OCTOBER 11, 2015--

MEDICAL HISTORY: 

ROBIN BERLIN

CURRENT:

BRAIN MRI 2013- Several cerebral cavernous angiomas with brain bleeds – multiple lesions within left temporal parietal lobe, right frontal lobe, left posterior temporal occipital lobe; left posterior parietal lobe, left splenium of the corpus callosum; multiple punctate lesions in right posterior parietal lobe, left frontal lobe and also within the right centrum semiovale, which could represent multiple cavernomas.  More punctate lesions noted within the pons. 

BRAIN MRI 2015- The thalami and basal ganglia appear within normal limits. No cerebellar lesion is identified. Tiny foci of magnetic susceptibility are again identified in the central pons (EPl SWAN, image 20), without interval change since the prior study (series 8, image 17). Vascular flow is identified in the carotid and basilar arteries. The visualized portions of the VII-VIIl cranial nerve complexes are within normal limits.

Mastoid air cells appear within normal limits. No orbital lesion is identified. The visualized portions of the paranasal sinuses appear within normal limits. No sellar or suprasellar mass is identified. Two right and one left subcortical white matter hyperintensities were also present on the prior exam.

At least five right and five left foci of magnetic susceptibility are identified on gradient echo and susceptibility-weighted images. Direct comparison with 8/10/2013 reveals pontine foci of magnetic susceptibility, unchanged. A left cerebellar focus of magnetic susceptibility is again identified. A left posterior temporal focus (image 25), without interval change (series 8, image 28). The largest focus is left occipital lobe (image 30) measuring 9-10 mm without interval change (series 8, image 32). Left posteriorparietal (image 36), without interval change (image 41). Left posterior margin of the splenium (image 36), without interval change (image 41). Left frontal lobe (image 44), without interval change since the prior study (image 50). Right high frontoparietal (image 45), without interval change (series 8, image 58). Cluster of three susceptibility foci (image 41), right frontoparietal, no change (series 8, image 58). Right posterior parietal (image 35), no change (image 44). Right subcortical white matter, posteroparietal, right (image 32), no change (image 37). No calvarial tesion is identified.

IMPRESSION:

1.No significant interval change. 2. Multiple bilateral foci of magnetic susceptibility. The largest of these appears to represent a stable cavernoma, left occipital lobe, without interval change. 3. The differential diagnosis for multiple foci of magnetic susceptibility includes cerebral amyloid angiopathy and/or microbleeds related to hypertension or vascular injury versus multiple cavernomas.

Horner’s syndrome- diagnosed June 2007 (visible since 2005). Second-order neuron lesion – cause unknown

Fibromyalgia – symptoms since 1997/diagnosed in 2006 –– fatigue, pain, insomnia,

IBS

Irritable bowel syndrome (with rapid transit - since birth)

Leaky gut

SIBO-small intestine bacterial overgrowth - Rifaximin treatment 4/08 and 1/13

Inflammation

Stenosis of celiac artery

MTHFR genetic mutation (C677T heterozygous) – potential blood clotting disorder

Reynaud’s Disease

Autoimmune disease indicated by Positive ANA 1:160 titer (8/2014)– negative for Lupus and Scleroderma. Test on 3/15 result 1:80.

Liver cyst

Low blood pressure

Mixed thyroid – hypothyroid alternating with hyperthyroid

Osteoporosis –Scores from February 2015: Lumbar Spine: BMD 0.856gm/cm2 with T-score at -1.7; 

Right Hip:  BMD 0.549gm/cm2 with T-score at -2.7; Left Hip: BMD 0.539gm/cm2 with T-score at -2.8

 Lumbar spine (further details in attachment at end of this document)

Spina bifida occulta at the terminal vertebra at the lumbosacral junction; Bulging discs;

Degenerative disc disease; Nerve root sleeve cyst (Tarlov Cyst); Lumbarization of S1 segment;

Scoliotic curvature of the thorocolumbar junction; Bertolotti’s Syndrome

Cervical spine :

Bone spurs at C6, C5 and C4 levels; Degenerative changes at the C4-5 and C5-6 levels;

Disc space narrowing at C4-5 and C5-6 levels are present; C4-5 and C5-6 broad disc bulge and herniation.

Pain in right hip and leg caused by osteoarthritis, bursitis, thin cartilage. bone marrow edema in hip socket with subchondral cyst. Orthopedic surgeon suggests hip replacement.

