Appendix 4 –Ref. Chapter 6 - Left arm claudication

Events and Drs’ visits from 10/20/99 thru 1/24/00

10/20/99 Visit Notes: Blood drawn – will check Sed Rate and Potassium. Should Pearl take Zestril prescribed by FFP even though her blood pressure at 158 is below the normal Systolic limit of 160 for a person over 45 years of age? Dr advised that Pearl should take it – target upper limit now is 130, not 160, based on Cardiology studies in the past few years. (Note: Cardiologist on a TV Women’s Health Program advised that 140/90 range is normal now.) Send Dr a copy of the Berkeley Heart Panel Test report when received. Next App’t Wed, 11/24/99, 9:45 am. (Note: Nurse called 10/21 to advise that Sed Rate is now 7 – reduce Prednisone to 10 mg/day, take it in morning. She faxed a copy of the report to Pearl – Potassium was slightly over range, but within range of other labs. The Berkeley Report was received later on 10/20 and a copy was transmitted to all the Drs.

10/20/99 - Berkeley Heart Panel Test Report was faxed to Pearl today. Review indicates only Lipoprotein(a) is a risk factor – it measures 19; mean is 5 and upper 10% is 23 (high risk group). Dr will discuss in app’t on 11/9. Copies were forwarded to the Rheumatologist, FPP, Hematologist and Podiatrist.

10/27/99 - Pearl went to Hospital Emergency at about 11:00 pm to check out cause of pain in her neck and left shoulder area, and numbness in her left hand. Her blood pressure was 147/72, Pulse 80, at 8:45 pm, but rose to 189/96, Pulse 92, at 10:15 pm. The dull pain had been present for several hours.

The Emergency Room doctors checked her blood pressure and ran an EKG – the pressure started out elevated similar to what I had measured but by 12:30 am had dropped to 159/58, Pulse 90. The EKG reportedly was good. They ran a blood test but didn’t advise the results.

They concluded that the pain was a muscle spasm between the neck and shoulder, being noticeable when she turned her head one way, but not the other. They discharged Pearl at 1:00 am with instructions to advise FPP of the occurrence, and return to the Emergency Room if the pain became worse. They also advised that she can take Darvocet to relieve the pain – she had two Darvocet tablets yesterday and noticed some relief for awhile after taking them.

Pearl is feeling OK upon our return home – the muscle spasm continues but is tolerable. She took a third Darvocet pill at 3:00 am.

10/28/99 - Letter faxed to FPP – "Pearl went to Hospital Emergency last night at about 11:00 pm to check out cause of pain in her neck and left shoulder area, and numbness in her left hand. Her blood pressure was 147/72 …….. (etc. – see above).

Pearl is feeling OK upon our return home – the muscle spasm continues but is tolerable. Pearl will stop by your office at 1:45 pm to see if you want to see Pearl at this time. Pearl also has appointments with the Hematologist on Monday, 11/1/99, and Cardiologist on Tuesday, 11/9/99."

(Note: At 2:15 pm we stopped by and advised FPP’s receptionist and nurse that another Dr measured Pearl’s pressure and found it normal at about 140/72 – FPP didn’t see Pearl).

11/1/99 - Visit with Hematologist, Mon, 10:30 am – Pressure 120/72, Pulse 92, Temp 98.2, Wt. 151.

High platelets bothered Dr last month – good that Sed Rate is down again. Bone marrow test in December ’98 showed blood is being made properly. Dr reviewed list of Pearl’s medications in hopes of reducing quantity (20) - talk to Cardiologist about taking both Zestril and Inderal – both do the same thing. Blood taken for test – will make app’t after seeing results. (Note: copy of report faxed to Pearl on 11/4/99 – everything within normal limits – platelet count wasn’t received. Requested again on 11/29/99 – Platelets down at 635 from 693 last month; WBC decreased to 13 from 15.3; RBC decreased to 3.77 from 3.85, both low – forwarded a copy of latest report to Rheumatologist, 11/29/99).

