# BIGPATS_DOC_STORE

CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 2/1/94 for .

History: Dear Eldre:

I saw Karen, age 6 years, in follow up for precocious puberty.  

She started Lupron 7.5 mg monthly during the first week of November.  Her mother reported no obvious change in secondary sexual characteristics.  There has been no vaginal discharge or bleeding.  

For the past two weeks, she has complained of almost daily headaches.  There has been no vomiting.  There has been a questionable decrease in appetite.   Karen has observed no change in her vision.  Mother reports a personal history of migraines.

Physical exam:  
Height: 125.9 cm        Weight: 31.8 kg         BP: 97/54               
Pulse: 83               
She has Tanner stage II-III breasts and Tanner stage I pubic hair.  
She looked well and had good color and hydration.   Skin was smooth and warm.  Thyroid gland was not palpable.   Chest was clear and her heart sounds were normal and there was no murmur.   There was no organ enlargement on abdominal examination.   She had 1.5 cm compressed breast tissue on the right and 2.0 cm on the left; the right nipple was 2.5 cm in diameter and the left nipple 3.0 cm in diameter.   The nipple was elevated off the surface of the breast.   

Pupils were equal and reactive to light.   She had a full range of extraocular movements.  Deep tendon reflexes were 2+ at the knees and 2-3+ at the ankles.  

Height has increased 2.9 cm and weight has increased 1.2 kg.  There has been no substantial change in breast size.

Laboratory studies:  The preliminary results of the repeat GnRH test done on the day of her office visit showed suppression of both FSH and LH with values of 0.9 and 0.2 mIU/mL prior to stimulation.   The peak FSH level was 1.2 and the peak LH 0.5 mIU/mL.

Impression: The cause of her headaches is unclear.  One worries about the possibility of an intra-cranial mass.   It is my understanding that a follow-up MRI and eye examination have been scheduled on February 14, 1994.

Disposition: I have advised continuing Lupron at the same dose (7.5 mg monthly).
Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Attending in Endocrinology


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 7/6/94 for .

History: I saw Karen, age 6 1/2 years, in follow-up for precocious puberty.

She reports no vaginal discharge or bleeding.  Breast size has apparently not changed.  General health has been good.

Current medications: Lupron 7.5 mg q month (0.22 mg/kg); Ventolin inhaler for wheezing; Propranolol 10 mg tid; Fiorinal for migraine-type headaches.

Physical exam:  
Height: 129.7 cm        Weight: 34.6 kg         BP: 95/45               
Pulse: 78               Pubic hair: Tanner II   
General: Well-developed, well-nourished.  
Skin: 
HEENT, neck and lymph nodes: unremarkable.
Neck: 
Chest: Clear.
Breasts: 1.4 cm. compressed breast tissue on the right, 1.6 cm. on the left; areola diameter 2.7 cm. on the right and 2.8 cm. on the left.
Heart: Normal heart sounds and no murmur.
Abdomen: Normal.
Genitourinary: Slightly pink ? stimulated vaginal mucosa; few dark curly axillary hairs on the right.  Pubic hair confined to the labia majora.
Extremities: 
Neurological:

Laboratory studies:  Serum LH and FSH 0.18 and 0.79 IU/L, serum estradiol <5 pg/ml, DHEAS 81 mcg/L; bone age 7 yeas 10 moths (SD 9.5 months).

Impression: On June 15th, she had an abbreviated GnRH stimulation test; baseline FSH and LH levels 0.8 and <0.1 IU/L, and 1.2 and 0.15 IU/L  after 45 minutes 

She has had a growth velocity of 9.1 cm. with weight gain of 4.1 kg in the past year.  Her growth rate has accelerated and her bone age is significantly advanced.  Although her current (random) gonadotropin levels are low, her response to GnRH was not completely suppressed.  I have, therefore, suggested reducing the interval between Lupron injections from 4 to 3 weeks in the hope that we might obtain more complete gonadotropin suppression.  I plan to repeat her GnRH test just before her next visit in three months to ensure that the new dose schedule is effective.

Thank you for the opportunity to share in this child's care.

Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Clinical Director
Associate Professor  of Pediatrics, HMS


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 10/5/94 for .

History: Dear Eldre:

I saw Karen, age 6 years 8.5 months, in follow-up for precocious puberty.

Medication:  Lupron Depot 7.5 mg q 3 weeks.

Interval history:  There has been no increase in pubic hair or axillary hair; there has been no change in breast size.  No vaginal spotting or bleeding. 

She reports occasional headaches (2-3 times per month), relieved with Tylenol.  Her sleep is undisturbed.  Her general health has been good and she reports no visual changes.

Physical exam:  
Height: 132.7 cm        Weight: 35.4 kg         BP: 99/51               
Pulse: 76               Breast: Tanner III      Pubic hair: Tanner II   
General: Well developed, well nourished.  Areolae:  right side 3.1 cm , left side 3.0 cm.  Approximately 2 cm compressed breast tissue bilaterally.  The remainder of the physical exam was unchanged.

Impression: Her linear growth has continued to accelerate indicating inadequate suppression of sex steroid production.

Disposition: Accordingly, I have increased the dose of Lupron Depot to 11.25 mg q 4 weeks.  I plan to repeat a GnRH test after three doses to evaluate the efficacy of the increased dose.
Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Clinical Director
Associate Professor  of Pediatrics, HMS


Problem list to date:
SECONDARY-SEXUAL-PRECOCITY                   11/15/93  
Transcribed by Sullivan_ma


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 1/30/95 for .

History: I saw Karen, age 7 years, for follow up of precocious puberty.

Medications:  Lupron. Depo 11.25 mg q4 weeks (0.3 mg/kg); Propranolol tid; Fiorinal 1 prn; Ventolin prn.   

She stated that her headaches have increased in frequency.   An MRI has been scheduled for February 13, 1995.  

She reports a good appetite and normal bowel movements.   She wears glasses for distant vision.   Apparently, her vision has not changed.

A repeat GnRH test done January 9, 1995 showed baseline LH and FSH 0.23 and 0.75 IU/L, respectively.   Post stimulation values were 0.2 and 1.0 IU/L, respectively, indicating satisfactory suppression of the hypothalomo-pituitary axis.

Physical exam:  
Height: 134 cm          Weight: 37.4 kg         BP: 80/56               
Pulse: 80               Breast: Tanner II       
General: Well developed, well nourished.   Areolae 2.4 cm; compressed breast tissue 2.0 cm.   Axillary hair 1-2+.   Pubic hair Tanner stage II.   The remainder of the exam was unchanged.

Impression: Karen's rate of growth has slowed and is now normal.   Her precocious puberty appears to be adequately controlled on the current dose of Lupron Depo.

Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Clinical Director
Associate Professor  of Pediatrics, HMS


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 5/2/95 for .

History: I saw Karen, age 7 years 3.5 months, for follow up of precocious puberty.

Medications: Lupron 11.25 mg (0.29 mg/kg) q4 weeks; Ventolin inhaler prn, Fiorinal and Inderal prn for headaches.  

She feels well.  She does experience some tenderness of her breasts.   Her headaches have been well controlled.  There has been no vaginal bleeding or spotting.

Physical exam:  
Height: 137 cm          Weight: 38.7 kg         BP: 90/58               
Pulse: 72               Breast: Tanner III      Pubic hair: Tanner III  
Areolae measured 3.0 cm in diameter; compressed breast tissue ~2 cm diameter.  The remainder of the exam was unchanged.  

Bone age was 8 years 10 months giving a predicted height of 69", unchanged from the height prediction one year ago.

Impression: Karen appears to be doing well on suppressive therapy; however, her rate of growth suggests that sex steroid secretion may not be totally suppressed.  I have not changed the dose.  A repeat GnRH test will be done in July to ensure that gonadotropin secretion is adequately suppressed on the current dose.

Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Clinical Director
Associate Professor  of Pediatrics, HMS


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

I saw Karen, aged 7 years 9 months, for follow-up of precocious puberty. 

She reports no vaginal discharge, staining or bleeding.  There has been no breast tenderness or increase in breast size.  She does use daily an underarm deodorant.  There has been a possible increase in the amount of pubic hair.  There have been no behavioral changes.  She has intermittent headaches but they have not been severe.

Current medications: Lupron depo pediatric 11.25 mg every four weeks (0.026 mg/kg); Ventolin qd.; Fiorinal p.r.n.; Inderal 10 mg t.i.d. for treatment of migraine.

Physical exam:
HT: 139 cm              WT: 42.6 kg
BP: 96/58               Pulse: 82                   
Breast: Tanner III      Pubic hair: Tanner III  
She looked well. Physical examination revealed 2+ axillary hair.  She had "mushy" breasts with no more than 2 cm compressed breast tissue bilaterally.  Areolae were 2.3 cm on the right and 2.8 cm on the left.   Fundi revealed normal sharp disks.

Impression: She has grown 2 cm and gained 3.9 kg in nearly six months.  Her growth continues at a pre-pubertal rate.  There has been no progression in the signs of secondary sexual development.

