E-rounds #1 Cut and Paste version vol 1

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INITIAL CASE SUMMARY

Patient: W.D.

Date: April 13, 1999

Mr D. presented on April 12, 1999 for evaluation and recommendations of complaints of spinal and upper extremity symptoms, a heart condition that he described as angina, abdominal symptoms, and right knee discomfort. He desired a thorough diagnostic work-up and nutritional recommendations.

Upper extremity complaints consist of discomfort, “pinching,” between his shoulder blades associated with numbness of the first three digits of each hand. These symptoms are worse upon awakening and ease with movement. These hand symptoms have been present since 1994 but recently worsened doing cement work within the past several weeks. On one occasion the left hand actually “clenched.” He frequently uses a computer in his work, which irritates his neck. His right knee is sore from time-to-time and he has had arthroscopic surgery in the past.

Mr. D says that he has had chest discomfort for a number of years. He recalls a number of episodes when he had to stop walking up an incline around last Christmas.

He was recently evaluated and treated by Dr. Cardiologist who also recommended that he get some additional blood tests in this office: fasting lipid panel, liver function, and thyroid.

Recent history includes the diagnosis of inferolateral wall ischemia by his cardiologist. See his report dated February 15, 1999. His blood pressure has historically been good.

Present medications include Lipitor 10mg; Toprol XL 50mg; Isosorbide mononitrate 30mg; aspirin 325mg; and Nitrostat sublinqual .4mg prn.

Examination

Ht. 67 ¼” Weight: 160 BP: 106/62 Pulse: 58

Skin: warm and supple, small reddened round lesion on the left central temple under the arm of his glasses that is approximately 7-10mm in diameter. It does not appear to have

Mr. D

April 13, 1999

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a raised border. He remarks that this has been there for quite a while and doesn’t seem to heal.

Lymph nodes are non palpable.

Extremities: both hands appear swollen and his rings fit very tightly, exhibiting more than common swelling for him. There appears to be no edema in the legs and ankles. The dorsalis pedis arteries are readily palpable bilaterally. Toenails are well-formed and the skin color is excellent.

Orthopedic/Neurologic tests: Reflexes 2+ bilateral both upper and lower extremities. Phalen’s and Tinels were both negative. Sensorium of upper extremities intact, Thenar eminences preserved with mild bilateral adductor pollicis brevis weakness. Moderate tenderness was noted over thoracic segments 2, 3, and 4.

EENT: fundi, sclera, and eye reflexes are intact without abnormality. Gingiva, and mucosa of the oropharynx show excellent color. Teeth are in good repair.

Chest: normal contours. Heart and lung auscultation demonstrates normal tones and rhythm.

Abdomen: normal contours and sounds present. Deep palpation reveals mild LLQ tenderness.

Pelvis: absent for hernias, prostate palpates normally in size and texture.

ECG: see report of Dr. Cardiologist

Blood Chemistries

Coronary (arteriosclerotic) risk assessment:

The cholesterol is normal at 180 and your “good” cholesterol, HDL, is low at 40. Therefore the Chol/HDL ratio is 4.5, and above average. The LDL level is 89. This is the heavy fat in the blood and this level is quite good. The LDL/HDL ratio is average at 2.23. The triglycerides (another blood fat) are significantly elevated at 253 and is often associated with a low HDL.

The calcium level is quite low as is the phosphorus. It is much better to be closer to 10 with the calcium and 4.0 with the phosphorus; your levels are 8.8 and 2.8 respectively.

W.D.

April 13, 1999

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The thyroid is within normal lab values but generally is low normal. This can contribute to the elevated triglycerides and minor complaints of cold extremities.

The serum magnesium needs to be brought up closer to 2.0. Your PSA (prostate test) is entirely normal.

Urinalysis shows no abnormality although a pH of 5.0 suggests a high intake of refined carbohydrates (simple starches and sugars). Interestingly, refined carbohydrates elevate the triglycerides.

