Pure hypercholesterolemia, unspecified

E78.00

Clinical Vignette:

Patient Profile:

* Age: 45 years old

* Sex: Male

* Name: Robert

History of Present Illness:

Robert, a 45-year-old project manager at a busy marketing firm, visited the family practice clinic for his annual check-up. He has been generally healthy, though a bit overweight and aware that he doesn't exercise as much as he should. He enjoys dining out often due to his busy work schedule and admits he has a weakness for rich, fatty foods and desserts. Robert reported no recent changes in his health, no noticeable symptoms or discomforts.

Robert's family history, however, revealed that his father had a heart attack in his early 50s, and his mother was diagnosed with high cholesterol levels.

Physical Examination:

Robert's physical examination showed he was slightly overweight with a BMI of 28. He appeared otherwise healthy, with normal heart sounds and a blood pressure reading within the acceptable range.

Investigations and Diagnosis:

Given Robert's family history and lifestyle habits, the physician ordered a fasting lipid profile as part of his health check-up. The lab results came back with significantly elevated levels of LDL cholesterol, despite normal levels of triglycerides and HDL cholesterol.

Given his lab results, his family history, and the lack of identifiable secondary causes, Robert was diagnosed with pure hypercholesterolemia. A comprehensive lifestyle modification plan was provided to Robert, including dietary changes and regular exercise. The physician also started him on statin therapy to help control his cholesterol levels.

Diagnosis and ICD-10-CM Code:

Pure hypercholesterolemia, unspecified (E78.00)