Disposition: I have scheduled a GnRH test to ensure that gonadotropin secretion is adequately suppressed on the current dose of Lupron.   Meanwhile, she should continue to receive 11.25 mg monthly.  I plan to see her again in four months.


Sincerely,





Bernardo Bird, MD         
Clinical Director of Endocrinology
Associate Professor of Pediatrics, HMS


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

I saw Karen, age 8 years two months, for follow up of precocious puberty associated with neurofibromatosis.  

Medications: Lupron depot 11.25 mg (0.25 mg/kg) q4 weeks; Ventolin inhaler p.r.n.  

She reported no vaginal discharge, bleeding or staining.  There has been no obvious change in the size of her breasts.  She does use an underarm deodorant.   

She wears glasses but stated that she cannot clearly see the board, nor is she able to read properly.  She also reported headaches especially upon awakening in the morning often associated with dizziness.  These have responded to Tylenol.

Current medications: None.

Physical exam:
HT: 142 cm              WT: 45.3 kg
BP: 104/68              Breast: Tanner III        Pubic hair: Tanner III  
She looked well, had nasal congestion; numerous pigmented nevi.  No thyromegaly or lymphadenopathy.  Chest was clear.  Heart sounds were normal.  Abdomen revealed no organ enlargement or masses.  She has 2+ axillary hair.  Areolae were 2.4 cm on the right and 2.8 cm on the left; compressed breast tissue was approximately 2.0 cm bilaterally.  The breasts were soft and "mushy".
Bone age: 10 years

Laboratory studies: Bone age 10 years (SD=10 months).

Impression: Karen's growth rate and rate of weight gain are normal.  There has been no progression in secondary sexual development indicating adequate suppression of the hypothalamo-pituitary-gonadal axis.  She should continue to take Lupron 11.25 mg I.M. q4 weeks.  I asked Mrs. Andros to bring Karen's headaches and dizziness to your attention.

Sincerely,






Bernardo Bird, MD         
Clinical Director of Endocrinology
Associate Professor of Pediatrics, HMS


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

Karen is an 8 year 6 month old girl who has been on Lupron Depo injections q. monthly for precocious puberty associated with neurofibromatosis.  

She has been feeling well and finished second grade with good grades.  She has been sleeping well except for awakening from headaches described below.  She has a normal appetite and no report of hot-cold intolerance or fatigue.  Mother and Karen report no history of vaginal discharge or bleeding.  She has had fairly strong body odor but this has not represented a change.  She and mother report no change of breast  development, axillary or pubic hair.  She reports headaches which are mostly nocturnal and early morning, increasing in severity in the last several weeks.  She has no associated nausea, vomiting or dizziness.  She reports that she had a history of severe headache previously treated by you as a migraine headache with Inderal and another medication of which the mother is not sure of the name.

Current medications: She is on Lupron Depo injections 11.25 mg q. four weeks.  However, she did not receive her last monthly shot.  Mother said that she forgot to come in.

Physical exam:
HT: 144.5 cm            WT: 47.6 kg
BP: 105/39              Pulse: 85                     
Breast: Tanner IV       Pubic hair: Tanner IV   
General Appearance:  Well-appearing in no apparent distress. 
Skin:  Multiple cafe-au-lait spots and axillary freckles.  No dermal fibromas noted.  HEENT:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Fundi with sharp disks bilaterally.  Tympanic membranes normal.  Nares with large turbinates which appear pink without discharge.  Oropharynx without erythema or tonsillar adenopathy. 
Neck:  Normal thyroid.  No lymphadenopathy. 
Lungs:  Clear to auscultation bilaterally.   
Breasts:  Right areola is 2.6 cm and the left areola is 2.9 cm in diameter.  
Heart:  regular rate and rhythm, normal S1, S2 and no murmur.   
Abdomen:  Normoactive bowel sounds, soft, non-distended, non-tender, no  hepatosplenomegaly.   
Genitourinary:  Tanner IV pubic hair.  Estrogenized perineum with leukorrhea.   
Extremities:  Full 5/5 strength.  
Neurologic:  Cranial nerves II-XII intact.  However, she has a symmetric facial muscle tone but was unable to keep her eyes closed, but I attempted to open them manually.

Impression: Karen is an 8 year 6 month old girl with precocious puberty  associated with neurofibromatosis.  She missed her last Lupron dose and now has advanced in her breast Tanner stage to Tanner stage IV and has accelerated growth.

Disposition: 

1)  We will give her one dose of Lupron IM at 0.3 mg/kg (which equals 15 mg) today and start her on a q. four week regimen of 15 mg Depot injections.  

2)  We would like her to return to clinic in three months for reevaluation.  

3)  We have encouraged mom to reschedule a visit with you (Dr. Animal) as soon as possible to evaluate her worsening headaches.


Sincerely,





Valdeci DeNiro, MD         Bernardo Bird, MD         
Resident in Pediatrics       Clinical Director of Endocrinology
                             Associate Professor of Pediatrics, HMS


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

I saw Karen, age 8 years 11 months, for follow-up of precocious puberty.  

She has not returned for Lupron injections for approximately 3 months.   Apparently, her mother has a new job and gave the responsibility for bringing her to the hospital to an older sibling who did not follow through. 

Karen feels well and had no specific complaints related to sexual precocity.

Physical exam:
Height: 147.5 cm        Weight: 50.1 kg
BP: 107/56              Pulse: 74               
Breast: Tanner IV       Pubic hair: Tanner V    
She looked well, had normal color and hydration.  No thyromegaly.  No  lymphadenopathy.  Chest clear.  She has 3+ axillary hair.  She had bruises on the medial aspect of the right upper arm.  She stated that this was the result of "roughhousing" with her brother and falling.

Impression: Her growth chart shows evidence of growth acceleration in the past 3-6 months.  I presume this is the result of unrestrained pubertal growth acceleration.

Disposition: I discussed with Mrs. Andros whether or not she wishes Karen to continue Lupron therapy.  She stated that she does wish to continue.  Karen received a dose of 15 mg IM while in clinic.  She will return at 4 week intervals for additional therapy.



Sincerely,




Bernardo Bird, MD         
Clinical Director of Endocrinology
Associate Professor of Pediatrics, HMS


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 7/12/93 for evaluation of precocious puberty.

History: Karen is a 5 and 6/12 year old girl who was referred for evaluation of precocious puberty. 

She was first noted to have breast buds approximately 2-3 months ago. Mother noted no changes in the last few months. There was no expressible galactorrhea. A few fine pubic hairs were noted by mother along with slight vaginal discharge. There was no history of clitoris enlargement. She has neurofibromatosis and a strong family history of neurofibromatosis. She was born with numerous cafe-au-lait spots. She has been followed in the Neurofibromatosis Clinic by Dr. Animal and was last seen one month ago because of the concern of precocious puberty.  An MRI was ordered at that time.  

Karen's height and weight has been progressing normally, although her weight has increased over the last year.  She denies headache, visual changes, poor vision, diplopia. There was no history of polyuria, polydipsia, nocturia or a history of abdominal pain.  She admits to occasional vaginal pruritus.

Current medications: None.

Past medical history:  Notable for premature delivery at 32 weeks secondary to mother's injury.

Review of systems:  Noncontributory.

Family history:  Notable for neurofibromatosis on the maternal side. Mother's height is 5'0"; father's height is 6'0".

Physical exam:  
Height: 120.6 cm        Weight: 29.8 kg         BP: 90/60               
Pulse: 76               U/L ratio:  0.77        Arm span: 125           
Breast: Tanner III      Pubic hair: Tanner I    
General: Karen was a well appearing girl  in no acute distress.  Skin: Multiple cafe-au-lait spots. No neurofibromata.   HEENT: Normocephalic atraumatic. PERRL. EOMI.  Fundi difficult to visualize. Neck: Supple without thyromegaly or masses.  Chest: Normal. Clear lungs. The areolae measured 2 cm bilaterally. She has 2 cm. breast tissue bilaterally.  Heart: Regular rate and rhythm.  Abdomen: Normal active bowel sounds. Genitourinary:  No sexual hair. No enlargement of labia or clitoris.   Extremities: Normal. Neurological: Nonfocal.

Laboratory studies:  June 17, 1993:  MRI showed thickening of prechiasmatic optic nerves with enlargement of the optic chiasm and hypothalamus. No enhancement noted of this optic chiasm/hypothalamic mass. Multiple foci of high signal intensity within the cerebellum, brain stem, and basal ganglia. These lesions are consistent with foci of dysplastic tissue of neurofibromatosis.

Impression: Karen has a physical examination consistent with precocious puberty even though there is no sex steroid effect on her pubic hair and genital development. There is significant development of breast tissue on exam.  The most likely etiology is the optic chiasm/hypothalamic mass,  consistent with neurofibromatosis. At this time we will obtain a GnRH test to further evaluate the hypothalamic pituitary axis.

Disposition: Follow-up in three months.  Karen will also be evaluated at the Neurofibromatosis Clinic in one week.

Laboratory studies pending at this time include: Bone age, GnRH.
Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology   


Addendum: Hubert Chou, MD
Fellow in Endocrinology


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 9/27/93 for .

History: I saw Karen, age 5 years 8.5 months, in follow up for precautions puberty associated with a question mark optic tract glioma.

