Dr. J.’s back!

Dr. J. would like to apologize for his prolonged absence (except to Fred who probably welcomed Dr. J.’s prolonged absence). The Lil Resident fell ill about two years ago (the first of two major illnesses in two years), right at the same time that his work responsibilities changed and increased.  Fortunately the first illness is resolved and the second one, a curse from Mrs. Dr. J.’s side of the family, is now well controlled, and hopefully will remain so for the remainder of the Lil Resident’s many, many years ahead of her.

Were you expecting Wendell Wilkie?

Dr. J. feels that it’s time for him to reemerge from the shadows and provide commentary regarding Mrs. Clinton’s illness(es). By way of wiggle room, Dr. J. is theorizing what is going on with Mrs. Clinton based on his medical expertise as one trained in internal medicine and cardiovascular diseases. Dr. J. has a lot of experience managing patients with diseases at the interface of cardiology and neurology (e.g. fainting), so his speculation is borne out of experience rather than WebMD. Dr. J. does not have access to her medical records so he is basing his speculation on observation from the public record. Please bear with him.

This is what we know:

Mrs. Clinton has fallen a lot, since 2005, 11 years ago. She fainted while giving a speech in NY after suffering from a GI bug the day or two before the speech. She required IV fluids. In June 2009 it was reportedly due to slipping. She broke her elbow with that fall. After a bout of gastroenteritis (this is important later) in 2012, she fell and  hit her head, suffering a concussion (traumatic brain injury) so bad that, allegedly, it affected her memory and reportedly required special glasses (sunglasses, prism glasses). She used her head injury from 2012 to excuse her memory of events at the time when being questioned by the FBI. It also resulted in a blood clot in a vein that drains the brain of blood (the right transverse sinus, which ultimately drains to the jugular vein). Dehydration and trauma can cause a venous sinus thrombosis, which in turn can cause headaches, visual changes and seizures. This is an incomplete list of her falls and there are, in addition, photos of her being supported or assisted in the public record.

Mrs. Clinton has a coughing problem as well. Matt Drudge, for what it’s worth, has been cataloging her coughing spells for quite some time. This is important because her coughing spells are more frequent and longer lasting than the typical individual. Her cough has been attributed to severe allergies by her PCP.

Dr. J. brings up dehydration because dehydration due to pneumonia is the explanation for Sunday, September 11th’s spell. The September 11th spell is a pretty scary one because she could not even hold her neck up and collapsed as she was assisted into the vehicle. Dehydration is another buzzword associated with Hillary’s health. Bill brought up that she gets dehydrated a lot, occasionally, rarely when he was interviewed by Charlie Rose.

She also dresses inappropriately for the weather, which is especially unusual for someone who ‘rarely’ gets dehydration. Heavy clothing leads to increased insensible losses of fluid. The Gateway Pundit has pictures of her in a heavy coat in August in Nantucket giving a speech.

Lastly, we have the letter from her PCP. The letter is all well and good. She has pneumonia. She had previous sinus infection requiring an ear tube, and a CT with no brain abnormalities. She has a calcium score of zero in her coronaries, which is great, but surprising for anyone of her age. Fortunately we’re not worried about her heart and never were so it’s not germane.

It does describe the events of 9/11/16. She was overheated, dry, and felt dizzy. She returned home (to Chelsea’s) and rehydrated, and recovered nicely. She did make an appearance quick after her rehydration (unless it was her body double). Dr. J. doesn’t think it was a body double, however.

The letter has some oddities. For her thyroid, she takes Armour Thyroid (ground up critter thyroid extracted hormone) rather than Synthroid (pure T4). NO ONE USES ARMOUR THYROID! There’s nothing bad about it, it’s just weird.

Then she also takes B12 as needed. There is no ‘as needed use’ for B12. B12 is used to treat people with neuropathies and B12 deficiency anemia. She’s not known to be anemic (although that could help explain her spells).

