To whom it may concern,
I've been asked to provide a letter for Mr. ... upcoming surgery for what he tells me is a pre-cancerous lesion in his esophagus. Because I find him top be complicated and because you are likely to be obtaining information from many different sources, I put some things in different fonts and then will expand below on some items. Please read whatever you think relevant.
His current meds are:
- Lurasidone 40 mg po QHS with dinner consisting of at least 350 calories (rxed by this MD)
- Geodon 120 mg po QHS with at least 500 calories (rxed by this MD)
- Brintellix 20 mg QAM (RXED BY THIS md)
- Protonix 40 mg BID
- Terazosin 2 mg po QHS
- Tylenol 325 mg prn, TDNTE 3000 mg/day
- Ferrous Sulfate 375 mg TID
- Magnesium Citrate Spoonful BID
- Lactulose ii po BID
- Colace QD
- Acetyl Glutathione 100 mg BID [From here down, these meds are Rxed or suggested by Dr. ...]
- Pure Adrenal 400 mg iii po QAM/I po Q noon, likely by now already increased to ii at noon.
- L-Carnitine 1000 po BID
- Melatonin 2 mg I - ii po QHS
- SAMe 200 mg iii po QAM and ii po Q noon
His medical issues are below. Bullet points are in this font, with recent and relevant hospitalizations noted in some detail below. Elaboration which may or may not be relevant are in parentheses and/or in this font.
When I am stumped. I place the differential diagnosis I think about in this font, also in parentheses after the term "r/o."
Past and current Medical Hx:
5/30/14 - upper endoscopy by Dr. [...] revealed a 4 cm distal esophageal mass, a 5 cm hiatal hernia, and a 6 mm bulbar ulceration.
3/19/14 - 4/21/14 - Admission, CPMC for presyncope. The caregiver said the patient was crawling on the carpeted floor on his knees, unable to stand. The patient acutely decompensated in the emergency room, necessitating intubation. He suffered hemorrhagic shock.
*A) Emergency upper endo revealed a duodenal ulcer eroding into the gastroduodenal artery. He subsequently underwent duodenal artery Embolization/IR coil. He required multiple endoscopies to stop further bleeding, and 12 units of PRBC's. Gastrin levels were normal. No history of NSAID use. (Pt. coded three times in the ER (as above) and ICU. He developed above mentioned hemorrhagic shock secondary to the gastroduodenal artery bleed and was hypotensive in the ICU with an Hgb of 3.)
*B) Seizure secondary to hypoxia from massive GI bleed (no ictal events noted on EEG per Neurologist Dr. [...] after the fact and Keppra 500 mg IV BID given transiently and was D/Ced with no suggestion of continuing.
EEG/Video telemetry on 3/23/14 revealed no seizure but background EEG shows mild-moderate diffuse, intermittent disturbance of cerebral activity. CT of brain w/out contrast 3/20/14 showed mild cerebral atrophy and chronic small vessel ischemic changes otherwise no acute cerebral issues.)
*C) s/p Aspiration pneumonia while hospitalized, treated with Vanco/Zosyn, febrile with an increase in WBC's.
*D AMS - when in shock, he had altered mental status and then improved in his H and H but had a persistent waxing and waning mental state for a prolonged period thereafter. There is a verbal report of him throwing feces and a written account of him becoming aggressive and not knowing what city he was in and disoriented to place otherwise. 3/19-3/28/14, he was visited by consult liaison psychiatry and found to lack capacity to make medical decisions, lack capacity to leave hospital AMA as the patient was deemed to be delirious and unable to manipulate information in a logical manner and exhibited poor attention and memory. Essentially all his outpatient psych meds were stopped and he was given IV Haldol. During this time, he was also consulted by neuropsychologist Dr. [...] but this MD does not have the records of this despite requesting them from CPMC medical records several months back and from the neueropsychologist himself. Verbally, Der. [...] opined that in addition to the delirium present, there was evidence of an ongoing dementing illness and recommended not removing power of attorney until he could be fully evaluated neuropsychologically. He continues with POAttorney [...] to this day for management of property and personal affairs.
*E) Potential GU obstruction, possibly secondary to prostate Ca.
*F) hyperlipidemia
*G) Right hip/coccyx wound
*H) groin rash, started on Nystatin
*H/H as outpatient on 3/17/14 8.4 and 27.1.
*2/25/14 hospitalized at UCSF after sustaining loss of consciousness. The patient was found to have altered mental status, severe hypernatremia of 152, and sacral cellulitis. The patient's Hct went from 9.9 to 7.7 with a Hct of 23 during the hospital stay. A serum Fe was low at 33. Ultrasound of abd, CT head, chest X-ray, lumbar puncture were performed. Internal bleeding did not appear to be entertained when evaluating the records sent to me from UCSF. Curiously, he had symmetric wounds on his knees, tops of his feet, and large toes that looked like scrapes. Discharge Hct was 26.3.