Karen had a GnRH test July 26, 1993 which showed baseline LH and FSH of less than 0.1 and 2.0 IU/L and a unstimulated serum asteroidal level of less than 20 pg/ml.  Serum prolactin was 9.4 ng/ml and DS was 75 mcg/dL.  The peak LH response was 4.4 and peak FSH response was 12.0 IU/L and after 180 minutes, serum asteroidal was 32 pg/ml.  Baseline thyroid function test were normal.  These results were consisted with early puberty.

Meanwhile, there has been no apparent change in the size of her breasts, nor  has there been vaginal discharge, spotting or bleeding.  There is no history  of headaches or visual disturbances.  General health has been good and her appetite is excellent.

She has used Tylenol for treatment of an upper spurutory inspection and takes Flintstones with iron daily.

Physical exam:  
Height: 123 cm          Weight: 30.6 kg         BP: 80/50               
Pulse: 88               
Blood pressure (small adult cuff).  She appeared well developed well nourished and had good color in hydration.  She has Tanner Stage II breast with approximately 1.5 cm  of compressed breast tissue bilaterally.  The aerially of 2.0 cm in diameter.  There was no galactorrhea.  There was no clitoromegaly; the vaginal mucosa was red and did not appear stimulated and there was no labial enlargement or vaginal secretions.

Impression: Examination of Karen's growth curve suggests accelerated growth velocity consistent with precautious puberty.  I discussed the use of Lupron (a long hyphen acting GnRH analogue).  This should be initiated at a dose of 7.5 mg monthly with the repeat GnRH test performed after three months to confirm that she is appropriately suppressed.

Unfortunately, the medication is very costly and this family currently does not have health insurance.  It is my intention to contact the manufacturer in an effort to obtain the medication free of charge on a compassionate basis.

Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Eldre Animal, M.D.          RE: Karen Andros
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/21/88

Dear Dr. Animal:

We had the pleasure of seeing Karen in the Endocrine Program on 11/4/93 for .

History: I saw Tameka, age 5 years  8 1/2 months, in follow-up for precocious puberty associated with a ? optic tract glioma.

Tameka had a GnRH test July 26, 1993, which showed baseline LH/FSH of <0.1 and 2.0 IU/L and an unstimulated serum estradiol level of <20 pg/mL.  Serum prolactin was 9.4 ng/mL and DS was 75 mcg/dL.  Her peak LH response was 4.4 and peak FSH response 1.20 IU/L, and after 180 minutes, serum estradiol was 32 pg/mL.  Baseline thyroid function tests were normal.  These results are consistent with early puberty.  

Meanwhile, there has been no apparent change in the size of her breasts, nor has there been vaginal discharge, spotting or bleeding.  There is no history of headaches or visual disturbance.  General health has been good and her appetite is excellent.

She has used Tylenol for treatment of an upper respiratory infection and takes Flintstones with iron daily.

Physical exam:  
Height: 123 cm          Weight: 30.6 kg         BP: 80/50               
Pulse: 88               
(BP: small adult cuff)

She appeared well developed, well nourished and had good color and hydration.  She has Tanner stage II breasts with approximately 1.5 cm. of compressed breast tissue bilaterally.  The areolae are 2.0 cm. in diameter.  There was no galactorrhea.  There was no clitoromegaly; the vaginal mucosa was red and did not appear stimulated and there was no labial enlargement or vaginal secretions.

Impression: Examination of Tameka's growth curves suggest accelerated growth velocity consistent with precocious puberty.  I discussed the use of Lupron Depot (a long-acting GnRH analogue).  This should be initiated at a dose of 7.5 mg monthly with a repeat GnRH test performed after three months to confirm that gonadotropin secretion is appropriately suppressed.  

Unfortunately, the medication is very costly and this family currently does not have health insurance.  It is my intention to contact the manufacturer in an effort to obtain the medication free of charge on a compassionate basis.

Thank you for letting us share in the care of Karen.

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Calvert Caldwell
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/11/74

Dear Dr. Brezny:

We had the pleasure of seeing Calvert in the Endocrine Program on 10/10/91 for evaluation of short stature.

History: Rosaria is a 16 10/12 year old with short stature last seen 11 months ago by Dr. Berenberg.  At the time his work-up included a hematocrit of 37.6, a BUN of 18, a creatinine of 0.6 and a post-exercise growth hormone level of 3.9 ng/ml, (father states the exercise was not strenuous), IGF-1 was 0.98 U/L.  Since his last visit Calvert has grown at an annual rate of 3 cm per year.  He has not been using deodorant nor has he had any acne.  He continues to have only a small amount of pubic hair.  He has bowel movements qd to qod, denies cold intolerance or nocturia.  He is currently in 12th grade.  He denies visual changes or headaches.

Past medical history:  At 5 years of age, he was diagnosed as having "a lazy eye".  He has worn corrective lenses until recently

Family history:  Maternal menarche at 14, maternal height 5'.  Father shaved at 18-19 years of age and has a height now of 5'4".  Paternal grandfather if 5'5", paternal grandmother 4'11".  Maternal grandmother is 5'6" as well as the maternal grandfather.   The patient's 21 year old female sibling is 5'.  There is no thyroid family history no bowel disease nor arthritis.

Physical exam:  
Height: 152.7 cm        Weight: 32.7 kg         BP: 98/68              
Pulse: 88               U/L ratio:  0.82        Pubic hair Tanner: 2    R. testis: 3.2 x 1.4 cm L. testis: 3.2 x 1.5 cm
Phallus length: 6.5 cm  Mid-shaft diam.: 1.9 cm 
General: Comfortable, thin male with no apparent distress
Skin: Unremarkable.  HEENT: Pupils equal, round, reactive to light and accomodation, extrocular movement intact, fundi benign, high arched pallate. Neck: No thyromegaly.  Chest: Clear to auscultation.  Heart: Unremarkable.  Abdomen: No hepatosplenomegaly.  Genitorurinary: Prepubertal, uncircumsized phallus.  Extremities: No cyanosis, clubbing or edema.  Neurological: Unremarkable with deep tendon reflexes 2+.

In summary: Calvert has been growing slowly with a growth rate that might be compatible with the dip that is seen right before the pubertal growth spurt, and indeed on physical exam he only shows signs of early puberty.  At this time it is not possible to rule out endocrine deficiencies even though Calvert may only have constitutional delay and familial short stature.

Disposition: We recommended to Calvert that he be tested for IGF-1 and IGF protein binding 3 as an indirect assessment of his growth hormone status.  Furthermore, we also arranged for a bone age to see whether his bone age has advanced measurably since his last visit.  We also obtained the following studies:  Sodium 140 mEq/ml, potassium 4.5 mEq/ml, TCO2 27 mEq/ml, BUN 20 mg/dl, Cr 0.8 mg/dl, Phosphorus 5.4 mg/dl, Hct 40.8%, Mcv 86.3 fl, ESR 18 mm/hr (elevated).  The remaining studies are pending.  We also asked that Calvert be tested for antiendomyseal antibodies to rule out gluten endopathy.

Thank you for letting us share in the care of Calvert.

Sincerely,


Lancelot Blue, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

We had the pleasure of seeing Samantha in the Renal Transplant Program on May 17, 1994.  She has chronic renal failure secondary to unknown etiology.  She had a renal transplant on November 16, 1989.  

Samantha currently has mild URI symptoms with some nasal congestion and an occasional cough which is worse at night.  She does not have any fever.

Current medications include: IMURAN 100 mg q.d., PREDNISONE 15 mg q.o.d., CYCLOSPORINE 60 mg t.i.d. and FERGON 325 mg  b.i.d.

Physical exam:
     BP 130/73     P 89     R 18      WT 54.9kg
     HEENT: mild post nasal drip with some "cobblestoning" of the
     posterior oropharynx 
     Neck: supple with mild lymphadenopathy
     Chest: clear to auscultation without wheezes or crackles
     Heart: regular rate and rhythm
     Abdomen: soft, there is no tenderness or bruit over the graft site
     Extremities: no edema

Urinalysis:
          SPEC GR UA  1.004                PH UA       5          
          PROTEIN UA  N     mg/dl          GLUCOSE UA  N     mg/dl
          BLOOD UA    N                    WBC ENZ UA  0          
          RBC/HPF     0-5   /HPF           WBC/HPF     0-5   /HPF 
          WBC CAST    N     /LPF           RBC CAST    N     /LPF 
          GRAN CAST   N     /LPF           WAXY CAST   N     /LPF 
          Squamous Epithelial 5 - 10

Laboratory studies at this time include:
          BUN 14       CR 1.2        NA 137       K 3.0        CL 102
          GLUC 73      CA 8.7        PO4 2.8      CYA 80
          WBC 8.57     HCT 30.8      HGB 10.8     PLT 218
          N- 70.3      L - 20.1      B- .6        ABS N - 17.17
         

Samantha continues to well.  Her renal function is stable.  We suggest no changes in her current regimen.

She will return in three months.

Thank you for allowing us to assist in the care of Samantha.

