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FK (Constipation, Endometriosis, Family history:, Infectious?, Supplement…
FK
Constipation
Anorexia
Weight loss
Dizziness/Syncope
Mobility aid needed
endless fatigue all the time, chills 2-3 days/week, night sweats occasionally, very weak, very dizzy, often have to sit down on the floor when walking to and from my own bathroom at home bc I feel faint, no appetite
Risk of refeeding syndrome
Hospitalized for nutrition needs
Appetite and ability to keep food down improved when bowels are moving
Steatorrhea
Causes of steatorrhea
Alcoholic pancreatitis
Normal lipase levels, pt reports avoids alcohol - not it
Hereditary pancreatitis (mutations in genes such as PRSS-1, SPINK-1, CFTR, CTRC)
No sign of pancreatitis
Pancreatic insufficiency due to inherited conditions such as CF, Shwachman-Diamond syndrome, Pearson marrow syndrome, and Johanson–Blizzard syndrome
Normal pancreatic elastase
Celiac disease?
Tropical sprue
No diarrhea, not likely
Chronic liver diseases such as PBC, PSC
WNL LFTs, consider running AMA (anti mitochondrial antibodies)
MRCP? magnetic resonance cholangiopancreatography
Advanced pancreatic cancer
Unremarkable abdominal imaging
Distal ileal pathology (e.g., Crohn disease) or resection
Consider repeat colonoscopy if hysterectomy does not improve sxs
Giardiasis?
Stool sample for testing
Whipple disease
Unremarkable duodenal biopsies in 2022
SIBO
Check levels of fat-soluble vitamins: A, E, D, K; absorption tests
Vitamin E low
SIBO?
Presumptive tx Rifaximin
In process
Nausea
lost 25lbs in last 2 months
CT abdomen unremarkable
Colonoscopy 2022 WNL
Negative FOBT 2024
Recommended to try Pelvic floor PT
Had 3 sessions, found helpful but $$
Taking med to reduce opioid impacts on bowel function
Negative standard parasite/pathogen stool tests
GI Effects?
Abdominal migraine?
Gastroparesis?
Motility studies post op hysterectomy?
PCP has prescribed Motegrity or Linzess if not covered
Colonic hydrotherapy?
Endometriosis
Endo surgery and hysterectomy scheduled
this September
Endo lesions on diaphragm? Rectum?
Will know more after excision and hysterectomy
Avoiding: gluten, soy, dairy, corn, red meat, pork, eggs, caffeine, alcohol
Prior excision in 2020
Low ferritin, normocytic anemia
Iron infusions recommended
Received 1 infusion while inpatient
Continue for lethargy
Pain so severe requiring daily use of opioids
Referral to pain management/case management pending from PCP
This provider only did the presacral neuro-blocks (Jason Attaman) --> still needs a pain management specialist
Hormonal balance? Run day 3 and day 21 if can complete before surgery
How long after hysterectomy before checking?
Family history:
Cancer - Mom, brother, aunts, uncle, grandma (all dead)
Addictions - Mom, brothers, father, aunt, uncle, grandfather
Suicidal/Suicide - Mom+ sister, grandfather took own life
Headache/Migraine - Sister
Bowel disease - Mom- Ulcerative Colitis
Increased risk for IBD/Autoimmunity
Consider colonoscopy/endoscopy with biopsies
Rheumatology referral?
Depression - Mom, sister, brother
Infectious?
EBV? CMV?
HCV non reactive at last testing
Gingivitis? GI Microbiome?
Lyme?
Supplement support:
Vitamin D – 2,000 – 4,000IU
Vitamin C – 1,000 – 2,000mg per day
EFA’s – 3,000 – 6,000mg per day.
Only taking 1000 mg right now
Has been shown to improve symptoms in those with RA and reduce risk of CVD.
