast rice

7. FAMILY HISTORY

• First-degree relatives (parents, siblings, children) with:
  • High cholesterol or triglycerides
  • Premature coronary artery disease (CAD in males <55 years, females <65 years)
  • Stroke at a young age
  • Sudden cardiac death at a young age
  • Tendon xanthomas (strongly suggests Familial Hypercholesterolemia - FH)
  • Pancreatitis (suggests Familial Chylomicronemia Syndrome - FCS)
• Consanguinity (increases risk of homozygous genetic disorders)
• Ethnic background (some populations have higher genetic risk - e.g., South Asians, Ashkenazi Jews)

8. SOCIAL HISTORY

• Dietary fat intake - saturated fat, trans fat, fried food, red meat
• Carbohydrate and sugar intake (raises triglycerides)
• Fiber intake (fruits, vegetables, oats)
• Dairy and egg consumption
• Alcohol intake - frequency, amount per week (alcohol significantly raises TG)

• Physical activity level - type, frequency, duration
• Sedentary occupation?
• Smoking - current/ex-smoker, pack-years
• Recreational drug use (anabolic steroids, cocaine)

• Stress levels
• Ability to make dietary/lifestyle changes
• Socioeconomic status (affects food choices and medication access)

9. REVIEW OF SYSTEMS

• Weight gain or unexplained weight loss
• Cold intolerance, constipation, hair loss (hypothyroidism)
• Polyuria, polydipsia (diabetes)
• Fatigue
• Foamy urine, edema (nephrotic syndrome)
• Abdominal pain, jaundice (liver disease)

10. PHYSICAL EXAMINATION (findings to look for)

• Eruptive xanthomas (papular yellow lesions on buttocks/elbows - severe hypertriglyceridemia)
• Tuberous or tuberoeruptive xanthomas (elbows, knees - type III hyperlipidemia)
• Tendon xanthomas (Achilles, extensor tendons - FH)
• Palmar xanthomas (orange-yellow deposits in palmar creases - pathognomonic of type III/FDBL)

11. INVESTIGATIONS TO REVIEW / ORDER

• Total cholesterol
• LDL-C (direct LDL for non-fasting or TG >400 mg/dL)
• HDL-C
• Triglycerides
• Non-HDL-C (calculated)

• Fasting glucose / HbA1c (rule out diabetes - if TG >150 mg/dL)
• TSH (rule out hypothyroidism - if LDL-C >160 mg/dL)
• Serum creatinine, eGFR, urine protein (CKD, nephrotic syndrome)
• Liver function tests (liver disease)

• ApoB (especially in familial combined hyperlipidemia)
• Lp(a) (independent cardiovascular risk factor)
• APOE genotype (if type III/FDBL suspected)
• Genetic panel (FH gene panel if LDL-C >190 mg/dL, FCS gene panel if TG persistently >500 mg/dL)
• 10-year ASCVD risk score (Pooled Cohort Equation / ACC-AHA)

12. ASSESSMENT SUMMARY (What to document)

1. Type of dyslipidemia: Hypercholesterolemia / Hypertriglyceridemia / Mixed / Low HDL
2. Primary vs. secondary cause - documented after ruling out secondary causes
3. ASCVD risk category: Very high / High / Intermediate / Low
4. Genetic disorder suspected: FH, FCS, FDBL, FCHL, etc.
5. Co-morbidities contributing to or affected by dyslipidemia
6. Current treatment status and response

Quick Reference: Key Questions to Ask at Every Dyslipidemia Visit

• Harrison's Principles of Internal Medicine, 22e - "Lipoprotein Disorders" (Diagnosis section)
• Textbook of Family Medicine, 9e - "Dyslipidemia"
• Braunwald's Heart Disease, 15e - "Dyslipidemia"
• Andrews' Diseases of the Skin - "Xanthelasma"

DYSLIPIDEMIA — History-Taking Checklist

1. PATIENT DEMOGRAPHICS

• ☐ Name / Age / Sex / Occupation
• ☐ Date of visit
• ☐ Referral source: Self / GP / Screening / Specialist
• ☐ BMI & Waist circumference measured

2. CHIEF COMPLAINT / REASON FOR VISIT

• ☐ Routine screening / annual check
• ☐ Incidental finding on blood work
• ☐ Referred after cardiovascular event
• ☐ Family member newly diagnosed
• ☐ Symptomatic (chest pain, skin deposits, abdominal pain)

3. HISTORY OF PRESENTING ILLNESS (HPI)

• ☐ When was dyslipidemia first diagnosed?
• ☐ How was it detected? (lab / screening / event)
• ☐ Previous lipid values and trend?
• ☐ Any prior treatment initiated?
• ☐ Compliance with current therapy?
• ☐ Side effects from current medications?

