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Impressum

2/1/00 - Visit with the Cardiologist, Tues, 1:00 pm – Wt. 146; Pressure 132/82, Pulse 96. Indications of vasculitis have been gone for a month or more (no leg cramps, no foot skin discoloration). The Rheumatologist stopped Trental at our last visit on 1/24/00. (Pearl restarted Trental on 1/28 – thought circulation was reducing in her legs/feet). Pearl had flu-like symptoms for a month starting 11/13/99 even though she had a flu shot a month earlier. Took 2 consecutive anti-biotic prescriptions (Zithromax). Sed Rate went up to 34 in 11/24 test (was 7 on 10/20) – increased Prednisone to 12.5 from 10. Sed Rate finally went down to 15 on 1/24/00 so reduced prednisone back down to 10MG/day. Hematologist’s blood test of 1/10/00 shows protein is low, and platelets are high at 626. Dr advised Pearl that he thinks her heart is in good shape, that she should exercise as much as possible to build up her muscles and strength. He agreed that prednisone should be minimized to the extent possible as soon as possible, as the Rheumatologist is doing. She doesn’t have atherosclerosis – was surprised that an ultrasound scan hasn’t been done on her legs recently to evaluate the vasculitis that was present earlier. We advised she will get that in two weeks by the Vascular Surgeon. Dr will want to repeat the stress test sometime. Next app’t in 3 months – Tues., April 25, 1:00 pm.

2/10/00 - Called Rheumatologist’s office re new vascular problem in Pearl’s left foot. Pearl’s left heel is showing discoloration similar to that seen on right heel in July which resulted in an ulcer, HBO treatments, Trental, Pletal and increase in Prednisone. Should Pearl increase Prednisone? Dr advised "No". I told the nurse Pearl restarted the Trental on 1/28 after stopping it on 1/24 – she restarted because she felt the circulation in her legs was degrading. Today (2/10) she will start 3 pills/day as Dr originally prescribed (she was only taking 2 because of the side effects they had when she first started them). Pearl will be seeing the Vascular Surgeon on Monday.

2/14/00 - Visit with Vascular Surgeon, Mon. 2:00 pm – Events since Pearl was last seen (9/24/99) by Dr:

1. Prednisone dosage prior to start of vasculitis in June, 1999, had been down to 8 Mg/day for a month – Sed Rate climbed to 50 on 9/23 so prednisone was increased to 15 Mg/day. Sed rate was 15 on Jan 24 so prednisone was reduced to 10 Mg/day. Platelet count remains high at 626 (1/10/00).
2. Zestril was started on 10/20/99 by FPP (5 Mg) and increased to 10 Mg/day by the Cardiologist.
3. Pearl’s circulation appeared to be good, all discoloration had disappeared, and she had no more cramps so we asked the Rheumatologist if she could discontinue the Trental on 1/24/00. He said yes – she stopped it for 4 days then restarted it because her legs felt like circulation was affected.
4. Leg cramps disappeared in December. Pearl was weak until about the end of January – started to walk at that time – Art Fair, couple of malls, around block at home. Left heel discoloration and soreness began 2/9/00 making walking very painful – the episode last summer was with the right heel. She has been careful to stay off of it in hopes it won’t ulcerate like the right heel did, requiring HBO to heal.
5. The Cardiologist advised Pearl on 2/1/00 her heart is in good shape and repeated she doesn’t have atherosclerosis. He wants to do another stress test sometime. He encouraged lots of exercise.
6. Our prescription drug plan substituted Zantac for Pepcid. A drug interaction study indicates Zantac interacts with Petal but Pepcid doesn’t. Is this a concern for Pearl? Should she insist on Pepcid which she has been taking successfully for several years?

Discussion at this visit (2/14/00): Pressure 146/90

A doppler scan was performed in Dr’s office today – results were basis for discussion with Dr. Ankle/Brachial Index was .58 on right leg, .62 on left leg. Post Tibial indexes were lower, @ .40 for right and .57 for left. These readings are lower than those taken on 7/7/99 in Dr’s office and those taken on 7/11/99 at the Hospital during the emergency visit due to claudication in her legs. The 7/7/99 readings were 1.08 on right ankle and .70 on left ankle. Reading on 7/11/99 were .57 on the right and .89 on the left ankle. Flow in the toes has diminished significantly from the 7/7/99 scan. Ankle/Brachial Indexes were as follows in the several scans conducted on Pearl:

 

Purpura and ulcer in July-September, 1999, were on the right heel. Purpura which began 2/9/00 is on the left heel – the right heel looks clear at this time and has been since HBO treatments were completed in September, 1999. The left heel is not ulcerated yet (did ulcerate later on 2/25/00).

