OVERVIEW

This table states your main issues and the headline message.

Field Details Result Why

Title Coronary artery disease with high LDL, diabetes, chest burning, back pain, right-ear hearing loss — - Brings all key problems into one line for quick understanding. - Guides what needs attention first: heart risk, symptoms, and hearing.

One-sentence summary Cholesterol is high. Sugar control is good. Kidneys and liver are fine. Potassium runs a bit high. Chest, back, and hearing need follow up. Mixed - Cholesterol and symptoms require action now to lower risk. - Diabetes control and kidney function are on target, which is reassuring. - Potassium is borderline high, so we recheck soon for safety.

PATIENT CONTEXT – DEMOGRAPHICS

This table gives basic facts that guide risk and dosing.

Item Value Result Why

Age 58 years, male — - Age and sex affect heart risk and treatment targets. - Helps choose safe medicine doses and monitoring.

Height 184 cm — - Needed for body mass index and dose calculations. - Useful for tracking weight change over time.

Weight 85 kg Borderline - Body mass index about 25.1 kg/m², near upper normal. - Small weight loss improves triglycerides, reflux, and joint strain.

Waist 80 cm Good - Smaller waist links to lower heart and diabetes risk. - Suggests less central fat, which is protective.

PATIENT CONTEXT – SYMPTOMS

This table lists your symptoms, start dates, and what they point to.

Symptom Start/date Result Why

Chest burning at rest 3–4 months Needs work - No pain with walking, so less like classic angina, but heart disease means we still check. - Pantoprazole before breakfast fits reflux timing and should help. - Stress testing rules out silent ischemia safely.

Mid-back pain with flares Since age 30 Needs work - Worse with lifting and long sitting, which fits mechanical back pain. - Morning stiffness over 30 minutes points to stiffness and posture issues. - Not typical statin muscle pain, which is diffuse and symmetric.

Right-ear hearing loss with ringing 3 years, worsening Needs work - One-sided and progressive loss needs a full hearing test. - If inner-ear or nerve loss is confirmed, an inner-ear MRI is standard. - Early diagnosis protects function and rules out rare causes.

Dark skin patches, hip and low belly 6–8 months Watch - Sometimes itchy, common with friction or prior irritation. - If patches are scaly, tinea versicolor is likely and responds to antifungal cream. - See dermatology if patches spread, change, or do not improve.

CARDIOMETABOLIC GOALS

This table shows the targets for very high heart risk and explains each one in plain words.

Measure Goal Result Why

LDL cholesterol (“bad” cholesterol) Under 55 mg/dL [under 1.4 mmol/L] Not at goal - Lower LDL reduces plaque in arteries and future events. - With known heart disease, tight control gives the best protection. - Your current LDL is 143 mg/dL, so stronger treatment and adherence are needed.

Non-HDL cholesterol (all harmful cholesterol) Under 85 mg/dL [under 2.2 mmol/L] Not at goal - Non-HDL equals total cholesterol minus HDL, so it captures all harmful particles. - It predicts risk well when triglycerides are high. - Your non-HDL is 193 mg/dL, so we must reduce it.

ApoB (count of harmful particles) Under 65 mg/dL [under 0.65 g/L] Unknown - ApoB directly counts atherogenic particles that enter artery walls. - It falls as LDL falls and confirms risk reduction. - Ask the lab to add ApoB to your next fasting lipids.

WHAT EACH MEDICINE USUALLY DOES TO LDL

This table explains how much each medicine lowers LDL on average, when you see change, and key notes, all in plain words.

Medicine Typical LDL change When you see change Why

Repatha (evolocumab) About 60 percent lower First drop in 2–4 weeks, near full effect by 4–8 weeks - Strongest LDL lowering in your plan, even without statins. - Works well with diabetes and heart medicines you take. - Few interactions, so it is easy to combine with other drugs.

Ezetimibe 10 mg About 18 to 22 percent lower 2–4 weeks - Blocks cholesterol absorption from the gut, so it is gentle. - Very low muscle-ache risk, useful if statins caused pain. - Once-daily dose makes adherence easier.

Pitavastatin 2 mg About 35 to 40 percent lower 2–4 weeks - A statin with fewer drug interactions than some others. - Muscle aches can still happen, so we use a pain plan if retried. - Even low or intermittent dosing can add meaningful LDL lowering.

