Carol A Ide

Medical history

Since Carol spent almost half her life dealing with significant medical problems, listing them here seemed appropriate. This is our summary of her problems, as it stood at her death, with the information from her final hospitalization (mostly) not added.

I have also uploaded this as a PDF (as it existed when she died), along with her list of medications.

index




NB: type II diabetes mellitus, adrenal insufficiency, and ablative chemotherapy July 2008
No nitro (1 s.l. nitro tab dropped pressure from 130's systolic to ca 70 in Jan 2008)
Stage III CKD & dysautonomia - needs ca 3500 cc/day fluid; vagals with any volume depletion
Autologous stem cell transplant 18 July 2008
Pacemaker (implanted 15 December 2007)

Heme

myelodysplasia, POEMS, Castleman’s (4 biopsied lymph nodes), s/p auto July 2008, hyperuricemia


myelodysplasia (unclassifiable) (diagnosed from 29 July 2011 bone marrow (-20q in 15/20 metaphases; megakaryocytes have open chromatin, nucleoli, and hyperlobulated nuclei, anemia (27 July: hgb 8.8 (was 12.2 on 19 May), platelets stable at 110, wbc 3.6). lambda free light chain doubled to 11.1 mg/dL, CRP 50.3 mg/L (was 11.9 on 12 July 2010), serum M-spike increased to 1.5 g/dL, plasma cells are 10-20% of bone marrow cellularity (?-light chain restricted). VEGF in range, IL-6 elevated)

[NB: while on Cybor-D for presumed POEMS relapse (now known to be MDS) HgB increased from 8.8 (baseline), and intermittent low-grade fevers stopped; one week after the last treatment on cycle 1 day 8, the fevers resumed, and she also experienced increased neuralgia (overall pain increased from 6+ to 7), which gradually returned to baseline over five days.]

erythropoietin 369 mIU/mL (1 Dec 11); 112 mIU/mL (21 Sep 11)

started Aranesp 200 mcg s.q. every 2 weeks on 30 Jan 12. increased to 300 mcg s.q. every 2 weeks on 27 Feb
datelabHgBpltWBCANCBUNcreatinine
[numerous CBC's during her final hospitalization]
19 Mar 12SNCC8.8302.61.9  
16 Mar 12 [after 2 U PRBC 12 Mar]NLL10.0293.052.26321.62
12 Mar 12 [after 2 U PRBC 27 Feb]East7.3352.281.46271.68
27 Feb 12SNCC7.6542.51.5211.4
13 Feb 12SNCC8.4502.31.6211.3
30 Jan 12 [after 2 U PRBC 20 Jan]SNCC9.7663.22.6221.1
18 Jan 12NLL7.7552.521.50251.60
13 Jan 12SNCC9.4652.92.0221.3
29 Dec 11SNCC9.9802.11.5241.2
15 Dec 11East10.8533.552.91471.03
13 Dec 11 [after 2 U PRBC]East10.3544.033.21571.73
12 Dec 11East7.9513.472.56602.20
11 Dec 11 [after 1 U PRBC]East10.1683.713.23713.0
10 Dec 11East8.1712.602.00823.74
7 Dec 11East9.1762.981.64451.79
5 Dec 11 [after 2 U PRBC]East9.0582.782.17291.37
3 Dec 11East7.3862.261.41241.41
1 Dec 11SNCC8.5923.12.1191.3
17 Nov 11SNCC8.81032.61.8241.9
15 Nov 11SNCC9.51173.52.6372.6
3 Nov 11SNCC10.61022.81.9221.4
14 Oct 11East10.31123.192.27191.50
6 Oct 11SNCC10.91203.22.4  
22 Sep 11SNCC10.31163.32.5171.1
8 Sep 11SNCC10.21344.03.1191.1
25 Aug 11SNCC9.61182.62.0211.0
18 Aug 11SNCC9.91122.62.0180.9
11 Aug 11(2nd and last Cybor-D)SNCC9.51232.32.0270.9
27 Jul 11Mayo8.81103.62.78 1.0

POEMS (diagnosed summer 1996) ["polyneuropathy, organomegaly, endocrinopathies, monoclonal gammopathy, skin changes"; paraneoplastic on a plasma cell proliferative disorder (for more information see A Dispenzieri, ' POEMS syndrome: 2011 update on diagnosis, risk-stratification, and management', Am J Hematol 86 (2011) 592-601); no sclerotic lesions on skeletal surveys (at least annually from 1996 through 2011); Carol’s was indolent for years; tempo increased in 2003, dramatically in summer 2007; dramatic neurological improvement post autologous stem cell transplant]

VEGF: 88 pg/mL (1 Dec 11), 63 pg/mL (28 July 2011), 79 pg/mL (12 July 2010); 45 pg/mL (29 July 2009); 71 pg/mL (3 Nov 2008); 302 pg/mL (12 Feb 07); 484 pg/mL (8 Aug 06) (range 31-86 for all) [others rejected due to lipemia]
IL-6: 37.92 pg/mL (28 July 2011), 6.94 pg/mL (12 July 2010); 7.35 pg/mL (29 July 2009); 12.68 pg/mL (3 Nov 2008) (range 0.31-5.00 for all)

