Dear Ms. Purcell,

I am sorry nobody has attended to your questions or concerns as of yet. You have waited quite a long while, and I apologise for that. I believe that your case is so complex and interweaved among multiple specialties, that it's going to be difficult for any one physician, especially over the Internet, to give comprehensive information that will be able to address all of the issues. Please do list all of your medications and doses. Thank you. I am going to address the most concerning features of your problem list first ... then once we get things going we can address all of the others.

Problem List:

1. Partial Complex Seizure Disorder
2. Atherosclerosis of Brain Vessels (Cerebrovascular Disease)
3. Fatigue / Anemia
4. Left Hand Intermittent Numbness
5. Headaches with Temple Pain
6. Memory Impairment Concerns
7. Left-Sided Weakness more so than Right-Sided Weakness
8. Extreme Cold Intolerance / Feeling Extremely Cold

Partial Complex Seizure & Cerebrovascular Disease:

This must be under the care of the Neurologist, and is hopefully documented by an EEG Study. The Keppra causes weakness in about 9-15% of patients, and headaches in about 14% of patients, but:

• I suspect from your description that the Keppra prescription was preceded by your weakness and headaches?
• Have you had an MRI, EEG, Cerebrovascular Angiogram?
• How was the atherosclerosis (cerebrovascular disease) diagnosed?

Fatigue/Anaemia & Headaches with Temple Pain:

Yes, I would recommend you have a primary care physician, preferably someone who specialises in Internal Medicine who can coordinate your care, medications, consults, etc. .... and act as a singular point of contact for questions and concerns. For this issue of anaemia and fatigue, you will need a comprehensive, face-to-face, history and physical examination along with all routine labs, as well as B12 level, Folate level, TSH, free-T4, erythrocyte sedimentation rate (ESR), C-reactive protein level, lipid panel and fractionation, and any other labs your Internal Medicine physician sees warranted.

I would also perform a number of "autoimmune" antibody screening tests ... or better yet refer you to a Rheumatologist who can organise these. Why? One MAJOR concern I have is the temple tenderness you mentioned. This can be associated with a condition called Giant Cell (Temporal) Arteritis and has very serious body-wide vascular implications if present. It needs to be evaluated in a rather rapid manner by looking at a number of labs (as mentioned) and possible imaging studies like doppler ultrasound, MRI/MRA, angiography, and sometimes PET scans. My preference is MRA angiography and bilateral biopsy of the Superficial Temporal Arteries. Mayo Clinic Studies show that bilateral temporal artery biopsies yield 10% of the patients to be positive who would otherwise have been negative if only one side were biopsied. The MRA angiogram helps us to examine the great vessels of the chest, which can be affected by Giant Cell Arteritis (GCA). The Rheumatologist will weigh in on this issue and have his/her own opinions as well.

That's where I think we should begin. I am with you here for the long haul. But this is where I would start. You with me? Once you log in, all you have to do to reach this conversation is click in the upper right hand corner of the screen on the "My Questions" link ... I will be there. If I am gone, one of my colleagues here can step in and help until I am back ... but I check in on things every day.

Kindest Regards,
Daniel

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Daniel Nelson, MD

Thank you for the additional information and list of medications. I will point out that the meloxicam may very well likely counter the cardioprotective benefits of the daily baby aspirin.

The Haematologist will sort out any issues regarding anaemia and will be able to provide information and analyses for B12, folate, or other deficiencies or suspected problems in the realm of blood disorders and their respective treatments. While trained in Internal Medicine, Haematologists tend to restrict their practise to that subspecialty.

I remain concerned about your autoimmune status, even beyond Sjögren's Syndrome, and would again recommend an opinion by a Rheumatologist for workup of Sjögren's Syndrome, but also Giant Cell (Temporal) Arteritis (GCA), a much more serious autoimmune disorder associated with inflammatory problems in the great vessels of the chest, as well as the blood vessels in the brain and to the eyes. If missed, GCA can result in blindness and death. The Mayo Clinic has the most well documented strategies for evaluation of GCA, and as my training was there, if GCA is suspected, my approach is MRI/MRA (magnetic resonance angiography) of the Great Vessels in the chest and Temporal Arteries, and then an outpatient surgical approach to the tender portions of the Temporal Arter(ies) by Biopsy on one side with rapid frozen sections by pathology ... if the GCA changes are observed on frozen section, I stop ... the diagnosis is made right there. If the results are negative, I would proceed with biopsy of the opposite temporal artery, which in Mayo's studies discovers 10% of positive patients from those who would otherwise be labelled negative by only biopsying a single side. I would like you to see a Rheumatologist and mention to him/her specifically of your headaches, temple pain/tenderness, and any other symptoms like pain or ache while chewing food, visual disturbances, or other aches such as in your arms - especially as you described the left arm symptoms to me. This is manifestly important to me that you see a Rheumatologist for these symptoms. I implore you. Print this webpage and take it to him/her so that the Rheumatology doctor can read and understand my concerns in this process.

• Is your Monday doctor a Rheumatologist or Internal Medicine Specialist? Please print this page and take it with you.

The bone chilling cold intolerance may benefit from the increase in your thyroid hormone, Levoxyl, to 50 mcg (micrograms = mcg) daily. So problem number 8 on our list is being addressed here as well. I hope the increase helps. Followup TSH and free-T4 should be in about 1 month.

So, in a way all problems on the list are underway in some way or form. The Neurology issues are still a bit lacking to my satisfaction, but, we'll get to those once the Rheumatologic and Haematologic workups are underway, completed, or being treated.

Let me know of ANY questions or concerns you have in the meantime. I will be checking on your question thread here a few times a day, at minimum. I am truly concerned about you and want to follow this through to your feeling better and better! How do you feel about all this information thus far? I want to make sure I am serving you to your satisfaction.

Regards,
Daniel

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Daniel Nelson, MD

Well, your history is certainly filled with the autoimmune concerns given the previous diagnosis of Rheumatoid Arthritis (RA) at such a young age. And now, we have the Sjögren's Syndrome and other autoimmune concerns coming to the forefront. I remain concerned about GCA (giant cell arteritis) given those headaches, vision issues, temple tenderness/pain, and previous autoimmune diagnosis of RA. It is entirely possible to have more than one autoimmune condition present at a time ... and we just have to look down that route as thoroughly as possible.

May I ask why you were seeing an oncologist?

Regards,
Daniel

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Daniel Nelson, MD