Rick Clark Medical Record Summary - revised 1/15/2004

Current conditions

I am a 6 foot tall caucasian male born in July of 1959 (age 44).

Several carcinoid tumors in pancreas and liver. One in liver is large - 10 x 13 cm. Discovered 4/7/03. May have been misdiagnosed in 1996 as a hemangioma.

Portal hypertension, apparently induced by tumors in liver. Clot detected in posterior branch of the right portal vein.

Bleeding esophageal varices. Mostly under control by banding and sclerosing. Minor bleeding twice in early 2003 that stopped on its own. Severe bleed 4/5/03, received 6 units of blood, leading to discovery of tumors. Bled again 6/27/03 (4 units). Again 11/23/03 (0 units).

Gastric varices. Have not yet shown evidence of bleeding.

Spleen is enlarged.

My weight is 150 to 155 pounds. Gradually down from 190 pounds in late 2001. I think I've lost between 10 and 20 pounds of muscle.

Blood pressure is typically low around 100/60. Has been as low as 82/50 without distress. Pulse is between 50 and 60.

CBC counts are typically a little below normal.

Platelets often dip to "panic" levels, but recover without intervention.

Liver indicators are typically a little elevated.

Gall bladder removed in 1996 in response to abdominal pain and digestive complaints similar to those now blamed on Carcinoid tumors. Complaints gradually faded over two months following removal, with occasional brief recurrences.

A permanent metal self expanding biliary stent placed August 18, 2003 by Dr. McCormick. Replaced a clogged plastic biliary stent (10Fr x 9cm) placed May 6, 2003 by Cleveland Clinic.

Gilbert's Syndrome (jaundice during medical stress) diagnosed in 1995. No biliary constriction reported during ERCP in 1996. I test negative for hepatitis antibodies. Jaundice became extreme and debilitating for the weeks prior to stent placements for recent biliary constrictions.

Urine currently pale or dark yellow.

Bowel movements vary in quality. Sometimes solid. More often pasty. Sometimes loose. Sometimes pale. Usually sink.

Occasional chest pains after exertion (e.g. running).

Dull ache occasionally in liver area and more often in lower left side of gut.

Occasional "major carcinoid attacks" as described by me:
feels like my intestines are being liberally rinsed with hot sauce. I can often stop the attack with 5 or 10 minutes of adrenaline producing exercise, followed immediately by a deep nap.

Occasional "minor carcinoid attacks" as described by me:
feels like a slow drip of hot sauce in the upper left and right quadrants of my gut. I can sometimes stop the attack by drinking something acid like orange juice or unsweetened lemonade. These sometimes seem to be triggered by stress and starchy snacks.

Occasional abdominal distension following "carcinoid attacks" that I couldn't stop quickly enough. Distension is also caused by eating sugar, or any large meal, especially with starch.

Occasional severe heartburn (like a burning stone in the middle of my gut) after meals or snacks, especially when my belly is distended. Experienced occasionally since 1995 or so, but frequently since January 2002.

Finger nails thin and brittle, with distinct lines or facets running lengthwise.

Mental faculties still good, except more often failing to find familiar words or names.

More vulnerable to depression than in the past. I think this may be part of an ADHD and insomnia cycle. Or perhaps from use of beta blockers in small dosages.

Frequent belching and flatulence.

Facial flushing during meals occurs only seldom.

Current treatment regimen

Endoscopies as scheduled by gastroenterologist to inspect and sclerose esophagael varices. Most recent on 11/24/03.

Steel biliary stent in place.

Sandostatin LAR 30mg shot 1/month. Increased from 20mg on 8/13/03.

B12 1000 micrograms Subcutaneous shot 1/month.

Over the counter Vitamin w/Iron 1/day

Metaclopramide (gen for Regulan) 10mg 4/day to reduce food (and acid) time in stomach.

Protonix 40mg 2/day to reduce stomach acid (prevent gastric varices erosion).

Fluoxetine (prozac) 10 mg, 1/day for depression. Started 12/5/03.

Toprol XL TAB SA 25mg. Currently not taken. Had taken 1/2 per night since 11/26/03. Tried full tab in 2004, but triggered more depression and lethargy than I could handle. Discontinued experimentally 1/12/2004.

Donnatal Extentab up to 2/day - as needed for irritable bowel (typically < 1/day).

Oxycodon 5mg - 1 or 2 as needed occasionally for pain (typically < 1/day).

Tylenol as needed occasionally for fever or headache - seldom.

No prescribed diet, but avoiding large meals and sugar.

No prescribed exercise, but trying to exercise (jog, lift weights) 10 minutes after each meal. More typically only do that after one meal a day.

Recent Conditions

Red, bumpy, non-itchy rash on forehead, beginning to spread to face. Had since May 2002, but suddenly faded in August 2003. Occasionally recurs with certain foods and/or stress.