Sincerely,


Antonio Khan, MD           
Instructor in Pediatrics


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

     We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, August 16, 1994.  She has chronic renal failure secondary to .  She had a renal transplant on .
     Samantha has had no complaints since her last visit with us three months ago.  She has had no problems with hypertension.

Current medications include:
     IMURAN 100 mg q.d.
     PREDNISONE 15 mg q.o.d.
     CYCLOSPORINE 60 mg t.i.d.
     FERGON 325 mg  b.i.d.

Physical exam:
     BP 130/73   P 89   R 18   T    HT cm   WT 54.9kg   HC cm
     General: healthy
     HEENT: moist mucous membranes
     Chest: clear 
     Heart: regular rate and rhythm without murmurs, gallops, or rubs
     Abdomen: soft non-tender and non-distended.
     Extremities: warm and well profused.

Urinalysis:
     SPEC GR UA  1.005           WBC ENZ UA  N          
     PH UA       6               PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N          
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   3               BACTERIA    N     


Laboratory studies at this time include:
          BUN  14 CR 1.2 NA 141 K 3.7 CL106
          GLU 89 CA 9.1 PO4 2.8 CYA 183
          WBC  6.79 HCT 33.6 HGB 10.9 MCV 98.4 PLT 214
          N 72.3 L 18.7 B  .6 ABS N 4.91

     Samantha has no complaints since her last visit.  Her graft function is stable.

     We have asked Samantha to return in .

     Thank you for allowing us to share in Samantha's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Conrado Seinfeld, MD         Kinze Brando, MD
                                            Assistant in Nephrology


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

     We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, November 1, 1994.  She had a renal transplant on November 16, 1989.
     Samantha is well today.  She has no new complaints.

Current medications include:
     CYCLOSPORINE 60 mg t.i.d.
     IMURAN 100 mg q.d.
     PREDNISONE 15 mg q.o.d.
     FERROUS SULFATE 325 mg b.i.d.
     MYLANTA prn

Physical exam:
     BP 130/85   P 75   R 20     WT 55.9kg   
     General: she appeared well
     Skin: normal
     HEENT: normal
     Neck: supple, no masses, lymph nodes not palpable
     Chest: clear
     Heart: 2 heart sounds, no murmurs
     Abdomen: soft, right sided transplant non-tender
     Genitourinary: Tanner 5
     Extremities: no edema
     Neurological: normal
Urinalysis:
     SPEC GR UA  1.002           WBC ENZ UA  0          
     PH UA       0               PROTEIN UA  trace      
     BLOOD UA    1+              GLUCOSE UA  0     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    0     


Laboratory studies at this time include:
          CA          8.7   MG/DL       CR          1.3   MG/DL (H)
          CYA         159   MCG/L       GLU          91   MG/DL    
          PHOS        2.5   MG/DL (L)   BUN          15   MG/DL    
          NA          137  MMOL/L       K           3.3  MMOL/L    
          CL          100  MMOL/L       WBC        9.68   K/MM3    
          RBC        2.95   M/MM3 (L)   HGB        10.2    G/DL (L)
          HCT.       29.0       % (L)   MCV        98.3      FL (H)
          MCH        34.6      PG (H)   MCHC       35.2    G/DL    
          RDW        13.7       %       HDW        2.64    G/DL    
          PLT UNC     204   K/MM3       NEUT         86       % (H)
          LYMPH        12       % (L)   MONOS         1       %    
          EOS           1       %       CELLS C     100    
          ABS NEU    8.32   K/MM3       ABS LYM    1.16   K/MM3    
          ABS EOS     .10   K/MM3       MACRO        1+    


     Samantha is doing well.  She is attending college and studying mathematics.

     We have asked Samantha to return in 3 months.

     Thank you for allowing us to share in Samantha's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

     We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, February 21, 1995.  She has chronic renal failure secondary to an unknown etiology.  She had a renal transplant on 11/16/89.
     Samantha has been well since her last review.  She has no new complaints.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     PREDNISONE 15 mg po q.o.d.
     IMURAN 100 mg po q.d.
     FERGON 325 mg (2) po q.d.
     CARAFATE 1 g po p.r.n.
     MYLANTA 1 po p.r.n.

Physical exam:
     BP 130/80   P 90   R 20      HT 164cm   WT 60.9kg  
     General: normal, mild facial acne
     Skin: no rashes
     HEENT: normal
     Neck: supple, no masses, lymph nodes not palpable
     Chest: clear
     Heart: 2 heart sounds, no murmurs
     Abdomen: soft, right sided graft, non-tender
     Genitourinary: Tanner 3
     Extremities: no edema
     Neurological: normal
Urinalysis:
     SPEC GR UA  1.010           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   2+              BACTERIA    N     


Laboratory studies at this time include:
          CA          8.5   MG/DL       CR          1.4   MG/DL (H)
          CYA         191   MCG/L       GLU          76   MG/DL    
          PHOS        3.1   MG/DL       BUN          23   MG/DL (H)
          NA          136  MMOL/L       K           3.3  MMOL/L    
          CL          100  MMOL/L       WBC        9.18   K/MM3    
          RBC        2.97   M/MM3 (L)   HGB         9.4    G/DL (L)
          HCT.       29.0       % (L)   MCV        97.8      FL    
          MCH        31.8      PG       MCHC       32.5    G/DL    
          RDW        14.7       %       HDW        2.63    G/DL    
          PLT UNC     198   K/MM3       NEUT         80       % (H)
          LYMPH        18       % (L)   MONOS         2       %    
          CELLS C     100               ABS NEU    7.34   K/MM3    
          ABS LYM    1.65   K/MM3       ABS EOS     .00   K/MM3    
          MACRO        1+       


     Samantha is doing well.

     We have asked Samantha to return in three months.

     Thank you for allowing us to share in Samantha's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

     We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, May 16, 1995.  She had a renal transplant on 11/16/89.
     Samantha has had no problems since her last visit with us.  Her iron level has improved since starting Fergon.

Her current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     PREDNISONE 15 mg po q.o.d.
     IMURAN 100 mg po q.d.
     FERGON 325 mg (2) po q.d.
     MYLANTA 1 po p.r.n.

Samantha's physical exam was notable for:
     BP 130/75   P 76   R 20    WT 55.1kg   
     General:  No acute distress.
     HEENT: Moist mucous membranes without masses or exudates.  No cataracts visualized.
     Chest: Clear.
     Heart: Regular rate and rhythm without murmurs, gallops or rubs.
     Abdomen: Soft non-tender and non-distended without tenderness or bruits over the graft site. 
     Genitourinary: Tanner stage 5 female.
     Extremities: Warm and well perfused without clubbing, cyanosis or edema.  
     Neurological:  Non-focal.
A urinalysis revealed:
     SPEC GR UA  1.005           RBC/HPF     N          
     WBC ENZ UA  0               WBC CAST    N          
     PH UA       6               RBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N     mg/dl     SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          CA          8.6   MG/DL       CR          1.3   MG/DL (H)
          CYA         138   MCG/L       GLU          76   MG/DL    
          PHOS        2.7   MG/DL       BUN          18   MG/DL    
          NA          138  MMOL/L       K           3.4  MMOL/L    
          CL          105  MMOL/L       WBC       10.05   K/MM3    
          RBC        3.02   M/MM3 (L)   HGB         9.7    G/DL (L)
          HCT.       28.3       % (L)   MCV        93.6      FL    
          MCH        32.1      PG       MCHC       34.3    G/DL    
          RDW        13.9       %       HDW        2.71    G/DL    
          PLT UNC     204   K/MM3       NEUT AB    7.81   K/MM3    
          LYMPH A    1.38   K/MM3       EOS ABS     .10   K/MM3    
          NEUT-A     77.7       % (H)   LYMPH-A    13.8       % (L)
          MONO-A      5.2       %       EOS-A       1.0       %    
          BASO-A       .5       %       ATYP LY     1.7       %    


     Samantha has done well since her last visit with us.  Her renal function is at baseline.

     Thank you for the opportunity to participate in Samantha's care.  We would like to review her in three months.  In the interim, we would be happy to discuss or review Samantha should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Instructor in Pediatrics


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

     We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, August 15, 1995.  She had a renal transplant on 11/16/89.
     Samantha is here today for a follow up visit.  She has been stable.  There have been no blood pressure problems and she has gained some weight since her last visit.  Her CYA dose had been recently increased to 70 mg po tid due to low evening trough levels.

Her current medications include:
     PREDNISONE 15 mg po q.o.d.
     IMURAN 100 mg po q.d.
     CYCLOSPORINE 70 mg po t.i.d.
     FERGON 325 mg (2) po q.d.
     MYLANTA 1 po p.r.n.