*March 2013 prostate biopsies at UCSF under Dr. [...] showed atypical cells. Re-biopsy February 2014 showed several specimens to contain a high-grade prostatic intraepithelia neoplasia. He is currently be followed with PSA's.
*Adrenal adenoma. Followed by Dr. [...] two to tree times per year. At this time they are only watching for growth or activity through laboratory tests and ultrasounds. The presenting issue was his testosterone was deemed to be too high for a man his age by Dr. [...].
Renal insufficiency. This is greatly improved since earlier this year. In September 2013 had normal function. (2/29/2012 creatinine clearance was within normal limits at 74, but his total urine protein was increased at less than 160 and the normal range is less than 149.1. He has improved since. Dr. [...] opines this improvement is due to elimination of gluten from his diet through currently, he is back on dairy and wheat b/c he is at a residential home while he is being evaluated for lacking capacity and these multiple GI issues),
-Hemoglobin A-1 C's have been mildly elevated, but less than six.
-Psychiatry care with this MD, Dr. [...] (see below for more on this).
-Dysesthesias with water (see below for more on this.).
-Chronic fatigue (see below for more on this).
-Alternative care with Dr. [...] (see below for more on this).
-Vitamin D3 levels have been okay
-Hypercholesterolemia (as above)
-Heart scan negative in 2007
-Dermatology is with Dr. [...]
-Chronic tremor
-Sleep study 2013 negative for apnea
-Colonoscopy 2011 with Dr. [...]. He has a history of polyps and was told to get colonoscopy every two years.
-History of low magnesium
-History of increased LDH
-Bone density 2014 osteopenia, -1.3.
-Mild action tremor-
-s/p Left hip fracture due to fall, 9/13
-s/p tonsillectomy.
-Elaboration of some of the above points.
-Psychiatry Issues:
*Rule out bipolar disorder, not otherwise specified (with +/- mixed Akiskal criteria and a positive HCL-32; a negative TEMPS; a negative cyclothymia; a negative Goldberg Bipolar Spectrum Scale at 11; and a negative Mood Disorder Questionnaire at 4, though there are other M.D.s who have thought that he might be bipolar as well, including Dr. [...] from UCSF).
*Cognitive disorder, not otherwise specified, (apparently sub threshold for mild neurocognitive disorders in the past, most recent MOCA's x2 have been WNL, with 6/30/14 MOCA being 28/30 though notable for a persistent difficulty with verbal fluency (coming up with 11 ore greater words in one minute that begin with the letter F), with 9 words generated. On 4.26.14, he generated 8 words and scored 27/30.) Dr. [...] has opined that he has crossed the threshold into dementia while he was hospitalized but again, there is no written report that I have gotten at the time of this writing.)
THIS MD HAS WONDERED ABOUT R/O MULTIPLE SCLEROSIS (THE PATIENT HAD A CT OF HIS HEAD WITHOUT CONTRAST ON SEPTEMBER 8, 2008 FOR A NEW ONSET OCCIPITAL HEADACHE AND I DON'T SEE ANY EVIDENCE OF AN MRI IN IT. THERE WAS SLIGHT ASYMMETRY OF MILDLY PROMINENT EXTRA AXIAL SPACES AT THE CONVEXITIES, RIGHT GREATER THAN LEFT, WITHOUT ASSOCIATED MASS EFFECT. THIS MAY SIMPLE REPRESENT SLIGHTLY ASYMMETRIC CEREBRAL VOLUME LOSS, THE NEURO RADIOLOGIST OPINED IF THE PATIENT HAS A HISTORY OF RECENT TRAUMA AND/OR COAGULOPATHY, THIS COULD REPRESENT A SMALL, CHRONIC/RESOLVING SUBDURAL HEMATOMA OR SUBDURAL HYGROMA. OTHERWISE IT WAS CONSIDERED TO BE A NORMAL CT).
*History of concern over stimulant and benzodiazepine abuse.
*Unusual social history (His father essentially abandoned him 100% when he was in child psychotherapy and other people in the family aligned with the father and ignored him as well. There's a sense that there may be some parent child mismatch and without nurture and without interest in his welfare, there was a sense that his family didn't know what to do with him).