IgG-λ M-protein (discovered 1996)
[Mayo: latest serum M-protein is 1.5 g/dL, on 27 July 2011: previously varied between 1.0 and 1.2 since transplant]
[SNCC (Lincoln): latest 1.2 g/dL on 3 Nov 11; 1.2 g/dL on 12 May 2011; previously varied between 0.8 and 1.0 since transplant]
[highest: 2.18 g/dL 3 Feb 1997 (Mayo)]

elevated λ free light chain (all from Mayo)
dateλ FLCκ FLCκ/λ FLC ratio
27 July 1111.1 (0.57-2.63) mg/dL2.89 (0.33-1.94) mg/dL0.2604 (0.26-1.65)
12 July 105.07 (0.57-2.63) mg/dL1.77 (0.33-1.94) mg/dL0.3491 (0.26-1.65)
29 July 093.02 (0.57-2.63) mg/dL1.14 (0.33-1.94) mg/dL0.38 (0.26-1.65)
3 Nov 082.44 (0.57-2.63) mg/dL0.7760 (0.33-1.94) mg/dL0.32 (0.26-1.65)
4 Aug 085.20 (0.57-2.63) mg/dL0.5960 (0.33-1.94) mg/dL0.11 (0.26-1.65)
9 July 0810.4 (0 .57-2.63) mg/dL1.96 (0.33-1.94) mg/dL0.19 (0.26-1.65)
26 Nov 0715.5 (0.57-2.63) mg/dL2.03 (0.33-1.94) mg/dL0.13 (0.26-1.65)
14 Aug 0714.8 (0.57-2.63) mg/dL1.82 (0.33-1.94) mg/dL0.12 (0.26-1.65)
7 Aug 0611.2 (0.57-2.63) mg/dL4.06 (0.33-1.94) mg/dL0.36 (0.26-1.65)
17 Mar 039.62 (0.57-2.63) mg/dL2.24 (0.33-1.94) mg/dL0.23 (0.26-1.65)


cytogenetic studies
29 July 2011 bone marrow: 46,XX,del(20)(q11.2 q13.3) [15] / 46,XX [5]
3 Nov 2008 bone marrow: no clonal abnormalities
26 Nov 2007 bone marrow: plasma cell clone with monosomy 13 and an IGH gene rearrangement that did not translocate to one of the common myeloma translocation partners (CCND1, FGFR3, or c-MAF). bone marrow showed a normal karyotype (46XX) in 20/20 metaphases.

Castleman’s lymphadenopathy (3 biopsied left inguinal nodes, 1 left axillary—all mixed hyaline-vascular / plasma cell type) [a benign lymphoproliferative disorder, characterized by non-clonal angiofollicular lymphoid hyperplasia; for more see B Roca ‘Castleman’s disease: a review’ (Aids Rev 11 (2009) 3-7) and JA Al-Maghrabi, ‘Castleman’s disease: update on pathogenesis’ (Saudi medical journal 32 (2011) 451-458)]

FDG PET/CT 28 Jul 11 (interval improvement, with axillary lymph nodes showing decreased metabolic activity and size; increased metabolic activity in sacrum, bilateral iliac bones, and lesser in spine). Aug 07 (interval improvement); Aug 06 (multiple nodes with minimal or mild FDG avidity)

most recent known enlarged node: enlarged right inguinal node 22 February 2008 (2.7 x 1.1 x 0.7 cm by ultrasound)
ct c/a/p 12 July 2010 showed stable subcentimeter retroperitoneal nodes, no other adenopathy

status post
suspected cardiac and neural amyloid deposits (mass spec. eval of TTR negative for suspicious variants 10 Dec 2007; negative fat aspirates on 18 March 2003 and 30 June 1999)

hyperuricemia (2/2 Castleman’s): latest uric acid 4.6 (18 Jan 12); was 9.8 mg/dL (27 July 2011; off Niaspan, but note MDS); 7.7 mg/dL (16 Mar 2011, while on Niaspan), 5.2 mg/dL (3 Jan 2011)

Neuro

CVA x 2, peripheral neuropathy, dysautonomia, abnormal eeg, facial neuralgia (s/p resection R infra-orbital nerve)

possible seizure (11 Jan 2012): while walking with PT, after climbing stairs. felt ‘foggy’, legs felt weak. LE jerking. heard thumping. PT helped to ground. PT’s voice sounded ‘distant’. no LOC or injury

right MCA CVA (temporal-parietal lobes) 22 Oct 2010: sx left hemiparesis, dysphagia, mild dysarthria; converted to hemorrhagic 29 Oct 2010

cerebral infarct near posterior horn of left lateral ventricle [no unilateral symptomatic changes; incidental finding on MRI 13 Oct 2006 (could have been acute demyelination), no additional foci on Feb 07 MRI]

peripheral polyneuropathy in all four limbs [since ca 1994; 2007 EMG/NCS showed a severe demyelinating peripheral neuropathy or polyradiculopathy with secondary axonal degeneration, with evidence of a proximal myopathy; dramatic improvement in symptoms since auto]

abnormal eeg (7 Feb 12): intermittent alternating and bitemporal slowing, mild. No definite spike or sharp and slow waveforms were seen and there were no clinical seizures observed.

foot drop (bilateral) [AFO’s]

right-side CN V-2 facial neuralgia (probably due to radiation fibrosis) [s/p resection right infra-orbital nerve 1997]

autonomic dysfunction (with vagal and adrenergic components) (abnormal autonomic reflex screen 6 Dec 2007); suspected 2/2 amyloid deposits (since POEMS doesn’t affect autonomic nerves)

possible hyperhidrosis on holding beta blocker Nov 10 (increasingly severe diaphoretic episodes, ending with several lasting an hour each, with T=95.8 F at end; none since restarting Coreg)

pressure allodynia (mild; starting November 2006, resolved by 2009).
brush-type allodynia (possibly present in feet Jan 2010). definitely present starting 15 Dec 2010 in all four extremities (L>R, LE>UE); significantly worse 27 Dec 10, improved but still present 7 Jan 2011; increased to 6-1/2 of 10

possible migraine: crescent-shaped visual loss, lateral visual field right eye (17-23 Aug 10), no retinal detachment, CT orbits-head negative, headache with nausea and photophobia (24-28 Aug 10)

overall pain increased from 4 of 10 (December 2010) to 6 of 10 (February 2011) to 6-1/2 of 10 with spikes to 7 of 10 (starting Mar 2011)

Endocrine

primary adrenal insufficiency, type II DM, hypothalamic amenorrhea, hypovitaminosis D, empty sella, hypothyroidism

primary adrenal insufficiency (diagnosed February 2003, confirmed May 2003, reconfirmed October 2005)
adrenal crisis (10 December 2011) [no infection. after nephrotic syndrome etc.]