11/9/99 - Visit with the Cardiologist, Tues, 1:00 pm – The following items were listed for discussion with Dr – see visit comments below the list:

  1. Heel skin ulcer healed with 10 HBO treatments mid-September – circulation improved with Trental, Pletal.
  2. Sed rate found to be 50 on 9/23/99 (had been < 10) so prednisone was increased from 7 MG/day to 15; Sed Rate was 7 on 10/20/99 so reduced prednisone to 10 MG/day. Prednisone dosage began at 120 MG/day in December for Arteritis and gradually was being reduced – it had been at 8 or below since 5/24/99 –vasculitis first became evident on 6/24/99.
  3. Evaluation of Berkeley Heart Panel Test Report – Hematologist asked why homocysteines weren’t measured?
  4. Review blood pressure readings – 128/72 was average before onset of Giant Cell Arteritis/PMR in December ’98.
  5. Pearl’s visit to Hosp Emergency Room 10/27/99 due to pain in neck and left shoulder, numbness in left hand and sudden increase in blood pressure to 189/96 – EKG was OK, diagnosed as muscle spasm and anxiety. Pressure reduced to typical over two hour period.
  6. Pearl’s left hand gets numb sometimes – she is shaky, slightly nauseous daily, and loses appetite.
  7. Review current medications and dosages related to circulation and heart: Trental, Pletal, Zestril, Inderal LA and Premarin. Should Inderal be increased and Zestril discontinued, or Inderal be discontinued? Gynecologist reduced Premarin to .625 mg from .9 mg – any effect on cardiovascular condition?

Visit Notes: Wt. 151 lb.; Pressure 144/90, Pulse 120. Nurse ran ECG because Pearl’s pulse was unusually fast – result: Good. Dr advised Berkeley Heart Test Report indicates Pearl doesn’t have atherosclerosis – vasculitis is due to Giant Cell Arteritis. All readings are good except Lipoprotein(a), and that is offset by the very high HDL level – good genes. Pearl is in Group A which is a low risk group for heart disease. Homocysteine was not measured because Dr didn’t need that parameter and it is extra cost. Blood pressure is not "high" – no hypertension. Low diastolic offsets the elevated systolic pressure – currently the practice is to average systolic and 2/3 of diastolic, which results in (158+.67(77))/2 = 105. Dr increased Zestril to 10 mg/day instead of 5 – this is still a very low dose. He wants Pearl to keep on with the Inderal LA. Premarin reduction to .625 is OK. Dr is concerned about the potential long term effects of prednisone and Arteritis on the heart – he will monitor for pericardial effusion (fluid buildup in the sac - membrane - around the heart) and aneurysm in the aorta. Next visit: Tues., 2/1/00, 1:00 pm.

11/12/99 - Visit with Ophthalmologist, Fri, 10:30 am – Advised Dr of the following events since last visit:

  1. Completed HBO treatment of skin ulcer on right heel – healed after 10 visits.
  2. Sed Rate climbed to 50 in blood test on 9/23/99 – Rheumatologist increased prednisone from 6 to 15 mg/day. Platelets were 693 in Hematologist’s test of 10/4/99. Sed rate was 7 on 10/20/99 - lowered prednisone to 10 mg/day.
  3. Pearl went to Hosp Emergency 10/27/99 due to pain in neck, left shoulder, numb left hand and elevated blood pressure (189/96). ECG and evaluation indicated muscle spasm in neck – she was OK, released after numbness left and pressure subsided.
  4. Cardiologist had Berkeley Heart Blood Test done on Pearl – result: Cardiovascular system is good -no heart problem, no atherosclerosis and no hypertension. Vasculitis is all due to Giant Cell Arteritis.
  5. Blood circulation and pressure medicines (Trental, Pletal and Zestril) are helping Pearl maintain peripheral vascular circulation.
  6. Continuing with Trusopt – no change in right eye vision. Left eyesight remains good.