Bempedoic acid 180 mg About 15 to 20 percent lower 4–8 weeks - Works in the liver, not in muscle, so muscle-ache risk is low. - Helpful if ezetimibe is not tolerated or if more lowering is needed. - Can raise uric acid; report gout-like big-toe pain or tendon pain.

HOW COMBINATIONS ADD UP, USING YOUR LDL OF 143 mg/dL

This table gives easy estimates if doses are on time and you stay on schedule.

Treatment plan Estimated LDL after treatment What that means vs your goal under 55 mg/dL Why

Repatha alone Around 57 mg/dL Close to goal or at goal - A 60 percent average drop from 143 lands near 57 mg/dL. - Many patients reach target with Repatha alone if injections are on time.

Repatha plus ezetimibe Around 46 mg/dL Below goal - Adding ezetimibe gives another ~20 percent drop on the remaining LDL. - This low side-effect add-on commonly brings patients under goal.

Repatha plus bempedoic acid Around 46 mg/dL Below goal - Adds ~20 percent more lowering on top of Repatha. - Useful if ezetimibe caused aches or stomach issues.

Repatha plus pitavastatin 2 mg Around 34–37 mg/dL Below goal - Pitavastatin adds ~35–40 percent more on the remaining LDL. - Watch for muscle symptoms; use a stepwise pain plan.

Repatha plus ezetimibe plus bempedoic acid Around 37 mg/dL Below goal - Two non-statin add-ons together are an option if statin pain persists. - Keeps muscle risk low while meeting a strict target.

WHAT HAPPENS TO NON-HDL AND ApoB WHEN LDL FALLS

This table explains how the other markers move as LDL improves.

Marker What usually happens Why

Non-HDL cholesterol Usually falls by a similar percent as LDL - Non-HDL includes LDL and other harmful particles, so lowering LDL lowers non-HDL too. - Triglycerides also influence non-HDL, so diet and activity help.

ApoB Usually falls in step with LDL - ApoB counts the number of harmful particles in circulation. - Fewer LDL particles mean a lower ApoB number and lower risk. - Measuring ApoB confirms progress beyond LDL alone.

WHEN TO REPEAT BLOOD TESTS AFTER A CHANGE

This table sets clear timing to see the true effect and to keep you safe.

Change When to recheck Why

Start or restart Repatha 6 weeks - Repatha reaches steady effect by 4–8 weeks. - A 6-week lipid panel shows the real new baseline.

Start ezetimibe or pitavastatin 6 weeks - Both act within a month. - Six weeks confirms LDL response and checks for side effects.

Start bempedoic acid 8 weeks - Bempedoic acid has a slower onset. - Eight weeks captures near-steady impact.

Any change in perindopril or dapagliflozin 1–2 weeks for potassium and creatinine - ACE inhibitors and SGLT2 drugs can change kidney function and potassium. - Early labs protect against silent problems.

LIFESTYLE SNAPSHOT

This table covers habits that affect lipids, reflux, and pain.

Area Current Result Why

Steps About 2,000 per day Needs work - Add 1,000 steps each week toward 6,000 per day by 21 Sep 2025. - Two 10-minute walks after meals lower triglycerides and aid reflux.

Sleep 6–7 hours per night Borderline - Aim for 7–8 hours for pain control, appetite, and recovery. - A steady sleep time helps reflux and back stiffness.

Alcohol None Good - No alcohol supports blood pressure, weight, and triglycerides. - Avoids reflux triggers in the evening.

Tobacco Vapes nicotine Needs work - Quitting lowers heart and reflux risk. - Consider nicotine replacement or prescription aids and set a quit date.

Work stress High Needs work - Take standing and posture breaks every 45–60 minutes. - Thoracic extension and scapular squeezes reduce stiffness and pain.

CURRENT MEDICINES

This table lists what you take, how, and what to watch for.

Medicine Dose Schedule Purpose Result Why

Repatha (evolocumab) 140 mg Every 2 weeks Strong LDL lowering Good - Back on schedule after a gap. - Expect about 60 percent LDL reduction with consistent dosing. - Few interactions, easy to combine with other medicines.

Tirzepatide 5 mg Weekly, same day Diabetes and weight Good - HbA1c is at goal with this dose. - Mild enzyme rises can occur without pancreatitis; act only on severe upper-belly pain to the back. - Rotate injection sites and store in the refrigerator.