Samantha's physical exam was notable for:
     BP 129/88   P 90   R 18   WT 56.1kg   
     General: No distress.
     Skin: No rash was found.  Striae were present. 
     HEENT: Pupils were equal and reactive to light.
     Neck: Supple
     Chest: Clear to auscultation.
     Heart: No murmurs were found.  Lymph nodes not palpable.
     Abdomen: Soft, bowel sounds were present.  No tenderness in the graft area. Extremities: Full range of motion.  No edema was found. 
     Neurological: Intact.  No meningeal signs.  The patient was oriented.
A urinalysis revealed:
     SPEC GR UA  1.005           RBC/HPF     N          
     WBC ENZ UA  0               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N     mg/dl     SQUAM EPI   1-5        
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          CA          8.5   MG/DL       CR          1.4   MG/DL (H)
          CYA         319   MCG/L       GLU          93   MG/DL    
          PHOS        3.1   MG/DL       BUN          25   MG/DL (H)
          NA          132  MMOL/L (L)   K           3.9  MMOL/L    
          CL           98  MMOL/L       WBC        7.94   K/MM3    
          RBC        3.19   M/MM3 (L)   HGB        10.9    G/DL (L)
          HCT.       32.1       % (L)   MCV       100.5      FL (H)
          MCH        34.2      PG (H)   MCHC       34.0    G/DL    
          RDW        14.0       %       HDW        2.55    G/DL    
          PLT UNC     199   K/MM3       NEUT AB    5.82   K/MM3    
          LYMPH A    1.19   K/MM3       EOS ABS     .11   K/MM3    
          NEUT-A     73.3       % (H)   LYMPH-A    15.0       % (L)
          MONO-A      7.5       %       EOS-A       1.4       %    
          BASO-A       .7       %       ATYP LY     2.1       %    
          MORPH       YES               MACRO        2+ (*)
          HYPO         1+       


     Samantha has been stable since her last visit.  We will adjust the cyclosporine to 80 mg qam, 60 mg, 60 mg and we will recheck the level next week.

     Thank you for the opportunity to participate in Samantha's care.  We would like to review her in three months.  In the interim, we would be happy to discuss or review Samantha should you or the family wish it.

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

     We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, January 2, 1996.  She has chronic renal failure secondary to .  She had a renal transplant on 11/16/89.
     Samantha has no complaints, she feels very well.

Her current medications include:
     PREDNISONE 15 mg po q.o.d.
     IMURAN 100  mg   q.a.m.
     FERGON 325 mg (2) po q.d.
     MYLANTA 1 po p.r.n.
     CYCLOSPORINE 80 q.a.m., 60 q.1.p.m., 60 q.5pm
     CARAFATE 1 (500 mg) p.r.n.

Samantha's physical exam was notable for:
     BP 150/78   P 76   R 16    WT 53.5kg   
     General: No distress.
     Skin: No rash was found.  Striae were present. 
     HEENT: normal fundi bilaterally.
     Neck: no adenopathy.
     Chest: Clear bilaterally to auscultation.
     Heart: Regular rate and rhythm S1, S2, with no murmurs, gallops or rubs.
     Abdomen: Soft, non-tender and non-distended with a well healed abdominal scar.
     Extremities: no edema or hirsutism.
     Neurological: no tremor
A urinalysis revealed:
     SPEC GR UA  1.040           RBC/HPF     N          
     WBC ENZ UA  0               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  1+              GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   2-3        
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           3.3  MMOL/L       MCHC       35.1    G/DL    
          CA          8.4   MG/DL       RDW        14.1       %    
          MG          1.3   MG/DL (L)   HDW        2.93    G/DL    
          CO 2         24   MEQ/L       PLT UNC     192   K/MM3    
          CL           99  MMOL/L       NEUT AB    4.88   K/MM3    
          CR          1.7   MG/DL (H)   LYMPH A    1.22   K/MM3    
          CYA         201   MCG/L       EOS ABS     .11   K/MM3    
          GLU          73   MG/DL       NEUT-A     71.2       % (H)
          FE          152  MCG/DL       LYMPH-A    17.7       % (L)
          PHOS        3.2   MG/DL       MONO-A      7.1       %    
          NA          131  MMOL/L (L)   EOS-A       1.6       %    
          BUN          24   MG/DL (H)   BASO-A       .6       %    
          TIBC        162  MCG/DL (C)   ATYP LY     1.7       %    
          WBC        6.85   K/MM3       NF-2002  ABSENT    
          RBC        2.99   M/MM3 (L)   MORPH       YES    
          HGB         9.9    G/DL (L)   ANISO        1+    
          HCT.       28.2       % (L)   BASO ST    RARE (*)
          MCV        94.2      FL       RET         1.7       %    
          MCH        33.1      PG       

     Samantha is a clinically stable transplant patient.  We will reduce her CYA dose to 80-50-50.

     Thank you for the opportunity to participate in Samantha's care.  We would like to review her in two months.  Chemistries to be drawn in New York.  In the interim, we would be happy to discuss or review Samantha should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

     We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, May 21, 1996.  She has chronic renal failure secondary to an unknown etiology.  She had a renal transplant on 11/16/89.
     Samantha is doing very well.  She is now seven years post transplant.  She continues on her three times a day cyclosporine.

Her current medications include:
     PREDNISONE 15 mg po q.o.d.
     IMURAN 100 mg q.d.
     FERGON 325 mg b.i.d.
     MYLANTA 1 po p.r.n.
     SANDIMMUNE 80 q.a.m., 50 q.1.p.m., 50 q.5pm

Samantha's physical exam was notable for:
     BP 114/61   P 84   R    T    HT cm   WT 50.8kg   HC cm
     General: comfortable, alert.
     Skin: no lesions
     HEENT: eyes, nose and throat clear.
     Neck: supple with no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: S1, S2 normal with no murmur.
     Abdomen: soft and no tenderness over the graft site. 
     Extremities: no edema
     Neurological:  no focal deficits or meningeal signs.

A urinalysis revealed:
     SPEC GR UA  1.005           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   few        
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           3.6  MMOL/L       MCHC       34.3    G/DL    
          CA          8.6   MG/DL       RDW        15.0       %    
          CR          1.3   MG/DL (H)   HDW        2.81    G/DL    
          CYA         110   MCG/L       MPV         8.5      FL    
          GLU          83   MG/DL       PLT UNC     218   K/MM3    
          PHOS        3.2   MG/DL       NEUT AB    4.77   K/MM3    
          BUN          13   MG/DL       LYMPH A     .68   K/MM3    
          NA          136  MMOL/L       EOS ABS     .13   K/MM3    
          CL          101  MMOL/L       NEUT-A     78.3       % (H)
          CO 2         25   MEQ/L       LYMPH-A    11.2       % (L)
          WBC        6.09   K/MM3       MONO-A      7.1       %    
          RBC        3.08   M/MM3 (L)   EOS-A       2.1       %    
          HGB        10.3    G/DL (L)   BASO-A       .5       %    
          HCT.       30.0       % (L)   ATYP LY      .8       %    
          MCV        97.4      FL       MACRO-A       +    
          MCH        33.4      PG       LEFT SH  ABSENT    

     Samantha is a clinically stable.

     Thank you for the opportunity to participate in Samantha's care.  We would like to review her in  three months.  In the interim, we would be happy to discuss or review Samantha should you or the family wish it.

                Sincerely,


                Mitsuko Khan, MBBS, FRACP
                Director, Clinical Services


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, August 20, 1996.  She had a renal transplant on 11/16/89.

Samantha comes to us today for her regular check up.  Her only complaint is that she feels a little bit more tired than usual but otherwise she says she has been feeling well.

Her current medications include:
     PREDNISONE 15 mg po q.o.d.
     IMURAN 100 mg q.d.
     FERGON 2 tabs q.d..
     SANDIMMUNE 80 q.a.m., 50 q.1.p.m., 50 q.5pm

Samantha's physical exam was notable for:
     BP 132/66   P 84   WT 53.2kg   
     General: alert and attentive without any distress.
     Skin: normal.
     HEENT: normal.
     Neck: normal, lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm without any murmurs.
     Abdomen: soft and no tenderness over the graft site. 
     Extremities: normal.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.005           RBC/HPF     1-2        
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   many       
     WBC/HPF     N               BACTERIA    N     
Many vaginal squam.

Laboratory studies at this time include:
          K           3.7  MMOL/L       MCHC       35.9    G/DL    
          CA          8.6   MG/DL       RDW        15.2       %    
          CR          1.4   MG/DL (H)   HDW        2.93    G/DL    
          CYA         133   MCG/L       MPV         8.0      FL    
          GLU          97   MG/DL       PLT UNC     224   K/MM3    
          PHOS        3.1   MG/DL       NEUT AB    7.84   K/MM3    
          BUN          23   MG/DL (H)   LYMPH A    1.22   K/MM3    
          NA          135  MMOL/L       EOS ABS     .45   K/MM3 (H)
          CL           99  MMOL/L       NEUT-A     76.9       % (H)
          CO 2         26   MEQ/L       LYMPH-A    11.9       % (L)
          WBC       10.19   K/MM3       MONO-A      5.6       %    
          RBC        3.22   M/MM3 (L)   EOS-A       4.4       %    
          HGB        11.0    G/DL (L)   BASO-A       .3       %    
          HCT.       30.6       % (L)   ATYP LY      .9       %    
          MCV        95.1      FL       MACRO-A       +    
          MCH        34.2      PG (H)   LEFT SH PRESENT    

Samantha is doing well.  Her renal function is stable.