Visit Notes: Eye pressures were good – 14 & 15. Dr advised that eyes both look healthy – performed ultrasound scan of right eye – showed nerve is good, presence of floaters. Took photo. Continue Trusopt if Pearl thinks it is doing her some good – optional with Dr. Next app’t 1/14/00, 10:30 am.

11/14/99 - Visit to Walk-in Clinic Sunday, due to flu-like symptoms (coughing, earache, runny nose, pain throughout body, slight fever). Received prescriptions for Zithromax (5 day regimen with 1 refill) and Protuss medicine with Codeine for cough and pain. Start second Z-pack after 7 to 10 days if not well.

11/24/99 - Visit with Rheumatologist, Wed. 9:45 am – Wt 149; Pressure 140/80. Blood sample taken for Sed Rate and Potassium. Discussed two articles re bone building: no need to change from calcium carbonate to Citracal – news that Citracal is absorbed 2.5 times better is marketing ploy. No need to consider Parathyroid Hormone injections for Pearl’s condition. Next app’t Wed, 12/29/99, 10:30 am.

Events since last visit on 10/20/99 were reviewed with Dr:

  1. Pearl went to Hosp Emergency Room, 10/27/99, to check out cause of neck/shoulder pain, numbness in hand on left side and high blood pressure reading. EKG was good – blood pressure gradually reduced – was released after diagnosis that cause was muscle spasms. No recurrence.
  2. Visited Gynecologist, 10/28/99 – prescribed a bone density scan to see changes if any since original on 12/17/98. Rheumatologist advised that Medicare will only pay for a scan every two years – results wouldn’t affect current treatment anyway, would only satisfy curiosity. We declined.
  3. Visited Hematologist, 11/1/99 – blood test (General Chemistry) showed all items within normal limits. Platelets weren’t measured. Rheumatologist thinks platelets likely were measured – request copy again. (This was done on 11/29/99, forwarded copy to Dr. – Platelets still high at 635 but down from 693 on 10/4/99).
  4. Visited Cardiologist, 11/9/99. Nurse ran an EKG because Pearl’s pulse was 120 beats/min upon arrival – result was good. Dr advised that Berkeley Heart Panel test results show Pearl doesn’t have atherosclerosis – vasculitis is due to Giant Cell Arteritis. All readings were good except Lipoprotein(a), and that is offset by very high HDL level – good genes. Blood pressure is not "high" – low diastolic offsets the elevated systolic – currently the practice is to average 2/3 of the diastolic with the systolic to determine hypertension. Dr increased Zestril to 10 mg/day – Pearl had been taking 5 mg/day. Dr is concerned about long-term effects of prednisone on heart – he will monitor her every 3 months for pericardial effusion and aorta aneurysm.
  5. Visited Ophthalmologist, 11/12/99 – both eyes look healthy; ultrasound scan showed nerve is good in right eye.
  6. Visited Walk-in Clinic on Sunday, 11/14/99, due to flu-like symptoms. Started Zithromax 5 day regimen and Protuss cough/pain medicine. Repeated Z-Pack for another 5 days. On 11/23/99 still having difficulty with coughing through the day and night.

11/29/99 Call from Rheumatologist’s nurse – Sed rate is 34 (was 7), increase prednisone to 12.5 mg/day – 10 in AM and 2.5 in PM. Potassium is unchanged at 5.1, .1 above upper limit of normal range.

11/29/99 - Visit with the Allergist, Mon, 3:30 pm – Pearl’s history since last visit, 4/19/99:

  1. The Rheumatologist recommended on 5/21/99 that skin test not be done by the Allergist until prednisone is stabilized.
  2. Vasculitis in lower legs started 6/24/99 – arteriogram of legs showed several blockages of main arteries in both legs. Sore developed on skin of right heel and wouldn’t heal due to poor circulation in the feet – had 10 hyperbaric oxygen treatments and wound healed. Started Trental and Pletal to promote circulation, then Zestril to reduce blood pressure. Cardiologist checked her heart and determined it is in good condition, cholesterol is low, and hypertension is not present.
  3. Blood Sed Rate became elevated (50) due to prednisone dosage being too low (7) – increased dosage to 15, then to 10 – now at 10 mg/day. Sed rate went back down to normal (under 30).
  4. Had flu-like symptoms starting 11/14/99 – has had two consecutive dosages of Zithromax (6 pills each), finished 11/27/99. Received flu shot 10/11/99 but perhaps wasn’t effective. Coughing persists but is at a much reduced level.