Dapagliflozin 10 mg Morning with breakfast Diabetes, kidney-heart Good - Kidney function is normal which supports safe use. - Stay well hydrated; pause during vomiting or diarrhea. - Helps protect kidneys and heart in diabetes.

Cosyrel (bisoprolol + perindopril) Label 2.5 mg; exact strengths unknown Night BP and heart Info needed - Exact milligrams for both parts guide blood pressure and potassium monitoring. - Perindopril can raise potassium; night dosing may reduce daytime lightheadedness. - Stand up slowly to avoid dizziness.

Duloxetine 30 mg Night Nerve and muscle pain Caution - Higher stomach bleeding risk if combined with NSAIDs like ibuprofen or naproxen. - Can cause dizziness or nausea, so night dosing helps tolerance. - Do not double doses if one is missed.

Coenzyme Q10 1,000 mg total 500 mg morning and 500 mg night Comfort if a statin is retried Optional - Evidence for muscle-ache relief is mixed, but it is safe. - Take with food to improve absorption and stomach comfort.

Tadalafil 5 mg Night Prostate and erectile symptoms Caution - Never combine with nitrates due to dangerous blood pressure drops. - May lower BP with Cosyrel; skip on dizzy days and rise slowly. - Tell all clinicians you use tadalafil.

Pantoprazole 40 mg 30–60 minutes before breakfast Reflux Good - Morning timing improves acid control and chest burning. - Consider magnesium level if used longer than one year. - Combine with reflux habits for best results.

Levothyroxine 25 mcg On waking, empty stomach Thyroid Good - Take with water only; wait 30–60 minutes before other pills or food. - Coffee, calcium, and iron reduce absorption if taken together. - Recheck TSH 6–8 weeks after any dose change.

Recently stopped Ezetimibe 10 mg; Pitavastatin 2 mg Stopped 2 months ago Lipids Review soon - Stopped due to back pain; ezetimibe has low muscle risk and may be retried. - If aches recur, bempedoic acid is a non-statin option.

PCSK9 history Inclisiran for about 2 months, then stopped — LDL Note - Now back on Repatha which works quickly when taken on time. - Consistency is key to reach the LDL goal.

KEY FINDINGS FROM PRIOR WORK

This table summarizes what we agreed before and rewrites the targets and effects in plain words.

Date Source in this chat Key points Result Why

10 Aug 2025 Guideline check - LDL goal under 55 mg/dL. - Non-HDL goal under 85 mg/dL. - ApoB goal under 65 mg/dL. - Average LDL lowering: Repatha about 60 percent, ezetimibe about 20 percent, pitavastatin 2 mg about 35–40 percent, bempedoic acid about 15–20 percent. Good - These are standard goals for people with heart disease. - Combining medicines safely helps reach strict targets with fewer side effects.

10 Aug 2025 Care plan - Stay on Repatha. - Retry ezetimibe with a pain plan. - If aches return, switch to bempedoic acid. - Start thoracic physiotherapy. Good - The plan balances LDL lowering with comfort and safety. - Physiotherapy focuses on posture, thoracic mobility, and shoulder blade strength.

10 Aug 2025 Tirzepatide safety - Small enzyme rises are common. - Do not rely on enzyme numbers alone. - Seek care for severe upper-belly pain to the back. Good - Prevents over-reacting to mild lab changes. - Keeps focus on true warning symptoms.

10 Aug 2025 Hearing pathway - Audiology first. - MRI of inner-ear nerves if loss is inner-ear and one-sided. Good - Standard and efficient pathway for progressive one-sided loss. - Rules out rare but important causes.

10 Aug 2025 Interactions - Limit NSAIDs with ACE inhibitor and SGLT2 drugs. - Never use tadalafil with nitrates. Good - Lowers kidney stress and bleeding risk. - Prevents dangerous blood pressure drops.

WHAT CHANGED SINCE LAST REPORT

This table lists new data and medicine changes.

Date New item Details Result Why

09 Aug 2025 New labs Lipids high; HbA1c 5.6 percent; potassium 5.1 mmol/L Mixed - Cholesterol worsened and needs action. - Diabetes control is on target, which supports current doses. - Potassium is borderline high, so we recheck soon.

11 Jun 2025 Older labs LDL 145 mg/dL; triglycerides 182 mg/dL; potassium 5.3 mmol/L Baseline - Establishes a starting point for trends. - Shows potassium was higher earlier than now.