*Rule out psychotic disorder, not otherwise specified, likely secondary to right hemisphere cerebral damage secondary to motor vehicular accident versus chronic paranoid schizophrenia versus secondary to social emotional processing disorder vs due to mystery diagnosis (see below)-(There's a definite history when we have tried decreasing his Geodon that there was a massive up tick in major depressive episode symptoms and I wonder about psychotic equivalents, but I also wonder if perhaps what we were doing was removing his 5HT2C antagonism by going down on the Geodon and, for the record, not that much. A subsequent neuropsychology consult obtained suggests he did not have any psychotic symptoms but was treated at the time by anti-psychotics)-
*Mid disorder secondary to probable right hemispheric change secondary to motor vehicular accident versus part of the psychotic condition outlined above versus part of bipolar disorder vs due to mystery diagnosis,
*Positive avoidant personality disorder, but the patient does not meet criteria for social phobia, (Shame/humiliation may play a large part of this process)
*Sexual troubles versus adverse drug reactions versus relationship issues.
*Rule out anxiety disorder secondary to motor vehicular accident/traumatic brain injury vs due to mystery diagnosis.
*Rule out pain disorder/hyperalgesia/dysesthesia (Please also see fibromyalgia note below. I also wonder about Lyrica and a pain specialist like Dr. [...], though several of his primary care doctors have suggested not involving more specialists for this man who already is on a plethora of medications. In fact, some of the medications may be causing some of his troubles, they have opined)-
*History of polypharmacy -- (at present, the patient is on a great deal fewer meds than he has been on in the past. Previously, he was on a number of meds and when they were altered, like the Geodon, he tended to do worse, get more fatigued, etc).
*Fatigue/Alternative Care Issues:
Fibromyalgia/chronic fatigue syndromePLEASE ALSO CONSIDER FULL DIFFERENTIAL DIAGNOSIS FOR CHRONIC FATIGUE SYNDROME, WHICH INCLUDES INFECTIOUS ETIOLOGIES, SUCH AS LYME DISEASE, CHRONIC EPSTEIN BARR VIRUS, INFLUENZA, AND HIV INFECTION; OTHER VIRAL INFECTIONS, SUCH AS HHV-6, RETROVIRUSES, ENTEROVIRUSES, AND TUBERCULOSIS; NEUROENDOCRINE ISSUES, LIKE HYPOTHYROIDISM, HYPERTHYROOIDISM ADDISON'S DISEASE, ADRENAL INSUFFICIENCY, CUSHING'S DISEASE, AND DIABETES; PSYCHIATRIC CONDITIONS, INCLUDING BIPOLAR AFFECTIVE DISORDER, SCHIZOPHRENIA, DELUSIONAL DISORDERS, DEMENTIA, ANOREXIA NERVOSA, AND BULIMIA NERVOSA; NEUROPSYCHOLOGIC ISSUES, SUCH AS OBSTRUCTIVE SLEEP SYNDROMES, SUCH AS SLEEP APNEA OR NARCOLEPSY, MULTIPLE SCLEROSIS, AND PARKINSONISM; HEMATOLOGIC ISSUES, LIKE ANEMIA, LYMPHOMA, AND OCCULT MALIGNANCY; RHEUMATOLOGIC ISSUES, LIKE FIBROMYALGIA, SJOGREN'S
SYNDROME, POLYMYALGIA RHEUMATICA, GIANT CELL ARTHRITIS, POLYMYOSITIS, DERMATOMYOSITIS, DERMATOMYOSITIS; AS WELL AS OTHER ISSUES, INCLUDING NASAL OBSTRUCTION FROM ALLERGIES, SINUSITIS, ANATOMIC OBSTRUCTION; CHRONIC ILLNESS, SUCH AS CHF, RENAL, HEPATIC, PULMONARY DISEASE, AND AUTOIMMUNE; PHARMACOLOGIC SIDE EFFECTS, SUCH AS BETA BLOCKERS OR ANTIHISTAMINES; ALCOHOL OR SUBSTANCE ABUSE, HEAVY METAL EXPOSURE AND TOXICITY, SUCH AS TO LEAD; AND BODY WEIGHT FLUCTUATIONS, SUCH AS SEVERE OBESITY OR MARKED WEIGHT LOSS, ALL OF THESE ISSUES ARE TAKEN FROM AMERICAN FAMILY PHYSICIAN, MARCH 15, 2002, WHICH DOES HAVE A FAIRLY LENGTHY DIFFERENTIAL LIST, MORE SO THAN I COULD FIND IN BOTH CECIL AND HARRISON'S PRINCIPLES OF INTERNAL MEDICINE. THE DIFFERENTIAL DIAGNOSIS FOR FIBROMYALGIA, ACCORDING TO THE SAME JOURNAL, AMERICAN FAMILY PHYSICIAN, IS MUCH SHORTER IN THIS REVIEW ARTICLE OF 2007 BUT INCLUDES SEVERAL OF THE SAME THINGS LISTED ABOVE FOR CHRONIC FATIGUE SYNDROME, PERHAPS WITH THE ADDITION OF THE MYOFASCIAL PAIN SYNDROME AS WELL AS SIDE EFFECTS TO STATINS AND OTHERWISE THERE IS A LARGE DEGREE OF OVERLAP, WE PREVIOUSLY TREATED HIM FOR FIBROMYALGIA WITH NEURONTIN AND CYMBALTA AS THEY ARE BOTH LISTED AND HAVE FDA TYPES OF INDICATION OR AT LEAST A STRONG EVIDENCE BASE.)
