Report Samples

 

Below you will find the work-up of a sample client who has agreed to have her reports displayed here, for educational purposes. Normally client reports are never posted anywhere online. These reports are completely anonymous, all identifiers have been removed.

I will post each section as it is completed. First, the diagnoses evaluation, an educational document giving the client a solid baseline of understanding of what is going on, where they are and some ideas of where they may be able to go--understanding that not all diagnosis prove to be correct and that some may be side effects of medication or their other diagnoses. Where do the records we use come from? Basic records (list of diagnosis and lab results) are often available on-line and a patient, once paperwork and HIPAA documents are signed, may transfer them to an iRNPA. The complete records take longer. In this case we are requesting 20 years of records, including hospitalizations, so it may take a while.

All patients have a right to their complete records. Some people routinely request them (for example, after a hospitalization) and store them. I request copies of all my test results. Others use their online portal to monitor the overview provided. A slip of a finger, a wrong button pushed, could mean a wrong diagnosis entered, so it is a good idea to check and if anything looks odd to you, call the office and find out if an error was made.

This client did not request an evaluation and comparison of available treatments, but treatment options are included in the diagnostic work-up.

Next is her MediKey.

 

Sample Diagnosis Report -- Detailed

 

 

Client #4520  63 y.o. female

Diagnosis Detail

Fibromyalgia

Definition:  (CDC)

Fibromyalgia is a disorder of unknown etiology characterized by widespread pain, abnormal pain processing, sleep disturbance, fatigue and often psychological distress. People with fibromyalgia may also have other symptoms; such as,  

  • Morning stiffness
  • Tingling or numbness in hands and feet
  • Headaches, including migraines
  • Irritable bowel syndrome
  • Sleep disturbances
  • Cognitive problems with thinking and memory (sometimes called "fibro fog")
  • Painful menstrual periods and other pain syndromes

American College of Rheumatology states that:  Fibromyalgia often co-occurs (up to 25-65%) with other rheumatic conditions such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS).  Rheumatic conditions are all linked to Systemic INFLAMMATION

Causes and Concerns:

  • New research shows that about half of fibromyalgia patients have damage to nerve fibers in their skin and other evidence of a disease called small-fiber polyneuropathy (SFPN), this can often be confirmed with a skin biopsy.  (Aug. 6, 2013, HealthDay News)
  • Obesity is a common comorbidity (occurs with) of fibromyalgia that may compromise clinical outcomes. The adverse impact of obesity is evidenced by hyperalgesia (extreme sensitivity), disability, impaired quality of life and sleep problems. Recent evidence suggests weight loss improves fibromyalgia symptoms, perhaps resulting from patients adopting healthier lifestyles and taking more positive attitudes toward symptom management, and overall quality of life.  (Relationship Between Fibromyalgia and Obesity in Pain, Function, Mood, and Sleep. The Journal of Pain, 2010; 11 (12): 1329 DOI: 10.1016/j.jpain.2010.03.006)
  • Toxins associated with FM:  Phthlates and Parabens, TEST urine.  In addition to obesity, elevated levels of phthlate have been associated with chronic fatigue syndrome, fibromyalgia, ADD, syndrome X, diabetes, arteriosclerosis, allergies, and much more.
    • “Phthalate plasticizers are the most abundant man-made pollutants that have recently received wide-spread attention…  Insults occur to various organs, including the reproductive system, pulmonary, central nervous system, immune system and liver. Toxic reactions are also reported involving inflammation, mitochondria and carcinogenicity.”  (Kovacic, P. , How dangerous are phthalate plasticizers? Integrated approach to toxicity based on metabolism, electron transfer, reactive oxygen species and cell signaling.  Medical Hypotheses - April 2010)

     

TREATMENTS: 

Alternative treatments with published supporting research:  (click here and note: table 2 states protocols used) http://www.jacobteitelbaum.com/resources/Effective-Treatment-Of-Severe-Chronic-Fatigue-States.html

 

Ann Myers, MD, Functional Medicine MD offers this list of causes/ treatments for FM symptoms:

  • 1. Gluten intolerance 
    Gluten has been liked to more than 55 diseases and is often called the "big masquerader." The reason for this is that the majority of gluten intolerance symptoms are not digestive in nature, but are instead neurological, such as pain, cognitive impairment, sleep disturbances, behavioral issues, fatigue and depression.