Recent Symptoms No chest pain with walking; burning at rest. Hearing loss progressing. Mixed - Pattern favors reflux, but heart disease requires a stress test. - Hearing continues to worsen, so ENT and imaging are needed.

2 months ago Medicines Stopped ezetimibe and pitavastatin; paused Repatha for inclisiran; now back on Repatha Improving - Consistent Repatha dosing should lower LDL again within weeks. - Add-on choices remain if the goal is not met.

LATEST LABS – 09 AUG 2025

This table shows the newest results and what they mean for you.

Test Value Range Result Why

Total cholesterol 231 mg/dL 100–199 Bad - Above range and adds risk. - Needs combined lifestyle and medicine changes.

LDL (“bad”) 143 mg/dL 0–99 Bad - Far above your target under 55 mg/dL. - Add-on therapy and strict dosing are needed.

HDL (“good”) 38 mg/dL ≥39 Bad - Lower protective cholesterol. - Activity, weight control, and diet quality help.

Triglycerides 205 mg/dL 0–149 Bad - High triglycerides increase risk and raise non-HDL. - Reduce sugars and refined starch; add fiber and fish.

VLDL 61 mg/dL 5–40 Bad - High due to elevated triglycerides. - Improves with diet changes and activity.

Non-HDL 193 mg/dL Lab “desirable under 130” Bad - Above lab range and above the heart-disease goal under 85. - Confirms high atherogenic particle load.

HbA1c 5.6% 4.8–5.6 Good - Diabetes control at target with current plan. - Keep weekly dosing and lifestyle steps.

Creatinine 0.97 mg/dL 0.76–1.27 Good - Kidney function is normal and supports current medicines. - Continue hydration and regular checks.

eGFR 91 mL/min/1.73 m² ≥60 Good - Kidney filtration is healthy. - No dose changes needed for kidney reasons.

Sodium 143 mmol/L 134–144 Good - Normal salt level. - No action needed.

Potassium 5.1 mmol/L 3.5–5.2 Borderline - High-normal and close to the upper limit. - Recheck in 1–2 weeks due to ACE inhibitor and any NSAID exposure.

Bicarbonate 27 mmol/L 18–29 Good - Normal acid-base status. - No action needed.

Troponin I Unknown 0.00–0.16 Unknown - Value not readable on the image provided. - If available, share the number to complete the heart review.

OLDER LABS – 11 JUN 2025

This table gives the earlier results to show trend.

Test Value Range Result Why

Total cholesterol 214 mg/dL 100–199 Bad - High at baseline, showing persistent elevation. - Confirms need for stronger therapy.

LDL 145 mg/dL 0–99 Bad - High at baseline and still high later. - Reinforces need for PCSK9 adherence and add-ons.

HDL 48 mg/dL ≥39 Good - Protective level then. - Drop later suggests lifestyle tune-up is needed.

Triglycerides 182 mg/dL 0–149 Bad - Elevated at baseline. - Later increase to 205 shows diet and activity matter.

Non-HDL 166 mg/dL Lab “desirable under 130” Bad - High baseline and rising later. - Confirms excess atherogenic particles.

Fasting glucose 116 mg/dL 65–99 Borderline - Mildly elevated fasting value. - Matches A1c near goal.

HbA1c 5.7% 4.8–5.6 Borderline - Slightly over lab range. - Improved to 5.6 percent later.

Creatinine 0.89 mg/dL 0.76–1.27 Good - Kidney function normal. - Safe to continue current doses.

eGFR 99 mL/min/1.73 m² ≥60 Good - Excellent filtration. - No dose changes for kidneys.

Potassium 5.3 mmol/L 3.5–5.2 Bad - Above range then, improved to 5.1 later. - Keep monitoring due to ACE inhibitor.

AST 17 IU/L 0–40 Good - Normal liver test. - No sign of liver injury.

ALT 18 IU/L 0–44 Good - Normal liver test. - Safe to continue current plan.

Urine ACR 8.55 mg/g 0–30 Good - No protein leak from kidneys. - Diabetes not damaging the filter.

TRENDS

This table shows how key numbers changed.

Measure 11 Jun 09 Aug Result Why

LDL 145 143 Bad - Still far from your target under 55 mg/dL. - Needs consistent Repatha and likely an add-on.

HDL 48 38 Bad - Drop reduces natural protection. - Improve activity, diet quality, and weight.

