THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: May 5, 2016 05:15 PM Thursday; Rod Welch

VA notify fall caused elevated CRP-HS and major bruise.

1...Summary/Objective


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CONTACTS 

SUBJECTS
CRP HS 20 300% Elevated Lab 150503 Caused Bruise Fall 150501 Balance                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
1503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1503 -    ..
1504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
1505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150501 - Follow up ref SDS 5 0000. ref SDS 4 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150505 -            [On 160512 1418 letter to Doctor Jha asks about radiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
150506 -            study to identify scope of problem, if any, related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150507 -            calcium crystals (otoconia) moving into semicircle canals                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150508 -            and disrupting balance that compounds sway problem.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
150509 -            ref SDS 6 PL52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150511 -             ..
150512 -            [On 160512 1418 at 1545 Doctor Jha advises that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
150513 -            neuroimaging can look for calcium crystals in vestibular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150514 -            semicircluar canals, and recommends consulting neurologist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150515 -            and neuroradiologist. ref SDS 6 GL8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150517 -             ..
150518 -            [On 160513 1100 telecon with Lauren, PCP - requested                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150519 -            referral to neurology to resolve balance problems; Lauren                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150520 -            will consult Neurology, make referral to Physical Therapy,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150521 -            ref SDS 7 R46H  She will schedule meeting to personally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
150522 -            perform Dix-Hallpike test to diagnosis BPPV, and further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150523 -            perform head maneuvering procedures (Epley, Semont, etc) to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150524 -            move calcified crystals disrupting balance. ref SDS 7 YK72                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
150526 -             ..
150527 -            [On 160519 0800 "vestibular hypofunction" diagnosed during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
150528 -            meeting with Mike in Physical Therapy, as causing falls                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150529 -            unrelated to dizziness. ref SDS 8 S95O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
150530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150533 -  ..
1506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1508 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150901 - Submitted letter to VA medical team saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150902 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150903 -    1.  Subject:  Fall Siginficant Bruising Elevated CRP-HS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
150904 -        Date:  2016-05-05 18:35                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
150913 -         ..
150914 -    2.  Met with Doctor Simpson in Cardiology yesterday on 160504 1000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150915 -        He was concerned 300% elevated CRP-HS 20.6 lab the day before,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150916 -        shows arterial inflammation that occurs with impending coronary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150917 -        events.  Since lipid panel was favorable, and CCTA on 151019,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150918 -        showed no evidence of atherosclerosis, the doctor indicated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150919 -        anomalous CRP-HS might be a lab error.  He discussed ordering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150920 -        another blood draw to verify actual status. ref SDS 4 V64J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
150922 -         ..
150923 -    3.  Also discussed balance issues with Doctor Simpson, as a result                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150924 -        of falling again while hiking mountain trails this past Sunday                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150925 -        May 1st. [...shown in case study on 140101 0600. ref SDS 1 YS8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
150926 -        On reflection the fall Sunday, seems similar to falling on Half                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150927 -        Dome hike last year on 150916, ref SDS 2 O87H, which was later                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
150928 -        treated by your team beginning on 150923. ref SDS 3 EU6O  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
150929 -        fall on Sunday did not appear to cause severe injury, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150930 -        occurred previously, i.e., no external bleeding.  There is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150931 -        however, an expanding bruise on the right hip, today about 6" x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150932 -        7".  Doesn't hurt.  Didn't even know it was there until someone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150933 -        pointed it out.  Accordingly, do not expect treatment by your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150934 -        department is needed.  I didn't think the prior injury needed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150935 -        medical care, which later proved to be an error.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
150937 -         ..
150938 -    4.  Research indicates this level of bruising can elevate CRP-HS in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150939 -        the range of 20-30; thus, I am at the low end of the range for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150940 -        bruise-related elevated CRP-HS.  Therefore, propose waiting for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150941 -        a week or two until the bruise resolves, then test for CRP-HS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150942 -        to see if the lab normalizes.  Studies have also shown long                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150943 -        distance runners can have elevated CRP-HS at 20.  Since I am                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150944 -        hiking, rather than running do not expect this elevates CRP-HS,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150945 -        but it might at levels of 11 - 15 miles per day, 300+ miles per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150946 -        month.  Hiking has been curtailed to 10% of normal the past 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150947 -        months.  However, beginning last Friday, was finally able to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150948 -        hike 11, 11, 21, 22 and then 15 the morning of the lab on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
150949 -        Tuesday.  This raised HDL from mid-40s (just guessing) to 57 on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150950 -        Tuesday.  Conceivably, it could be a factor in elevated CRP-HS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150951 -        as well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150953 -  ..
150954 - Doctor Simpson's Progress Notes show work plan to order another lab in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150955 - September to test CRP-HS. ref SDS 4 5R6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
150957 -  ..
150958 - Letter to medical team continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
150959 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150960 -    5.  Research indicates loss of balance (Benign Paroxysmal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
150961 -        Positional Vertigo - BPPV) that caused falling last September,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150962 -        and again on Sunday, can occur with calcium buildup in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150963 -        semicircular canals near the ears, often an age related malady.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150964 -        On 060308, HEENT at Kaiser tried Cerumen plug treatment to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150965 -        relieve Millie's dizziness at about my current age, 71.  It was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150966 -        ineffective.  On 060623, she had an MRI on her head to test for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150967 -        distant metastasis arising from primary IBC.    Fortunately,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
