A 54-Year-Old Man Comes to the Office for a Routine

question 942

Multiple Choice

A 54-year-old man comes to the office for a routine follow-up visit.  He feels well and has had no ongoing symptoms but has noticed a slow increase in his weight over the past year.  He says, "When the nurse weighed me around this time last year I was 74.8 kg (165 lb) and now I am 82.5 kg (182 lb) .  I don't know what's causing that; my diet hasn't changed."  The patient was diagnosed with HIV a year ago and initiated on antiretroviral therapy, which improved his CD4 count and viral load.  He has no other chronic medical problems and has tested negative for hepatitis B and C viruses.  His father had coronary artery disease and died of a myocardial infarction at age 55.  The patient has a 28-pack-year smoking history and continues to smoke a pack of cigarettes daily.  He used intravenous drugs in the past but is currently not using alcohol or illicit drugs.  Temperature is 36.5 C (97.7 F) , blood pressure is 112/72 mm Hg, pulse is 76/min, and respirations are 16/min.  BMI is 26.9 kg/m².  There is adipose tissue deposition on the back of the neck.  Abdominal examination reveals increased girth without a substantial increase in subcutaneous fat and palpable hepatomegaly with a soft, nontender liver edge.  No striae, bruising, or skin atrophy are present. Laboratory studies reveal a normal complete blood count, basic chemistry, hepatic function panel, hemoglobin A1c, and TSH level.  Lipid profile is as follows: Liver ultrasound reveals increased parenchymal echogenicity, consistent with steatosis.  Besides recommending lifestyle modifications, including regular exercise, tobacco cessation, and a heart-healthy diet, what is the best next step in management of this patient?

• A)Order ACTH stimulation test
• B)Start gemfibrozil
• C)Start nicotinic acid
• D)Start pravastatin
• E)Stop antiretroviral therapy