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Georgia Bonds, age 80 overweight black woman on chronic oxygen therapy in wheelchair - very friendly accompanied by two very friendly gentlemen. Biggest problem is her intractable low back pain/sciatica. DISEASE FEATURES IgG kappa monoclonal protein 0.9 2020 IgG 1719 and kappa 198 and K/L 14 at Dx Various xrays negative for lytic lesions PREVIOUS TREATMENTS . CURRENT TREATMENTS . Disease Status: . Treatment Goal: . ACTIVE PROBLEMS Monclonal gammopathy, 3/1/20 COPD Advanced age Diabetes Mild neuropathy Mild anemia Chronic midline back pain with bilateral sciatica Obesity CKD, grade III Low back pain/sciatica INTERIM HISTORY AND ASSESSMENT Ms. Bonds has an IgG kappa monoclonal gammopathy. We don't yet know whether this is an aggressive process that will need treatment or a stable process that will not. I hope the latter because she is 80 and in a wheelchair a lot and on chronic oxygen, and just does not look to be a good candidate for chemotherapy. She does not seem to have any problems related to this monoclonal gammopathy, but that is what we are trying to sort out. We will check with her nephrologist whether he ever tested for monoclonal proteins in the past and get those results if he did. I might consider an MRI of her L-spine because she has chronic sciatica and it would be good to make sure there is no lytic lesion there. She had an xray in 2017 that showed severe degenerative disk disease at L5S1 which may well explain her pain and for which there is probably not much we can do as she is a terrible candidate for back surgery. Unfortunately, she is very heavy, so that makes her pain worse and makes it difficult for her to change positions or ambulate, so she does a lot of sitting and eating. We did talk about a low carb diet, but I'm not optimistic she'll do anything with that info. I'm not anxious to put her through a bone marrow biopsy. I'm pretty sure it will show a moderate amount of plasma cells like 20%. I think the main issue is the stability of this protein, so we'll check the levels again in 3 months. In the final analysis, unless this is a very aggressive process, treating seems unlikely to improve either the quantity or the quality of her life. Past Medical History: Diagnosis Date • Acute on chronic respiratory failure (HCC-CMS) 7/23/2019 • Anemia • Arthritis • Asthma • Bilateral venous insufficiency • CHF (congestive heart failure) (HCC-CMS) • Chronic kidney disease • Chronic obstructive pulmonary disease (HCC-CMS) • Diverticulosis • DM (diabetes mellitus) (HCC-CMS) • Environmental allergies • Fatigue • Gastroesophageal reflux disease • Gout Hx • History of mammogram 12/9/13 • Hyperlipidemia • Hypertension • Obesity • Sleep apnea • SOBOE (shortness of breath on exertion) Past Surgical History: Procedure Laterality Date • CATARACT EXTRACTION Bilateral 04/2010 Dr Lavery • COLONOSCOPY 02/04/2013 Dr Beyer; due 2016; Diverticulosis/Hemorrhoids/Polyps x 3 • HYSTERECTOMY • TRIGGER FINGER RELEASE Right R thumb Medications and Allergies have been reviewed and updated in the Mosaic system. REVIEW OF SYSTEMS Except as noted in the history and assessement above, all other systems are negative. EXAMINATION Vital signs were reviewed abnormalities discussed above. General: Looks well; overweight HEENT: conjunctiva clear; no jaundice Cervical nodes: none palpable Supraclavicular nodes: none palpable Axillary nodes: none palpable Inguinal nodes: none palpable Lungs: decreased sounds. On nasal oxygen CV: RRR Abd: soft and non-tender; no HSM; no masses Skin: no significant rashes Ext: Edema: none; Tenderness: none Neuro/Psych: Gait: wheel chair Speech: clear, but slow and halting Affect: NL Cognition: Oriented;

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INTERIM HISTORY AND ASSESSMENT Mr. Dixon is referred for evaluation of his anemia. Though only 80, he has a host of medical problems and is very frail. Although he had a severe episode of hematuria a few years ago requiring transfusion, he does not seem to have had severe enough blood loss to cause his current anemia. His hgb has been low for about 5 years. His ferritin recently was 81 with a normal TIBC and mildly low serum iron and saturation. I doubt that he has iron deficiency, but I can't be sure it isn't playing a role and repletion of his iron stores would help Procrit work better if we go that route. He had an iron infusion 3 days ago an is due for a second in about 4 days. This should replete his iron stores and help to answer the question. I'll see him back in 2 weeks and check a cbc, retics, iron stores, etc, and then see him again 3-6 weeks later. If the anemia continues in the 7 - 8 range with repleted iron, then he would be a candidate for erythropoietin therapy. His has multiple severe medical problems and I think is no longer a candidate for any sort of aggressive or risky diagnostic or therapeutic procedure. Every-other week Procrit would be fairly easy and could possibly improve his quality of life, though of course it would have zero effect on the quantity of his life.

