Mrs. W, aged 33, presented with left shoulder and arm pain present for 1 year, worse 1 week.
She later added that she had been "very tired, lethargic and not very interested in doing things recently, perhaps for 6 months."
She had a painful arc on examination, was very tender over the front of the shoulder joint and her Cervical spine left C4-5 posterior joint was stiff and sore.
I manipulated the stiff cervical joint, which modified the extent of the painful arc so the pain started further down during the arc of adduction movement.
Day 4. She returned for review.
X-ray had revealed "Extensive calcification in the rotator cuff in keeping with rotator cuff degenerative change."
Vitamin B12 was 181, low in the reference range of 148 - 560.
She wasn't anaemic ( haemoglobin 12.6)
Her shoulder had been "really very painful since last seen."
Loosening her neck joint hadn't helped the shoulder.
She was started on daily vitamin B12 injections of 1mg.
Day 6. "Not aching continuously now."
Day 9. Injections to now be every 3 days.
Day 35. "Just starting to pain," 11 days from last injection,
Day 50. 15 days since last injection, "now niggling for 4 days."
Day 63. "Sore 3 days" and had next injection.
Nine months later again, I noted that she was having B12 injections 6 weekly. There was no further note mentioning shoulder pain at 9 visits during the next 5 years.
This case history illustrates a little known cause of calcific tendonitis in the rotator cuff of the shoulder, which should be more widely known.
Mr. Z, 48, had shoulder pain on and off for 3 years, disturbing his sleep for one week now. He had a painful arc on testing.
The first episode had been treated by a cortisone injection on the left side, which helped only very briefly (for 2 days.)
The X-ray was reported both times as normal.
This episode was treated by daily injections of vitamin B12. The notes read "shoulder starting to feel better" by day 2, and "distinctly better last 24 hours" by day 8.
Mrs. E wrote out some experiences...
"Neck pressed in back of chair - chair rocked, floor moved.
When walked head filled and lots of pressure on back of neck - neck creaks like gravel.
Sitting down and rubbed my neck - moved something and pressure feeling left. Might be coincidence.
terrible feeling came back when went down the street in car, on way home - in my neck and forehead.
Full head all night.
(Next day) When I got out of bed rocked up and down on floor.
Dusted, eyes went funny and creepy numbness over my face.
Felt bit better as day progressed.
All night head and neck heavy.
(Next day) Morning head clearer - unreal feeling disappeared.
(Next day) That evening went to school to duplicate (this was in the 1980's) head filled - strange feeling - sneezed in bed - clearer.
(Next day) Ears on edge - in other world - nose stinging and fizzy and feels 'drawing' sensation.
Eyes stinging and gritty.
Head filled back of ears to forehead.
Numbness and weakness."
Modern copiers are less smelly than the old duplicating machines
but still produce gases which can sensitize people exposed.
Neck disorders can affect one's sinuses, and both can be brought on by the same allergies.
Dr. John Piesse once put a group of his patients needing repeated spinal adjustments, through comprehensive allergy elimination management. He found that they then needed much less treatment for their spine.
Mr. C, aged 64 had previously needed a large needle up his nose to wash out his maxillary sinus - a very unpleasant treatment.
This time, the infected mucus discharged with the help of Bactrim plus cortisone (the "PNSL" stands for prednisolone.)
One of the hazards of cortisone treatment is also illustrated here, the abdominal pain.
Also illustrated is typical, barely readable doctors handwriting (mine.)
Mr. W 74, "Didn't wake at 5-6am with heartburn after the B12 injection. He felt better in health during the day."
Mrs. W (no relation) "Slept ++ and got a rash on the arm injected, but the day after B12 injection she felt better than usual."
People suffering from a sleep deficit sometimes get a striking need to sleep after their first B12. One woman reported that she had to pull her car over and have a nap before she got home.
Mrs. X found "B12 injections stop her headaches (previously almost daily,) hairfall stopped - growing now, less worrisome, sleeping better."