    2. Candida overgrowth
    Candida is a fungus, or yeast, and a very small amount of it lives in your intestines. When overproduced, Candida breaks down the wall of the intestines and penetrates the bloodstream, releasing toxic byproducts into your body and causing a host of unpleasant symptoms such as brain fog, fatigue, digestive issues and pain. Virtually every one of my patients with fibromyalgia has had Candida overgrowth.

    3. Thyroid
    It's vital that your doctor check all six blood markers to accurately measure your thyroid gland’s function. It’s also imperative that your doctor use the optimal levels rather than the standard reference range when assessing and diagnosing thyroid disorders. Getting my patient’s thyroid levels into an optimal range typically alleviates their fatigue, brain fog, sleep disturbances and depression. 

    4. Vitamin deficiencies
    Magnesium, vitamin D and B12 deficiency are the most common vitamin deficiencies I see in those who have been diagnosed with fibromyalgia. I've had several patients completely reverse their fibromyalgia symptoms with magnesium alone. The best way to measure magnesium is a red blood cell (RBC) magnesium level, which can be tested through any conventional lab.

    5. Small Intestine Bacterial Overgrowth (SIBO) and Leaky gut
    There are more bacteria in us and on us then there are of our own cells. When these bacteria get out of balance through use of antibiotics or a sugar-rich diet, we can lose our ability to digest and absorb nutrients, particularly B12. Gluten can cause SIBO and leaky gut and SIBO and leaky gut can lead gluten and other food intolerances. It’s a catch-22 and a vicious cycle. You must "fix the gut" first in anyone with fibromyalgia.  **WITH THE GERD, B-12 DEFICIENCY AND FM, YOU ARE EXHIBITING CLASSIC SIGNS OF THIS, IT NEEDS TO BE ADDRESSED--PL

    6. Mycotoxins
    Mycotoxins are very toxic substances produced by molds. Conventional environmental mold testing only tests for levels of mold spores and does not test for mycotoxins. I use a urine mycotoxin test in my clinic to determine if someone has been exposed to toxic molds.

    7. Mercury toxicity
    I recommend that all my patients find a biological dentist and have their mercury amalgam fillings removed. Mercury is toxic to our bodies and can be one piece of the puzzle for those with fibromyalgia. I then recommend heavy metal testing using a pre- and post-DMPS urine challenge test.

    8. Adrenal fatigue 
    Adrenal fatigue is a result of the chronic stress. Chronic pain is a stress to the adrenal glands, though it's typically not the initial adrenal stressor. The initial stressor is usually something such as food intolerances, Candida, mercury toxicity, vitamin deficiencies or mycotoxins. My goal is to support the adrenals with adaptogenic herbs while we search for the root cause of the stress and correct it.

    9. MTHFR mutations
    This is a genetic test you can get though any conventional lab. The more mutations you have to the MTHFR gene the less able you are to methylate and detoxify toxins, such as mercury and lead. The more mutations you have at this gene the higher your requirements for methyl-B6, methyl-B12 and folinic acid in order to keep your detoxification pathways working properly.

    10. Glutathione deficiency
    Glutathione is the most critical part of our body’s detoxification system. Glutathione gets recycled in our body — unless our toxic burden gets too high, or we lack GSTM1 and GSTP1, the enzymes needed to recycle and produce glutathione. Taking glutathione or the precursors (NAC, alpha lipoic acid, milk thistle) often help dramatically with fatigue.

    As you can see from the above list, many of these causes are interrelated, and often there's no single root cause of fibromyalgia.

MERCURY’S Relationship to Chronic Fatigue and Fibromyalgia (as well as Neurosarcoidosis??):  http://www.functionalmedicineuniversity.com/public/903.cfm

1: Mercury is known to denervate nerve fibers, similar to the pathology of multiple sclerosis. In other words it makes it so the nerves do not work.

2: Mercury can leak into the blood-brain barrier and reduce nerve conduction velocity and visual evoked responses, diagnostic tests used for multiple sclerosis.

3: Mercury can inhibit the action (binding) of happy hormones, like serotonin, at the synapse (nerve to nerve connection) leading to depression.