Osteoarthritis in knees, chrondomalacia patella in knees, misaligned kneecaps, two knee injuries:  1997 and 2003

Insomnia – since 1996

Skin: psoriasis, seborrheic dermatitis, Schamberg’s disease, Terry’s nails

Eyes: Horner’s syndrome, posterior vitreous detachment; rough Bowman’s membrane, blurred night vision, scant drusen (macular degeneration early stage)

Ganglion cyst on left wrist

GYN: Stenotic cervix; ovarian cysts 1.8cm and smaller ones on left ovary and 0.66cm right ovary;  

3 uterine fibroids (8mm, 5mm, 4mm); uterine calcifications

Fibrocystic breast disease – several complex cysts; heterogeneously dense breast tissue; 1cm fibroadenoma right breast

Herpes simplex at age 26

Hyperplastic vulvar dystrophy (squamous cell hyperplasia)

DES exposure in utero

Spectracell lab testing (March 2014) showed deficiencies in copper, B6, pantothenic acid, biotin

Osteopath diagnosis (2009):

Adrenal insufficiency, low HDL cholesterol, decreased platelets, anemia, low growth hormone, low dhea, high candida, low amino acids, Epstein Barr virus, low insulin, human herpes virus 6, low cortisol, low testosterone, low DHEA

PAST MEDICAL HISTORY:

DES exposure in utero

Dry birth

Chronic childhood ear infections

Car accident at age 12 - whiplash

Menses: age 13

Head hit by metal schoolyard gate – age 15

Car accident at age 16 – damaged cervical spine – car drove off cliff

Car accident at age 30 – steering wheel locked on freeway

Mononucleosis at age 20

Lariam poisoning – 1995 (Indonesia).  Sick from January,1996 to December, 1996.  Seizures, 

neurological impairment, tremors, night sweats, insomnia

Human Parvovirus B19 with arthralgia: February –June 2010 (physical therapy March 2010)

Lumbar spine sprain – September 2006 - physical therapy from September 2006-April 2007 (also for osteoarthritis in knees)

Physical therapy – October-November 2009 –neck pain

Walking pneumonia - 1990

Disabling adjustment by upper cervical chiropractor – August2006

Spider bite –Egg-sized purple-black lump on hip- August 2005

 12-hour severe headache following colonoscopy prep on June 7, 2007

SURGERIES:

In-vitro fertilization - 10 times between 2000 and 2002

17 cycles of fertility drugs (including Heparin and Lupron)

Breast lump – excisional biopsy - left breast – benign - 2001

Pre-cancerous mole removed from left foot - 2002

Salzmann’s nodule removed from left eye - 1993

Benign nodule removed twice from left lower eyelid – chronic inflammation and fibrosis –  2002 and 2009

Perianal hemangioma removed- 2002

DENTAL WORK:

Upper jaw gum tissue graft – June 15, 2004

Dental implant- November, 2004- November 2005. Bone is pulling away from the implant.

SUPPLEMENTS, VITAMINS AND PRESCRIPTIONS:

 CALCIUM-626mg, MCHC 1500mg, Phosphorous 398mg (Metagenics CalApatite Bone Builder)

MULTI-VITAMIN (Metagenics PhytoMulti)

PROBIOTIC (Perfect Biotics+ by Probiotic America – Dr. Cary Nelson) 

VITAMIN K2 100 mcgSolgar

VITAMIN B6 (50mg) Whole Foods (once weekly)

L-LYSINE (1000mg) Solaray

L-Glutamine (2000mg) Natural Factors

MAGNESIUM (500 mg-slow release) Jigsaw Health

PANTOTHENIC ACID (500mg twice a day) Solaray

DHEA (10mg) Country Life

COPPER (2mg) Solaray (once weekly)

BIOTIN 1000 mcg Solgar

TYLENOL- nightly (500-1000mg)

FOR SLEEP: UNISOM (doxylamine succinate) 18mg

Allergies: 

Penicillin

Pollens, grasses

Bermuda, blue, smooth brome, meadow fescue, johnson, rye grasses, timothy

Pollens, trees

Bailey acacia, Arizona cypress, Arizona ash, pepper tree, cedar, elm, walnut tree, olive tree, oak mix

Pollens, weeds

Dock-sorrel, Russian thistle, lamb’s quarters, ragweed w/f mix, sage cm mix, careless/pigweed

Molds

Penicillum mix (indoors), alternaria tenius, aspergillus, cladosporium

Epidermals

Dog hair/dander, horse hair/dander, cat hair/dander, cat pelt,

 std mite d. Farinae

Foods:

Low level - crab, lobster, shrimp, oysters, tuna, walnuts, wheat, soy, corn, pistachios,  cherries, oranges, cantaloupe, watermelon, lima beans, squash, asparagus,  hazelnut, peanut

Moderate level – milk, coconut, string beans

FAMILY HISTORY:

Mother died of pulmonary disease in 2004 at age 87. 

She had colorectal cancer in 1973, and had surgery in which part of her colon was removed. She had mitral valve prolapse, angina and three heart attacks (the first in 1998 at age 81).  She also had high blood pressure, chronic pneumonia and osteoporosis, from which she lost 8 inches in height. She also had thyroid disease and Alzheimer’s disease.

