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- Events and Drs’ visits from 8/11/99 thru 10/20/99
8/11/99 - Visit with FPP, Wed, 10:15 am – Pressure 132/84, Pulse 96. Blood tested today for Potassium, B-12 and Sed Rate (requested that results be faxed to us). Prednisone is now at 7 mg/day. Pearl has a bruise on her right ankle that makes standing and walking painful. Dr prescribed an X-ray to see if bone breakage is evident – concern is due to osteoporosis and steroid therapy she’s on. Discussed the artery blockages in both legs – gave Dr a copy of the recent arteriogram. Dr suggested serious consideration be given to surgery to shunt the knee blockages. Discussed possible side effects of Pepcid and Inderal – Dr advised not to be concerned – Inderal side effect of concern would be asthma more than claudication. Need refill of Triamcinolone – Dr wants Pearl to use less of this, and don’t use it for neck rashes – see him if neck rash develops, it may be a reaction to something. Dr wrote a prescription for Inderal LA (3 mos., 1 refill). Darvocet is being used at rate of about 2 pills/week for pain. Next app’t in two months – Mon, Oct 11th, 10:45 am
Results of 8/11/99 Blood Test – Sed rate was 10; Platelets were high @ 555 (400 high limit); WBC, RBC and Hemoglobin were unchanged (out of limits); B-12 and Potassium were good. Forwarded copy of test to the Hematologist – he said OK until next visit 10/11.
8/12/99 - Visit with the Podiatrist, 1:30 pm – X-ray was taken of right foot/ankle to evaluate bone condition at bruised area. Dr advised there is no damage to bone evident. – but wants to check it again in two weeks. App’t made for Thurs, 8/26/99, 1:30 pm. He will send a report to the FPP.
8/19/99 - Visited the Podiatrist Thurs because foot skin crack developed at bruise – gave Pearl topical medication to promote healing – Dermagran; Bactroban; Vanicream.
8/20/99 - Visit with Rheumatologist, Fri, 9:00 am – Pressure = 142/70; reviewed medications. Gave Dr a copy of 8/11/99 Blood test results showing Sed rate at 10 - Dr reduced Prednisone to 6 mg/day (5 & 1). Dr reviewed Pearl’s feet – was concerned about red blotches around edges and open sore on heel, suggested she be seen by the Vascular Surgeon within next few days. Small right toe is red and also has an open sore inside. Dr prescribed medication (Trental, 400 mg, 3/day) to promote blood circulation, also suggested she try baby aspirin. She’s allergic but maybe the prednisone will alleviate the sensitivity to aspirin (tried one later that day and had allergic reaction to it-discontinued). He would like to see her be able to take the aspirin (1 per day) in conjunction with the Trental. We expressed concern about taking Vitamins C, E and Niacin – he advised C & E should be no problem, take with or without meals – hold off on the Niacin. Re blood test: Platelets @ 555 are not of concern – if at 1,000 they would be. Next app’t Thurs, 9/23, 10:30 am. (Note: later we rescheduled Vascular Surgeon’s app’t to Thurs, 8/26/99, 11:40 am, from 9/24/99, 10:00 am.)
8/26/99 - Visit with Vascular Surgeon , Thurs, 11:40 am – Blood Pressure 130/80. Dr viewed Pearl’s right ankle and both feet. The right ankle had an open wound which was of major concern to Dr, also purple blotching was present around the heel and some toes of the right foot. He suggested she go to the hospital to get the foot wound cleared up. We advised that the Podiatrist is treating the foot wound and we had an appointment in an hour for follow-up with the Podiatrist. Dr would like to receive the Podiatrist’s input in the matter and would hold final arrangements pending the Podiatrist’s review.
Vascular Surgeon said the blotching is evidence of vascular circulation problems - he agreed with the Trental medication prescribed by the Rheumatologist last week. We advised that Pearl tried baby aspirin also but got a reaction (itching skin). Since Trental takes a couple of months for effect, Dr prescribed Pletal to be taken in addition to the Trental. Pletal will dilate the arteries but will cause headache for a week – and shouldn’t be taken by people with heart disease – it will take two weeks to become effective.