4: Mercury can cause hearing loss.

5: Mercury can decrease norepinephrine and dopamine activity at synapses, damaging our molecules of emotion. This can make a person lack zip, enthusiasm, joy, and creativity and make him anxious, insomniac, and terribly tense.

6: Mercury can create peripheral neuropathy, auto-immunity and interferes with synapse transmission, decreasing infection control so the unsuspecting victim gets recurrent sinusitis, prostate or gum infections, as examples.

7: Hidden mercury toxicity can be at the root of a resistant Candida infection. Sometimes you just cannot clear Candida symptoms until you get rid of the mercury.

8: Mercury is also a major undiagnosed cause of chronic fatigue and fibromyalgia.

9: Whenever we see someone resistant to all treatments, there is a high probability mercury toxicity is at the root of it.

10: Mercury toxicity can create any baffling neurologic disease as well, burning & migrating pain and impair cure for any disease of other body systems.

 **  It is imperative that you be tested for mercury

Restless leg syndrome

  • High Rate of Restless Legs Syndrome Found in Adults With Fibromyalgia (impairs much needed sleep)
  • Oct. 15, 2010 — A study in the Oct. 15 issue of the Journal of Clinical Sleep Medicine found that adults with fibromyalgia had a much higher prevalence and risk of restless legs syndrome than healthy controls. The study suggests that treating RLS may improve sleep and quality of life in people with fibromyalgia.
  • Results show that the prevalence of restless legs syndrome was about 11 times higher in the fibromyalgia group than the control.

This is a serious issue with autoimmune patients since they require 8-9 hours of good sleep per night.  First thing is to check all medications and supplements to be certain they are not causing or contributing to the problem.  I checked yours.  Then practice good sleep hygiene:

  1. Maintain a regular bed and wake time schedule every day, including weekends.
  2. Establish a regular, relaxing bedtime routine such as soaking in a hot bath or hot tub and then reading a book or listening to soothing music.
  3. Create a sleep-conducive environment that is dark, quiet, comfortable, and cool.
  4. Sleep on a comfortable mattress and pillows.
  5. Use your bedroom only for sleep and sex.
  6. Finish eating at least two to three hours before your regular bedtime.
  7. Exercise regularly, but complete your workout at least a few hours before bedtime.
  8. Avoid caffeine (e.g., coffee, tea, soft or energy drinks) close to bedtime, as it can keep you awake.
  9. Avoid nicotine (e.g., cigarettes, tobacco products) too close to bedtime.
  10. Avoid alcohol close to bedtime.

The hot bath often works especially well, as does massage.  There are also meds if needed.  Melatonin is good first choice for sleep.  I recommend an evaluation by a functional or integrative doctor if you continue to have this issue.

 

Peripheral neuropathy

Causes:

  • Diabetes
  • Chemotherapy
  • Use of Statin drugs (damage to mylin sheath, made from cholesterol)
  • Physical blockage, usually from spine out of alignment
  • Nutrient deficiency:  acetyl-L-carnitine, lipoic acid, vitamin E, B1, B6
  • Fibromyalgia & Neurosarcoisosis

***  Small fiber polyneuropathy:  Treatments remain the same as with all neuropathic pain except:  “In the only published study specifically examining treatment of small fiber neuropathy, both gabapentin and tramadol were found to be effective.”  (Curr Pain Headache Rep. 2011 June; 15(3): 193–200)

 

Sarcoidosis 

Sarcoidosis is a disease of unknown cause that leads to inflammation.   It can affect various organs in the body. (NIH)

AUTOIMMUNE:  Normally, your immune system defends your body against foreign or harmful substances. For example, it sends special cells to protect organs that are in danger.  These cells release chemicals that recruit other cells to isolate and destroy the harmful substance.

Inflammation occurs during this process. Once the harmful substance is destroyed, the cells and the inflammation go away. In people who have sarcoidosis, the inflammation doesn't go away.