Diagnosis

1. Hypertriglyceridemia

2. Angina per history

3. Mild carpal tunnel syndrome-bilateral

Recommendations

Lifestyle modifications must include exercise. This is to be engaged with the oversight of your cardiologist. I would recommend strongly that you avoid sugars and refined carbohydrates. Enclosed is a modified Pritikin diet which will give you insight into what foods to avoid. It would also be helpful if olive oil is used in place of other cooking oils or fats and may be of great benefit to your stomach discomfort taken by tablespoon one hour before meals. Recent research has shown that moderate consumption of red wine has significant heart and vascular benefits. I will recommend that you obtain a nerve conduction study to evaluate the carpal tunnel syndrome more definitively and that you wear wrist braces during the night.

Spinal adjustments with focus on the neck and thoracic spine should continue as necessary for the relief of spinal discomfort and potential positive effect upon the carpal tunnel syndrome.

Nutritionals/botannicals

Lyc-2000( vit C-Lysine): 1tsp twice daily in juice

Alph-E-Mixed(1000 iu mixed tocopherols): 1 capsule daily

Salmolinic(omega 3 & 6 fatty acids): 2 capsules twice daily

Carnitine-300(300mg L-Carnitine): 2 capsules twice daily

Extress-Super(50mgs B-complex): 1 capsule twice daily

Chromamin(1mg chromium chelate): 1 daily

Selenamin-200(200mcg selenium): 1 tablet twice daily

Mr. D

April 13, 1999

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Folic+B12(vits B12 and Folic acid): 3 tablets dissolved under the tongue twice daily

Q10 Plus(CoQ10, Mg, K, Taurine, Ginko, Hawthorne) 2 capsules twice daily

Neo-Cario(B3, Mg, Terminalia, Inula, Khella, Astragalus, bromelain) 2 caps twice daily

Additional supplementation of calcium and vitamin D is indicated. Because of the need to keep the quantities of supplements low, I recommend that you focus on high calcium foods. We can supplement calcium in the future in liquid form or as calcium citrate, with the addition of vitamin D, if your blood levels do not rise over the next 6 to 8 weeks.

Discussion

My first intent is to help you continue to lower your triglycerides and to do all that we can do to favor the health of the heart muscle and the blood circulation to it.

In reviewing your previous lab tests of 11-31-98 and 2-3-99, comparing these to the most recent lipid panel, it is clearly apparent that your blood fats continue to fall significantly. I would recommend that we re-test periodically, every 8 to 10 weeks.

The most conservative way to manage your arm/hand symptoms is to use the wrist bracing at night and during the day if necessary. We should continue to treat this in the office over the next two weeks and monitor outcome.

I recommend that you seek to establish a relationship with a medical physician for continuation of your present care and monitoring of this condition. Also the skin lesion on the left temple needs to be evaluated and treated. I would be happy to make recommendations of medical practitioners if you would like.

Thank you for the opportunity to assist you in achieving better health.

G. Lumsden, D.C., P.C.

REPORT OF FINDINGS

Patient: W. D.

Date of examination: June 11, 1999

Mr. D has been away recently with his National Guard duties and says that he has gone off of his diet somewhat. He returns for follow-up testing. He has had no incidents of chest pain and has been physically very active and is feeling well.

Medications: Lipitor 10mg; Toprol SL 50mg; Isosorbide mononitrate 30mg; aspirin 325mg; and Nitrostat sublinqual .4mg prn.

Supplements: A, B, C, E, he is not sure of the doses.

Wt: 158# fully clothed BP: 108/74

Weight loss has been excellent with the loss of approximately 4 pounds since April. Exercise consists of largely walking. Dietary changes have continued to be implemented in the form of near complete abstinence from sugar and reduced fat intake except for his recent activity in the Guard.

Findings include an excellent response in the cardiovascular risk assessment. Because of the continued lowering of the cholesterol and LDL, the respective ratios are solidly within normal limits and are: 3.5, and 1.71, down from 4.5 and 2.23 last test. The platelet count has increased to 287. It is preferred that this number be less than 250.

The raise in the serum magnesium from last test looks very good as does the Calcium and Phosphorus. In general there are mostly improvements in the blood test values.

Recommendations:

Lyc-2000(vit C with L-Lysine): 1 tsp in juice twice daily

Vit E(d-alpha tocopherol or mixed tocopherols): 800-1000 iu’s daily

Extress-Super(50mg B-complex) 2 daily

B12/Folic Acid(1000mcg B12 on resin/.8mg FA)1 dissolved under the tongue twice daily

Salmolinic(Omega 3 and 6 fatty acids-marine and plant sources): 2 capsules 3 times daily

Chromamin(1 mg chromium chelate): 1 tablet daily

Selenamin-200(200mcg’s Selenium chelate): 1 tablet daily

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W. D.