Thank you for the opportunity to participate in Samantha's care.  We would like to review her in three months. In the interim, we would be happy to discuss or review Samantha should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Placido Romanov, M.D.          RE: Samantha Borodin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/73

Dear Dr. Romanov:

We had the pleasure of seeing Samantha in the Renal Transplant Program on Tuesday, January 7, 1997.  She has chronic renal failure secondary to .  She had a renal transplant on 11/16/89.
Samantha offers no complaints today.  She has been doing well.

Her current medications include:
     PREDNISONE 15 mg po q.o.d.
     IMURAN 100 mg q.d.
     FERGON 325 mg b.i.d.
     SANDIMMUNE 70 q.a.m., 40 q.1.p.m., 40 q.5pm

Samantha's physical exam was notable for:
     BP 138/76   P 94   R 14    WT 51.8kg   
     General: well appearing and in no distress.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm.
     Abdomen: soft without bruits or tenderness at graft site.
     Extremities: no edema.
     Skin: no lesions.

A urinalysis revealed:
     SPEC GR UA  1.002           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   many       
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           3.2  MMOL/L       MCHC       34.7    G/DL    
          CA          8.2   MG/DL (L)   RDW        14.7       %    
          CR          1.2   MG/DL       HDW        2.74    G/DL    
          CYA         108   MCG/L       MPV         7.9      FL    
          GLU          86   MG/DL       PLT UNC     236   K/MM3    
          PHOS        3.0   MG/DL       NEUT AB    5.05   K/MM3    
          BUN          12   MG/DL       LYMPH A    1.06   K/MM3    
          NA          132  MMOL/L (L)   EOS ABS     .13   K/MM3    
          CL           97  MMOL/L       NEUT-A     73.4       % (H)
          CO 2         26   MEQ/L       LYMPH-A    15.4       % (L)
          WBC        6.89   K/MM3       MONO-A      6.5       %    
          RBC        3.33   M/MM3 (L)   EOS-A       1.9       %    
          HGB        11.2    G/DL (L)   BASO-A       .2       %    
          HCT.       32.3       % (L)   ATYP LY     2.6       %    
          MCV        96.9      FL       MACRO-A       +    
          MCH        33.6      PG       LEFT SH  ABSENT    

Samantha continues to have stable renal function.  We will space out her visits to every six months and we have instructed her to continue to have her bloods drawn once a month.

Thank you for the opportunity to participate in Samantha's care.  We would like to review her in six months. In the interim, we would be happy to discuss or review Samantha should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stanwood Leary, M.D.          RE: Joanne Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/12/89

Dear Dr. Leary:

We had the pleasure of seeing Joanne in the Endocrine Program on 10/3/94 for congenital hypothyroidism.

History: Mother denies any problems except for some bronchitis and wheezing last March for which she received Ventolin.  She has good energy and plays hard.  She is in kindergarten and especially enjoys gym.

Current medications: Synthroid 0.075 mg each night with which she is compliant.

Review of systems:  No problems with skin, hair or constipation.   She has a good appetite and sleeps well.  Her immunizations are up to date and she has no known allergies.

Physical exam:  
Height: 111.8 cm        Weight: 20.9 kg         BP: 110/50              
Pulse: 100              
General: She is a bouncy, slim girl. Skin: Normal, normal hair.   HEENT: Within normal limits.    Chest: Clear to auscultation.    Heart: Grade I/VI intermittent vibratory systolic murmur.  Pulses are normal.   Abdomen: Benign.   Neurological: Deep tendon reflexes are 2+ and there is no tremor.

Laboratory studies:  Her laboratory tests today show a T4 of 10.5 and a TSH of 2.6.   At her mother's request since we were drawing blood, we also obtained a lead level of less than 5 and a CBC which was normal and which is attached to this letter.

Impression: In summary, Joanne has congenital hypothyroidism but is clinically euthyroid with excellent growth.   She also has an apparently benign heart murmur.

Disposition: I will continue her on Synthroid 0.075 mg qd and gave her a prescription for the next six months.   I would appreciate it if you would obtain a T4 and TSH level in six months. I would like to see her back to clinic in 12 months.
Thank you for letting us share in the care of Joanne.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Stanwood Leary, M.D.          RE: Joanne Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/12/89

Dear Dr. Leary:

I was so pleased to see Joanne back in the Endocrine Program on 11/30/95 at 6-6/12 years of age, now a first grader and doing beautifully on her thyroxine treatment for congenital hypothyroidism.

Current medications: She is taking her 0.075 mg. of L-thyroxine faithfully.

Physical exam:
HT: 120.8 cm    WT: 26.2 kg    Arm span: 120 cm
BP: 101/36      Pulse: 55      Bone age: 5.9 years            
She is growing and gaining appropriately.  She has no pubertal changes with a perfectly normal physical.  No palpable thyroid.  Her bone age today is 5-9/12 and I have repeated thyroid function tests.

Impression: If these are normal, she will remain on the same dose and will see you to have her thyroid function tests including a T4 and a TSH done again in approximately 6 months.  I would like to see her in 12 months.   
Please send me a copy of the results you get in 6 months and if these are normal, then I will see her again in 12 months.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   


Addendum: T4 10.6 ug/dl, TBGI 0.96, TSH 6. uU/ml.  She is euthyroid.


CONTENT:
Stanwood Leary, M.D.          RE: Joanne Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/12/89

Dear Dr. Leary:

I had the pleasure of seeing Joanne back in the Endocrine Program on 10/10/96 at 7 5/12 years of age in assessment for congenital hypothyroidism and its attendant thyroxine replacement.  Because she has been very faithfully given her l-thyroxine and because the TSH had crept up slightly above upper limits of normal even on .088 mg a day, we had increased her to .1 mg a day.  She is taking this faithfully in addition to the occasional use of Decadron for her asthma and allergies.

Physical exam:
HT: 125.2 cm    WT: 30.8 kg       BP: 120/57              Pulse: 97               
The thyroid is not palpable.  She is prepubertal, and the exam was otherwise unremarkable.

Laboratory studies:  TSH  1.00   uU/mL (normal)

Impression: I will keep her on the same dose.  The compliance with the medication is excellent.



Sincerely,




Varda Hugo, MD                   Nilto Carter, MD             
Resident in Pediatrics           Associate in Endocrinology   


cc:  Varda Hugo, MD  Department of Medicine  Children's Hospital

     Mr. & Mrs. Keith Meiggs   20 Holland Street   Winchester, MA  01890


CONTENT:
Clotilde Seinfeld, M.D.          RE: Joanne Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/12/89

Dear Dr. Seinfeld:

We had the pleasure of seeing Joanne in the Endocrine Program on 9/26/91 for evaluation of .

History: I saw Joanne Meiggs in Pediatric Endocrine Clinic on September 26, 1991 for follow up.  Joanne is now a 28 month old girl with congenital hypothyroidism.  She is receiving Synthroid .075 mg once a day.  Mother's report is that there is no problem at all.

Physical exam:  
Height: 92.4 cm         Weight: 14.6 kg         Pulse: 84               
On physical exam, Joanne's length is 92.4 cm, weight is 14.6 kg, respiratory rate 24 and pulse 84 per minute. Developmentally she is Tanner stage 1.  The rest of the exam is unremarkable.

In summary: My impression is that Joanne has congenital hypothyroidism and is doing well on current therapy.  Her thyroid function tests reveal T4 15.2 ng/dl, P3 168 ng/dl, PSH .3 IU/ml, and TBGI .96.  Those results are in the very good range, therefore I would like to continue Joanne on the same amount of medication and see her back in the Clinic in six months for follow-up.

Please feel free to contact me if you have any concerns.

Disposition: 

Thank you for letting us share in the care of Joanne.

Sincerely,


Mitsuko Simpson, MD             Mitsuko Simpson, MD             
Chief, Emeritus              Chief, Emeritus


CONTENT:
Stanwood Leary, M.D.          RE: Joanne Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/12/89

Dear Dr. Leary:

We had the pleasure of seeing Joanne in the Endocrine Program on 8/13/92 for follow-up of congenital hypothyroidism.

History: Joanne is now 3 and 3/12 years old with congenital hypothyroidism. She has been given Synthroid since birth. Her current dosage is .075 mg once a day. She is doing well on the current replacement therapy.

Current medications: Synthroid .075 mg/day.

Review of systems:  Negative.

Physical exam:  
Height: 99.1 cm         Weight: 16.1 kg         BP: 90/60               
Pulse: 84               Arm span: 100.5         Breast Tanner: 1        

The remainder of the general physical examination was unremarkable.

Impression: Joanne has congenital hypothyroidism. She is clinically euthyroid on current therapy. Thyroid function tests revealed a T4 of 10.8 mcg/dL, TSH 1.4 mcu/mL, TBGI .99, T3 150 ng/dL, all within normal limits. I am pleased with her progress and would like to continue her on the same amount of medication.

Thank you for letting us share in the care of Joanne.

Sincerely,


Elmo Domingo, MD                 
Attending in Endocrinology


CONTENT:
Stanwood Leary, M.D.          RE: Joanne Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/12/89

Dear Dr. Leary:

We had the pleasure of seeing Joanne in the Endocrine Program on 9/9/93 for follow-up of congenital hypothyroidism.