Instead, some of the immune system cells cluster to form lumps called granulomas in various organs in your body

 

Neurosarcoidosis:

Following from:  www.ninds.nih.gov/disorders/neurosarcoidosis/xml_neurosarcoidosis.htm‎

Neurosarcoidosis is characterized by inflammation and abnormal cell deposits in any part of the nervous system – the brain, spinal cord, or peripheral nerves.  It most commonly occurs in the cranial and facial nerves, the hypothalamus (a specific area of the brain), and the pituitary gland.  It is estimated to develop in 5 to 15 percent of those individuals who have sarcoidosis.  Weakness of the facial muscles on one side of the face (Bell’s palsy) is a common symptom of neurosarcoidosis.  The optic and auditory nerves can also become involved, causing vision and hearing impairments.  It can cause headache, seizures, memory loss, hallucinations, irritability, agitation, and changes in mood and behavior. 

Causes and Concerns:

Excessive inflammation: (this next section is from holistic source: http://www.mdwellnessmd.com/holistic-treatment-in-nj/sarcoidosis-specialist-doctor-in-nj/)

One of the underlying causes of sarcoidosis is excessive inflammation in the body. There are many inflammatory agents in our food supply that must be strictly avoided if you have sarcoidosis. You may be over-consuming carbohydrates, especially in the form of high fructose corn syrup (HFCS). You may also be eating too much fried foods, polyunsaturated vegetable oils, and food additives like nitrates, MSG and artificial sweeteners. These substances are highly toxic and cause inflammation.

Symptoms of low levels of vitamin D
There’s substantial evidence that sarcoidosis is one of the symptoms of low levels of vitamin D and vitamin D metabolism. Low levels of vitamin D can contribute to this disease, however many patients with sarcoidosis have hyperactive immune systems, which can cause excessive vitamin D.  Excess vitamin D will increase calcium levels in the cells, which will activate the nerve cells and cause excess inflammation, leading to more damage. Calcium deposits in tissues like lung and kidney are the hallmark of sarcoidosis. These calcium-laden lesions are named granulomas. Therefore, vitamin D supplementation should be very carefully monitored. Special blood tests looking at various forms of vitamin D should be utilized to determine your needs. . Sarcoidosis specialist MD Wellness can help determine what your body requires.

Food Allergies
If you have sarcoidosis, food allergies may be contributing to your problems. You may also have a high incidence of bowel flora imbalances with excessive levels of pathogenic bacteria and low levels of beneficial bacteria. Often times, sarcoidosis patients also have leaky gut syndrome. These imbalances can over activate your immune system and add to inflammation.

Envirnonmental Allergies
If you have sarcoidosis you want to be careful to minimize your exposure to environmental allergies like mold and mold toxins. These harmful, common poisons can over stimulate your immune system and contribute to “autoimmune” disease.

Treatments

There is no agreed upon standard of treatment for neurosarcoidosis.  Doctors generally recommend corticosteroid therapy as first-line therapy for individuals with the condition (this therapy has considerable undesirable health ramifications and I would caution you to speak with your MD, or seek a second opinion regarding this--PL).  Additional treatment with immunomodulatory drugs such as hydroxychloroquine, pentoxyfilline, thalidomide, and infliximab, and immunosuppressive drugs such as methotrexate, azathioprine, cyclosporin, and cyclophosphamide, have benefited some individuals.  While the use of corticosteroids and other immunosuppressive drugs is effective, these medications also have undesirable side effects. Side effects and experience with certain drugs may play a role in medication choices. (www.ninds.nih.gov/disorders/neurosarcoidosis/xml_neurosarcoidosis.htm‎)

Nutritional:  (very important in systemic inflammation!)

Dietary Recommendations

  • Prostaglandin Diet

Avoid:

    • All fried foods (deep fried and pan fried) Trans fats- Margarine
    • Hydrogenated and partially hydrogenated vegetable oils
    • Commercially processed vegetable oils
    • Polyunsaturated vegetable oils- mayonnaise, salad dressings, nuts and nut butters, cooking oils, and all other vegetable oils (except olive oil and coconut oil)
    • Excess arachidonic acid – shrimp, lobster, crab, and other shellfish and mollusks
    • Excess alcohol
    • Food additives
    • Any refined sugar or high fructose corn syrup
  • Avoid toxins in the diet
  • Eat a balanced diet

 

I found this center near you:

 

Lyme Disease  (your previous diagnosis of Lyme disease, and the similarities to both Neurosarcoinosis and Fibromyalgia cause me to include info here) 