Triglycerides 182 205 Bad - Higher now, which raises non-HDL. - Cut sugars and late-night calories; add post-meal walks.

Non-HDL 166 193 Bad - Rising total of harmful particles. - Strong reason to add ezetimibe or bempedoic acid.

HbA1c 5.7% 5.6% Good - Slight improvement to the top of the normal range. - Stay on current dose and habits.

Potassium 5.3 5.1 Borderline - Improved but still high-normal. - Recheck to ensure safety with ACE inhibitor.

QUESTIONS FOR YOUR DOCTORS – DIAGNOSIS

This table lists the diagnosis questions to answer next.

Question Result Why

Is chest burning reflux or angina? Do I need a stress test now? Needed - Coronary disease is present, so we must rule out heart ischemia. - Pain occurs at rest and has lasted months. - A stress test is a safe way to check.

Is back pain muscle or joint or nerve? Needed - Longstanding positional pain points to mechanical causes. - Exam and X-ray guide therapy and the need for MRI.

Is right-ear hearing loss inner-ear or middle-ear? Needed - One-sided progressive loss needs hearing tests. - MRI of inner-ear nerves is done if inner-ear loss is confirmed.

QUESTIONS FOR YOUR DOCTORS – TESTS

This table lists the tests to schedule and why.

Question Result Why

Fasting lipids with ApoB and non-HDL after 6 weeks of on-time Repatha Scheduled - Target date 21 Sep 2025 shows steady Repatha effect. - Confirms progress toward the strict LDL goal.

Lp(a) one time Needed - Reveals inherited risk that standard lipids miss. - Helps set how low LDL should go.

Potassium, creatinine, sodium in 1–2 weeks Needed - ACE inhibitor and any NSAID use can raise potassium and stress kidneys. - Early check prevents silent problems.

Audiology and tympanometry; MRI of inner-ear nerves if sensorineural Needed - Standard pathway for one-sided progressive hearing loss. - Rules out rare but important causes such as nerve tumors.

Thoracic spine X-ray; MRI only if red flags Needed - Long history and morning stiffness need baseline imaging. - MRI reserved for weakness, numbness, fever, trauma, or cancer history.

QUESTIONS FOR YOUR DOCTORS – MEDICINES

This table prepares medication decisions.

Question Result Why

Confirm Cosyrel strengths for bisoprolol and perindopril Needed - Exact milligrams guide blood pressure targets and potassium monitoring. - Ensures correct dose, especially with tadalafil on board.

When and how to retry ezetimibe 10 mg with a pain plan? Soon - Take at night for convenience and consistency. - If aches return, stop, check a CK blood test, and call.

If aches return, add bempedoic acid instead? Option - Low muscle-ache risk and good LDL drop. - Works well with Repatha and without a statin.

Keep tirzepatide 5 mg or increase? Discuss - Balance weight goals, A1c data, and stomach tolerance. - Dose changes affect appetite and GI side effects.

Safer pain plan that limits NSAIDs? Needed - Prefer acetaminophen and topical diclofenac to protect stomach and kidneys. - Keep any NSAID dose low, duration short, and always take with food.

QUESTIONS FOR YOUR DOCTORS – SIDE EFFECTS AND FOLLOW-UP

This table covers safety and timing.

Question Result Why

Move pantoprazole to before breakfast? Done - Works better than bedtime dosing for reflux. - Matches when acid pumps are most active.

Prevent low blood pressure with Cosyrel plus tadalafil? Ongoing - Night dosing and slow position changes reduce dizziness. - Skip tadalafil on dizzy days to avoid extra BP drop.

Check magnesium on long-term PPI? Consider - Rare low magnesium can occur after more than one year. - Testing is simple and prevents silent problems.

Confirm exact dates for labs and visits Set - Potassium by 24 Aug. - Stress test by 24 Aug. - ENT by 07 Sep. - Lipids by 21 Sep.

MEDICATION SCHEDULE (24-HOUR PLAN)

This table shows what to take, when, how, and the reason.

Medicine Dose When With food? How to take Reason Result Why

Levothyroxine 25 mcg On waking No Water only; wait 30–60 minutes before food or other pills Thyroid Good - Best absorption gives stable hormone levels. - Separating from coffee, calcium, and iron prevents under-dosing.