We asked about reducing/stopping Inderal which Pearl has been taking for years – it is a beta blocker which is a vasoconstrictor. Dr said he can’t reduce the Inderal without guidance from a cardiologist. Since Pearl is taking it to prevent migraine headaches he will refer her to a cardiologist and a neurologist. (James called the Vascular Surgeon on 8/27 for referrals to a cardiologist and neurologist – Pearl is holding up starting Pletal until discussion with the cardiologist).
Dr will prescribe hyperbaric oxygen therapy (HBO) to promote healing of the foot sore and the blotching. This would be done in the hospital, along with intravenous administration of antibiotics for foot infection. Dr will await the Podiatrist’s evaluation. No app’t was made.
8/26/99 - Visit with the Podiatrist, 1:30 pm – The wound on the right heel was viewed. Dr doesn’t see signs of infection so antibiotics likely are not needed. In the event the wound is an allergic reaction to either the Dermagran dressing or the Bactroban cream, he applied Ferris PolyMem dressing for wound care and discontinued the Dermagran and Bactroban. HBO can be done on an outpatient basis, and the group that does the HBO will evaluate need for antibiotics when viewing the wound.
Since Pearl is allergic to so many foods and is on so many prescription medications he thinks it would be best if Pearl not enter the hospital for wound treatment at this time. He contacted the Vascular Surgeon later that evening and advised him of his evaluation – they agreed that Pearl would be treated with HBO as an outpatient. Follow-up the next morning (8/27/99) – the Podiatrist’s office arranged for HBO on Thursday, 9/2/99, 8:15 am at the Hospital.
8/27/99 - Note: Pearl’s wound looks much better the next morning (8/27) after discontinuing the Dermagran and Bactroban. Review of drug information indicates Dermagran is a zinc based product with a slightly acidic formulation Bactroban may be a problem for people allergic to preservatives and dyes.
8/27/99 - Contacted FPP’s Office for referral to a cardiologist for Pearl. Nurse recommended a Group. Contact with the Group resulted in an appointment with the Cardiologist on Thursday, 9/2, at 1:30 pm.
8/30/99 - Contacted Rheumatologist by fax regarding Trental and prednisone dosages: Should prednisone be increased from 6 MG/day? Pearl has been feeling poorly since the prednisone was reduced to 6 MG. She has had a headache above her right eye (forehead), and complained that she feels like she is reverting back to the discomfort she had before starting the prednisone. The headache may be due to the Trental – both Trental start and prednisone reduction to 6 MG were done on 8/20. He advised Trental can be reduced to 2/day to reduce headaches and nausea, and Prednisone can be increased to 7 MG/day if symptoms of PMR/Arteritis are being experienced with 6 MG/day.
9/2/99 - Visit with HBO Dr (Hyperbaric Oxygen) Unit at the Hospital, 8:30 am, Thurs.
Pearl’s heel wound was cleaned of debris (scab, etc.) and viewed. It appeared to be very clean and susceptible to healing from inside out. A test was performed to see if oxygen therapy would improve blood/oxygen supply to the foot and toes – the test showed HBO would be beneficial. The wound was dressed with a saline pad – it should be changed once or twice a day. An app’t to start HBO was tentatively scheduled for Friday, 9/3, at 10:00 am. Pearl has an app’t with the Cardiologist at 1:30 pm she must get clearance from him to receive HBO.
9/2/99 - Visit with Cardiologist, 1:30 pm, Thurs. – Blood Pressure was 140/90, Rate 62. An EKG was done. Dr advised Pletal can be taken along with Inderal LA – the only effect might be a reduction of the effects of the Inderal. The Inderal should never be stopped. Dr was most curious about the cause of the atherosclerosis – he didn’t understand the cause until we discussed Giant Cell Arteritis and PMR. He tentatively attributes the foot problems to the Arteritis since there is no other cause apparent – she has none of the typical risk factors for atherosclerosis. He plans to send a blood test specimen to California for special diagnosis – this will take about 3 weeks to get results – the blood will be drawn next week. We discussed Pearl’s need for HBO therapy tomorrow for a wound on her heel and told him the HBO Dr wanted him to "sign off" for the HBO. Dr prescribed an echocardiogram and stress test to be done in order to assure Pearl can take HBO. The echocardiogram was done at 3:00 pm but the stress test couldn’t be done until Friday, 9/3, at 1:30 pm. (This means that Pearl can’t undergo HBO until Tuesday, 9/7). An app’t was scheduled for 9/9/99 to review the results of the Cardiologist’s tests.
