Hyperlipidemia htn

69 YO female with HTN, asthma, PCV, DM2, hyperlipidemia and non alcoholic fatty liver disease had a chest x ray d/t persistent cough.
It showed mild lingular opacity - Atelectasis or pneumonia.
She was given a 5-day course of Augmentin and Doxycyline.
She repeated the CXR ~ 10 days after completion of antibiotics which now show opacity at the lingula appears slightly more prominent in comparison to prior study.
Doctor ordered Chest CT.
Is this something to be concerned about?
Thank you.

Hi, and thank you for your time, I will try to be as succinct as possible. I just finished med school and even with decent medical literacy I feel buried with all of this data. Please let me know your thoughts.
Patient: late 60s Caucasian M, 165lbs. HPI: mild belching, sweaty, non-jaundiced, no pain, no NVD. Pt works regularly as a physician, swims, socializes, travels - appears extremely healthy. PMH: HTN, hyperlipidemia, Ankylosing Spondylitis, BPH, HLA B27+. Meds: Losartan, atorvostatin, gabapentin, celebrex. FMH: alpha 1 anti trypsin (father deceased early 50s), NSCLC (mother deceased late 80s). Numerous siblings but none with cancer or relevant disease. PSH: none. Allergies: Penicillin. Social hx: non smoker currently (smoked cigars very rarely from age 37-45 prior to a bad bout of pneumonia, none since), no recreational drugs in the last 50 odd years but marijuana and shrooms occasionally as a teen, regular drinker - used to be moderate, now heavier at approx 1.5 bottles of wine/night - high functioning alcoholic.
About 1 mo ago he got regular blood work for his health/recent pain assoc with Ank Spon. Shoulder X-ray - arthritic but otherwise normal. Bloods: ALP 160 U/L (reference range 46-116 U/L), AST: 34 U/L normal, ALT 30 U/L normal, PSA: 14.7 ng/ml (<4 but monitored and prostate okay), Bilirubin total: 0.5 normal, Alk phos bone specific: 16.6 mcg/L (reference range 7.6-14.9). U/S in GP murky but showed abnormal findings.
Now it gets tricky as I am thousands of miles away and don’t want to pester him with every detail. I believe he had a CT or MRI in late Dec which showed a 7cm liver mass in posterior right lobe. Biopsy completed. Results: Adenocarcinoma, moderately differentiated, trichromatic stains highlight fibrosis, reticulum stain + fibrosis. Iron stain shows no deposition. CK7 +, CK20+ focal, CDX2 negative, HepPar1 negative, Ca19-9 +. Immunohistochemical stain: CK17 +, CK19 +. Interpretation: results suggestive of upper GI tract or pancreatobiliary origin.
Colonoscopy + EGD - clear aside from some diverticulitis and hemhorrhoids.
Oncology appt early Jan: working dx HBP. Ordered AFP, CBC, CA 19-9, Carcinoembryonic antigen, CMP, Guardant 360, PET CT skull to thighs, pathology consult, HOPESQ solid tumors comprehensive, TSO mutation, Archer Fusion, Extraction FFPE-PK, Extraction FFPE agencourt, HS_PDLONE.
PET results this week confirmed approx 7cm mass in liver, small met in L2, and ?in biliary tree.
Tx plan for now: Immuno therapy 4 weeks followed by Cisplatin. No radiation. Inoperable. F/U with rheumatology + ophthalmology (eye issues w/ ank spon).
Questions: 1) why can’t they tell where it is from yet? Is this Gallbladder, CCA (I’m thinking perihilar?), or pancreatic. Other than alcohol he has no risk factors for CCA (eg Primary sclerosing cholangitis, liver fluke, etc) 2) Why just Cisplatin + immuno and not Cisplatin + Gemcitabine + immuno? 3) He is totally asymptomatic aside from moderately elevated ALP, mild increase in belching and night sweats - if it is CCA why isn’t he jaundiced/in pain/GI presentation? 4) How did it get to L2? 5) Would a liver transplant help? Should I see if I am a candidate? 6) why no MRCP/ERCP? 7) what are some of these tests- TSO, archer fusion etc? 8) what is the focal CD20+ on his biopsy? I thought that was for lymphoma. 9) My Mom is worried about prognosis. I am already aware this is terminal but hesitant to give her a timeline as I am NOT on oncologist and don’t want to freak her out. My estimation is average 1 yr, more if we are lucky and immuno targets mutations. 10) Any other questions we should ask his doc?
He is receiving care at an excellent hospital, and I am totally supportive of what his Onc is recommending, his expertise, and thankful for his care but I am thousands of miles away and can’t return home for another 6 weeks. Just devastated, slightly confused, and looking for clarity. Thank you for any and all input.