There is also some loosey goosey wording in Dr Bardack’s letter. She says, “Mrs. Clinton’s medicines include…” not “Mrs. Clinton’s medicines are…” ‘Include’ could be her just writing all fancy-like, but it could be worded so as to leave out things. Also she says Hillary Clinton ‘has not developed new medical conditions this year…’

So that’s Hillary’s medical history per the public record in a nutshell, so what does Dr. J. think is going on? Dr. J. thinks that the truth is out there, but the whole story isn’t being revealed. There are a lot of questions about Parkinsons and seizures. She may have an undisclosed seizure disorder from her fall, but she has no reported abnormalities on her Sinus CT. CT’s are not the best for small subtle brain findings, but nevertheless, Dr. J. is willing to take things at face value.

Dr. J. thinks that Hillary Clinton is sensitive to losses of volume. He thinks that she has orthostatic hypotension (BP drops while she is standing) and as a result feels faint or needs support on occasion.

On 9/11/16, she was outside, it was warm, but not hot, she was standing for a while, and she did, frankly, have pneumonia which made her more dehydrated than usual. She became orthostatic and she fainted. Even the scary video can be explained by fainting, wobbly head and all.

So why is she so sensitive to volume loss? That’s the big question. She’s had problems with falls going back to 2005, so Dr. J. thinks that this is a chronic issue.

One major diagnosis that could be possible is diabetes insipidius, where your body, for a few different reasons (not enough vasopressin made by your hypothalamus, or your kidneys don’t respond to vasopressin), can’t hang on to water, you make a lot of dilute urine, and are thus dry.

The other major way you are sensitive to dehydration is that you can’t vasoconstrict your blood vessels. There are a legion of diseases that cause orthostatic hypotension via impaired vasoconstriction. The first is medications (BP meds, Parkinsons meds) but she doesn’t reportedly take those. The other causes are clustered together as autonomic failure. Autonomic failure comes in two categories, primary and secondary. Secondary means caused by something else. Diabetes mellitus, amyloidosis, multiple myeloma, Parkinsons, or other causes of small fiber neuropathy can cause it. Dr. J. doesn’t have reason to think she has a secondary cause.

This leads us to primary autonomic failure. The major causes are Pure Autonomic Failure, Multisystem Atrophy, and Dr. J. lumps Lewy Body Dementia with these.

Of the possibilities Dr. J. suspects that if she has one of these that Pure Autonomic Failure is the leading candidate. It results in orthostatic hypotension, is slow in progression, and pretty much only the autonomic nervous system that is affected. Largely it is the blood vessels, but sometimes nerves to the GI and GU tract are affected.

The treatment include an abdominal binder worn when standing for long periods of time to prevent BP from dropping when standing, which would explain Mao Jackets on Nantucket Island in August. Also short acting medications like midodrine and droxidopa to cause temporary vasoconstriction (4-5 hours per dose), salt and liberal hydration are also critical.

Sleeveless dresses are de rigueur on Nantucket Island.

It would explain the B12 to treat a (small fiber) neuropathy. ‘As needed B12’ might really mean everyday, it wasn’t specific in Mrs. Clinton’s Doctor’s letter.  It would explain why we don’t really see a chronic tremor, nor an expressionless face, and why she’s been falling for 11 years without progressive neurologic degeneration could not be hidden in public life. MSA has a life expectancy of about 5 years from diagnosis, and Parkinson’s plus Autonomic Failure would have similar timeline.

Also Pure Autonomic Failure doesn’t affect cognitive function, other than when you feel like you will pass out and Mrs. Clinton does have her wits about her by and large, which is also why Dr. J. does not suspect Lewy Body Dementia.

Given her constellation of symptoms, if she has something like Pure Autonomic Failure, she should come clean. That malady is not incompatible with public service. Indeed, FDR ran this country from a wheelchair, so there’s no reason Hillary can’t run the country mostly seated.

If she has something more ominous, however, such as MSA, or Lewy Body Dementia, those diagnoses are incompatible with public service.

Six Words: Don’t you think she looks tired?

That all being said, she did look worn out when she was asked to comment on the Chelsea Bombing. She didn’t have a lot to say about an event without a lot of facts released. Also of note, she spent 12 days in August without appearing publicly.

Regardless of what’s going on, Dr. J. wishes no ill upon Mrs. Clinton, and he hopes she is getting the best care possible while on the campaign trail.

Dr. J.