The Vascular Surgeon deferred to other specialists to determine how much of the vasculitis is atherosclerosis and how much is arteritis – he suspects there is some of both going on in Pearl’s legs. He prescribed a sed rate test – if it is higher than the last one he would encourage the Rheumatologist to increase the prednisone. Dr gave Pearl prescriptions for Pletal and Pepcid. We discussed interaction between Pletal and Zantac (Zantac was pushed on Pearl as a substitute for Pepcid recently due to Pepcid being more expensive). Next visit: 3/13/00, Monday, 2:40pm. (Sed rate results obtained 2/16/00 show an increase to 19 (was 15 on 1/24/00)).

Contacted Rheumatologist ‘s office 2/16/00 to advise sed rate results and see if Pearl should increase prednisone from 10 Mg/day. Dr‘s office called back and said don’t change. I sent a follow-up letter requesting that he consult with the Vascular Surgeon about Pearl’s vasculitis – 2pe16a0.doc.

2/18/00 – Increased prednisone to 12.5 mg/day without Dr’s consent to try to gain improvement of deteriorating left heel skin discoloration. On 2/25/00 the skin cracked producing an open wound, as the right heel did last summer.

2/24/00 - Visit with new Internist, Thurs, 10:00 am: Wt.147; Press.160/86; Pulse: 100; respiration: 20/min; 98.1 deg.

Pearl’s status since last visit with Dr, 12/16/99 -

1. MRI scan prescribed for right eye socket which was slightly swollen, by Ophthalmologist on 12/27/99 – no problem evident.
2. Platelets still high at 626 in blood test by Hematologist on 1/10/00 – had been 693 in Oct., 635 in Nov.
3. Cardiologist advised Pearl 2/1/00 her heart is in good shape – still thinks Pearl doesn’t have atherosclerosis.
4. Called Rheumatologist 2/10/00 to advise him that left heel is showing same discoloration that right heel had last July which eventually ulcerated and required 10 hyperbaric oxygen treatments to heal.
5. Vascular specialist did a doppler scan of Pearl’s legs on 2/14/00 – indicated poorer circulation than scans done in July, 1999. Had sed rate measured – it increased to 19 from 15 measured on 1/24/00 by Rheumatologist.
6. Pearl was on 10 mg/day of prednisone since 1/24/00 – we requested that the Rheumatologist increase it after seeing sed rate go up to 19 three weeks later. The Rheumatologist said to keep it at 10 mg/day. We increased it to 12.5 on 2/18/00 because Pearl’s sore heel was not improving.
7. We reduced Lasix and Potassium from the daily dosage to the same amount but every other day, on 2/18/00, hoping to improve circulation in her legs and feet.
8. Gave a copy of sed rate History Chart to Dr (c:\xl\pearl\Arterit9.xls).

Discussion with Dr:

1. Can/should Lasix and Potassium be discontinued to improve peripheral circulation? They were prescribed April, ’99, by FPP to alleviate slight edema in Pearl’s ankles. A month later the vasculitis started. Ans: If taken only for edema they can be tapered off – consider every third day, every fifth day, then take as needed for edema. Take potassium when taking Lasix. Continue low salt diet.
2. Can Allegra-D be a contributor to the peripheral vascular problem? It reportedly constricts blood vessels – prescribed by Allergist to block effects of histamine. Started to take this in April, ‘99, few months before vasculitis started. Ans: Talk to Rheumatologist and Allergist about Allegra-D.
3. Is Pepcid better to take with Pletal than Zantac with Pletal? Drug interaction is noted for Zantac, but not Pepcid. Ans: Pepcid is good – Dr doesn’t like interaction of Zantac and Pletal – he thinks drug company will go along with new prescriptions for Pletal and Pepcid furnished by the Vascular Surgeon.

