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8-Jul-97
Presented for a check up.
Complains of being irritable. She says she has been crying and is often tired.
Past Medical History:
Rheumatic Fever as a child.
Heart murmur.
Occasional chest pains.
Hysterectomy at 23 years old, including removal of one ovary.
On Examination:
Small heart murmur
Provisional Diagnosis: Aortic flow murmur. (Not important)
Diagnosis final: Perhaps requires Hormone Replacement.
Treatment : Hormone replacement therapy was started.
.15-Jul-97
Feels better on Hormone Replacement Therapy.
.13-May-98
Thyroid tests a bit low
TSH 7.2 (Reference Range <5 is normal.)
Treatment: Thyroxine (Thyroid Hormone) daily.
Continue hormone replacement therapy, (HRT).
25-May-98
She reports that she feels reasonable and has more energy.
She complains that she is very irritable.
28-Oct-99
Patient reports an impression of poor healing after burning her foot on boiling water.
Treatment: a broad spectrum multivitamin
.24-Feb-00
Presenting Complaint:
Tired & run down.
Had head spins if she rolls over in bed at night.
No obvious head movement triggers the symptoms mentioned.
When examining her, moving the patient’s head does not trigger any head “spins”.
Presenting Complaint:
Breathless and short of breath on exertion if carries clothes off line, from lawn. Mentions she goes to sleep easily at 6.30 pm.
On Examination:
All OK.
Investigations
Iron studies normal:
Thyroid Function tests reported OK
.23-Mar-00
Presenting Complaint
Vertigo (spins and wobbles) if lies down, rolls over, or gets out of bed.
Requests a painkiller for arthritis in knees and back.
Prochlorperazine (Stemetil) prescribed for positional vertigo, (wobbles and spins).
(This is a traditional medical treatment for this symptom).
Heart Echocardiogram and Chest X-ray are essentially normal when looked at today.
.8-Jun-01
Steroids injected for granuloma annulare.
(Granuloma annulare is a knobbly rash at the elbow, in this patient . It is thought to be due to an immune reaction in the skin). 21-Aug-01
Complains of hot sweats and hot flushes.
The flushes are typical of hormone deficiency flushes.(They rise up into the face).
She also complains of joint aches.
She mentions she is short tempered and crying easily at the slightest provocation.
Full Blood Count as well as electrolytes, liver function tests and cholesterol are all normal.
.
15-Nov-01Investigations
Vitamin B12: normal 237 (Reference Range 140-780 pM),
Vitamin (Red Blood Cell) Folate is Normal >950 (Reference Range 340-950)
Mineral Zinc decreased 8.0 (Reference Range 12.0-28.0),Celiac antibodies within range:
Antigliaden IgG 0.25 (Reference Range <1.00),
Antigliaden IgA 0.29 (Reference Range <1.0),
Thyroid tests
Free T4 14.3 (Reference Range 11-25)
TSH 7.6 (Reference Range .2-4.0).
This is usually interpreted as being a normal thyroid , perhaps running little cooler than preferable).
.20-May-02
Complains of Pains in her left chest going through to her back including her left arm. There is pain in her shoulder and she finds it "hard to breathe."
The patient is very concerned that she may have pericarditis.
She also complains of having a wet cough with yellow -green phlegm and of having a fever.
Patient relates that she has had pericarditis before.
On Examination
No fever,
Pulse rate 84 regular
BP 160/100 (This is high).
Mildly red throat.
Investigations from recent hospital assessment are all normal
Treatment on this occasion: broad-spectrum penicillin antibiotics.
.21-Feb-03
Complains of :
Being unwell,
Dizzy,
Flushes,
Sleep disturbance,
Appetite loss with mild weight loss of 3 kg over two weeks,
Feeling depressed.
Sore shoulders with housework, shoulder discomfort easing after rest.
.27-Feb-03
Antigliaden IgG 0.30 (Reference Range <1.0)
Antigliaden IgA 0.24 (Reference Range <1.0)
A gluten free diet was initiated.
.30-May-03
Feeling better,
Bones are still sore in wrists, knees, neck, shoulder and base of spine.
Bloat gone,
Her nausea is gone, constipation gone, and wind (flatus) are gone.
Her energy levels are better and her tiredness shows some improvement.
Complains that if she works for a few hours, she cannot lift shoulders over 90 degrees from the vertical, due to the discomfort.
This discomfort takes a number of days of rest to settle.
On Examination:
Patient very unhappy and in a lot of pain.
Complains of pain so severe that its like the skin is crawling,
Complains of migraine like pain in her head.
Complains of the hands being really "bad".
Patient feels very bad in morning but warms up as she moves around.
Tramadol ( a supposedly non-narcotic painkiller) gives some pain relief only.
She describes some strange feelings in her head.
The impression is that these symptoms are a continuation of the preceding few months’ complaints.