My patient has recently had Covid. He is on Day 18 of symptoms. Though they are improving, he is still sick with a mild cough, congestion, and fatigue. He is 67 y.o. with a hx of HTN, hyperlipidemia, hypothyroidism and obesity.
What advice/recommendations do you have for your patients moving forward with the healing process? All is appreciated.

Hey guys! I just wanted to share my experience and some advice to pay it forward since this group has been highly supportive while I was preparing for my NAPLEX. I took my NAPLEX on 08/17 and I am happy to share that I passed while working full time. I got 69 on the RxPrep test and 72 on the NABP preNAPLEX 4 days before my exam. One thing to keep in mind is that although the exam tests for minimum competency, it is not easy at all and I was sure I failed it after I took it. Here are the things that I did.
General tips:

• Trust your guts! You know more than you think even if you are feeling like you are doing something wrong.
• Take some free time, sleep, exercise, and treat yourself. Your brain needs some rest time to consolidate all the information you are learning and reviewing.
• Focus on understanding the big picture on every topic. There is no way to know every detail in the book and the NAPLEX won't test you in all the details; however, you might get some very specific questions. What worked for me was to actually take the big picture of the disease state and start building from there.
• You will feel that you failed lol the exam has weird wording and some random questions that might throw you off.
• While taking the exam make sure you are completing 70 to 80 questions per 2 hours so you have enough time to finish all the questions. Also, read carefully.
• Take the tutorial even if you don't need it. Those free 10min are a great opportunity to dump all the formulas, mnemonics, and any last minute information you memorize before the exam lol
• I reviewed materials and notes the day after the exam and 2 hours before my exam. This is a very personal preference, but reviewing stuff 2 hours before my exam helped to warm up my mind.

Materials:

• I used RxPrep QBank with the 2022 book (changes are not significant from the current version in my opinion)
• Pyrls (not free but very helpful in summarizing big topics and on the go study with the app).

Study methods:

• Consistency is very important. Even if you have a busy day with work, residency, or life, try to review or study something daily. I had days that I only reviewed stuff for 1-2 hours, but my main study schedule was 6-4 hours of study sessions daily.
• I made a separate word document on the underlined information on the big topics. This helped me to revisit those topics quickly.
• I did not cover the entire book (even though I recommend doing it just once). Chapters that I heavily focused on were foundations, cardio, ID, Psych, Neuro, Endo, Anticoagulation, Respiratory, Pain, GI, and some topics from Special Populations. I only glanced at oncology chapters (I took that risk cuz it was just a lot). Things that I focused on in oncology were BSA calculations, chemo man, safety things with the meds, and chemo nausea regimen. The rest of the onco stuff Jesus took care of it. I also did quizzlets that had the special gal things from every chapter.
• QBank helped a lot. I invested more time in the QBank than in the actual book. I repeated the questions until I get 80-90s on main and small topics. I also made my RxPrep notebook with their own feedback. I used the QBank feedback to study as well and is very straightforward.
• Math: I did the QBank math multiple times until I got 90s. However, the NAPLEX math is different from RxPrep, the wording is just not it and not as straightforward as the RxPrep. However, RxPrep was enough to ensure that you understand the math. In the exam, they use a virtual scientific calculator, but you can ask for a physical one. I used the physical one since I am kinda slow clicking numbers lol Virtual and physical calculator model is Texas Instruments TI-30XS MultiView Scientific Calculator. I recommend practicing math with this calculator to get familiarized and to use it to its best potential so you can save some time, but is not a must.

My Exam:

• It was all over the place so do not underestimate the small topics.
• ID: I got plenty of questions on choosing an abx based on the bacteria's characteristics (gram +/-, cluster etc). Pay attention to allergies and resistance. I also got questions about UTIs, Pneumonia, STDs (know the bacterias name and characteristics since they won't give you the actual STD name to choose a regimen), and Fungal infections.
• HIV: Know your drugs, brands, and opportunistic infections. Also the diagram on where these drugs act.
• Cardio: HTN, Hyperlipidemia, CAD, ICS, and Heart Failure are a must.
• Anticoagulation: Know everything! Including CHADs Score. I got lots of questions on the dosing for VTE, make sure to calculate CrCl as well.
• Onco: BSA dosing, safety things. Lucky I did not get a lot on this lol
• Math: TPNs, BioStats, PK, and compounding.
• Foundations: Med Safety is a must!! Make sure you understand med safety since all questions will be SATA on this. Honestly, the entire foundations chapters will be on the exam. Although I did not had any questions on antidotes, I did got random questions on natural supplements that I never heard off lol, compounding agents (I had to tell if it was a thickener, sweetener etc).