June 11, 1999

Discussion:

Please avoid any extra iron intake. I have attached a sheet of high iron foods. Do not completely avoid all of them—just the foods with the highest iron content (top five or six). Do not take supplements that contain iron.

This is an excellent improvement. Good work!

I appreciate the opportunity to participate in your effort to improve your health.

G. Lumsden, D.C., D.A.B.C.I.

REPORT OF FINDINGS

Mr. D

59 years

December 10, 1999

G. Lumsden, D.C., P.C.

Mr. D returns for follow-up evaluation of his cardiovascular risk profiles and general blood chemistries. His present complaints include some interscapular discomfort that seems to be related to some mild chest discomfort that he indicates to be along the central left parasternal area described as “pulling.” These symptoms seem to be present after he walks. Nitroglycerin, sublingual, is still used from time-to-time. He confesses that his diet has slipped somewhat during the Thanksgiving holiday.

Weight: 154.5 pounds BP: 100/60 P: 88

Heart and lung tones are clear and regular.

Spinal: moderate tenderness is present in the para T3-T5 tissues. The spinous process of T5 is prominent. Para sternal palpation does not reveal tenderness.

Impression: Low grade angina?

Costo-vertebral chest wall syndrome

Recommendation: spinal manipulation, 2 visits to assess effect on this complaint

Blood chemistries

Cardiovascular risk assessment: Chol/HDL ratio is 4.34 and above average. The previous tests were 3.5(normal) and 4.5, respectively. The LDL/HDL ratio is 1.95(normal) with the previous tests at 1.71, and 2.23, respectively. The triglycerides have risen from 156 on your last test to 285.

Serum magnesium continues to be low at 1.62. Increased absorption my be helped by additional B6 supplementation. The calcium has risen nicely since the initial test although the phosphorus is low at 2.6. As a result the calcium in the serum is not nearly as available for use as it should be. Low phosphorus is helped with supplemental vitamin D.

Urinalysis: normal

Impression: Hypertryglyceridemia

Less than adequate serim magnesium value 275.20

Not metabolizing calcium due to poor phosphorus 275.30

Recommendations:

Supermins(beta-carotene, Vit E, selenium) 2 tablets twice daily

Extress-Super(50mg B-complex) 2 daily

D-nat-5(5000iu’s Vit D per capsule) 2 caps twice daily with meals

Lyc-2000( vit C-Lysine): 1tsp twice daily in juice

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Mr. D

December 10, 1999

Magamin-forte(250mg magnesium chelate) 1 tab twice daily-not with calcium

Salmolinic(omega 3 & 6 fatty acids): 2 capsules twice daily

Extress-Super(50mgs B-complex): 1 capsule twice daily

Chromamin(1mg chromium chelate): 1 daily

Folic+B12(vits B12 and Folic acid): 3 tablets dissolved under the tongue twice daily

Q10 Plus(CoQ10, Mg, K, Taurine, Ginko, Hawthorne) 2 capsules twice daily

Neo-Cario(B3, Mg, Terminalia, Inula, Khella, Astragalus, bromelain) 2 caps twice daily

Calcium

Discussion

It is our intent to preserve health and actually improve it. The above nutrient recommendations are tailored to your needs based upon the lab results and the nature of your heart condition. Please continue with your low-sugar, low-fat diet, and regular exercise.

Spinal manipulation of the interscapular region seems to have resulted in a pronounced improvement of the chest complaints. It is suggested that you return periodically for treatment of this area as these symptoms will likely be recurrent. A visit frequency of every 4 to 6 weeks should be effective.

G. Lumsden, D.C., P.C.

Pt. W.D.

On September 21, 1999, Mr. D. had a coronary arteriography. Evident on this study was an old occlusive lesion in the proximal right coronary artery with good collateral a. development. There was also slight plaque development in the origin of the right coronary. Occlusive disease was also present in the circumflex branch of the left coronary artery. It was felt that this was his main issue and coronary bypass surgery was recommended at Good Samaritan Medical Center during his post-test report of findings.

Mr. D at that time decided not to go through with the procedure.