type II diabetes mellitus (since approximately 1995; insulin dependent since February 2005)
[last HgB-A1C 6.1% on 27 July 2011 (by a Boronate Affinity method); was 6.3% on 14 June 2011; 6.1% on 12 July 2010, but HgB-A1C has been low relative to DBG’s since 2003 (with splenomegaly and high MCV and RDW suggesting early destruction of RBCs) (note ‘stable mild prominence of spleen’ on 12 July 2010 CT; Dec 11 echo has splenomegaly with spleen 14.5 cm. note also HgB has usually been out of range low since auto]

hypothalamic amenorrhea (since 1990) [12 July 2010: LH 2.6 IU/L (postmenopausal=10.0-60.0); FSH 6.1 IU/L (postmenopausal=16.7-113.6); estradiol =<10 (postmenopausal = <10)]

vitamin D deficiency [latest 46 ng/mL (3 Jan 11) at 50000 IU D-2 M Th]
[25-hydroxy-vitamin D low at 17.0 ng/mL 16 Apr 07; still low at 18.7 on 6 Sep 07 despite 2000 IU q.d. p.o. D-3; after changing to 50000 IU D-2 Monday and Thursday, has been greater than 40; increased June 2011 to three times per week every third week]

empty sella (first observed 8 July 1997)

hypothyroid
  TSHfree T4free T3
12 Mar 12East5.28 (0.40-5.50)0.3 (0.6-1.5)
18 Jan 12NLL4.64 (0.40-5.50)0.5 (0.8-1.8)
12 Dec 11East5.43 (0.40-5.50)[not measured]
2 Dec 11East4.21 (0.40-5.50)0.5 (0.6-1.5)
25 Oct 11NLL3.09 (0.40-5.50)0.7 (0.8-1.8)
27 Jul 11Mayo6.3 (0.3-5.0)0.6 (0.8-1.8)2.4 (2.0-3.5)
4 Jan 11NLL4.06 (0.40-5.50)1.0 (0.8-1.8)
also high at 5.4 on 7 Aug 2006

PTH 37 (27 Jul 11), 35 (29 July 09), 17 pg/mL (3 Nov 08)

Renal

stage II/III CKD, nephrotic syndrome (Dec 11), simple L renal cyst

stage II/III chronic kidney disease (eGFR extremely labile–e.g. 57 on 16 Dec 2011, 13 on 10 Dec 2011)

proteinuria
2-3 Dec 11: 24-hour urine collection, 4305 mg
2 Dec 11: protein/creatinine ratio on spot urine 3.94 (was 3.42 on 18 Nov 11)
212.4 mg microalbumin / g creatinine 3 Jan 2011
(on 24-hour urine collection, >1g/24 hrs once prior to this, in June 00—1199 mg/24 hrs; latest: 176 mg /24 hrs with small monoclonal lambda plus IgG lambda fragment (27 Jul 11); 100 mg/24 hrs with no apparent M-spike (12 July 10); was 355 mg/24 hrs before auto (12 Jul 2008))

serum creatinine spikes [fewer since we increased p.o. fluid and salt in December 2007]
[all resolved with volume replacement; no dialysis]
[10 Dec 11: creatinine 3.74 (adrenal crisis); reduced to 1.03 on 15 Dec 11]
[15 Nov 11: creatinine 2.6, eGFR 20.5 (sx SOB, fatigue, edema, ?pain, ?weakness and tremors]; reduced to 1.9 two days after holding Altace. note CTA on 3 Nov 11]
[earlier] three times in 2006: 2.1 in May (Zaroxylan), 3.1 in Sep (inadequate fluid intake), 3.1 in Oct (dehydration, after starting Revlimid); in Jan 2007 associated with septic shock; Oct 07 (after starting Revlimid at lower dose). in Apr 2008 associated with sepsis. 1.9 on 29 July 2009. 2.39 on 21 Feb 10 with URI; Oct 10 with CVA e.g. 2.11 on 29 October and 2.28 on 23 October (but 1.04 on 5 November!)]

Iothalamate clearance 27 ml/min/SA (10 July 2008); was 54 ml/min/SA (30 Nov 2007)

cyst, on anterior superior pole left kidney, first observed by US 22 Mar 02 (simple cyst, 1.0 x 1.3 x 1.1 cm); on 1 Dec 06 CT 1.1 cm small complex cyst or solid lesion (soft tissue attenuation); on 13 Aug 08 US 1.4 x 1.4 x 1.1 cm; on 29 July 09 CT larger than Aug 07; on 24 Sep 09 US simple cyst 16 x 15 x 17 mm

Pulmonary

mild pulmonary hypertension, complex sleep apnea (on VPAP Adapt SV), restrictive pulmonary disease with severely reduced diffusing capacity

pulmonary hypertension (note elevated PCW) [latest RVSP 46 on 7 June 2011; highest RVSP 80 on 1 Oct 2007]
[echo: 10 Nov 2011 = 46; 7 Jun 2011 = 46; 23 Oct 2010 = 44; 1 Apr 2009=40-50; 10 July 2008=36; 16 Dec 07=41; 26 Nov 07=51; 1 Oct 07=80; 25 Jan 07=35; 17 Oct 2006=52; 7 Apr 04=31; 29 Oct 03=29; 19 Mar 03=51; 20 Feb 03=46; 27 Mar 02=30]
[TEE: 3 Oct 07: 50-60]
[cath: 28 Feb 03 = 58/10/13; PCW 24/25/21]

Resmed VPAP Adapt SV starting 14 July 2011. pressure support minimum 5, maximum 10, EEP 12 cwp. medium Quattro ResMed full face mask. series # 20101928426 (same PCB), SW SX432-0201. (was on CPAP 3 June-13 July 2011(5 cmH2O); ResMed S9 escape, and swift FX nasal pillows (small))
mixed waking apnea observed on waking starting April 2011 (associated with slight lethargy–eyes 3 verbal 5 motor 6 = total 14 GCS; sometimes sits with head and less often body tilted to left; occasionally has trouble staying upright). initially resolved after starting AdaptSV, but recurred Oct-Nov 11, resolved after adding 2L O2 at night, but then recurred, and resolved after discontinuing O2
discontinued O2 6 March 2012 (started Dec 2011)

restrictive pulmonary disease:
dateplaceFEV1/FVCFEV1FVCTLCDLCODLCO-HgBDLCO/VA
10 Nov 2011East7559%62%52%27%29%61%
19 May 2011Pulm.7973%75%86%40%41%77%
10 July 2008Mayo77.261%65%66% [He]42%43%(VA=67%)
28 May 2008East7569%76%69%34%36%68%
5 Mar 2008East7473%81% 37%39%62%
5 Dec 2007Mayo77.060%64%64% [He]37%38%(VA=66%)
14 Aug 2003Mayo80.585%87% 70%70%(VA=84%)

CT 12 July 2010: a few scattered tiny bilateral unchanged pulmonary nodules

CTA chest 8 November 2011: vague filling defects within the pulmonary artery on the right, more likely to reflect artifact. Evidence of a definitive pulmonary embolus not seen. lung parenchyma show some patchy atelectasis. no consolidations.