It isn't always a good tale...
Mrs. H suffered from allergies and would get swollen, red, itchy around her eyes after coffee.
200mcg of vitamin B12 and she got pins and needles in hands and shoulders, itch that night. Her face was swollen, itchy and weeping for two days.
Mr. J felt "much improved" for 1 day only, after his first vitamin B12 injection. The b12 level had been low normal at 295 (ref range 170 - 740.)
His hair cobalt was low, at 0.04ppm (ref range for him .121 - 0.315.) This is the element in the center of the B12 molocule.
Mrs. G was 5ft 6inches and 195lb. She had "no energy, great swings in mood," dry skin and hair, and loss of activity, drive and libido. She was clinically depressed.
Unlike the situations presented on the thyroid medicine page, her tests were very abnormal, with T4 4.1 (RR 9 - 23) and TSH 105 (RR 0.1 - 5.5 then) - typical of myxoedama.
Mrs. W by contrast, felt "tired, aches generally, 3-4 months now. Feels cold when other people are hot. Memory poor and slow on the uptake. Heavy periods."
She had pretty much a full house of appropriate symptoms, and felt better on a trial of T3 medication, but her thyroid blood tests were perfectly "normal."
Ms. R was 34, had tiredness, backache, dry hair and was always freezing. One test of her thyroid pro-hormone (T4) had been in the upper half of the range 11 years earlier. It was now in the lower half. The active thyroid hormone (T3) was now in the lowest quartile.
Her thyroid stimulating hormone (TSH) level was mid-range.
T4 13.0 pmol/L ( Ref range 10 - 19)
T3 4.1 pmol/L (Ref range 3.5 - 6.5)
TSH 1.65 mIU/L (Ref range 0.5 - 4 (but see thyroid medicine page about this range.)
She was given a therapeutic trial of T3 tablets, 20mcg. twice a day.
Three weeks later she reported feeling "heaps better - 70%." Her hands were warm, feet cold at times still (previously always so.) Previously she had been "weak, effort to lift an arm, everything was a drain." This was 80% better, although still a bit tired. Her indigestion was better.
A few months later she reported that as soon as she went off the thyroid hormone treatment, she wanted to sleep all the time. She resumed the T3 and 17 months later was still reporting benefit from it.
Interestingly, at this visit she reported that a VEGA electrodermal test had shown a pituitary gland problem. This would fit with the TSH not being elevated in the presence of thyroid deficiency.
Now,fifteen years later, TSH test would be the only test ordered, and she might be told her thyroid was not the problem.
Mr. P, 25, complained of "not sleeping properly, craving sugar, spells of feeling weak, fainty and shaky."
His glucose tolerance test was as follows...
fasting glucose 5.5mml/l
30 minutes after glucose load 8.5 .....felt "slightly uneasy"
1 hour result 10.8 ...."increasing drowsiness"
1.5 hours glucose 9.2 ..."still drowsy, yawning. slight confusion"
2 hours 6.1mml/l ..."same"
2.5 hours 6.1 ..."feeling clear and calm, not drowsy"
3 hours 2.9mm/l ..."same, starting to feel hungry"
3.5 hours 1.1mm/l ..."was tired, now a little nervous and apprehensive, starting to tremble" - then "trembling badly, having trouble writing, fearful"
4 hours 4.5 ..."still trembling, lapsing into momentary sleep"
4.5 hours 4.7 ..."trembling virtually stopped, but still hunger cravings"
5 hours 4.8 ..."still hungry, tired, lapsing into momentary sleep"
5.5 hours 5.2mm/l ..."feeling clear and calm, but hungry"
6 hours 5.4mm/l ..."same"
1.1mm/l blood glucose is 20mg/dl - pretty low!
The result of a glucose tolerance test has to be looked at with the symptoms recorded at the time. The glucose levels on their own are not a whole lot of use often.
This chap did well on a diet of whole foods with low glycaemic index.