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Oncology History - can you tell what this means? Stage IV prostate cancer s/p prostatectomy in 2004 with one dose of Leuprolide in 2010. Newly diagnosed with T6 lytic legion and retroperitoneal metastasis. PSA elevated to 7.5. NEJM HAD ARTICLE ON INTERMITTENT VWS CONTINUOUS ANDROGEN DEPRIVATION IN PROSTATE CANCER, BUT THIS LOOKED AT 7 MONTHS COMBINED BLOCKADE, AND IN THOSE WHO'S PSA < 4 RANDOMIZED CONTINOUS OR INTERMITTENT adt. INTERMITTENT RESULTED IN SMALL BENEFITS IN QOL FOR ERECTILE DYSFUNCTION AND MENTAL HEALTH, BUT EFFECT ON SURVIVAL WERE STATISTICALLY INCONCLUSIVE. PLAN 12/27/17 TRELSTAR. 7/10/18 PSA 0.1, HIGH 16. 10/2018 PSA 0.3, HGB DECREASED, IMAGING STABLE TO SLIGHTLY PROGRESSED. Trelstar 11.25 mg IM every 3 months given with xgeva 7/819. Docetaxel 11/2019 it was repeated under Cancer of the Prostate on the problem list AAAaaa

Things I can't remember

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BMI Index

Under = <18.5
NL = 18.5–24.9 
Over = 25–29.9 
Obesity = BMI >=30
Calculator

CKD

G1     >90
G2     60 - 89
G3a   45 - 59
G3b   30 - 44
G4     15 - 29
G5     <15

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Quotes

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Adrian Rogers, 1931-2005

“You cannot legislate the poor into prosperity by legislating the wealthy out of prosperity. What one person receives without working for, another person must work for without receiving. The government cannot give to anybody anything that the government does not first take from somebody else.

When half of the people get the idea that they do not have to work because the other half is going to take care of them, and when the other half gets the idea that it does no good to work because somebody else is going to get what they work for, that my dear friend, is the beginning of the end of any nation. You cannot multiply wealth by dividing it.”

William Christopher Handy

Life is like a trumpet – if you don’t put anything into it, you don’t get anything out of it.


J.K. Rowling

“It takes a great deal of courage to stand up to your enemies, but a great deal more to stand up to your friends.
(Harry Potter and the Sorcerer’s Stone – 2001 – Albus Dumbledore)

“Now is the time that we must choose between what is right and what is easy.”
(Harry Potter and the Goblet of Fire -2005)

Abraham Lincoln

Better to remain silent and be thought a fool than to speak out and remove all doubt.

Confucius

Choose a job you love, and you will never have to work a day in your life.

Anonymous

To Kill an American

You probably missed it in the rush of news last week, but there was
actually a report that someone in Pakistan had published in a
newspaper an offer of a reward to anyone who killed an American, any
American.

So an Australian dentist wrote the following to let everyone know what
an American is… so they would know when they found one. (Good on ya,
mate!!!!)

An American is English, or French, or Italian, Irish, German, Spanish,
Polish, Russian or Greek.

An American may also be Canadian, Mexican, African, Indian, Chinese,
Japanese, Korean, Australian, Iranian, Asian, or Arab, or Pakistani,
or Afghan.

An American may also be a Cherokee, Osage, Blackfoot, Navaho, Apache,
Seminole or one of the many other tribes known as native Americans.

An American is Christian, or he could be Jewish, or Buddhist, or
Muslim.

In fact, there are more Muslims in America than in Afghanistan.Continue reading »


Alexander Graham Bell

When one door closes, another opens: but we often look so long and so regretfully upon the closed door that we do not see the one which has opened for us.

Lou Holtz

Life is ten percent what happens to you and ninety percent how you respond to it.

Barry Goldwater

A government that is big enough to give you all you want is big enough to take it all away.

Charles Kingsley

If you want to be miserable, think about yourself, about what you want, what you like, what respect people ought to pay you and what people think of you.

Cicero

If you don’t know where you come from you will always be a child.


Father Denis Edward O’Brien -USMC

"It is the soldier, not the reporter,
Who has given us freedom of the press.
It is the soldier, not the poet,
Who has given us freedom of speech.
It is the soldier, not the campus organizer,
Who has given us the freedom to demonstrate.
It is the soldier,
Who salutes the flag,
Who serves beneath the flag,
And whose coffin is draped by the flag,
Who allows the protestor to burn the flag."


Sir William Osler

The best preparation for tomorrow is to do today’s work incredibly well.

Nancy Pelosi

We have to pass the bill so that you can find out what is in it...   -- On March 9, 2010, Pelosi said of the Affordable Care Act

Robert G. Ingersoll

The time to be happy is now; the place to be happy is here. The way to be happy is to make others so.

Winston Churchill

If you will not fight for the right when you can easily win without bloodshed, if you will not fight when your victory will be sure and not costly, you may come to the moment when you will have to fight, with all the odds against you and only a precarious chance of survival. There may even be worse case; you may have to fight when there is no hope of victory, because it is better to perish than to live as slaves. 
John Brown

I am now quite certain that the crimes of this guilty land will never be purged away but with blood."


Colin Powel

Leadership is solving problems. The day soldiers stop bringing you their problems is the day you have stopped leading them. They have either lost confidence that you can help or concluded that you do not care. Either case is a failure of leadership

Eleanor Roosevelt

Great minds discuss ideas
Average minds discuss events.
Small minds discuss people.


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