PSG retitration (23 Feb 2012): total recording time 385 min., total sleep time 296.5 min (sleep efficiency 77%, moderately reduced). normal sleep latency at 12.5 min. REM latency is delayed at 191 minutes. increased percentage of N1 sleep at 26.6%, decreased percentage of REM sleep at 4.9%. EEP titrated with pressures between 6 and 13 cwp. best overall EEP at 12 CWP, resulting in an improved apnea-hypopnea index of 13.7 events/hr. with sleep observed during both supine and nonsupine REM sleep, oxygen saturations were maintained generally at greater than 90%. performed on room air. no periodic limb movements identified. additional EEG leads were applied. no EEG abnormalities noted. No reflux, bruxism, or other parasomnias observed. RECOMMENDATIONS: Adapt SV EEP 12, pressure support min 5 max 10. based on this study, does not appear to need supplemental oxygen at night as previously recommended.

overnight oximetry (25 Nov 11): on 2L O2 and VPAP. valid sampling 08:14:33 (including 03:49:06 < 90% (46%), 00:06:29 <80% (1%), and 0<70). awake SpO2 97.0%. time < 88% 176.1 min, SpO2 range 76.0 to 98.0%. pulse range 52 to 128 (mean 82). 188 desaturation events (17 / hour).

2nd night PSG (Adapt SV titration) (1 July 2011): total recording time 468 minutes, total sleep time 278 minutes, for a calculated sleep efficiency of 59%, which is mildly reduced. Sleep latency is significantly reduced at 90 minutes; REM latency is delayed at 176 minutes. All stages of sleep were observed with increased percentage of N1 sleep at 14%, and decreased percentage of REM sleep at 9%. Adapt SV titration was performed according to standard protocol. End expiratory pressure was titrated with pressure ranging between 5 and 12 cwp. Best end expiratory pressure identified was at 11 (sic) cwp, resulting in an improved apnea hypopnea index of 6.5 events per hour; this was associated with a high sleep efficiency of 96%. With sleep observed during non-supine, non-REM sleep, no significant central events were identified. No periodic limb movements were identified with an index of 0 events per hour. ECG reveals normal sinus rhythm with mean heart rate of 90 beats per minute. Occasional premature ventricular contraction was observed. No EEG activity was identified to suggest seizure disorder. No reflux, bruxism, or other parasomnias were observed. No snoring was observed while on Adapt SV therapy.

PSG (1 June 2011): split-night study. pre-treatment AHI 22 (total sleep time 135.5 minutes, of 179.0 minutes recording). AHI during treatment: 25 (total sleep time 164 minutes of 207 minutes recording)–1 obstructive, 65 central, 1 mixed. increased central events on CPAP. total SpO2 average wake 98%, average sleep 92%, lowest 86%. REM sleep 16.4% of total sleep time N1 20%, N2 63.6%, N3 0%. REM latency 220.5 minutes; sleep latency 23 minutes. 0 PLM. 43 spontaneous arousals; 41 respiratory related arousals. recommendation from titration study: NCPAP 5 cm

Cardiovascular

pacer, ? cardiac amyloid deposits, apical ballooning, CAD, hypertension, dyslipidemia, mitral regurgitation, Raynaud’s, LVH

dual chamber pacemaker (implanted 15 Dec 2007, because of bradycardia with periods of asystole (with spontaneous restart) up to 20.98 seconds)
generator: Medtronic ADAPTA DR model ADDRS1 serial number PWA206770H
lead 1: Medtronic model 5076-52cm serial number PJN1423621 site RV
lead 2: Medtronic model 5076-45cm serial number PJN1449342 site RA

possible cardiac amyloid deposits
stage I diastolic dysfunction consistent with impaired relaxation on echo [stage II on 1 Oct 07]; nonspecific intraventricular conduction delay on ECG’s since May 2006 (29 Oct 2010 QRSD=108; read as borderline IVCD with LAD consider LAFB). bradycardia & asystole. also one Ntg resulted in systolic pressure drop from ca 130 to ca 70
note: Apr 2009 echo showed normal diastolic function but Oct 2010 (and June and Nov 2011) echos again showed stage I diastolic dysfunction

left ventricular apical ballooning (February 2003) [anteroapical hypokinesis, caused by a catecholamine storm, associated with internal or external stress and with removing beta-blockers]

smooth lesion of the LAD, involving first diagonal, 50-60% occlusion in worst view (LAO cranial) [cinventriculogram and cinangiogram, 28 Feb 2003]

hyperlipidemia [most recent 13 Oct 11 (2 months after starting Crestor): cholesterol 112, triglycerides 346, HDL 24, LDL 19, VLDL 69]

mitral regurgitation [Nov 11 minimal to mild by TTE; Oct 10 mild by TTE; Apr 09 moderate by TEE, Apr 09 moderate by TTE (with systolic prolapse of posterior leaflet); Nov 07 mild by TTE; Oct 2007: severe by TTE; on TEE moderate to severe visually, moderate by PISA]