150968 -        that was negative.  Doctor Rugo at UCSF later treated Millie's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150969 -        dizziness on referral from Kaiser, as side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
150970 -        Cetuximab.  Dose was reduced, and Millie's dizziness resolved.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150971 -        This does not establish causation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
150972 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
150973 -            [On 160519 0800 "vestibular hypofunction" diagnosed during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
150974 -            meeting with Mike in Physical Therapy, as causing falls                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150975 -            unrelated to dizziness. ref SDS 8 S95O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
150977 -         ..
150978 -    6.  In this case, there is history of dizziness correlated with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150979 -        statins.  Dose reduction reduced my dizziness several years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150980 -        ago.  The past few years taking very small dose of statin drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150981 -        seems unlikely to be a significant factor.  While dizziness and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150982 -        balance are related, the 2 falls in this case were not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
150983 -        accompanied by dizziness.  These were sway-related events,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150984 -        where stepping in rough, somewhat uncertain terrain, actually                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150985 -        stepping across a stream on protruding rocks and logs.  These                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150986 -        conditions, along with fatigue caused the body to sway beyond                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150987 -        the range of normal activity, i.e., sitting, standing walking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150988 -        Sensory perception failed to register sway until the body was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
150989 -        beyond a point of recovery.  I remember vividly being about 6"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
150990 -        from the ground and asking myself "What am I doing here?"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
150991 -        There was no "spinning" sensation, as in vertigo.  As well,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
150992 -        balance is never an issue on daily hikes, because they occur on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150993 -        a flat roadway (shoulder) surface that presents no swaying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150994 -        issues.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
150996 -         ..
150997 -    7.  With Half Dome coming up in September, asking if there might be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
150998 -        a surgical solution similar to Heller Myotomy on LESV, you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
150999 -        performed on 091216?  Alternatively, could radiation dissolve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
151000 -        calcium buildup in semicircle canals to restore normal balance?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
151001 -        Can Radiology test for calcium buildup in semicircle canals                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
151002 -        similar to testing for calcium in arterial blood vessels,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
151003 -        showing scope of the problem.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
151005 -  ..
151006 - Ask Doctor Jha for radiology support on calcium in balance canals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
151007 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151008 -            [On 160512 1418 letter to Doctor Jha asks about radiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
151009 -            study to identify scope of problem, if any, related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
151010 -            calcium crystals (otoconia) moving into semicircle canals                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
151011 -            and disrupting balance that compounds sway problem.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
151012 -            ref SDS 6 PL52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151014 -             ..
151015 -            [On 160512 1418 at 1545 Doctor Jha advises that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
151016 -            neuroimaging can look for calcium crystals in vestibular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151017 -            semicircluar canals, and recommends consulting neurologist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
151018 -            and neuroradiologist. ref SDS 6 GL8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
151020 -             ..
151021 -            [On 160513 1100 telecon with Lauren, PCP - requested                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151022 -            referral to neurology to resolve balance problems; Lauren                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
151023 -            will consult Neurology, make referral to Physical Therapy,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
151024 -            ref SDS 7 R46H  She will schedule meeting to personally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
151025 -            perform Dix-Hallpike test to diagnosis BPPV, and further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151026 -            perform head maneuvering procedures (Epley, Semont, etc) to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
151027 -            move calcified crystals disrupting balance. ref SDS 7 YK72                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
151028 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151030 -         ..
151031 -    8.  If nothing can be done medically, we'll look for performance                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151032 -        adjustments that mitigate exposure to balance issues.  Current                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
151033 -        consideration is switching to a hip-pack (lowers center of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
151034 -        gravity, that improves balance), rather than backpack.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151035 -        will reduce leverage that accelerates falling, and so provide 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
151036 -        - 2 seconds additional time to make adjustments that avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
151037 -        falling.  The problem to solve is that by the time sensory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
151038 -        perception recognizes being off balance, the fall has completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
151039 -        - there is no time to adjust.  Will have someone hike behind                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151040 -        this year, rather than in front, to recognize wavering from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
151041 -        fatigue, and suggest resting, rather than "press the envelope"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
151042 -        scurrying up the hill.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
151044 -         ..
151045 -    9.  Copying Wound Care Clinic in case we wind up needing additional                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
151046 -        support, as occurred with the prior fall.   Recall during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
151047 -        meeting on 151215, you found Hydrafera Blue was effective on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
151048 -        the prior injury.  Could it help in this case?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
151050 -         ..
151051 -   10.  Thanks very much for terrific care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
151052 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151060 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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151076 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
151077 -