Mrs. D was 3 months into a pregnancy and tired all the time. Folic acid tablets 5mg with each meal helped her, as it often does in this situation.
This very large dose of folic acid is because it may be treating hypoglycaemia, when it is increasing a liver enzyme needed for making glucose. Folate requirements in pregnancy are high anyway, right up till delivery of the baby, and in the past in poor malnourished mothers, deficiency was a cause of abruptio placentiae.
Three months later, a blood test showed macrocytic anaemia, with borderline lowhaemoglobin (115g/l, reference range 115-164) and elevated MCV of 97 (RR 76-100.)
I've made a note on that blood test report "restart folic acid," and gave her a vitamin B12 injection as well (and noted later she had felt better after it.)
Two months further on, Haemoglobin 121, MCV 95 - both improved.
Mr. G had been admitted to intensive care three times, on suspicion of heart attack. He had chiropractic treatment and went to relaxation training.
He now had a 1 year history of left chest pain, associated with breathlessness, tight feeling in chest, and fainty feeling.
I examined him and found his left intercostal muscles and thoracic spine were tender.
FEV 1 and FVC before and after exercise were normal, making asthma unlikely.
He then reported pins and needles in his right arm with an attack, so hyperventilation was suspected. Diazepam 2mg subsequently aborted and attack.
Anxiety can make people feel like breathing more heavily, due to this being part of the "fright-fight-flight" adrenaline mediated response to stress.
Anxiety also tightens muscles and precipitates pain if the involved muscles are already sore.
Master T, 14 years old, had Osgood-Schlatter knees, a condition where the bone attachment below the knee cap, weakens and fractures.
he had white spots on his fingernails.
I gave him 40mg of zinc as the sulphate, intravenously. White spots on nails indicate zinc deficiency, which can cause weakness of body tissues such as here.
Two days later, his notes read "He used to be really tired all the time, and now has more energy."
Mrs. C, 49, complained of feeling fainty and having smelly urine.
She also had "sleepless, no energy, low back pain keeping her awake, constipation and flushes."
She was not well.
On examination, blood pressure was 130/80 laying down, 105/80 standing (and then felt giddy.)
A stick test of her urine showed positive nitrites and microscopy showed lots of bacteria but no white blood cells. These findings were confirmed by a pathology laboratory, and she had >100 million Escherichia coli organisms per litre on culture, which is taken to indicate evidence of infection.
I prescribed Urolucosil (Sulfamethizole) while waiting for the results of the culture, but two days later she was no better.
The E coli was reported as resistant to sulphonamide, which fitted with her lack of response. Nitrofurantioin (OK on test) was prescribed instead and she later reported feeling..."not as dizzy" and urine microscopy was clear (at 3 weeks.)
The rest of her story was a complicated mix of emotional, toxicity, musculoskeletal and endocrine problems.
The points from her history are that a stick test showing no white blood cells doesn't rule out urine infection, and expected symptoms such as passing urine frequently and painfully, may be absent.
It's worth being proactive and taking urine samples to medical checks and asking for them to be checked. Stick tests are rapid and inexpensive.
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Adduction is to draw a part of the body inward toward the median axis of the body - down from vertically up, here.
Bactrim is a brand of co-trimoxazole, a combination of sulphonamide and trimethoprim, two synthetic antibacterials.
Prednisolone is one type of cortisone.
Myxoedema is the name for severe thyroid deficiency, referring to the swelling of shins which can occur now.
Anaemia is low haemoglobin, the substance which carries the oxygen in our red blood cells.
Anaemia can be normocytic (with normal sized red cells,) macrocytic (with elevated MCV - "mean cell volume" - larger sized red cells,) or microcytic when they are smaller (usually from iron deficiency.)
When breathing is tested using spirometry, FEV1 is the forced expiratory volume at 1 second. This is from flat out maximum speed expiration.
The FVC is the total volume of air expelled with maximum effort, during this test.