Create a SOAP note for a 59‑year‑old audio‑only telehealth visit with borderline high cholesterol and triglycerides, severe vitamin D deficiency, normal renal function, and normal glycemic control.

SOAP Note for 59-Year-Old Telehealth Audio-Only Visit

Subjective

• 59-year-old patient presenting for audio-only telehealth visit for laboratory results review
• No specific symptoms reported during this encounter
• Patient able to communicate effectively via audio-only platform

Objective

Vital Signs:

• Not obtained during audio-only visit

Laboratory Results:

Lipid Panel:

• Total cholesterol: 208 mg/dL (borderline high)
• LDL cholesterol: 124.4 mg/dL (above optimal goal of <100 mg/dL) 1, 2
• Triglycerides: 209 mg/dL (elevated; goal <150 mg/dL) 3
• VLDL: 41.8 mg/dL (elevated)
• Non-HDL cholesterol: 166.2 mg/dL (calculated; goal <130 mg/dL for triglycerides ≥200 mg/dL) 1

Metabolic Panel:

• BUN: 7 mg/dL (low-normal)
• eGFR: 106.3 mL/min/1.73 m² (normal renal function) 3
• MCV: 95.3 fL (normal)

Glycemic Control:

• Hemoglobin A1c: 5.5% (normal; no diabetes) 3

Vitamin D:

• 25-hydroxyvitamin D: 6.4 ng/mL (severe deficiency; goal >20 ng/mL, deficiency defined as <20-30 ng/mL) 3

Assessment

1. Mixed dyslipidemia with borderline high total cholesterol, elevated LDL cholesterol, and hypertriglyceridemia

   • LDL 124.4 mg/dL (goal <100 mg/dL) 1, 2
   • Triglycerides 209 mg/dL (goal <150 mg/dL) 3
   • Non-HDL cholesterol 166.2 mg/dL (goal <130 mg/dL given triglycerides ≥200 mg/dL) 1

2. Severe vitamin D deficiency (6.4 ng/mL)

   • Level <10 ng/mL indicates severe deficiency with dramatically increased risk for osteomalacia 3
   • Important caveat: Elevated triglycerides (209 mg/dL) may cause falsely low vitamin D measurements, potentially masking true vitamin D status 4

3. Normal glycemic control (A1c 5.5%)

   • No evidence of diabetes or prediabetes 3

4. Normal renal function (eGFR 106.3 mL/min/1.73 m²)

   • No contraindication to metformin or other renally cleared medications 3

Plan

1. Mixed Dyslipidemia Management

Immediate Therapeutic Lifestyle Changes (First-Line): 1, 2

• Dietary modifications:

  • Reduce saturated fat to <7% of total daily calories 3, 1, 2
  • Limit dietary cholesterol to <200 mg/day 3, 1, 2
  • Eliminate trans-fatty acids 3, 2
  • Increase viscous (soluble) fiber intake to 10-25 g/day 3, 2
  • Add plant stanols/sterols up to 2 g/day 3, 2
  • For elevated triglycerides: decrease simple sugar intake and increase dietary omega-3 fatty acids 3, 2

• Physical activity:

  • Goal: at least 150 minutes per week of moderate-intensity aerobic exercise 1
  • Include resistance training 2 days/week 2

Pharmacologic Therapy:

• Initiate moderate-intensity statin therapy immediately (do not delay for lifestyle modifications alone in patients requiring treatment) 1, 2
• Goal: achieve at least 30% reduction in LDL-C from baseline (target LDL <100 mg/dL) 1, 2
• Secondary goal: non-HDL cholesterol <130 mg/dL given triglycerides ≥200 mg/dL 1
• Reassess lipid panel in 4-12 weeks after initiating statin to evaluate response and adjust intensity as needed 1

If targets not achieved after statin optimization:

• Consider adding ezetimibe as second-line therapy 1
• Do not use bile acid sequestrants with triglycerides >200 mg/dL as they can paradoxically worsen hypertriglyceridemia 1

2. Severe Vitamin D Deficiency Management

Critical Consideration:

• Elevated triglycerides (209 mg/dL) may cause falsely low vitamin D measurement 4
• Recommend repeat vitamin D level after triglycerides are controlled to confirm true deficiency status 4
• Risk of vitamin D toxicity exists if high-dose supplementation is given based on falsely low reading 4

Initial Conservative Approach Given Measurement Uncertainty:

• Start ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3) 1,000-2,000 IU daily (standard maintenance dose) 3
• Defer loading dose (50,000 IU weekly or single high-dose bolus) until triglycerides controlled and vitamin D level rechecked 3, 4
• Recheck 25-hydroxyvitamin D level in 3-6 months after lipid optimization 3

If Vitamin D Deficiency Confirmed After Lipid Control:

• Consider loading dose regimen: 50,000 IU weekly for 8-12 weeks, then maintenance 1,000-2,000 IU daily 3
• Follow-up vitamin D level 3-6 months after loading dose to ensure adequate response 3

3. Cardiovascular Risk Assessment

• Obtain blood pressure measurement at next in-person visit or via home monitoring 3
• Calculate 10-year ASCVD risk score to further guide statin intensity 1
• Screen for additional cardiovascular risk factors: smoking status, family history of premature CHD 3

4. Monitoring and Follow-Up

• Lipid panel in 4-12 weeks after statin initiation 1
• Vitamin D level in 3-6 months after triglycerides controlled 3, 4
• Annual lipid panel once at goal 3, 2
• Monitor for statin-related adverse effects (myopathy, elevated liver enzymes) 2

5. Telehealth Considerations

• Audio-only telehealth acceptable for laboratory review and medication management 5, 6, 7
• Recommend in-person visit for blood pressure measurement and comprehensive cardiovascular risk assessment 6
• Patient satisfaction with audio-only telehealth typically high for established patients 5, 7

6. Patient Education

• Explained mixed dyslipidemia diagnosis and cardiovascular risk
• Discussed importance of therapeutic lifestyle changes as foundation of treatment 1, 2
• Reviewed statin therapy benefits and potential side effects 2
• Explained potential interference of high triglycerides on vitamin D measurement 4
• Emphasized need for repeat vitamin D testing after lipid control 4
• Provided written dietary recommendations for lipid management 1, 2