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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.
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