Good luck everyone! There is honestly not an easy way to prep for this than just working hard and being consistent. Trust in your knowledge and even if you fail, keep your head up and use it as a force to continue fighting.

There's slight variation between USPSTF and divine podcast screening guidelines for DM, Hyperlipidemia screening.
Diabetes
USPSTF: Screening at 35-70 years q3 year. (Obese/overweight).
Divine: 40 - 70 years old q6months in obese/overweight, HTN+ve people over 45 years old - q6 months.
Same thing with screening for hyperlipidemia.
Which one to follow?

41F, Caucasian, got an MRI for chronic insomnia - scattered supratentorial foci of WM hyper-intensities. Out of differential diagnoses I do NOT have migraines, HTN, hyperlipidemia, only chronic insomnia. No family history of AI.
Is demyelination the most likely cause? Could I have CVD if no risk factors? I have 6-7 subcritical lesions. Spine MRI is pending. Radiology says lesions don’t meet criteria for dissemination in space.
Can WMHs be congenital (I was born at 32 weeks)and I’ve had them for life? Could insomnia have caused them? Could Covid have caused them? I’m trying to understand logically how I have them at my fairly young age.
Neuro appt is pending (months away). Thanks for replying, I am very apprehensive (this was incidental finding).

Summary of Q: Px has toe pain. RF include smoking, HTN, CAD, hyperlipidemia, and 4cm, pulsatile, nontender mass in inguinal region. CT shown in Q. Pedal pulses are +2. NSIM?
Answer is Surgery.
I thought we operate on aneurysms if the patient is >5.5cm.
What I want to know is if the answer is surgery because:
a) aneurysm is pulsatile (despite being nontender)
b) symptoms (left toe pain...that could be completely unrelated to the aneurysm)
​
The explanation says that large aneurysms greater than 3cm are treated surgery; AMBOSS says it is 5.5cm? What is the cutoff for surgery?

68 yr old with PSA 3.3 down from 3.4 last year, but urologist felt nodule on right side on dre. I have MRI in 2 weeks. This isn't going to be fun. I'm in reasonably good health with the usual problems of HTN, hyperlipidemia, djd, gerd, and renal calculi. I walk 5 miles a day without fail. SH stopped smoking and drinking 40 years ago.

42YOF. Height: 5ft 7in. Weight: 225lb.
PMH: HTN, migraines, hyperlipidemia, sleep apnea (currently using vpap), s/p tonsillectomy, open hysterectomy w/ left salp&ooph and rt salpingectomy. Possibly pertinent family hx: sister is deaf in 1 ear d/t "some autoimmune disorder"
Meds: Daily: Topamax 75mg, magnesium 300mg, Riboflavin 300mg, Norvasc 5mg, Lisinopril 20mg, Lipitor 10mg, CoQ10, Tumeric w/black pepper, vitamin D, MVI. PRN: Maxalt, Reglan, Tylenol, motrin.
Situation: have been getting intermittent low frequency tone in right ear since end of summer 2021. At the time, had a leak in the basement and thought I was hearing the sump pump. Got the leak fixed, and still hear it. It almost exclusively happens at home, but has also been while away at a conference, and on vacation. It seems to be worse when I am sitting or laying down.
What I have done: saw ENT. They did hearing tests and said my hearing is excellent. They did an exam and didn't see anything unusual. My dentist has a laser-light therapy for TMJ, I did 3 rounds. It maybe helped decrease how often the tone comes, but it didn't last long.
Does anyone have any other suggestions?