History: Joanne is now 4  and 3/12 years old with congenital hypothyroidism. She has been taking Synthroid since birth.  The current dose she is taking is .075 once a day. She shows good compliance with the medicine except there was one ..

Physical exam:  
Height: 105.8 cm        Weight: 18.4 kg         BP: 100/60              
Pulse: 80               Breast: Tanner I        Pubic hair: Tanner I    
The general physical exam was unremarkable.

Impression: Joanne has congenital hypothyroidism and is clinically euthyroid on her current therapy. I will obtain a thyroid function test today. I would like to continue her on the same amount of Synthroid. If this needs to be adjusted, I will call mother to let her know.

Thank you for letting us share in the care of Joanne.

Sincerely,


Elmo Domingo, MD                 
Attending in Endocrinology   


Addendum: Joanne's thyroid function tests are completely normal.  T4 14.2, TBGI 1.03, T3 159 and TSH 1.6.


CONTENT:
Shahin Stone, M.D.          RE: Miguel Wiesner
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/25/89

Dear Dr. Stone:

We saw Miguel in the Endocrine Program on 9/21/95 for premature sexual development.

History: Miguel is a 6 and 2/12 year old black male with an approximately 5 month history of increased body and axillar odor.  His mother has not noticed any axillary or pubic hair development.

Current medications: Occasional nebulizer treatment, greater during the winter.
Past medical history:  Pregnancy complicated by preterm contractions; however, he was delivered at 37 weeks via spontaneous vaginal delivery with a birth weight of 6 lb. 2 oz.  He was hospitalized at age 6 months for meningitis, which was complicated by the development of subdural empyemas requiring operative drainage.  He was hospitalized for 3 months, and postoperatively, he required extensive occupational therapy, physical therapy, and speech therapy.  He received anti-seizure medication after his admission.  He is currently in the first grade.  His mother reports that he has now returned to a normal level of physical development, but remains slightly behind in speech development and continues in speech therapy at his school.  His mother reports that he has good nutrition.  Infectious disease history is remarkable for the meningitis.  Immunological history is negative.  Other hospitalizations include a tonsillectomy and adenoidectomy secondary to sleep apnea, and development of unknown seizures at age 3 years which resolved.

Review of systems:  Slight right eye astigmatism and a history of reactive airway disease.

Physical exam:
Ht: 122.6 cm    Wt: 29 kg    Arm span: 102.4 cm    U/L ratio:  0.95
BP: 82/58               Pulse: 60      Pubic hair: Tanner I    
R. testis: 1.2 x 0.8 cm     L. testis: 1.2 x 0.8 cm 
Phallus length: 7 cm        Mid-shaft diam.: 1.8 cm 
General:  well developed, well nourished, healthy appearing male.  Skin:  smooth.  HEENT:  extraocular movements intact, pupils equal, round and reactive to light and accommodation.  Neck:  supple, nontender, without masses or adenopathy.  Chest:  clear to auscultation.  Heart:  regular rate and rhythm.  Abdomen:  soft, no palpable masses.

Additional studies:  Bone at HCHP at a chronological age of 5 years, 11 months was read as 7 years.

Impression: No evidence of precocious puberty or premature adrenarche as there has been no development of secondary sexual characteristics, and the bone age is appropriate for chronological age and height age.   He most likely has the normal development of body odor seen during adrenache occuring between the age of approximately 6 and 8 years old.  Of note, his testes are slightly small.

Disposition: We would like Miguel to follow up in the pediatric endocrine clinic in 6 months for repeat measurements of his height and reexamination.  His mother was instructed to call if there are any signs of pubic hair development.



Sincerely,




Randall Robinson, M.D.            Leif Pavarotti, M.D.             
Fellow in Endocrinology           Attending in Endocrinology   


cc:  Randal Robinson, M.D.   Brigham and Women's Hospital  
     75 Francis Street  Boston, MA  02115


CONTENT:
Shahin Stone, M.D.          RE: Miguel Wiesner
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/25/89

Dear Dr. Stone:

I saw Miguel in the Endocrine Program on 5/30/96 for follow-up possible premature adrenarche.

History: Miguel is now 6 and 11/12 years old.  He has been doing well since his last visit.  One month ago, he had an excision of a pre-auricular pit.  His mother has not noted any pubertal development, and his testes appear small.  He is using deodorant.  Of note, he has had considerable weight gain, but denies large snacks or excessive juice intake.

Current medications:  Ventolin nebulizer p.r.n., multivitamin.

Physical exam:
Height: 128.3 cm      Weight: 37.9 kg
BP: 110/48            Pulse: 83               Pubic hair: Tanner I    
R. testis: 1.4 x 1 cm   L. testis: 1.5 x 1 cm   
Phallus length: 6 cm    Mid-shaft diam.: 1.5 cm 
General appearance:  diffusely overweight.  Skin:   normal texture, hyperpigmented neck (? early acanthosis).  HEENT:   PERRL, EOMI, optic discs not visualized.  Neck:  no thyromegaly.   Lungs:  clear.  Heart:  regular rate and rhythm without murmur.   Abdomen:  soft without hepatosplenomegaly.  Extremities:  well-perfused.   Neurologic:  normal patellar deep tendon reflexes.

Impression: Miguel has no evidence of precocious puberty or premature adrenarche.  His bone age performed 05/18/96 was 9 years.  This would apparently give him an increase in bone age of two years over a one year interval.  However, I never received that last bone age for review, so I cannot confirm the reading of 7 years at a chronologic age of 5 years 11 months.  He has had a mild acceleration in growth velocity; however, at the same time, he has had a significant weight gain of 8.9 kg over the past eight months.  Since his ideal body weight is 27 kg, he is 140% overweight.  Obesity will certainly cause accelerated growth and advancement in bone age.

Disposition:  I think it is important that Miguel sees a nutritionist, and his mother will call you to set up an appointment at HCHP.  In addition, increased exercise would be helpful.  I would appreciate if you could  sent a copy of the prior bone age (I think there may have been an error in that I received two copies of this month's bone age).  If weight gain  continues to be a problem, we have started an obesity clinic here at Children's Hospital.  If possible, I would like to see Miguel back in four to six months to assess his growth velocity and weight.

Thank you for letting me share in Miguel's care.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Kirby Swartzenegger, M.D.          RE: Abraham Wesley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/19/88

Dear Dr. Swartzenegger:

We had the pleasure of seeing Abraham in the Endocrine Program on 11/8/91 for evaluation of .

History: I most recently saw Abraham in diabetes on November 8, 1991.  As you know, he is a 3 and 9/12 year old boy who has had diabetes for over 2 years.  He is currently maintained on pure pork insulin, receiving between 3 and 4 of Regular and 9 1/2 NPH before breakfast, and between 1 and 2 of Regular and 4 of NPH at night, giving him a total daily dose of 1.0 units/kg/day.  He is supposed to be maintained on a 1500 calorie ADA diet, but he's likely getting a few more calories than this.  Since his last visit, his intercurrent history has been unremarkable.  He has very rare mild hypoglycemia, and has had no severe hypoglycemia since his last visit.

Physical exam:  
Height: 104.2 cm        Weight: 19.7 kg         BP: 95/65               
There was no thyromegaly.  The insulin sites look normal.  The remainder of the exam was unremarkable.

Lab studies showed a random urine of 5% glucose, negative ketones and negative protein. Lab values reveal a hemoglobin A1 of 10.0%, blood sugar 396.  Thyroid functions were normal, with a T4 of 8.5 mcg/dl, and TSH 1.2 mcU/ml.  

Abraham continues to do quite well with his diabetes.  There are no struggles relating to his diabetes care, and he even occasionally helps out with his own insulin administration.  The parents do report, however, some behavioral struggles related to food intake at his meals.  Looking at his growth curve, Abraham is displaying normal linear growth, but continues with excessive weight gain, whereby he is approximately 5 lbs overweight for his ideal body weight.  Abraham's weight gain is likely due to overeating, and his large insulin dose is likely secondary to his eating pattern.  It is also possible at this point that his large insulin dose is contributing to his weight gain, but his parents have been resistent to the idea of slightly decreasing his dose, because of resultant higher blood sugars in the face of continued overeating.  We plan to have Abraham to see our dietician again at the next visit.

Eating issues aside, we are very pleased with Abraham's progress.  We plan to see him again in 3 months time in order to follow his course.

Thank you for allowing us to participate in Abraham's care.  Please don't hesitate to call if you have any questions.

In summary: 

Disposition: 

Thank you for letting us share in the care of Abraham.

Sincerely,


Bernardo Bird, MD         Bernardo Bird, MD         
Attending in Endocrinology   Attending in Endocrinology


CONTENT:
Kirby Swartzenegger, M.D.          RE: Abraham Wesley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/19/88

Dear Dr. Swartzenegger:

We had the pleasure of seeing Abraham in the Endocrine Program on 5/15/92 for .