Pantoprazole 40 mg 30–60 minutes before breakfast Water Take before the first meal of the day Reflux Good - Maximizes acid pump blocking and symptom relief. - Works best with small early dinners and head-of-bed elevation.

Dapagliflozin 10 mg With breakfast Yes Hydrate; pause during vomiting or diarrhea Sugar, kidney-heart Good - Lowers sugar and protects kidneys and heart. - Hydration prevents dizziness and kidney strain.

Cosyrel (bisoprolol + perindopril) Label 2.5 mg; strengths unknown Evening Either Stand up slowly; take at the same time daily BP, heart Info needed - Exact milligrams tailor BP goals and potassium checks. - Evening dose may reduce daytime lightheadedness.

Duloxetine 30 mg Night Snack if nausea Swallow whole; do not double doses Nerve and muscle pain Caution - Night dosing limits daytime sedation and nausea. - Avoid routine NSAIDs to reduce bleeding risk.

Tadalafil 5 mg Night Either Never use with nitrates Prostate and erections Caution - Can add to BP-lowering from Cosyrel; monitor for dizziness. - Tell all clinicians you use tadalafil to prevent unsafe combinations.

Coenzyme Q10 1,000 mg total 500 mg morning and 500 mg night With meals Optional supplement Comfort Optional - Mixed evidence for muscle ache relief, but generally safe. - Take with food for better absorption.

Tirzepatide 5 mg Weekly, same weekday Either Rotate injection sites; keep in refrigerator Diabetes and weight Good - A1c is at goal; continue same day weekly. - Report severe persistent belly pain, which is rare.

Repatha 140 mg Every 2 weeks — Keep refrigerated; allow to warm to room temperature before injection LDL lowering Good - Strongest LDL effect when injections are on time. - Expect major LDL improvement within 4–8 weeks.

MISSED-DOSE QUICK RULES

This table shows what to do if a dose is missed.

Drug Result Why

Levothyroxine If same day, take later on an empty stomach; if next day, skip - Avoids double dosing and keeps steady levels. - Empty stomach prevents poor absorption.

Pantoprazole Take next morning - Works best before breakfast for acid control. - Bedtime dose is less effective.

Dapagliflozin, Cosyrel, Duloxetine, Tadalafil, CoQ10 If same day, take when remembered; if next day, skip - Prevents accidental overdosing. - Keeps a simple, safe routine.

Tirzepatide Take within 4 days of the usual day; if more than 4 days, skip and resume next scheduled day - Keeps a steady weekly rhythm without stacking doses. - Reduces side-effect risk.

Repatha If less than 7 days late, inject and keep the same schedule; if more than 7 days late, inject and start a new 2-week cycle from that day - Maintains steady LDL lowering. - Simple rule avoids confusion about future dates.

STORAGE

This table notes storage rules for injectables.

Drug Result Why

Repatha, Tirzepatide Good if refrigerated - Keep in a refrigerator and protect from light. - Do not freeze, and do not shake pens or syringes. - Follow the box for allowed time at room temperature before use.

DRUG INTERACTIONS

This table highlights pairs to avoid or to monitor and what to do.

Pair What happens Risk Result Why

Duloxetine plus NSAIDs (ibuprofen, naproxen, diclofenac) Higher stomach bleeding risk Moderate Bad combo - Prefer acetaminophen first for pain. - If an NSAID is needed, use the lowest dose for the shortest time with food. - Watch for black stools, vomiting blood, or new stomach pain.

Perindopril (in Cosyrel) plus your potassium trend ACE inhibitor can raise potassium Moderate Watch - Recheck potassium and creatinine in 1–2 weeks. - Avoid potassium salt substitutes and high-potassium supplements. - Stay hydrated, especially during hot weather or illness.

NSAID plus ACE inhibitor plus SGLT2 (dapagliflozin) “Triple whammy” can stress kidneys Moderate to High when ill or dehydrated Avoid when possible - Limit NSAIDs; use acetaminophen or topical options first. - During vomiting or diarrhea, pause dapagliflozin and perindopril until eating and drinking normally. - Check labs after any NSAID course if you feel unwell.

Tadalafil plus nitrates Dangerous blood pressure drop High Never - Do not combine under any circumstance. - If nitrates are needed in an emergency, tell staff you take tadalafil.

Cosyrel plus tadalafil Both lower blood pressure Moderate Caution - Keep tadalafil at night and rise slowly from sitting. - Skip tadalafil on dizzy days. - Check home BP if you feel lightheaded.