Dr checked Pearl’s pulse in various parts of her body – circulation appeared good. He advised her not to walk on her discolored left heel, to avoid ulceration. Circulation medications being taken: Pletal is good; Zestril is good – both dilate blood vessels. Trental might not be of value for circulation. Ru-tuss, formerly taken by Pearl, is stronger than Allegra-D. Next app’t: 2 months – Thurs, 4/27/00, 10:00 am.

2/29/00 - Visit with Dermatologist, Tuesday, 3:20 pm – Ref: see letter 2pe29a0.doc for background information prepared for Dr. What is the cause of, and recommended course of treatment for, left heel skin discoloration and ulceration that is present now? Dr advised the indications are an immune system disorder causing vasculitis of the feet. Both heels were discolored during the visit – the open wound on the left heel had not soiled the dressing since the night before indicating it was closing up. We had used PolyMem – a three component dry dressing. Dr prescribed ultravate salve be placed directly on the wound and immediate surrounding area. Also, he would like the prednisone be increased to 15 mg/day from the 12.5, if Rheumatologist would agree to that. Exercise that won’t place pressure on the heel would be OK – since he doesn’t consider this to be atherosclerosis, exercise won’t improve the circulation. Next App’t – Tuesday, 3/7/00, 11:40 am. Note: Ultravate was discontinued on 3/3 due to skin getting soggy - PolyMem restarted – drainage stopped and wound closed within 24 hours. (However, it reopened and continued to drain slightly).

2/29/00 - Contacted Rheumatologist’s office to request increase of prednisone to 15 mg/day – Nurse said if the Dermatologist wants 15 Dr would agree to it – he was not in so she would inform him Wed. AM. She also requested a visit report from the Dermatologist. (I contacted Dr‘s Voice Mail and requested the report be furnished to the Rheumatologist). Pearl began 15 Mg (10 in AM and 5 in PM) 2/29/00. During the night she felt improvement in circulation in her legs. Nurse called back Wed. AM to confirm Dr agrees.

3/6/00 - Visit with Hematologist, Mon. 10:15 am - Pearl’s status since last visit with Dr, 1/10/00:

1. New vascular problem showed up in Pearl’s left heel on 2/10/00 – discoloration, soreness, then skin ulceration on 2/25/00. Last summer the same problem occurred in her right heel requiring HBO to heal.
2. Doppler scan of both legs by the Vascular Surgeon on 2/14/00 showed no improvement since 7/11/99 scan.
3. Sed rate increased from 15 to 19; Dermatologist recommended prednisone increase to 15 mg/day, 2/29.

Wt. 145 lb.; Pressure 140/80. Blood tested, included sed rate and Potassium. Hematologist thinks Pearl’s blood readings are as expected for person on prednisone. Nothing alarming – platelets though elevated (626K) are not of concern (over 1,000K would be). Immunoglobulin G when low (below 500) is an indicator of infection – Pearl’s readings while slightly low (637) are not of concern. Bone Marrow test taken in December, ’98, showed she is making blood cells within normal range, though on low side. Next visit in 3 months – Wed, 6/7/00, 10:30 am.

3/6/00 - Visit with Rheumatologist, 11:45 am – Wt. 144; Pressure 120/72. Discussed opinions of other doctors about Pearl’s vasculitis and heel ulcer. Dr thinks it is typical plaque buildup and blockages due to atherosclerosis – arteritis affects only temporal type arteries. He recommends angioplasty be done at once before it is necessary to do shunt surgery. We inquired about increasing prednisone to 20 – 15 for several days hasn’t made a difference. Also we asked about a specialty clinic that Dr might be aware of that might be able to sort out Pearl’s arteritis/vascular problem. Dr advised that we could try 20 mg/day (15 AM and 5 PM) for a month to see if it is an immune problem or atherosclerosis. He can refer us to either of two reputable clinics. We agreed to wait for a month – the right heel cleared up last year after several months; hopefully the left heel will do the same without need for the clinic observation. Dr said if the blockage is immune-related he can reduce the prednisone and start Pearl on Methotrexate. Dr gave Pearl prescriptions for mail order of Darvocet and prednisone (5 mg). Next app’t: Mon, 4/10/00, 3:15 pm.