Visit Notes: Prescriptions written for 90 day supply with 3 refills for Mail Order via our insurance plan:

Allegra – 1 at night as needed

Allegra-D – 1 in AM

Vanceril Inhaler – 16.8GM 4 puffs twice daily

Serevent Inhaler – 6.5g 2 puffs twice daily as needed

Vancenase AQ (preferred – Drug company got Nasonex approved by the Allergist as substitute) - 1 spray each nostril, twice daily – the Allergist prescribed Beconase AQ instead of Nasonex on 11/29/99.

the Allergist wants to perform skin test on 12/13/99 at 2:30 pm – hold Allegras for 5 days before, and avoid all antihistamines for 3 days before. We canceled skin test because Pearl’s prednisone dosage was increased again after seeing the Allergist – not rescheduled at this time (12/7/99).

12/8/99 - App’t with Vascular Surgeon, 3:00 pm – Vascular Surgeon wasn’t in the office; technician advised that the visit was to be for a repeat ultrasound scan of the leg arteries – the last was done in July. However, since Medicare won’t pay for the scan until Feb, 2000, he suggested that we reschedule. New app’t is Mon, 2/14/00, 2:00 pm. The scan will be done first then the Vascular Surgeon will see Pearl having the scan results immediately after. Pearl’s legs seem to be OK at this time – hasn’t had calf cramps recently, only "shin splints" after walking a block or so.

12/13/99 - Visit with FPP on Mon, 10:00 am – related events since last app’t on 10/11/99:

  1. Visited Hematologist, 11/1/99 – blood test (General Chemistry) showed all items within normal limits – Platelets still high at 635 but down from 693 on 10/4/99.
  2. Visited Cardiologist, 11/9/99. Nurse ran an EKG because Pearl’s pulse was 120 beats/min upon arrival – result was good. Dr advised that Berkeley Heart Panel test results show Pearl doesn’t have atherosclerosis – vasculitis is due to Giant Cell Arteritis. All readings were good except Lipoprotein(a), and that is offset by very high HDL level – good genes. Blood pressure is not "high" – low diastolic offsets the elevated systolic – currently the practice is to average 2/3 of the diastolic with the systolic to determine hypertension. Dr increased Zestril to 10 mg/day – Pearl had been taking 5 mg/day. Dr is concerned about long-term effects of prednisone on heart – he will monitor her every 3 months for pericardial effusion and aorta aneurysm.
  3. Visited Ophthalmologist 11/12/99 – both eyes look healthy; ultrasound scan showed nerve is good in right eye.
  4. Visited Walk-in Clinic on Sunday, 11/14/99, due to flu-like symptoms. Started Zithromax 5 day regimen and Protuss cough/pain medicine. Repeated Z-Pack for another 5 days. Had difficulty with coughing through the day and night until 12/11 – now coughs infrequently.
  5. Blood tested on 11/24/99 – Sed rate and potassium. Sed rate is 34 (was 7), increase prednisone from 10 mg/day to 12.5 mg/day – 10 in AM and 2.5 in PM. Potassium is unchanged at 5.1, .1 above upper limit of normal range. Copy faxed to Pearl.

Visit Notes: Wt 148; Temp 97.9F; 142/70’’Hg, 84 bpm. Blood specimen taken; no follow-up app’t suggested by Dr - following prescriptions written:

Lasix – 30 days supply from local store; 90 days and 3 refills for Mail Order

Potassium – 30 days supply from local; 90 days and 3 refills for Mail Order

Anaspaz\Levsin - 90 days and 3 refills for Mail Order

Blood test results received 1 ½ weeks later – everything tested was normal.