Raynaud’s phenomenon (diagnosed fall 2002)

left ventricular hypertrophy (echo 7 Jun 11, 23 Oct 10, echo 1 Apr 09 (mild concentric LV hypertrophy))

history of hypertension (started antihypertensives 2001/2002)

intermittent hypotension starting 2006 (secondary to dysautonomia; increased p.o. fluid and salt Dec 07; through early summer 2008 only one episode; summer 2009 increasingly presyncopic esp. associated with defecation, and positional changes (probably o/a/o increased activity post-transplant); some hypotension 2010 o/a/o delayed gastric emptying 2/2 Victoza (resolved); hypotension related to hypovolemia during CVA-associated hospitalizations Oct-Nov 2010; related to adrenal crisis Dec 2011)

history of angina (emotional trigger, not exertional)

history of bradycardia (resolved; status post pacer implant)

carotid arteries: carotid duplex 7 Feb 12 no significant change since 22 Oct 10. 23 Oct 2010: R ICA stenosis 40-59% (increased from 0-39% on 12 June 2007); L ICA stenosis 0-39% (unchanged)
attenuated right vertebral artery [discovered on MRA May 2007]

possible PFO on transthoracic echo 1 April 2009; not seen on TEE on 22 Apr 2009 with saline injection; no obvious interatrial shunt on 23 Oct 2010 echo; not seen on TTE on 7 June 2011 with saline bubbles

episodes of chest pain starting in 2009:
12 Feb 12
(0710 on waking. sharp epigastric pain 4/10 with nausea. SPO2 96% HR 90. shifted to left lateral decubitis (from supine). 0715 sharp upper abdominal pain, 6/10. 90/53, HR 87, SPO2 98% HR 89, nausea reduced, epigastric pain resolved. 0730 RR 15 SPO2 89% HR 87. 72/47, HR 87; abdominal pain resolved, nausea reduced further) 0732 supine, breathing more deeply RR 16 SPO2 98% HR 71. 100/69 HR 86
4 Feb 12
(sharp midsternal pain =6, radiating to the neck bilaterally, accompanied by significant nausea and sharp upper abdominal pain. duration ca ½ hr)
27 Nov 11
(sharp burning midsternal pain, 6/10, started while defecating, B/P 135/71 HR 86 (regular) RR 20, with sharp pain left back 6/10; developed radiation to throat burning and tightness 4/10; n/c on lying down; duration 70 minutes 2030-2140)
22 Sep 11
(reported sharp stabbing midsternal pain, radiating to right neck, 4/10. accompanied by nausea. gradually resolved. duration ca 30 minutes)
11 June 11
(at 0800 reported sharp midsternal pain, radiating to neck (L>R), 5 of 10, unknown duration, no change since it started, not diaphoretic. 0815 crushing pain, 3/10, not radiating. 0830 resolved)
7 May 11
(dull midsternal pain, 4/10, radiating to left neck, not diaphoretic, no change, duration 1925-1955)
6 May 11
(sharp midsternal pain, 4 or 5/10, not radiating, not diaphoretic, no change, accompanied with nausea, duration ca ½ hour, ca 2200)
20 Feb 11
(sharp midsternal pain, 5/10 at worst, radiating to neck bilaterally, duration ca 0740-0945, started on sitting up, gradually declined)
1 Dec 10
(sharp midsternal pain, 6/10 at worst, not radiating, ca 1030-ca 1115, no obvious provoker or ameliorator [based on Carol’s later report])
21 Oct 10
(sharp pain, initially epigastric, 6/10 at worst, started ca 2030, at 2200 2/10, at 2230 4/10 R chest, resolved 2245)
20 Oct 10
(sharp midsternal pain, 4/10, initially radiating to jaw bilaterally, started 0640, by 0650 reduced to 1 or 2 / 10; resolved by 0655, no obvious provoker or ameliorator)
14 Sep 10
(while walking out of ENT office post endoscopic debridement of R paranasal sinuses, sharp mid-sternal chest pain, 6 to 7 of 10, not radiating, diaphoretic, duration ca 10 min., ended almost immediately after vomiting thick mucus)
12 Aug 10
(ca 1600, sharp pain right jaw radiating to right ear and superiorly, 8 of 10. progressed to sharp mid-sternal chest pain, 7 of 10 at worst, radiating to right jaw and ear and superiorly. resolved after ca 20 minutes)
31 May 10
(overnight; woke with sharp midsternal pain, 6/10, radiating to throat bilaterally, resolved after ca 5 min)
19-22 July 09
(after a fall; dull intermittent pain, mostly epigastric, not radiating, usually 1 or 2/10)
25 May 09
(sharp midsternal pain 6/10 radiating bilaterally to the jaws, started while lying in bed, no ameliorating factors, ca 15 min. duration)
24 April 09
(sharp midsternal pain 6/10 radiating to forehead, duration ca 15 min., no obvious provoking or ameliorating factors)
12 April 09
(sharp midsternal pain 7/10 not radiating, no obvious provoking or ameliorating factors, duration ca 20-30 min)

LE segmental arterial study (August 2010): R dorsalis pedis ankle-brachial index mildly depressed (0.82), others normal; toe plethysmography within broad normal limits

ENT

chronic sinusitis (s/p 5 sinus surgeries), hx lytic R maxillary lesion (s/p excisions, irradiation)

chronic sinusitis, with right-side ciliary dysfunction [s/p hyperbaric oxygen (35 dives) for presumed osteomyelitis May-July 2007 with temporary improvement; s/p 2 endoscopic sinus surgeries, with most right-side ethmoid air cells opened]

[current treatment includes endoscopic debridement of right paranasal sinuses every 3-5 weeks]

history of lytic right maxillary lesion (1988–89) [clinical course suggests unifocal Langerhans’ cell histiocytosis; pathology didn’t confirm] [s/p excision of 5 teeth, curettement, irradiation (2000 rads)]