3/7/00 - Visit with the Dermatologist, Tues, 11:40 am – Viewed Pearl’s left heel discoloration and ulcer. Indication is vasculitis, poor circulation to the foot. Cause of poor circulation is not known by Dr - he recommends that the Rheumatologist and Cardiologist discuss that and reach an agreement. We told him we stopped the Ultravate because of the skin turning mushy and went back to the PolyMem dressing – the wound seems to be getting better since then. Dr advised that Pearl continue the prednisone dosage of 15 mg/day for another week – if improvement isn’t noticed, step up to 17 ½ per day for a week, then up to 20 per week if not improved. If the wound doesn’t heel he recommended treatment by Wound Care. No app’t was made to see Dr again for this heel discoloration and ulcer condition.

3/10/00 - Visit with Ophthalmologist, Friday, 9:50 am – Pressures: 15R, 14L. Dr noted there had been a slight hemorrhage in Pearl’s left eye but it was stopped now. He scheduled another app’t in 3 weeks to recheck the left eye. Only reason speculated was high blood pressure. Photos were taken with and without dye. We discussed the MRI report. Basal Ganglia is a nerve located at the brain stem. Chronic sinusitis is not uncommon. We advised Dr of intent to visit a renowned Clinic because of 3 uncertainties: Arteritis therapy; Vasculitis cause; and Sinusitis therapy – he favored that. Next app’t: Tues., March 28, 3:30 pm in Leesburg.

3/13/00 - Visit with Vascular Surgeon, Monday, 2:40pm – Pearl’s left heel ulcerated since we last saw Dr. He thought the heel looked worse this time than a month ago. We assured him it is now looking like it is on the mend. He took a photo of it. He advised to be careful not to let clothing rub against the discolored skin since it might slough off a layer of skin. He reiterated that surgery is not recommended for Pearl as long as there may be inflammation of the arteries (such as giant cell arteritis) – surgery in that case would only aggravate her vasculitis. We advised him that Prednisone is now at 15 mg/day - we went to a Dermatologist when the ulcer developed. The Dermatologist recommended the increase to 15 – we had already increased to 12 ½ two days after our last visit. Sed rate is now at 16, down from 19. When her foot heals he recommends exercise to promote circulation in the legs and feet.

We advised of our scheduled app’t with a renowned Clinic March 30 because of three problems: Arteritis therapy; Vasculitis; Chronic Sinusitis – he agreed it should be worthwhile. No follow-up app’t was scheduled pending the results of the Clinic visit. We advised we have not been able to get Pepcid yet – he’s had his nurse following up on this. She advised she was contacted today by our insurance company and they agreed Pearl should get two 20 mg pills/day, especially because of the high prednisone dosage. FPP’s nurse called 3/21/00 to advise that she convinced our insurance company to authorize Pepcid for 6 months.

3/20/00 - Visit with the Podiatrist, Mon, 1:30 pm – Pearl’s heel wound was viewed – scab was removed and PolyMem dressing applied. Dr recommended HBO therapy and set up an app’t for Tues., 3/28/00, 8:30 am. Dr also removed part of middle toe nail on left foot which was ingrown. Next app’t Fri, 3/24, 1:00 pm.

3/20/00 - Pearl increased Prednisone dosage to 20 Mg/day (10 in morning and 10 at night) since heel discoloration continues.

3/24/00 - Visit with the Podiatrist, 1:00 pm – heel wound slightly larger – Dr debrided it again. Deferred future visit pending outcome of app’t with Wound Care on Tuesday.

3/25/00 - Decreased Prednisone back to 15 Mg/day since no change noted in heel discoloration, and Pearl was losing some energy.

3/28/00 - Visit with Wound Care, 8:30 am – Dr viewed wound and had oxygen test done on the left foot and heel. Test showed tissue was getting enough oxygen to promote healing. There is no need for HBO therapy. Keep moist with Biafine cream. Next app’t Tues., 4/11/00, 11:30 am.

3/28/00 - Visit with Ophthalmologist, Tues., 3:30 pm – Pressures were 17R and 14L. Hemorrhage still present in left eye – Dr expected it would have cleared by now. It isn’t serious, just shouldn’t be there. He said it is typically a result of high blood pressure. Pearl is on Zestril to reduce blood pressure. Dr will monitor this at next visit, Fri, 4/28/00, 11:40 am.