4. SYMPTOM REVIEW

Cardiovascular

• ☐ Chest pain / tightness (angina)
• ☐ Shortness of breath on exertion
• ☐ Palpitations
• ☐ Leg pain / claudication while walking (peripheral arterial disease)
• ☐ Prior stroke or TIA (slurred speech, facial droop, arm weakness)

Pancreatitis (ask if TG suspected > 500 mg/dL)

• ☐ Acute epigastric pain radiating to back
• ☐ Nausea & vomiting

Skin / Tendon Deposits (signs of hereditary dyslipidemia)

• ☐ Xanthelasma - yellowish deposits around eyelids
• ☐ Tendon xanthomas - lumps over Achilles / extensor tendons
• ☐ Tuberous xanthomas - deposits over elbows / knees
• ☐ Palmar xanthomas - yellow deposits in palmar creases
• ☐ Eruptive xanthomas - papular lesions on buttocks / elbows
• ☐ Corneal arcus (especially significant if age < 45)

5. PAST MEDICAL HISTORY — Rule Out Secondary Causes

• ☐ Each of the above conditions asked about and documented

6. MEDICATION HISTORY

Drugs that can CAUSE or WORSEN dyslipidemia - ask about all:

• ☐ Corticosteroids
• ☐ Thiazide diuretics / Non-selective beta-blockers
• ☐ Oral contraceptives / Estrogens / Progestins
• ☐ Cyclosporine / Isotretinoin
• ☐ HIV protease inhibitors (especially ritonavir - can cause extreme hypertriglyceridemia)
• ☐ Anabolic steroids
• ☐ Atypical antipsychotics

Current lipid-lowering therapy:

• ☐ Statin - name, dose, duration
• ☐ Fibrate (gemfibrozil / fenofibrate)
• ☐ Ezetimibe
• ☐ PCSK9 inhibitor
• ☐ Omega-3 fatty acids / Niacin / Bile acid resins
• ☐ Supplements: fish oil, red yeast rice
• ☐ Any muscle pain / weakness? (statin myopathy - check CK if yes)

7. FAMILY HISTORY (Critical for genetic dyslipidemias)

• ☐ High cholesterol in first-degree relatives (parents, siblings, children)
• ☐ High triglycerides in family
• ☐ Premature CAD in male relative < 55 years
• ☐ Premature CAD in female relative < 65 years
• ☐ Early stroke or sudden cardiac death in family
• ☐ Tendon xanthomas in family → strongly suggests Familial Hypercholesterolemia (FH)
• ☐ Recurrent pancreatitis in family → suggests Familial Chylomicronemia Syndrome (FCS)
• ☐ Consanguinity
• ☐ Ethnic background (South Asian, Ashkenazi Jewish = higher genetic risk)

8. SOCIAL HISTORY

Diet

• ☐ Saturated fat / trans fat intake (fried food, red meat, processed food)
• ☐ Carbohydrate and sugar intake (major driver of high TG)
• ☐ Fruit, vegetable, and fiber intake (oats, legumes)
• ☐ Dairy and egg consumption

Alcohol

• ☐ Frequency and units per week
• ☐ Binge drinking pattern (heavy alcohol significantly raises TG)

Physical Activity

• ☐ Type, frequency, and duration of exercise
• ☐ Sedentary occupation?

Smoking

• ☐ Current / ex-smoker / never
• ☐ Pack-years if applicable

Other

• ☐ Anabolic steroid use
• ☐ Recreational drug use

9. REVIEW OF SYSTEMS (Clues to secondary causes)

• ☐ Weight gain / unexplained weight loss
• ☐ Cold intolerance / constipation / hair loss → hypothyroidism
• ☐ Polyuria / polydipsia / excessive thirst → diabetes
• ☐ Foamy urine / leg swelling / edema → nephrotic syndrome
• ☐ Abdominal pain / jaundice / dark urine → liver disease
• ☐ Fatigue / generalised weakness
• ☐ Irregular periods / hirsutism → PCOS

10. PHYSICAL EXAMINATION (Document these findings)

11. INVESTIGATIONS TO ORDER / REVIEW

Fasting Lipid Panel (12-14 hours fast)

• ☐ Total cholesterol
• ☐ LDL-C (use direct LDL if non-fasting or TG > 400 mg/dL)
• ☐ HDL-C
• ☐ Triglycerides
• ☐ Non-HDL-C (calculated)

Rule Out Secondary Causes

• ☐ Fasting glucose / HbA1c (if TG > 150 mg/dL)
• ☐ TSH (if LDL-C > 160 mg/dL)
• ☐ Serum creatinine / eGFR
• ☐ Urine protein
• ☐ Liver function tests

Additional Tests (if indicated)

• ☐ ApoB - if FCHL suspected (elevated apoB confirms increased ASCVD risk)
• ☐ Lp(a) - independent cardiovascular risk factor
• ☐ APOE genotype - if type III / FDBL suspected (palmar xanthomas + mixed hyperlipidemia)
• ☐ FH gene panel - if LDL-C > 190 mg/dL
• ☐ FCS gene panel - if TG persistently > 500 mg/dL
• ☐ 10-year ASCVD risk score (ACC/AHA Pooled Cohort Equation)

12. ASSESSMENT SUMMARY — Document All

• ☐ Type of dyslipidemia: Hypercholesterolemia / Hypertriglyceridemia / Mixed / Low HDL
• ☐ Primary vs. Secondary cause determined (secondary causes ruled out)
• ☐ ASCVD risk category: Very High / High / Intermediate / Low
• ☐ Genetic disorder suspected: FH / FCS / FDBL / FCHL
• ☐ Comorbidities identified and documented
• ☐ Current treatment status and response to therapy

Quick Prompt Card — Ask at Every Visit