Opthalmological

subretinal hemorrhages (resolved), possible migraine aura

history of bilateral subretinal hemorrhages (not diabetic) (Nov 07, 2/2 elevated VEGF associated with POEMS), resolved after auto (Sep 09)

buried optic nerve head drusen (Sep 09)

anisocoria: R 1-2 mm larger 6 November 2007 (R 0.5 mm larger 14 May 2007)

metamorphopsia (Oct 07; reduced but still present in Sept 09; resolved in 2012)

history of accommodative spasm [sudden onset blurred distance vision, associated with stress, MS, head trauma]

crescent-shaped visual loss, lateral visual field right eye (17-23 Aug 10), no retinal detachment, CT orbits-heads negative, headache with nausea and photophobia (24-28 Aug 10)

sudden bilateral blurred near vision, 2/2 Amantadine (13 Nov 10)

Infectious disease

hx of MRSA, mdr M. chelonie, mdr E. coli (ESBL), shingles

MRSA, sinus and groin (Aug-Sep 2006, Nov 2006); after decolonization attempt sinus only (Jan-Jun 2007), with different sensitivity; sinus culture on 24 May 2007 negative for MRSA (positive for Enterobacter aerogenes & multi-drug resistant Mycobacterium chelonie)
[23 Nov 2010: sinus culture MRSA+]
[14 July 2008: nares culture negative for MRSA]
[22 May 2008: blood culture MRSA+]
[5 Dec 07: nares negative for MRSA; 7 Sep 07: throat, nasal, genital, and perineal cultures negative for MRSA]

multi-drug resistant Mycobacterium chelonie (24 May 07, sinus culture; treated with 1 course of Zyvox)

multi-drug resistant Escherichia coli (14 Jan 11, urine culture; ESBL producer; treated with Macrobid)

shingles (left flank) (29 October 2009-Dec 2009)

Gastro-intestinal

IBS, hemorrhoids, mild diverticulosis, incarcerated abdominal hernia

irritable bowel syndrome (diagnosed 2006; no current treatment)

on colonoscopy: no polyps, small grade 1 internal and external hemorrhoids, and multiple diverticula in sigmoid colon, descending colon, and transverse colon (diverticulosis of mild severity) (30 June 2011)

hematuria prob. 2/2 Plavix (INR 1.2); negative urine cytology 3 Dec 11 (Nov-Dec 2011)

incarcerated abdominal hernia, superior right to umbilicus (found on physical exam, no pain, 20 Jan 12)

Musculo-skeletal

30 June 2010
(fall) fracture proximal 4th left metatarsal (inferred from x-ray 16 March 11 showing old fx proximal 4th + distal 5th l metatarsal, well aligned)
10 Dec 2005
(fall) avulsion fracture, 5th left metatarsal (with ankle sprain)
18 Nov 1995
broken toe [right #5 (?)]
4 May 1986
fracture, distal shaft right fibula

proximal LE muscle weakness possibly 2/2 steroid use

Skin

hypertrichosis, hyperpigmentation, alopecia areata (all resolved), stasis dermatitis

hypertrichosis, hyperpigmentation [both resolved post transplant]

history of alopecia areata, posterior scalp (ca 7 cm diameter 1997–99; noticed again Feb 06 2.5 cm; May 06 3 x 2.5 cm; Nov 06 ca 3.5 cm, not present April 2007)

stasis dermatitis (diagnosed 16 March 2011)

Injuries and falls

11 Jan 2012
(while walking with PT; after climbing stairs. felt foggy, legs felt weak. LE jerking. heard thumping. PT helped to ground. PT’s voice sounded ‘distant’. no LOC or injury)
8 Jan 2012
(controlled descent to ground while in bathroom; started shaking, legs felt weak and then “gave out”. no LOC or apparent injuries)
16 Nov 2011
(fell while walking up stairs from bathroom o/a/o shoe falling off; no syncope or apparent injuries)
6 Sep 2010
(fell while walking to bathroom to defecate; felt “shaky”; no LOC; hit head [raised R occipital lump])
30 Jun 2010
(hit and twisted [?] left foot when shoe fell off while ascending stair; echymoses and sharp pains left foot just proximal to toes 2-4, lateral to toe 5, and mid-lateral; fx proximal 4th left metatarsal)
28 Apr 2010
(fell while turning, walking with only AFO’s, no LOC, hit l. knee and chest)
16 Sep 2009
(fell walking down 2 stairs to bathroom; syncope)
15 July 2009
(fell at start of walking with walker; legs felt very weak, she felt shaky. legs gave out)
31 Dec 2008
(fell backwards while pulling covers back on bed)
14 June 2008
(fell off bed while transferring to bed)
27 May 2008
(fell forward walking to commode; lost control of walker)
25 Mar 2008
(fell transferring from wheelchair to chair, with friend)
13 Mar 2008
(fell transferring self from wheelchair to commode; alone)
19 Nov 2007
(fell forward off wheelchair)
18 Sep 2007; ca 25 Sep; ca 27 Sep; 29 Sep
25 May 2007
(fall at Clarkson Hosp, bruising around eye and nose)
13 May 2007
(fall; right ankle)

pregnancies


full-term, elective Caesarian section, 4 April 1991 (transverse lie and mild pre-eclampsia)
spontaneous abortion, March 1988

Transfusions

(type O-positive) (many during the last hospitalization)
4 April 2012[2 units PRBC](HgB=7.9)
4 April 2012[2 apheresis units platelets](plt=42)
1 April 2012[2 apheresis units platelets](plt=53 and dropping)
30 March 2012[2 apheresis units platelets](plt=38)
29 March 2012[2 apheresis units platelets](plt= *)
28 March 2012[2 apheresis units platelets](plt=33)
27 March 2012[1 apheresis unit platelets](plt=34)
24 March 2012[2 units PRBC](HgB=8.3)
23 March 2012[1 unit PRBC](HgB=7.5)
23 March 2012[2 apheresis units platelets](plt=28)
12 March 2012[2 units PRBC](HgB = 7.3)
27 February 2012[2 units PRBC](HgB = 7.6)
20 January 2012[2 units PRBC](HgB = 7.7)
12 December 2011[2 units PRBC](HgB = 7.9)
10 December 2011[1 unit PRBC](HgB = 7.1)
3 December 2011[2 units PRBC](HgB = 7.3)
12 November 2010[2 units PRBC](infections after CVA)
8 August 2008[2 units PRBC](peri-transplant engraftment syndrome)
27 July 2008[2 units PRBC](autologous stem cell transplant)
27 and 25 July 2008[2 apheresis units platelets](autologous stem cell transplant)
27 January 2007[2 units PRBC](septic shock)
25 February 2003[2 units plasma](choley)