Discussion with HBO Nurse, after Cardiologist’s app’t – Dr can’t perform HBO without the Cardiologist’s sign off. Reschedule HBO to Tues., 10:00 am, assuming favorable results of stress test. Contact the nurse after stress test results are known to confirm HBO app’t.
9/2/99 - Pearl started Pletal – will take 1/day for 7 days, then on 9/9/99 will start 2/day.
9/3/99 - Dual Isotope Stress Test was conducted on Friday, 1:30 pm thru 5:15 pm. Stress was induced via pharmacological agents (persantine or adenosine). Pearl’s right leg felt like circulation was better after the test – she suffered no ill-effects during or from the test, just felt tightness in her chest during stress administration. Asked the nurse to request that Dr call the HBO Dr when he determined the test results – I gave her a second copy of the HBO report received earlier that day. HBO therapy is waiting for Dr’s input.
HBO Therapy began 9/7/99 at 10:00 am after Pearl was cleared by the Cardiologist. It will continue each weekday at 10:00 am for 10 sessions – wound will be examined at that point and 10 more sessions will be done if wound still hasn’t healed at that time.
9/9/99 - Visit with the cardiologist, Thurs, 2:45 pm – BP 162/86, Pulse 88, Wt. 151 lb. Re Echocardiogram Test of last week: heart muscle is thickened, left ventricular hypertrophy – caused by high blood pressure. (Note: Cardiologist on TV Women’s Health Program advised that 140/90 range is normal for blood pressure.) Re Stress Test of last week: Normal except tightness when stressed indicates probability of heart disease. Dr thinks neither of these conditions is due to Arteritis. He wants to take a blood test (Berkeley Heart Panel) - app’t made for 9/17/99, Friday, 8:45 am. Fast, except water is OK, for 12 hours; medications are OK. Dr will be our primary care physician for the heart condition. He requested that Pearl’s blood pressure be monitored 3 times a day, including periods of work. FPP’s Office hasn’t provided a legible copy of the reports of Echocardiogram, Carotid Artery Study and ECG tests done on Pearl on 12/14/98. The copy sent via fax was smeared and unreadable; 4 repeated requests were not answered. I advised I will obtain them from the FPP and send them to Dr. (I did so on 9/10/99). Next app’t in 2 months – 11/9/99, Tuesday, 1:00 pm.
9/17/99 - Blood specimen for Berkeley Heart Panel Test was drawn in the Cardiologist’s office, 8:55 am. Results expected in 10 days – nurse will call with results.
9/17/99 - Visit with Ophthalmologist, Fri, 3:20 pm – Pressure 14 & 16 (good); 20/25 vision in left eye. Pearl thinks peripheral vision improved a little from HBO therapy – she’s had 7 treatments to clear up a skin ulcer on her right heel – 3 more to go. Dr advised the HBO therapy can indeed help the eye health. Also, prednisone helps the retina. We advised Dr that Pearl is now on Trental and Pletal to improve circulation. Cardiologist ran stress test and echocardiogram on Pearl and confirmed atherosclerosis effect in heart – thickening and hardening of heart wall. Both eyes continue to look healthy – took a picture of her right eye. Continue Trusopt – next app’t in 2 months, Fri, Nov 12, 10:30 am.
9/22/99 - Final (10th) HBO treatment was received Wed., heel wound is closed - no further treatments needed.
