MR01 - Doctor Visit Summary
Patient: Stephen A. Weller
DOB: 09/25/1936
Sex: Male
Purpose: Longitudinal inflammatory illness summary (2019–2025)
Chief Issue
History of severe systemic inflammatory illness beginning in 2019, characterized by disabling joint
and muscle pain, markedly elevated CRP and ESR, anemia, and positive ANA. Objective
laboratory remission documented 2022–2025 without chronic immunosuppressive therapy.
Timeline Summary• 2015–2018: Stable baseline labs. Normal inflammatory markers.
• 2019–2020: Progressive joint and muscle pain. Rising inflammatory markers.
• 2021 (Peak): CRP >30 mg/L; ESR ~70 mm/hr; hemoglobin ~10–11 g/dL; ANA positive
(homogeneous).
• Late 2021: Short steroid courses produced temporary improvement. Concurrent reintroduction
of ~4 oz beef daily after ~20 years of avoidance.
• 2022: Steroids discontinued. CRP and ESR normalized. Hemoglobin recovered. Sustained
clinical improvement.
• Jan 1, 2024–Present: Strict carnivore diet (beef, fat, eggs, butter, salt, raw whole milk).
Inflammatory markers remain low; patient asymptomatic.
> 2015–2018: Stable baseline labs. Normal inflammatory markers.
> 2019–2020: Progressive joint and muscle pain. Rising inflammatory markers.
> 2021 (Peak): CRP >30 mg/L; ESR ~70 mm/hr; hemoglobin ~10–11 g/dL; ANA positive
(homogeneous).
> Late 2021: Short steroid courses produced temporary improvement. Concurrent reintroduction
of ~4 oz beef daily after ~20 years of avoidance.
> 2022: Steroids discontinued. CRP and ESR normalized. Hemoglobin recovered. Sustained
clinical improvement.
> Jan 1, 2024–Present: Strict carnivore diet (beef, fat, eggs, butter, salt, raw whole milk).
Inflammatory markers remain low; patient asymptomatic.
Objective Laboratory Course
• CRP peaked >30 mg/L in 2021; currently stable in low-normal range. • ESR peaked ~70 mm/hr in 2021; currently normal (<20 mm/hr). • Hemoglobin dropped to ~10.4 g/dL during peak inflammation; now stable ~13+ g/dL. • Renal and hepatic function preserved throughout. • No ongoing steroid or immunosuppressive therapy.
> CRP peaked >30 mg/L in 2021; currently stable in low-normal range.
> ESR peaked ~70 mm/hr in 2021; currently normal (<20 mm/hr).
> Hemoglobin dropped to ~10.4 g/dL during peak inflammation; now stable ~13+ g/dL.
> Renal and hepatic function preserved throughout.
> No ongoing steroid or immunosuppressive therapy.
Clinical Interpretation
Corticosteroids produced short-term suppression of inflammatory markers. Sustained remission
occurred after steroid discontinuation and coincided with reintroduction of beef followed by strict
carnivore diet adoption. Objective labs over multiple years demonstrate durable remission.
Current Medications
• CRP peaked >30 mg/L in 2021; currently stable in low-normal range. • ESR peaked ~70 mm/hr in 2021; currently normal (<20 mm/hr). • Hemoglobin dropped to ~10.4 g/dL during peak inflammation; now stable ~13+ g/dL. • Renal and hepatic function preserved throughout. • No ongoing steroid or immunosuppressive therapy.
Current Medications
- > Levothyroxine 75 mcg daily > Amlodipine 5 mg daily > Aspirin 81 mg daily > Electrolyte mix (Na 1000 mg, K 200 mg, Mg 60 mg daily) > Potassium 99 mg daily > Magnesium glycinate 240 mg dail