Surgeries

24 May 2007endoscopic debridement, with biopsy, right maxillary sinus (Dr Rapp, St Elizabeth’s)
10 Sep 2004left inguinal lymph node excision (Dr Windle, St Elizabeth’s)
2 Apr 2003left inguinal region lymph node excision (Dr Windle, Bryan LGH West)
25 Feb 2003choleycystectomy (Dr Mota, Bryan LGH East)
20 Mar 1998right paranasal sinus endoscopic surgery (Dr Rapp, Bryan)
13 Aug 1997Caldwell-Luc approach; resection of right infraorbital nerve (Dr Puig, Roch. Meth.)
20 Jun 1996left inguinal region lymph node excision (Dr Windle, St Elizabeth's)
24 Mar 1993bilateral paranasal sinus endoscopic surgery (Dr Fritsch, Bryan)
25 Feb 1993left axillary tail lymph node excision (Dr Griffin, St Elizabeth's)
4 Apr 1991Caesarean section (Dr Milius, St Elizabeth's)
1988-89several oral surgeries (excision of teeth 2-6, with curettement) (UNMC Dental Col)

Family history

son
alive [born 1991] [no significant medical problems]
father
died at age 40, of coronary occlusion, due to chronic mitral insufficiency
mother
alive [born 1926] [removed for privacy]
half-sister
alive [born 1966] [removed for privacy]
paternal grandfather
died at 84, of arteriosclerotic heart disease; other significant conditions: pneumoconiosis, gangrene toes both feet
paternal grandmother
died at 89, of cardiac arrest, due to congestive heart failure, due to arteriosclerotic cardiovascular disease
maternal grandfather
died at 80, of congestive heart failure, due to arteriosclerosis; other conditions: diabetes mellitus
maternal grandmother
died at 59, of cardio-renal disease and liver atrophy, due to liver atrophy due to choleyditis; major findings: fibrosis atrophy of liver and old chronic contracted gall bladder

Hospitalizations

2012 23 Mar-10 AprBryanLGH Eastcontinued epistaxis 2/2 thrombycytopenia; anemia; cerebral hypoperfusion syndrome, nephrotic syndrome
2011 10-16 DecBryanLGH Eastadrenal crisis (c/c: hypotension, weakness, lethargy)
2011 2-7 DecBryanLGH Eastnephrotic syndrome; hematuria
2010 15–30 NovMadonna RehabCVA
2010 13–15 NovBryanLGH Eastblurred vision ? 2/2 Amantadine
2010 5–13 NovMadonna RehabCVA
2010 29 Oct–5 NovBryanLGH EastCVA (ischemic stroke converted to hemorrhagic)
2010 27–29 OctMadonna RehabCVA
2010 23–27 OctBryanLGH EastCVA
2009 1–6 AprilBryanLGH Eastsepsis
2008 6–9 AugustBryanLGH Eastfever (peri-transplant engraftment syndrome)
2008 16–19 JulyRochester Meth.conditioning and stem cell transplant
2008 7–8 JanBryanLGH Eastchest pain
2007 14–15 DecBryanLGH Eastchest pain; bradycardia & asystole (pacemaker)
2007 15–18 NovBryanLGH Easthypoglycemia, hypothermia
2007 4 Oct–1 NovMadonna Rehabneuropathy, weakness
2007 29 Sep–4 OctBryanLGH Easthypotension
2007 25 Jan–2 FebBryanLGH Eastseptic shock (on vent 2 days, on 2 pressors 1 day)
2006 17–20 OctBryanLGH Eastacute renal failure, hypotension, abdominal pain, edema
2003 24 Feb–MarBryanLGH Eastcholeycystectomy, apical ballooning
2003 20–23 FebBryanLGH Eastadrenal insufficiency
1991 4–8 AprSt Elizabeth’sCaesarian section

Central lines

10-16 Dec 2011right IJ [adrenal crisis; hypotension; suspected septic shock]
23-27 Oct 2010right IJ [stroke, hypotension, syncope]
July-August 2008:Hickman, right IJ [autologous stem cell transplant]
Nov-Dec 2008AshSplit, right IJ [autologous stem cell transplant–collection only]
29 Sep 2007 - 4? Oct 2007left sub-clavian [hypotension; suspected sepsis]
25 Jan 2007 - 2? Feb 2007right IJ [septic shock]

Vaccinations

(NB: NO LIVE VACCINES–s/p high-dose ablative chemotherapy prior to autologous stem cell transplant 18 July 2008.)
(all revaccinations scheduled after auto completed)
seasonal flu: 13 October 2011 [Hurlbut]
2 years s/p auto [at Mayo Rochester]
(1) tetanus-diphtheria booster (12 July 2010) (Sanofi-Ave, U3059CA)
(2) pneumococcal 23-valent (12 July 2010) (Merck Shar, 0499Z)
(3) HIB (12 July 2010) (Sanofi-Pas, UH092AA)
(4) Salk polio (inactivated) (12 July 2010) (Sanofi-Pas, B1090)
(5) MMR (12 July 2010) (Merck Shar, 1269Y)
(6) HepB (12 July 2010) (Glaxosmith, AHBVB880AA)
H1N1 (18 November 2009) [Hurlbut]
14 months s/p auto
(1) seasonal flu (6 October 2009) (Novartiss, lot 97846P2A) [Walgreens Lincoln]
(2) tetanus-diphtheria (8 October 2009) (DeCAVAC, U2862AA, esp. 02 Mar 11) [Hurlbut]
(3) Salk polio (inactivated) (8 October 2009) (IPOL B1090 expires 11-28-10) [Hurlbut]
(4) HebB (8 October 2009) (Recombivax HB 1678x expires 8-23-11) [Hurlbut]
(5) HIB (8 October 2009) (ActHib UF596AB expires 2-5-11) [Hurlbut]
12 months s/p auto
(1) Tdap 29 July 2009 (Aventis Pa, lot UF457AA) [Mayo Rochester]
(2) HepB 29 July 2009 (Glaxosmith, lot AHBVB765AA) [Mayo Rochester]
(3) Pneum-23 29 July 2009 (Merck, lot 1577X) [Mayo Rochester]
(4) Hib 29 July 2009 (Sanofi-Pas, lot UF570AB) [Mayo Rochester]
(5) IPV 29 July 2009 (Sanofi-Pas, lot B0476) [Mayo Rochester]