This question is in regards to my dad. He is 61 y.o./caucasian. He is 5’9” and approximately 165lbs. He exercises daily (cardio and weight lifting) and is very health-conscious. He was diagnosed with hyperlipidemia in his mid 30s, but has controlled it entirely with diet and exercise and all labs (aside from his PSA) are totally normal. He is a retired healthcare provider.
He has never smoked and drinks 1-2 beers every week (sometimes less). He takes a baby aspirin daily. He had back surgery 3 years ago for sciatic nerve pain.
Family history: HTN and heart disease in his father (who was a smoker for many years and died at 91 y.o.). DM2, HTN, and colon cancer with extensive metastasis in his mother (smoker for many years and died at 80y.o.).
He has had urinary frequency for years and after getting his labs revealing a high PSA (he didn’t tell me what the number was), he saw a urologist and had samples taken of his prostate. His results came through his patient portal today and (forgive me if I say this in a dumb way lol) all of his 12? samples were 3+4, except one that was 4+3.
He tried to call the urology office, but it was close to closing time. He doesn’t seem to be anxious about the whole thing, but wouldn’t tell anyone if he was. I also work in healthcare, but I’ve never worked in oncology. I understand that that his results could be much better, but could be worse, too.
Is it likely that he will receive radiation? A prostatectomy? What does his survival look like given his scores? Whatever his doctors suggest to him, he will do. He’s a good patient.

What are the latest screening guidelines to get your answer correct on final exam?..TIA!

65 male, no chronic HTN, no hyperlipidemia total cholesterol 200 (not sure on break down possibly slightly high LDL), exercise regularly, healthy diet. No smoking, maybe 2 bottle of wine per week.
Recent sharpish/ achey chest pain, recurrent, remitting.
Ekg normal with some PAC and PVC on stress test, no st depression.
Chest Ct (non angio/no contrast) for general rule outs and said some calcification was found moderate/severe CAD, getting echocardio and nuke stress test next
How diagnostic is a straight chest ct for CAD. I found indication for CTA but no straight chest ct anywhere.
Also just found out from family low key he may have done alot of coke in the 80s but stopped by 1993. Alot of info out there on coke being bad for CV and stuff like prinzmetal.angina but thats all more acute type. Could this have had an effect 30+ years down the road
Thanks
(This is father in law im a PA-S btw)

What kind of interview questions are asked at community-based residency interviews? Should I prepare for them like I would a non community-based pharmacy residency interviews? Specifically, should I still focus on HTN, DM, Hyperlipidemia? Should I go over OTCs or chronic respiratory diseases? Any insight is appreciated!!

After attending many appointments and undergoing extensive testing, this is my last resort and final attempt to get answers.
I’m a 24 year old male with chronic but stable SOB, palpitations for three years post covid. Worsening SOB lying flat and waxing and waning pulse. Family hx positive for HTN, hyperlipidemia, paroxysmal A-fib (father). Medications include albuterol PRN, Nasacort and Claritin D qd. I’m fairly healthy and eat a relatively balanced diet (could use some work), and exercise 2-3 times a week on average. Tall and slender build.
Previous testing: several EKGs, one echocardiogram two years ago, holter monitor. ALL UNREMARKABLE Labs: unremarkable, but last metabolic panel showed elevated LDLs of 104mg/dL
Here are my most worrisome symptoms at the moment:
1) turbulent decrescendo swooshing while running on treadmill with headphones in (last about 3 seconds and comes and goes after 15 seconds) 2) my hands seem to have some pitting edema (indentations/mark in my hands occur very easily and last ~10 mins). This is more of a newer symptom. Doc said sodium sensitivity?? 3) body shakes with each pulse while laying down at times 4) sometimes I notice my pulse high while laying down or resting (high 90s), then it will slow down dramatically (70s).
Final remarks: these symptoms are troubling and not improving. This is my last option. Happy to answer any questions. Thank you for advance!

49 y/o female. 63inches, 240Lbs. Hx: HTN, Hyperlipidemia, right wrist ORIF, total hysterectomy. Meds: coreg,norvasc, lexapro. No family history of breast cancer. Recent breast biopsy report showed diagnosis of fibroepithelial lesion. There was a comment on differential dx fibroadenoma vs pyllodes tumor. The radiologist who did the biopsy said it was benign and she would see me in a year for mammogram. My question is shouldn't there be further investigation to make sure its not a phyllodes tumor, which could be cancerous?