Patient is seeing Dr. [...] for this work-up, upon my suggestion, as little has helped him over the years for this fatigue and I have seen Dr [...] successful when others have not been, including getting a consultation with a Rheumatologist (who found no rheum issues). He opines that at least in part, [the patient's] chronic fatigue issues (the pt. describes it as having less hours in the day and historically responds poorly to changes in medications for several days/weeks until his body can adjust) are related to genetic polymorphism blocks in his methylation and liver detox cycles (he is suggested to have abnormalities in his MAO-A enzyme, MTRR and BHMT enzymes (important in homocysteine handling) and has suggested a number of complementary alternative medicine fixes as well as us trying very high doses of Nuvigil (which we did try and he was on prior to entering UCSF for what is probably the first signs of his GI bleed. We have left him off it so as to not cloud any issues here but it and Ritalin appeared to be helping him in the past.)B/C he is in the residential facility, he has also stopped B complex vitamins, B-12 shots, is possibly being exposed to heated plastic when served food, is not using a sauna blanket for 15 minutes a day and is no longer on Vitamin D. I believe these are items recommended to him by Dr. [...].)
*Dysphasia - I believe these are thought to be part of the above chronic fatigue story.
Lastly, here are some thoughts that are not necessarily diagnoses but may be helpful nonetheless.
-He has a mystery diagnosis. To help him try to treat it, he has been to many MD's seeking help and has created a website, unusualsymptom.info to try to track his labs, procedures, etc over the years. It may help to look at it as it is searchable and thoughtfully organized.
-Pt. has a tendency towards black and white thinking.
-The concept of neuro rehabilitation with Dr. [...] may have been helpful but was suggested against by Dr. [...].
-As mentioned above, decreasing the Geodon led to a severe increase in depressive symptoms and agitation in a way that was somewhat unexpected for the amount of Geodon that was dropped-
-When we tried to get a Lamictal level done when he was on it in the past, he noticed some worsening in sleep, suggesting some bipolarity or glutamatergic issues at play. Despite the fact that his Lamictal levels were not necessarily adequate to prevent depression according to thoughts on this by Ivan Goldberg, enhancing the mysteriousness of his diagnosis-
-Changes in medication should be the smallest possible because of his sensitivity to medications and because the amount of time that it takes for him to re-equilibrate to medication changes is profound. He may need to be reminded of this because sometimes he forgets experiences that he has had, negative or positive-
-Since there is a possibility of brain trauma versus a neurologic condition and inflammation at play, I wonder if N-acetylcysteine or Namenda or Lamictal at a higher dose could help some of his symptoms.
-Dr [...] strongly believes that he was previously on way too many medications and it's always worth it to remember the effect of polypharmacy in this gentleman-
-One of my guiding principles in treating him is that he actually hasn't met criteria for depression and therefore can't, necessarily, meet criteria for major depression or bipolar disorder, depressive episode. It might be that he can't remember why it was that he was psychiatrically-hospitalized for depression and given ECT and he's misremembering the timing of the events, but he certainly hasn't been depressed for two weeks at a time with all the other major depressive symptoms since I've started working with him and yet is still wildly symptomatic of all of these difficulties. This suggests to me that depression is one of the symptoms he's presenting with from another condition, but he is unlikely to have pure functional major depressive disorder and, by the same token, functional bipolar disorder-
-Dr. [...'s] notes are not suggestive of a psychotic process and this is important heuristically-
-It should also be remembered that sometimes the patient poo-poos suggestions from doctors, including my own, and then forgets that he's ever been offered these choices and then gets angry when he thinks that he's being slighted-
-I still wonder about a pain specialist who might have some insights into integrative health issues. But again, I've been strongly warned by Dr. [...], who had spoken to the patient's previous doctor, who felt similarly, that the fewer specialists, the better. Her experience with hyperalgesia and dysesthesia has not been overall positive and so she is setting reasonable expectations-
Please call me if there are any questions.