From:  http://lymedisease.org/lyme101/lyme_disease/lyme_symptoms.html

Fast Facts

  • Lyme is fastest growing vector-borne disease
  • 85% do not recall tick bite
  • Less than 70% of people develop a rash
  • Treatment should begin without testing if rash is present
  • Lab tests may be negative in the first 4-6 weeks

Early symptoms

  • Flu-like illness (fever, chills, sweats, muscles aches, fatigue, nausea and joint pain)
  • Rash (10% have EM rash)
  • Bell’s palsy

TESTS:  Western Blot  Antigen detection tests look for a unique Lyme protein in fluid (e.g. blood, urine, joint fluid). Sometimes people whose indirect tests are negative are positive on this test.

 

Later Symptoms

  • Headache
  • Stiff neck
  • Light or sound sensitivity
  • Cognitive impairment
  • Sleep disturbance
  • Depression, anxiety, or mood swings
  • Arthritis
  • Fatigue
  • Abdominal pain, nausea, diarrhea
  • Chest pain, palpitations
  • Shortness of breath
  • Tingling, burning or shooting pains
  • Fibromyalgia
  • Vision & hearing impairments

 

The IDSA thinks Lyme symptoms after treatment represent a possibly autoimmune, “post-Lyme syndrome” that is not responsive to antibiotics. ILADS physicians believe that on-going symptoms probably reflect active infection, which should be treated until the symptoms have resolved. These physicians are using the types of treatment approaches employed for persistent infections like tuberculosis, including combination treatment with more than one antibiotic and longer treatment durations. 

Functional and integrative MDs are using many other forms of therapy for chronic Lyme and a visit to one is recommended.

 

Vitamin D deficiency

  • Sarcoidosis is one of the symptoms of low levels of vitamin D and vitamin D metabolism. Low levels of vitamin D can contribute to this disease, however many patients with sarcoidosis have hyperactive immune systems, which can cause excessive vitamin D.  Excess vitamin D will increase calcium levels in the cells, which will activate the nerve cells and cause excess inflammation, leading to more damage. Calcium deposits in tissues like lung and kidney are the hallmark of sarcoidosis. These calcium-laden lesions are named granulomas. Therefore, vitamin D supplementation should be very carefully monitored.  (http://www.mdwellnessmd.com/holistic-treatment-in-nj/sarcoidosis-specialist-doctor-in-nj/)
  • Sarcoidosis is one of the few diseases where you need to be cautious in supplementing with vitamin D and cautious in getting good amounts of sun exposure. The reason is that in sarcoidosis, 4–11% of the patients develop high serum calcium (hypercalcemia). In any hypercalcemic condition, caution is needed in supplementing with vitamin D. While supplementation doesn’t need to be avoided, it should be closely monitored by a health care professional, to make sure that it doesn’t further increase serum calcium levels.  (http://www.vitamindcouncil.org/blog/randomized-controlled-trial-vitamin-d-supplements-carry-only-slight-risk-in-sarcoidosis/)

 

Osteopenia

Osteopenia refers to bone mineral density that is lower than normal peak, but not low enough to be classified as osteoporosis.

Causes:

  • Aging, being thin, white, Asian, family history, lack of exercise, smoking, cola drinks, excessive alcohol consumption, medication side-effect, esp: chemotherapy, steroids, radiation – WebMD  (I checked your meds and this is not a significant risk with your current list – PL),
  • Zinc deficiency:  One important clue that you may have a zinc deficiency is an alkaline phosphatase blood test below 70. (http://www.functionalmedicineuniversity.com/public/904.cfm)  

**Your last two alkaline phosphatase:  61 iu/ 60iu

  • Check:  RBC intracellular nutrient and toxic heavy metal profile (cadmium?)
  • A zinc deficiency can come from cadmium, plasticizers, unbalanced high calcium doses, and more.
  • Check parathyroid levels as this is the gland responsible for calcium and phosphorous regulation

 

B12 vitamin deficiency

Symptoms:

  • strange sensations, numbness, or tingling in the hands, legs, or feet
  • difficulty walking (staggering, balance problems)
  • anemia
  • a swollen, inflamed tongue
  • yellowed skin (jaundice)
  • difficulty thinking and reasoning (cognitive difficulties), or memory loss
  • paranoia or hallucinations
  • weakness
  • fatigue

Recent (2013) articles in New England Journal of Medicine and Harvard Health @ Harvard.edu state this is fairly common—especially with Vegans/ vegetarians, people with gastric bypass surgery and people over 50.