Levothyroxine plus food or other pills Food and pills block absorption Moderate Separate - Take levothyroxine alone on waking with water. - Keep at least 30–60 minutes before breakfast and other medicines. - Coffee, calcium, and iron especially interfere.

If clopidogrel is ever added plus some PPIs Some PPIs weaken clopidogrel Moderate Use pantoprazole - Only applies if clopidogrel is started later. - Pantoprazole is preferred if a PPI is needed with clopidogrel.

KEY HIGHLIGHTS

This table shows what is going well.

Point Result Why

HbA1c 5.6% on 09 Aug 2025 Good - Diabetes control is on target with your current dose and habits. - Supports steady weight and lower heart risk.

eGFR 91–99 mL/min/1.73 m² Good - Kidneys are healthy and support your medicines. - No dose limits needed for kidney reasons now.

Urine ACR 8.55 mg/g Good - No protein leak from kidneys, a key diabetes goal. - Confirms dapagliflozin benefit and control.

Liver enzymes normal Good - No sign of liver injury on current therapy. - Safe to continue the plan.

Repatha restarted Good - Strong LDL lowering is back on board. - Expect major improvement in LDL within the next 6 weeks.

KEY CONCERNS WITH REMEDIATION PLAN

This table lists each problem, risk, action, owner, date, and success check.

Concern Risk Reason Plan Owner Due date Success check Result Why

LDL and non-HDL too high Heart attack and stroke - LDL 143 mg/dL and non-HDL 193 mg/dL are far above goals. - Repatha pause and stopping ezetimibe/statin worsened numbers. - Stay on-time with Repatha. - Mediterranean diet and earlier, smaller dinners. - Retry ezetimibe with a pain plan. - If aches return, start bempedoic acid. You and Cardiology 21 Sep 2025 labs - LDL under 55 mg/dL. - Non-HDL under 85 mg/dL. Active - Clear steps and dates are set. - Add ApoB and Lp(a) to complete the risk picture.

Borderline high potassium Abnormal heart rhythm if higher - ACE inhibitor can raise potassium. - Occasional NSAIDs and dehydration add risk. - Repeat potassium and creatinine. - Hydrate daily, especially in heat. - Limit NSAIDs and avoid potassium salt substitutes. You and Primary care By 24 Aug 2025 - Potassium 3.6–5.0 mmol/L. - Creatinine stable. Active - Early lab check protects kidneys and heart. - Education reduces future spikes.

Chest burning Reflux likely; must rule out angina - Not linked to walking. - Persistent symptoms for months. - Pantoprazole before breakfast plus reflux habits. - Schedule a cardiac stress test. You and Cardiology Book by 24 Aug 2025 - Fewer reflux symptoms. - Negative stress test. Active - Lifestyle and timing improve acid control. - Testing keeps heart risk managed.

Right-ear hearing loss Hearing decline; rare tumor to rule out - Progressive and one-sided over 3 years. - Audiology and ENT evaluation. - MRI of inner-ear nerves if sensorineural loss is confirmed. You and ENT By 07 Sep 2025 - Audiogram complete. - Next steps defined. Active - Standard pathway finds cause and protects hearing. - Urgent care if sudden new drop occurs.

Thoracic back pain Limits function and sleep - Longstanding pain, worse with sitting and early stiffness. - Thoracic X-ray baseline. - Start physiotherapy for posture, thoracic mobility, and scapular strength. - Heat and topical diclofenac; keep oral NSAIDs rare. You and Physio Start by 17 Aug 2025 - Pain average 3/10 or lower. - More daily steps. Active - Desk breaks every 45–60 minutes and ergonomic setup help. - Log flares and triggers to tailor therapy.

LIFESTYLE AND HOME MONITORING

This table gives daily targets and why they matter.

Action Frequency Target Result Why

Steps Daily Build to 6,000 per day by 21 Sep 2025 Needs work - Extra movement lowers triglycerides and blood pressure. - Supports weight, mood, and sleep quality.

Diet, Mediterranean Daily Vegetables, legumes, whole grains, nuts, fish; fiber ≥30 g/day; no sugary drinks; dinner by 19:30 Needs work - Lowers LDL and triglycerides while supporting glucose control. - Earlier, smaller dinner reduces reflux at night.