Selected last tests, procedures

bone marrow (30 March 2012, East)
[* waiting]
(29 July 2011, Mayo) (hypercellular bone marrow with 10-20% lambda light chain-restricted plasma cells and atypical megakaryocytes (open chromatin, nucleoli, hyperlobated nuclei), karyotype shows -20q in 15 of 20 metaphases (46,XX,del(20)(q11.2q13.3) [15]/46,XX[5]). no JAK2 V617F mutation. no ring sideroblasts or dual esterase positive cells identified. myelodisplasia, not further classifiable)
bone scan (2 August 1988, Radiology Associates)
(fairly homogeneous assimilation of tracer throughout the skeleton except for some increased activity in the right maxilla (which may reflect recent tooth extraction) and the region of the right ankle (probably represents earlier fracture); remainder of the scan is entirely w/n/l
cardiac catheterization (28 Feb 2003, East)
(coronary arteries: left main normal. LAD smooth lesion involving 1st diagonal; good antegrade flow; lesion 50-60% in worst view (LAO cranial); in other views either not visible or much less severe. circumflex nondominant and normal. right coronary artery dominant and normal; extensive anteroapical hypokinesis suggesting infarction and/or stunning; LV pressure 137/10/17. right atrium 11/8/8. right ventricle 58/10/13. pulmonary artery 56/26/40. pulmonary capillary wedge 24/25/21. sats RA 63% RV 61% pulmonary artery 62% aorta 93%)
carotid duplex (7 Feb 12, East)
[carotid atherosclerosis; 40-59% predicted right internal carotid stenosis, 0-39% predicted left internal carotid stenosis, bilateral antegrade vertebral flow]
chest x-ray (30 March 2012, East)
[* waiting]
(3 Dec 11, East) [The visualized bones of chest are unremarkable. Heart size is w/n/l. The lungs are moderately expanded, no evidence of acute infiltrate, mass, or edema. Left-sided approach dual lead cardiac pacemaker is present]
colonoscopy (30 June 11, Gastroenterology Specialties)
small grade 1 internal and external hemorrhoids, and multiple diverticula in sigmoid colon, descending colon, and transverse colon (diverticulosis of mild severity)
Dexascan (27 Jan 2011, AMI)
cf. 2007 Dexascan. BMD from AP spine L1-L4 is 1.293 g/cm^2, T-score 0.9; Z-score 0.4 (normal, low fracture risk); BMD worse in spine but better in left femur; BMD from left femur 1.140 g/cm^2, T-score 1.2, Z-score 0.8. lateral vertebral assessment without compression injury
ecg 10 Dec 2011, East
(SR, nonspecific IVCD (QRSD = 124, QRS axis - 49), poor R wave progression, wider QRS than 13 Nov 10
echocardiogram, transthoracic
(*waiting for 30 March 2012 results)
(10 November 2011, East). LVEF 55%. normal LV systolic function. stage 1 diastolic dysfunction consistent with impaired relation. normal RV, LA, RA. calcified mitral annulus. minimal to mild mitral regurgitation. aortic valve sclerosis, with no aortic regurgitation. normal tricuspid structure, mild regurgitation. normal pulmonic valve structure, minimal regurgitation. no obvious interatrial shunt. normal aortic root, IVC. no pericardial or pleural effusion. normal movement all LV walls. RVSP elevated at 46, consistent with mild to moderate pulmonary hypertension
echocardiogram, transesophageal (22 Apr 2009, East)
LVEF 55%. thickened mitral valve leaflets and annulus; mild mitral regurgitation. mild aortic valve sclerosis, no regurgitation. mild tricuspid regurgitation. no intratrial shunts by saline injection. grade 1 plaque in aortic arch, ascending and descending aorta. normal motion of all wall segments
eeg (7 Feb 12, East)
intermittent alternating and bitemporal slowing, mild. No definite spike or sharp and slow waveforms were seen and there were no clinical seizures observed.
hematest (13 Nov 2010, MRS)
negative
mammogram (27 January 2011, AMI)
benign: stable appearance. scattered benign calcifications unchanged. scattered fibroglandular tissue remaining
pacer check
normal telecheck 10 August 2011; last in-office check May 2009
PAP smear (4 January 2011, Hurlbut)
normal
PFTs (11 Nov 11, Peterson)
TLC 52% of predicted, with FEV1/FVC 0.75. FVC 62% of predicted, FEV1 59% of predicted. Raw 154%, Gaw 47%. DLCO 27% of predicted (29% adjusted for HgB)
physical (6 January 2011, Hurlbut); pre-op physical (23 May 2007, Hurlbut)
skeletal survey (27 July 2011, Mayo)
n/c since 12 Jul 10. marked cortical thickening and increased density involving the calvarium. cortical thickening involving femoral, tibial, and fibular diaphyses. anterior wedging multiple thoracic vertebral bodies. synostosis right distal tibia and fibula. soft tissue calcifications both legs, greater on right. soft tissue swelling both lower extremities. surgical clips left inguinal region and RUQ. AICD. patchy sclerosis left sacral ala raises the possibility of stress fracture
stress test (2 June 2010, East)
Lexiscan protocol. suboptimal test o/a/o GI radiotracer uptake. Otherwise normal; no evidence of MI. fixed anteroseptal defect, probably due to breast attenutation artefact. normal LV systolic function; LVEF 90%. TID ratio 0.76. summed stress score = 4; summed rest score = 9; summed different score = 3 [sic]. no significant change from 22 April 2009
venous doppler (31 March 2012, East)
[* waiting for results]