Supplementation is better absorbed sublingually (under the tongue) or by injection.  You are already getting good B-12 supplementation.

 

Primary hypercoagulable state

Hypercoagulable state: A condition in which there is an abnormally increased tendency toward blood clotting (coagulation).

Primary means inherited or born with.

There are numerous hypercoagulable states. Each has different causes and each increases a person's chances of developing blood clots such as those associated with thrombophlebitis (clot in the veins).

Causes of primary hypercoagulable states include elevated blood homocysteine levels, and inherited protein deficiencies (antithrombin III, factor V Leiden, protein S, protein C, and others).

I haven’t seen anything in the records I have to far to substantiate this, awaiting older records to make more detailed evaluation-- PL

 

GERD [Gastroesophageal reflux disease]

Stomach acid escapes into the esophagus, damaging tissue there, through a valve (sphincter) that should never open except to let chewed food down into the stomach. In GERD, the sphincter malfunctions.

Traditional thinking is that GERD is caused by excess acid, so antacids of all types are used with abandon, but that may no longer be a viable theory--and is probably contributing to the problem.  We need stomach acid to digest food and even if you wanted to, one could not neutralize all the stomach acid so it would be harmless.  Correcting the pH has become the more logical approach.  Now, specialists are prescribing what is essentially stomach acid to improve the pH and digestion.

How it works:  Stomach acid digests carbohydrates, so when it is low carbohydrates sit in the stomach or move through without being broken down and decay, causing gas and pressure. Carbohydrate malabsorption leads to bacterial overgrowth, resulting in more intra-abdominal pressure (IAP) which drives reflux (the pressure forces the sphincter to open and allow acid into the delicate tissue of the esophagus). Low stomach acid can contribute to both bacterial overgrowth (independently of carbohydrate intake) and carbohydrate malabsorption, the process looks like this:

gerddiagram

 

Let’s look at each step in turn.

Low stomach acid causes bacterial overgrowth

One of the chief roles of stomach acid is to inhibit bacterial overgrowth. At a pH of 3 or less (the normal pH of the stomach), most bacteria can’t survive for more than 15 minutes. But when stomach acid is insufficient and the pH of the stomach rises above 5, bacteria begin to thrive. Research mice, which were bred to be incapable of producing stomach acid, suffered from bacterial overgrowth – as well as inflammation, damage and precancerous polyps in its intestines.

It is also well documented that acid-suppressing drugs promote bacterial overgrowth. Long-term use of Prilosec, one of the most potent acid suppressing drugs, reduces the secretion of hydrochloric acid (HCL) in the stomach to near zero. In one trial, 30 people with GERD were treated with a high dose of Prilosec (40g/day) for at least 3 months. 11 of the 30 Prilosec-treated people developed significant bacterial overgrowth, compared with only one of the ten people in the control group.

While obesity, overeating, lying down after eating, bending over after eating, and wearing tight belts or clothing, play a role, for the problem to become chronic (which is what GERD is) then it is believed other factors are at work.

In is book, Heartburn Cured, Dr Robillard notes that when stomach acid is sufficient and carbohydrates are consumed in moderation, they are properly broken down into glucose and rapidly absorbed in the small intestine before they can be fermented by microbes. However, if stomach acid is insufficient and/or carbohydrates are consumed in excess, some of the carbs will escape absorption and become available for intestinal microbes to ferment into gas.  Evidence that bacterial overgrowth causes GERD is that tests have shown that antibiotics--erythromycin--can kill the bacterial overgrowth and stop the IAP and GERD.  

Try eating fewer simple carbs.  Sugar, bread, pasta, rice, starchy veggies (like white potatoes), etc. all contribute.  Stick with protein sources and veggies, primarily.  And don't overeat, or eat before bed. If that doesn't do it, then talk with your doctor about restoring your stomach acid. (http://chriskresser.com/the-hidden-causes-of-heartburn-and-gerd)