Thoughts from a FM doc working at FQHC

1. Physicians are not replaceable by midlevels. Absolutely not. This is true even for primary care. Period.
   
2. The amount of patient mismanagement is through the roof. It is actually unbelievable at times. I am saddened that we serve a rural and largely uninsured population that have been seen exclusively by midlevels for the past 5-10 years. And these patients are esrd, dm2, HF, etc. These pts are difficult even for a seasoned physician. And midlevels are caring for these pts? Some of them haven’t seen a primary care physician in years. Unbelievable
   
3. I frequently fu with these chronic dz pts that have had a1c >10 for the last 5 years. Many of these pts are compliant with medications. One of these pts stated that she has been taking the same dose of insulin for the past few yrs with no improvement of sugars and sugars are off the charts. Of course, their primary care midlevel never adjusted meds for past few years. I frequently have to re-H/P these patients in a short 15-30 minute time slot. These patients take time. Med students, this is the importance of history taking. Be good at this and you’ll fix several problems
   
4. Statins being thrown at anyone with a hyperlipidemia. Everyone on aspirin. HCTZ being prescribed for HTN in diabetics. MTP as an only HTN agent in pts with poorly controlled HTN. I have asked pts only on MTP why they are taking that. They say, “idk the ‘doctor’ told me to take it for blood pressure.” These pts have been on MTP for past several years without adjustment. No other indication for BB. Constant medication clean ups I have to do.
   
5. I hate to be mean but they frequently have very poor history taking and lack physical exam skills. The other day I saw an uninsured pt with left hand numbness and tingling. Previous Midlevel prescribed them gabapentin and sent to neurology. I followed up and diagnosed them with carpal tunnel syndrome. A medical student can do this. A medical student can save this uninsured pt time and money. I’ve seen MRI brains ordered for tension headache. Take a good history and do a physical pleeease.
   
6. I feel like I’m ranting but a huge part of my job is cleaning up messes.
   
7. Guess what? Many patients know this. Even in my population with poor health literacy. I frequently hear “that nurse doesn’t know what she’s doing” “I know they’re not doctors” etc. The other day I had a strep throat dude and he’s like “the PA told me that azithromycin was the strongest antibiotic and that’s what they prescribed me. The PA didn’t help me at all and I’m getting worst.” they’re seeing the gaps in care
   
8. I believe in close supervision of midlevels. I have midlevels who frequently staff patients to me. I appreciate them. But you will see the huge gap of knowledge. I used to round with PA students during residency as well. Independent midlevels should not exist.
   
9. Some ppl say that midlevels with experience should or can be independent. Nope. I work with midlevels who have been in health care since I was in elementary school. They still lack a huge amount of knowledge and clinical acumen. Our medical education is very different. Medical school and residency is not equivalent to their experience
   
10. On the plus side the patients appreciate a good physician. They have told me that. It humbles me. The tough days and nights of med school and residency prepared me for this. You may think that “hey this doctor is burned out.” I am not. I love what I do. Again the community will appreciate you. FM is the best specialty. The end.
    

Patient is a 57 year old, female, presenting Covid positive shortnes of breath and chest pain. Initial assessment shows Covid pneumonia and acute myocardial infarction.
Relevant history: Type 1 DM, CKD2, NPDR, HTN, PVD s/p bypass RLE, hyperlipidemia, obesity class 2. Patient had full vaccinations.
Patient was transferred to a level one trauma center where they attempted a PCI and the physician could not pass the balloon, despite a 50% blockage. Patient was brought up to the ICU and thrombolytics was initiated. An intra-aortic balloon pump was put in and due to the critical illness, physician opted to intubate and placed patient in a medically induced coma.
On hospital day two, an echo was done, and it came back fine.
Unfortunately, further information came in on hospital day 4 patient is in acute heart failure and COPD despite not having any history prior to admit. Not a smoker.
Attempts at weaning the patient off the ventilator fail as pulse ox drops to dangerous levels.
Patient diagnosed with Acute CHF and COPD.
My understanding according to the AMA, is that someone presenting with Covid and a myocardial infarction has a 56 or so percent of mortality.
The patient also went without treatment for COVID-19 due to physician, not feeling comfortable with paxlovid due to interactions with insulin and clopidogrel. Patient did not seek treatment from another physician, which I believe was a mistake. Perhaps an infusion of a more suitable medication could have been arranged.
Patient also went without their clopidogrel for 10 days due to coordination of care issues. Could this have played a part in precipitating the MI?
Questions: With the new diagnoses of CHF, COPD, and presumptive diagnosis of acute respiratory failure, with hypoxia secondary to the chemically induced coma, what are the chances of survival?
Given the timeline I’ve described, would it be reasonable to assume the relationship between Covid and these complications?
Would it be reasonable to assume the relationship between MI and demand ischemia?
Interestingly, the transfer hospital did not initiate treatment for COVID-19. Could this have changed the trajectory of the case?