12/16/99 - Visit with Internist, Thursday, 3:00 pm – described Pearl’s status with Dr to get acquainted. He reviewed Pearl’s medications and recommended no changes. He scheduled a follow-up visit in two months – Thurs, 2/24/00, 10:00 am.

12/21/99 - Visit with Ophthalmologist, Tues, 3:30 pm – right eye socket was swollen and slightly inflamed so we requested an app’t. Dr examined the eye and determined it was slightly swollen, bulging out about 2 mm more than the left eye. He prescribed an MRI to see what, if anything, was going on behind the eyeball. Pressure was 11 & 14; both eyes have cataracts due to aging, not prednisone. Next app’t Fri, 1/21/00 at 10:00 am. We scheduled an MRI to be done on Mon, 12/27/99, 9:30 am.

12/27/99 - MRI was done today, 9:30 am. Earlier X-rays were obtained and provided to Open MRI for comparison – they (3) were taken 11/10/98 for sinus infection. Open MRI will return the X-rays. MRI results will be forwarded to the Dr.

12/29/99 - Visit with Rheumatologist, Wed, 10:30 am – Wt 147; pressure 142/80. Blood tested; prescriptions for Fosamax and prednisone (1 MG) rec’d. Advised Dr that Pearl is feeling the best she has in the past year – no vascular problems evident, no red blotches on her feet. Only problems are her stamina (no muscle cramps anymore), stomach aches and headache resulting in visit to the Ophthalmologist and MRI. Next app’t 1/24/00, 11:00 am.

Blood test of 12/29/99 showed sed rate is 24, still high – no change to Prednisone dosage.

1/10/00 - Visit with Hematologist, Mon, 10:00 am – Wt 147; pressure 170/90, rate 88. Drew blood for CBC test. Pearl fatigues easily; no leg cramps anymore. Advised sed rate still higher than normal at 24. Dr felt liver – not hard, good; no swollen lymph nodes, good. Next app’t Mon, 3/6/00, 10:15 am

1/21/00 - Visit with Ophthalmologist, Fri, 10:00am – Pressure was 13 & 13. MRI showed eye is normal, however there was an indication of a previous stroke in a basal ganglia behind one eye – this is not associated with the arteritis; it could have happened anytime in the past. We will ask for more information about this at our next visit (MRI scan and report were not brought to the office for this visit). This unusual condition is not significant per Dr. Pearl can continue the Trusopt if she wants to – it won’t cause any harm, and doesn’t contribute to eye inflammation. Left eye looks healthy. Photographed both eyes with and without intravenous dye. Circulation looks good in right retina. Vision won’t get any better than it is in the right eye, but there is a cataract present that would interfere with vision in the right eye (worse than the left eye) if Pearl had vision. Perhaps that should be operated on someday. Dr advised Pearl will be on prednisone for several years. Dr advised that the right optic nerve is damaged from the arteritis and is precluding vision – we thought it was the rods and cones of the retina that were damaged. Next app’t Fri, Mar 10, 9:50.

1/24/00 - Visit with Rheumatologist, Mon, 11:00 am – Wt.147; Pressure 134/72. Hematologist’s blood test report indicates Pearl is low on protein – increase intake. Platelet count should be in report but isn’t (call later to Hematologist’s office learned that platelet count was 626 – requested copy be faxed to Pearl). Since Pearl isn’t having vascular problems Dr advised that Trental can be discontinued. Asked Dr why C-reactive Protein isn’t being monitored – he advised that it isn’t necessary to monitor both sed rate and CrP, and since he has been tracking sed rate he’ll continue with that. He wants to reduce prednisone dosage as soon as possible – hopefully the blood test today will allow that. He’ll call when results are in. Some people have been weaned off of prednisone in 6 months, others much longer. Long term side effects are bad, so sooner we can reduce/stop the better. Next app’t: Mon, Mar 6, 11:45 am. Nurse called 1/25: Sed Rate is 15 – reduce prednisone to 10 mg/day (Pearl will take all in morning unless Dr advises otherwise – nurse didn’t know what to advise).

 

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