Diahrea once to several times a day from November 2001 through February 2003. Broke the cycle by going on a strict Gluten free diet (diagnosed self as having Celiac disease. Later biopsy showed I was wrong, but diet did stop diahrea for several months, even after going back on wheat in May).

Serious jaundice until relieved by Common duct stents. Tea colored urine during jaundice.

Face flushed bright red early into most meals. Started January 2002, stopped (or perhaps became constant part of red forehead rash) in late 2002.

Fevers.

Hospitalized with blood infection by Enterobacter cloacae in May 2003 after biliary stent placement. Fever reached 105 degrees. Treated with broad spectrum antibiotics and Ciproflaxacin.
Two more fevers at the beginning and end of July 2003, reaching 103 degrees. These fevers were associated with left side abdominal pain. Treated with Keflex and Ciprofloxacin respectively. Fevers broke quickly with fasting, anti-biotic and Tylenol.
Fever in early August 2003, reached 103 degrees. Occurred while still on ciprofloxacin for earlier fever. This fever associated with burning pain in lower back, especially lower left back during urination (kidney?). Fever broke after a day, but extended Ciprofloxacin treatment.

Heart murmur, only detected when anaemic.

Blind patches in both eyes. (Central Serous Chorioretinopathy) intermittently from February 2003 through June 2003. Appears to have healed, perhaps thanks to Sandostatin. Not detectable at July 2003 opthalmology exam.

Hematology Complete Blood Counts - Part 1

(Note: blood work data not up to date)

2003	WBC cu mm	RBC m/mm3	HGB g/dl	HCT %	MCV fl	MCH pg	MHCH g/dl	RDW %	PLT mm3	MPV fl
8/14	3.8	3.83	11.3	33.7	88.0	29.5	33.6	17.7	117	8.7	Fasting
8/08	3.1	3.78	11.1	34.1	90.4	29.4	32.6	16.3	121	8.0	after Yellowstone car trip
7/24	3.0	3.88	11.4	34.7	89.5	29.4	32.9	14.7	72	9.4
7/17	3.2	3.73	11.2	33.7	90.3	30.2	33.4	14.5	92	9.1
7/10	3.9	3.52	10.7	31.8	90.5	30.3	33.5	15.0	139	6.8	after antibiotic and exercise
7/03	4.0	3.72	11.4	33.9	91.2	30.6	33.6	15.2	65	9.1	fever and pain
6/27	3.2	3.69	11.1	34.3	92.7	30.1	32.5	15.1	86	8.5	after sclerosing
6/19	2.7	3.52	10.5	33.3	94.6	29.8	31.5	15.7	93	8.0
6/12	3.2	3.34	10.4	31.3	93.7	31.1	33.2	16.2	105	9.3
6/02	6.5	2.82	9.3	27.2	96.5	32.8	34.0	15.3	91	7.8

Hematology Complete Blood Counts - Part 2 (differentials)

2003	GRAN %	LYMP %	MONO %	EOSI %	BASO %	GRAN /mm3	LYMP /mm3	MONO /mm3	EOSI /mm3	BASO /mm3
8/14		16	9	3			608	342	114		Fasting. Manual differential.
8/08	64.4	22.2	9.1	3.7	0.6	2000	700	300	100	0	after Yellowstone car trip
7/24	55.8	31.5	9.2	3.1	0.4	1700	900	300	100	0
7/17	57.2	31.4	8.4	2.5	0.5	1800	1000	300	100	0
7/10	67.4	23.7	6.6	2.3	0.0	2600	900	300	100	0	after antibiotic and exercise
7/03	75.5	13.8	9.4	0.9	0.4	3000	600	400	0	0	fever and pain
6/27	59.4	29.6	8.1	2.2	0.7	1900	900	300	100	0	after sclerosing
6/19		35.0	2.0	1.0			945	54	27		manual differential
6/12	59.3	29.8	8.1	2.2	0.6	1800	1000	300	100	0
6/02	79.1	14.5	5.1	0.9	0.4	5300	900	300	100	0

Chem Profiles

2003	GLUC mg/dl	BUN mg/dl	CREAT mg/dl	CALC mg/dl	Total BILI mg/dl	Total PROT mg/dl	ALBU g/dl	ALK PHOS u/l	AST u/l	Na mmol/l	K mmol/l	CHLOR mmol/l	CO2 mmol/l	ALT iu/l	Direct BILI mg/dl
08/10	132	15	1.0	9.0	7.0	6.7	3.8	1178	202	147	4.3	104	28	282		after Yellowstone car trip
07/10	161	19	0.9	9.0	1.0	6.9	3.7	605	41	144	4.5	102	27	97		after antibiotic and exercise
07/03					3.9	7.3	3.8	1013	498					410	2.4	fever and pain