Selenium – 400 – 600mcg/day
Zinc – 60mg per day
Vitamin E – 400IU/day
Bromelain: 250 – 750mg TID
Avoid Melatonin - can worsen RA sxs
Herbal support:
Curcumin: 1 – 1.5g/day in divided doses
Ginger: 8 – 10g dried or extracts/day
Valerian root: 1.5 – 3g/day
Uncaria tomentosa (Cat’s claw) – 20mg TID
Heightened allergic reactions, rash
MCAS?
Histamine determination WNL, WNL tryptase
Further labs ordered, pending: need to be run during a flare of the allergic-type reactions
During flare, still normal tryptase and serum histamine; other markers of mastocytosis negative
Worse rxs during menses
Estrogen dominance?
Aromatization converting T to estradiol?
Elevated CCP
Negative ANA, Neg Rf
Early stage of Rheumatoid Arthritis / Undifferentiated autoimmunity?
Unremarkable hand imaging (XR) in 2022
Consider repeat imaging of affected joints in a year: XR, MRI, ultrasound
Flare support:
Therapeutic fasting – 3-5 days duration during acute flares.13
Juice fasts or fasts with water or broth for up to 10 days can also be very beneficial.
Exercise – can improve strength and performance while maintaining range of motion
Passive ROM exercises
Hydrotherapy – heat to relieve stiffness and pain and relax muscles; contrast hydrotherapy during acute swelling.
Sjogren's? Has some signs of sicca
testing/labs/rheum referral
Lupus?
Other labs to check for lupus:
Anti nuclear antibodies (ANA) – would be positive
Negative
Anti-dsDNA and Anti-Sm – highly specific if positive
Anti-Ro/SSA and Anti-La (SSB) – more associated with Sjögren's
Anti-U1 RNP antibodies – more associated with MCTD
Antiribosomal P protein antibodies
Antiphospholipid antibodies
C3 and C4 or CH50 complement levels - would be decreased
C3 normal
ESR/CRP - would be elevated
WNL
Urine protein/creatinine ratio - would be elevated
Elevated levels at recent hospital stay
Normal CRP, SED rate
Repeat in a year and annually to track status of autoimmunity
High Abs. CD3+CD25+Lymphs
CD25 is the receptor for IL2 and is expressed on activated T cells, B cells, and macrophages. CD25 is expressed in certain types of B-cell lymphoma (hairy cell leukemia) and T-cell lymphoma (adult T-cell lymphoma/leukemia [ATLL]).
The interleukin-2 receptor is designated CD25. Originally isolated from T-lymphocytes, it is now known to be expressed on hairy cell leukemia and adult T-cell leukemia/lymphoma, classical Hodgkin lymphoma, and a subset of other peripheral T-cell lymphomas.
Generally non-specific marker of immune regulation
Allergies?
Environmental?
Food?
Trans-masc
3 years on testosterone injections, still cycling
Per
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9175596/
: only about 60% of transmasc patients on T have full cessation of ovarian and endometrium function
No especial sign of pathology, just in the 40%
Former smoker
2002 through 2010
Chest XR's notable for stable nodule, likely benign/hemangioma
Daily cannabis for pain management
Cyclical Vomiting syndrome?
Trial off cannabis: during hospital stay - low on suspects list
Insomnia: wake up frequently if I can fall asleep
Nightly trazodone
Sleep still very poor
Gabapentin helps for feeling sleepy, had not been using trazodone till this weekend
Migraine
Not a candidate for hormonal measures for endo
Interstitial cystitis, vaginal pain, dyspareunia
Pelvic floor PT referral, had only gotten to breathing exercises, needs more sessions
Chronic joint pain, worse since starting testosterone injections
Has trialed methotrexate; no improvement. Tried prednisone, led to psychosis. Other immunosuppression? NOT CURRENTLY
Normal thyroid panel and antibodies
Normal parathyroid
History: Myocarditis,
History: Adenomyosis
Allergies: prednisone = psychosis
Mold toxicity?
Toxin exposure?