Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Inquire about any current symptoms that might be related to dyslipidemia, such as:
Chest pain (angina)
Leg cramps
Peripheral artery disease (painful leg claudication) – though uncommon as a presenting symptom
Ask about the patient’s current diet and exercise habits.
Review any family history of heart disease or high cholesterol.
Objective:
Vital Signs: Include blood pressure.
Physical Exam:
Look for signs of xanthelasma (yellowish plaques around the eyelids) or xanthomas (fatty deposits on tendons) – though these are not specific to dyslipidemia.
Assessment:
Dyslipidemia based on prior lipid panel results (mention date of latest results).
Specify the type of dyslipidemia based on lipid profile (e.g., high LDL cholesterol, high triglycerides, low HDL cholesterol).
Calculate atherosclerotic cardiovascular disease (ASCVD) risk score using a validated tool (optional).
Plan:
Diet and Exercise:
Emphasize the importance of lifestyle modifications as the cornerstone of treatment:
Recommend a heart-healthy diet low in saturated and trans fats, and rich in fruits, vegetables, and whole grains.
Advise on regular physical activity (at least 150 minutes of moderate-intensity exercise per week).
Medications:
Consider initiating or adjusting medication therapy based on the type of dyslipidemia, risk factors, and treatment goals established in national guidelines (e.g., American College of Cardiology [ACC], American Heart Association [AHA]). Examples include:
Statins (first-line therapy for most patients)
Ezetimibe (inhibits cholesterol absorption)
PCSK9 inhibitors (injectable medications for severe cases)
Discuss potential side effects and benefits of medications.
Laboratory Follow-up:
Schedule follow-up blood tests (lipid panel) to monitor response to treatment (frequency depends on specific medications used).
Additional Considerations:
Address any underlying conditions that may be contributing to dyslipidemia, such as:
Diabetes
Hypothyroidism
Metabolic syndrome
Discuss smoking cessation if the patient smokes.
Provide resources for healthy lifestyle changes (e.g., educational materials, referrals to a dietitian or exercise program).
Follow-up:
Schedule regular follow-up visits to monitor lipid levels, blood pressure, and overall cardiovascular health.
Adjust medications as needed based on treatment goals and laboratory results.
Reinforce the importance of lifestyle modifications for long-term management.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding symptoms, risk factors, laboratory findings, treatment plan, and considerations for lifestyle interventions and comorbid conditions.