9/23/99 - Visit with Rheumatologist, Thurs, 10:30 am – Blood Press 140/70. Pearl had headache on right forehead and blood vessels were prominent visually on her right forehead (not bulging and not in area of her temporal artery) yesterday late afternoon, and very low diastolic blood pressure at 123/47 – headache and low pressure lasted a few hours. Same thing repeated in the late evening – both occurred a few hours after taking Pletal. Pearl was concerned it might be the Arteritis returning – Dr said he didn’t think so. Prescribed a sed rate test – will call to let us know the results in a few days. Told Dr about the hyperbaric oxygen treatments Pearl just completed (10) to heal her right heel skin ulcer. Also advised that Pearl had stress test and echocardiogram test done by the Cardiologist – also, a blood specimen was taken for a Berkeley Heart Panel test for lipoprotein(a) and homocysteines. Dr didn’t like the looks of Pearl’s right foot – still looks like not enough circulation. He was surprised that that the Vascular Surgeon hasn’t recommended arterial shunt surgery for her right leg. Dr wrote prescriptions for Darvocet and Trental. Next visit in 4 weeks - Wed, Oct 20, 9:30 am.
Rheumatologist’s nurse called 9/24 to advise that sed rate is 50 so Pearl should increase Prednisone to 15 MG/day – 10 in am and 5 in pm (start with 5 in am today, 5 at noon and 5 in evening).
9/24/99 - Visit with Vascular Surgeon, Fri, 10:00 am – Blood Pressure = 140/80. Advised Dr that Pearl completed 10 HBO treatments and was dismissed by the HBO Dr. Dr looked at Pearl’s foot and said it looks much better – the sore has healed and the blotching is reduced around the periphery of the right foot. Soreness in deep tissue will continue as it completes healing internally. Asked Dr again about decision not to perform shunt surgery on Pearl’s right leg. He said that is a last resort – surgery can result in complications worse than she has now. Continue with medication and exercise – likely that will bring good results for her. Advised Dr that Pearl’s pulse has increased – he said the Pletal is expected to increase it about 10% - as long as it remains below 100 it isn’t of concern. Check with the Cardiologist about pulse at next visit. Told Dr of visit with the Cardiologist earlier, stress test, echocardiogram and Berkeley Heart Panel Blood Test. Discussed blood pressure fluctuations including low readings and headaches – appears to be expected effects of Pletal. The Vascular Surgeon will advise the Cardiologist of his findings regarding atherosclerosis during this visit to keep him informed. Next app’t in 10 weeks – Wed, 12/8/99, 3:00 pm.
9/24/99 - Visit with the Podiatrist, Fri, 11:30 am – Dr observed the foot sore on Pearl’s heel after completion of the HBO. No further attention is required – bandage isn’t required other than to cushion the healed area as long as it is tender.
10/4/99 - Visit with Hematologist, Mon., 11:30 am – Wt. 152, Press. 132/80, Pulse 100, Temp 98. Advised Dr of Pearl’s status since last visit with Dr on 7/14/99:
Dr reviewed 8/11/99 Blood test by FPP – B-12 was normal. Took a blood specimen today to measure red blood cells. Examined Pearl’s liver, found OK – no gastric difficulties evident. Advise him of homocysteine findings in Berkeley Heart Panel Test. Next app’t Mon. Jan 10, 10:00 am. Nurse called with Pearl’s blood test results – platelets are higher – Dr wants app’t in a month rather than 3. Copy of report was faxed to Pearl – new app’t: Mon, 11/1/99, 10:00 am.
10/11/99 - Visit with FPP, Mon, 10:45 am:
Pearl’s status since last visit, Wed. 8/11/99:
Blood pressure: 166/88; Pulse: 94; Temp 96.2F. Dr felt good pulse in both ankles. Discussed Pletal and Trental – they and prednisone must be doing some good since Pearl can walk a block now; couldn’t walk more than 20 feet a couple of weeks ago due to right heel pain and right calf cramps. Reviewed blood pressure history in past year. High pressure and pulse since on prednisone, Trental and Pletal. Increased prednisone to 15/day since sed rate increased to 50 on 9/23. Platelets also high at 693. Dr prescribed Zestril to lower Pearl’s blood pressure. Gave a Flu shot to Pearl. Next app’t Mon. 12/13/99, 10:00 am.
Questions asked of FPP during 10/11/99 visit:
Recap of some reference literature regarding GCA: (not reviewed in 10/11/99 Visit)
10/20/99 - Discussion Items for visit with Rheumatologist – Wed, 9:30 am
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