Weight Weekly Lose 0.25–0.5 kg per week Needs work - Slow, steady loss improves lipids, blood pressure, and back pain. - Prevents rebound compared with crash diets.

Sleep Nightly 7–8 hours Borderline - Regular schedule reduces pain and improves appetite control. - Helps acid clearance and morning stiffness.

Home blood pressure Morning and evening for 7 days, then 3 days per week 120–129 / 70–79 mmHg Good - Your average is about 110 / 65; monitor for dizziness. - Check sitting and standing if lightheaded on Cosyrel plus tadalafil.

Fasting glucose 3–4 times per week 80–130 mg/dL Good - Confirms diabetes control between A1c tests. - Helps relate readings to meals and activity.

Pain log Daily Note triggers and what helps Needed - Guides physiotherapy adjustments. - Helps link flares to sitting time, lifting, or sleep.

NEXT STEPS WITH DATES

This table keeps tasks, dates, and the reason in one place.

Task Date How Result Why

Move pantoprazole to before breakfast; keep levothyroxine alone on waking Today Adjust timing Done - Best timing improves reflux control and thyroid absorption. - Reduces drug-food interactions.

Book physiotherapy and thoracic spine X-ray; start walking plan By 17 Aug 2025 Call physiotherapy; imaging order Scheduled - Rehab starts and posture program begins. - Imaging rules out structural issues.

Repeat potassium, sodium, creatinine By 24 Aug 2025 Local lab Scheduled - Confirms safety with ACE inhibitor and SGLT2 therapy. - Detects silent kidney or potassium changes early.

Schedule cardiac stress test By 24 Aug 2025 Cardiology Scheduled - Rules out heart ischemia as a cause of chest burning. - Sets the baseline for future symptoms.

Audiology and ENT; MRI of inner-ear nerves if sensorineural loss By 07 Sep 2025 ENT clinic Scheduled - Defines hearing type and cause. - MRI only if indicated to avoid unnecessary testing.

Fasting lipids with ApoB, non-HDL, and Lp(a) after on-time Repatha 21 Sep 2025 Lab draw after 8–12 hour fast Scheduled - Shows true response to Repatha and any add-on. - ApoB and Lp(a) complete the risk picture.

RED FLAGS – SEEK URGENT CARE

This table tells you when to go now.

Symptom Threshold/action Result Why

Chest pressure or pain with sweating, breathlessness, or nausea Lasts over 5 minutes, call emergency services Emergency - Possible heart attack; time-sensitive. - Do not drive yourself.

Fainting, new one-sided weakness, trouble speaking Emergency care Emergency - Possible stroke; minutes matter. - Seek immediate help.

Severe upper belly pain spreading to the back Emergency care Emergency - Could be pancreatitis or ulcer. - Higher priority than lab numbers alone.

Black stools or vomiting blood Emergency care Emergency - GI bleeding risk is higher with duloxetine plus NSAIDs. - Requires urgent treatment.

Fever over 38.5°C Same-day care Urgent - Infection stresses heart, kidneys, and diabetes control. - Earlier treatment prevents complications.

Blood pressure under 90/60 with dizziness Same-day care Urgent - Risk of falls and low blood flow to vital organs. - May require medicine timing changes.

Blood sugar under 60 or over 400 mg/dL not improving Urgent care Urgent - Severe low or high sugar harms the brain and heart. - Needs prompt treatment.

Sudden new hearing loss Same-day ENT or emergency Urgent - Early therapy can protect hearing if appropriate. - Do not wait for routine appointments.

MISSING INFO TO COMPLETE THE FILE

This table lists the last items needed to finalize dosing and plans.

Item Why needed Result Why

Exact Cosyrel strengths, bisoprolol and perindopril milligrams per tablet Needed for dose safety and for blood pressure and potassium plans Missing - Exact numbers set targets, adjust doses, and guide potassium checks. - A clear note from the box or prescription will complete this.

Troponin I number on 09 Aug 2025 Helps assess chest symptoms Missing - Confirms if there was any silent heart strain during symptoms. - Adds confidence when interpreting the stress test.

ApoB and Lp(a) Complete risk picture and LDL strategy Ordered - ApoB shows particle count, and Lp(a) shows inherited risk. - Results can justify a lower LDL goal or extra therapy.

Audiogram and thoracic imaging reports Guide the hearing and back plans Pending - Defines hearing loss type and the need for MRI. - Directs physiotherapy focus and home exercises.