April 22, 2001

Wednesday evening I noticed that my left leg was becoming very painful. The pain ran all the way up and down the back of my leg. By Thursday my knee had become very swollen and the pain now radiated throughout my lower leg. I went to see No Name at the clinic. He looked at the leg, poked it a few times and told me that I had a blood clot. He gave me a prescription for Warfarin 2.5 MG and told me that I would have to take this medication for at least a year. No Name also gave me a prescription for a stocking to wear during the day.

No Name gave me a synopsis of the summary letter he got from the Gypsy. Gypsy wrote, “In summary, she’s had Graves Disease treated with PTU initially but had some problems with her liver and then radioactive iodine. She has since been on synthroid and gained a significant amount of weight. She also has microalbuminuria, dyslipidermia, painful Achilles masses which look like Xanthomata, Meniere’s Disease and Plantar fasclitis. Her main complaints are that of muscle weakness primarily of the proximal leg muscles, weight gain, fatigue and what she describes as adrenaline rushes. She sees the Blonde Bimbo and was last seen in June of 2000. She was basically told that she had these symptoms because she was overweight. She has gone as far as sent her CT Scan of the abdomen down to California for a second opinion who thought her adrenals were slightly large.”

Gypsy went on to say, “I think that some of her symptoms can be due to post-menopausal status, which include memory problems, feeling run down, sluggish, lethargic, no energy, some forgetfulness. She does comment on snoring more lately and although we didn’t get into the potential for a sleep apnea, it certainly is there with her size. I think that a lot of her symptoms including the weight gain, the fatigue, the muscle aches, the muscle weakness can be due to an under replaced thyroid hormone and you’ve already started to increase her dose. Head and neck exam revealed slight exophthalmoses, normal extracular movements, normal cranial nerves. No cranial adenopathy. JVP was not elevated and carotid upstroke was normal. She did have a mild buffalo hump beginning at the back of her neck. Thorax exam revealed normal heart sounds, normal chest exam with no adventious sounds or murmurs. Abdomen was obese, soft and non-tender. There was no evidence of any striae and extremity exam revealed proximal leg weakness, specifically at the hip flexors but with normal reflexes, down-going plantars and no obvious wasting or fasciculations of the muscle group. The arms did not seem inappropriately smaller than the rest of her body.”

She closed her letter with the following impressions; Widebertha has many problems, not all of which fit together. Problem #1 is that of her excessive thirst and polyuria. I don’t see any base line lab results for specific gravity of the urine ordered or what her serum sodium is doing. I think those need to be repeated. Preferably repeated after an overnight fast. The polydypsia could also be due to undiagnosed diabetes and I have not seen a blood sugar although I ‘m sure that it’s probably within normal limits. It might be worthwhile doing an oral glucose tolerance test just to see what her blood sugars do with the glucose load. She also drinks diet Pepsi during the day. This is a huge amount of caffeine and maybe contributing to her symptoms of adrenaline rushes at night, difficulty sleeping and then feeling exhausted and fatigued. I have advised her not to take any beverages that have any kind of caffeine in them for the next little while.” She continues on with, “I don’t get the impression that this is diabetes insipidous, although it could very well be, but I think we should just repeat these urine tests with the specific gravity and make sure she doesn’t have any abnormal glucose tolerance.

She continues with, “Problem #2 is the proximal leg weakness is a bit of a concern, because she can’t get out of a chair without using her hands and she has on exam, very limited hip flexor muscle strength. Again, my gut impression is that this is because of maybe a bit of clinical hypothyroidism and that she is not adequately replaced especially given her size. I think we need to make sure that she doesn’t have any element of polymyalgia rheumatica and should probably do just a screening ESR, C-reactive protein, ANA, C3/C4. Again I suspect that these will be normal.

Gypsy goes on to say, “Problem #3 is post-menopausal status. Although she’s had a lumpectomy, it was for benign breast disease and she has no family history of breast cancer. I think that with regards to osteoporosis bone protection and limited cardiovascular protection, I think that she should definitely be put on hormone replacement therapy. This may also help with some of her symptoms. I also agree with the CT Scan of the head and I’m thinking that perhaps a trial of SSRI may be beneficial both for her symptoms and for some potential weight loss.”

Gypsy, at least, bothered to get many of my symptoms right. She seems to have forgotten that I have done a six-month trial with hormone replacement therapy. Nothing changed. My symptoms remained throughout the therapy. As for the SSRI’s, I refuse to go that route until all other options have been tried.

 

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