Her family medical history consisted of diabetes, heart attacks, strokes, high blood pressure, thyroid problems, atrial fibrillation

Father died of cancer of the esophagus and a heart attack in 1994 at age 71. He also had high blood pressure and gout.

His family history consisted of diabetes, heart attacks, aneurism, paternal grandmother had some type of abdominal cancer: (ovarian/uterine/colon/pancreatic/stomach?)

Sister diagnosed with pancreatitis in 2003 at age 47

Spine details attachment

Lumbar spine:

(Pelvic & hip x-ray series 7/25/13)

Spina bifida occulta is noted at the terminal vertebra at the lumbosacral junction.

Terminal vertebra at the lumbosacral junction is transitional with a broad synchondrosis with the sacrum. 

**Bertolotti’s syndrome (see below)

Compare to:

(Lumbar Spine MRI-7/29/ 2013) L3-4 diffuse disc bulge 4.5mm. It impresses on the ventral aspect of the dural sac causing mild central stenosis. There is mild foraminal stenosis secondary to this bulging disc, with bulging disc measuring 4.5mm.

L4-5 Mild facet degenerative changes are present.

L5-S1 Diffuse disc bulge impressing on ventral aspect of the dural sac. Facet degenerative changes are present. Bulging disc at this level is 4mm. Nerve root sleeve cyst (Tarlov) on right side.

Lumbarization of S1 segment. 

Compare to:

X-ray lumbar spine: (8/2/13)

Scoliotic curvature of the thorocolumbar junction, convex towards right side. This has a Cobb angle measuring about 8 degrees.

Short ribs are seen from the T12 level. 

Partial lumbarization of S1 segment. 

Facet degenerative changes are seen throughout the lumbar spine. 

A limbus vertebra of L4 noted on flexion and extension lateral views. 

Facet degenerative changes at the L5-S1 level are present.

Cervical spine :

(Cervical Spine x-ray 8/2/13)

Mild uncinate spurs at C6, C5 and C4 levels.

Degenerative changes at the C4-5 and C5-6 levels.

Reversal of lordosis centered at C4-5 level.

Slight retrolisthesis of C5 on C6 noted with disc space narrowing at that level.

With flexion, there is angulation at the C4-5 level. 

Disc space narrowing at C4-5 and C5-6 levels are present.

Compare to:

(MRI Cervical Spine 8/10/13)

Minimal anterolisthesis of C3-4. 

Retrolisthesis at C4-5. C4-5 mild disc bulge and endplate osteophytic ridging which effaces the ventral subarachnoid space.  Left-sided foraminal narrowing. 

C5-6 broad disc bulge and endplate osteophytic ridging. Left-sided foraminal narrowing.

Dr. Baron says cervical spine: 4-5 and 5-6 lateral herniation to the left and Spondylolisthesis – bone slipping forward.

Compare to:

(MRI Cervical Spine 2007):  Bone marrow signal demonstrates fatty replacement of the bone marrow

C3-C4 Disc bulge

C4-5 Mild bony disc ridge complex with left disc herniation into the left neural foramen with moderate to severe left neural foraminal narrowing

C 5-6 Bony disc ridge complex with herniation of disc material into left neural foramina with moderate to severe left neural foraminal narrowing and ventral effacement of the CSF with mild impression on the cord

 C6-7 Neural foraminal narrowing is seen. 

Pain and buckling of upper right leg (prior to 9-2014 MRI)

-Dr. Eli Baron (neurosurgeon) says it may be due to a tear in the annulus fibrosis of the L5-S1 disc. The outer edge of the disc has a defect in it which likely irritates the nerves. 

-Dr. Gianconi (radiologist) says it may be caused by the L4-5 disc bulge and the Tarlov cyst.

- Dr. Jason Snibbe (orthopedic surgeon) says osteoarthritis with bone marrow edema of socket and thinned cartilage. He recommends hip replacement (10-2014)

Frequent muscle strains of piriformis and gluteus medius muscles

** Bertolotti's syndrome: a form of back pain associated with lumbosacral transitional vertebrae. It can be treated surgically with posterolateral fusion or resection of the transitional articulation. Non surgical treatments include steroid injections in the lower back or radiofrequency sensory ablation. Bertolotti's syndrome is defined by a transitional 5th lumbar vertebra resulting in partial sacralization. Of importance is that this syndrome will result in a pain generating 4th lumbar disc resulting in a "sciatic" type of a pain correlating to the 5th lumbar nerve root. Usually the transitional vertebra will have a "spatulated" transverse process on one side resulting in articulation or partial articulation with the sacrum or at time the illium and in some cases with both. This results in limited / altered motion at the lumbo-sacral articulation. This loss of motion will then be compensated for at segments superior to the transitional vertebra resulting in accelerated degeneration and strain through the L4 disc level which can become symptomatic and inflame the adjacent L5 nerve root resulting in "sciatic" or radicular pain patterns. This is a congenital condition and is usually not symptomatic until one's later twenties or early thirties.