History: I most recently saw Abraham in Diabetes on May 15, 1992.  As you know, he is a 4 and 3/12 year old boy who has had diabetes since August 1989.  He is currently maintained on pure pork insulin, receiving 3 1/2 of Regular and 11 of NPH before breakfast, and 2 of Regular and 4 of NPH before dinner, giving him a total daily dose of 1.05 units/kg/day.  He is also maintained on a 1400 calorie ADA diet.  Since his last visit, there have been no significant struggles with the diabetes.  Abraham experiences rare, symptomatic hypoglycemic reactions.  Results of home glucose monitoring reveal blood sugars between 50 and 180 before breakfast, and 60 and 240 before dinner.

Physical exam:  
Height: 108 cm          Weight: 20 kg           BP: 80/50               
The insulin sites looked normal.  There was no thyromegaly.  The remainder of the exam was unremarkable.

Laboratory studies:  Random urine showed negative glucose, negative protein, and negative ketones.  A hemoglobin A1 was 9.1%, representing very good control, with a random blood sugar of 45.

Impression: I am very pleased with Abraham's progress.  His hemoglobin A1 is the best value he has had since diagnosis.  Both he and his parents appear to be coping very well with the demands of a diabetes treatment program.  I plan to see Abraham again in three months in order to follow his course.

Thank you for allowing me to participate in Abraham's care.  Please don't hesitate to call if you have any specific questions.

Thank you for letting us share in the care of Abraham.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Kirby Swartzenegger, M.D.          RE: Abraham Wesley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/19/88

Dear Dr. Swartzenegger:

We had the pleasure of seeing Abraham in the Endocrine Program on 3/2/93 for follow-up  of insulin dependent diabetes mellitus.

History: As you know, he is a 5 and 1/12 year old boy who has had Type I diabetes since 1989. He is currently maintained on Pure Pork insulin, receiving 3-4 Regular and 12 1/2 NPH before breakfast, and 1-2 Regular 4 1/2 NPH before dinner, giving him a total daily dose of 1.01 units/kg/day. He is also maintained on a 1400 calorie ADA diet. At this point, Abraham is asking for more food, especially around dinner time. Aside from having chicken pox last December, his intercurrent history has been unremarkable. There are fewer struggles with the diabetes routine especially in regard to eating. Results of home glucose monitoring reveal blood sugars generally between 60 and 200 before breakfast and dinner.

Physical exam:  
Height: 113.7 cm        Weight: 21.6 kg         BP: 110/80              
There was no thyromegaly. His insulin sites look normal.  The remainder of the exam was unremarkable.

Laboratory studies:  Random urine 5% glucose, negative ketones and negative protein. Hemoglobin-A1 10.2% with a random blood sugar of 337.

Impression: Abraham continues to do well with his diabetes. At this point, there are fewer behavioral struggles. As he is hungry after dinner, the parents will contact our dietitian to arrange for more calories later in the day. I plan to see Abraham again in three months time in order to follow his course.

Thank you for letting us share in the care of Abraham.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Kirby Swartzenegger, M.D.          RE: Abraham Wesley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/19/88

Dear Dr. Swartzenegger:

We had the pleasure of seeing Abraham in the Endocrine Program on 11/16/93 for follow up of insulin-dependent diabetes mellitus.

History: Abraham was diagnosed with diabetes mellitus at age 17 months, and has subsequently done well.  Interval history is notable for one upper respiratory infection with moderate ketonuria.  He is currently in kindergarten and adapting well to this regimen.

Current insulin dosage is AM: 3-4 units Regular 12.5 units NPH, PM: 1-2.5 units Regular 4 units NPH for a total of 0.85 u/kg/day.  There have been no symptoms of hyper- or hypoglycemia.  Of note, Abraham is rarely symptomatic even when blood sugars have been documented as low as 30's mg/dL.  Pre-breakfast blood sugars are between 100-240 mg/dL, and pre-dinner between 80- 280 mg/dL.

Physical exam:  
Height: 116.2 cm        Weight: 23.95 kg        
General: Well appearing.  Neck: Thyroid smooth and symmetrical.  Chest: Lungs clear.  Heart: Without murmurs.  Genitourinary: Tanner stage I.  Extremities: Injection sites without atrophy or hypertrophy.

Laboratory studies:  Glycosylated hemoglobin 10.9%.  Urinalysis with 1% glucose, no ketones or protein.

Impression: Abraham is a 5 and 9/12 year old boy with Type I diabetes mellitus under reasonably good control.  Growth and development are appropriate, and behavior appears to be under better control recently.  Thyroid function tests and serum cholesterol from June 1993 were normal.

Disposition: We recommend an increased evening NPH dose of 4.5 units.  Blood sugars are to be checked occasionally at lunch and at 2:00AM to establish baseline values.  A return visit is recommended for three months.
Thank you for letting us share in the care of Abraham.

Sincerely,


Gleide Crane, MD             Etta Kramer, MD           
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Darlene Swartzenegger, M.D.          RE: Evelyn Leavitt
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/89

Dear Dr. Swartzenegger:

We had the pleasure of seeing Evelyn in the Endocrine Program on 9/24/92 for evaluation of poor growth.

History: Evelyn is 3 and 2/12 years old white girl who was premature and weighed 2 lbs. and 7 oz. at birth at 32 weeks gestation of a twin pregnancy. She had  coarctation of the aorta and patant ductus arteriosus in duct artery repairs at age 6 weeks. She has had a good appetite and eating habits and was doing well until about age 2 1/2 years. Mother states she stopped growing in height at about age 3. Play and activity are normal. Mother is also concerned about a swollen right breast line but denies galactorrhea or hair growth on the body. 

Mother states that Evelyn started to stutter about 3 months ago. This problem is present in father also.

Current medications: None.

Past medical history:  As per HPI. Delivery was by caesarean section and Evelyn required brief ventilatory support and required a transfusion. She used Prosobee formula and she has been a good eater. She has frequent ear infections. She recently fell and had two rib fractures on the left side and elbow dislocation on her left arm. Hospitalizations as above.

Review of systems:  Non-contributory other than the fact that she seems a little more tired her other siblings. She has had two episodes of lethargy in 6/92. She also complains of occasional gastric pain.

Family history:  Twin sister and brother of 16 months old are growing normally. Mother is age 27 and her height is 5'4". Father's height is 5'6"-5'7". There is no contributory illnesses in the family. Both grandmother's are reported to be 5'2" in height.

Physical exam:  
Height: 84.8 cm         Weight: 11.2 kg         BP: 110/60              
Pulse: 110              U/L ratio:  1.12        Arm span: 85            
Breast: Tanner I        Pubic hair: Tanner I    
Skin:  Warm and dry without rashes.   HEENT: Oropharynx is clear. Conjunctivae non-injected.   Neck: Supple without lymphadenopathy or thyromegaly.   Chest:  Clear to auscultation. There is a well healed surgical scar on the left posterior chest.   Abdomen: Soft without hepatosplenomegaly.   Genitourinary: No erythema and normal external genitalia.   Extremities: Without cyanosis, clubbing or edema. No short fourth metacarpals.   Neurological:  Non-focal.

Impression: Evelyn, though short for her age, has been growing at a normal velocity. This pattern may be a normal variant, or be indicative of endocrine abnormalities such as growth hormone deficiency or hyperthyroidism. Celiac disease is also a consideration.

Disposition: Discharge home and return in six months for follow-up.

Laboratory studies pending at this time include: Somatomedin-C, T4, TSH and Anti-endomysial antibodies.
Thank you for letting us share in the care of Evelyn.

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Demetrios T. Herodotou, MD
Fellow in Endocrinology
Beth Israel Hospital


CONTENT:
Darlene Swartzenegger, M.D.          RE: Evelyn Leavitt
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/89

Dear Dr. Swartzenegger:

We had the pleasure of seeing Evelyn in the Endocrine Program on 4/8/93 for evaluation of short stature.

History: As you know, Evelyn is now a 3 and 9/12 year old girl status-post coarct and patent ductus arteriosis repair at 6 weeks of age. Since her last visit 6 months ago, she has been doing quite well overall. According to her mother she has had no significant illnesses, specifically no vomiting, diarrhea and only mild upper respiratory infections. She has had an unremarkable appetite and has one bowel movement daily. Her overall energy level has been quite good and she has required no recent medications.

Physical exam:  
Height: 89 cm           Weight: 11.9 kg         BP: 92/64               
Pulse: 88               Breast: Tanner I        Pubic hair: Tanner I    
General: Evelyn was a well appearing girl.  Skin: Texture normal, turgor good.  HEENT: Intact extraocular movements, equally responsive pupils and a moist oropharynx.  Neck: Without thyromegaly.  Chest: Clear to auscultation. Heart: Regular rate and rhythm with no murmur.  Abdomen: Soft without hepatosplenomegaly or masses.  Genitourinary: Normal.  Neurological: 2+ and equal deep tendon reflexes. Muscle bulk and tone was normal.

Impression: Since her last visit, Evelyn has exhibited a normal pattern of growth. This is along the delayed curve in the Bayer Bailey chart and is consistent with the mildly delayed bone age of her last visit. We have elected to see Evelyn again in six months to again monitor her growth but have opted for no other studies currently.

Thank you for letting us share in the care of Evelyn.

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Luetta Shields, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Shields:

     We had the pleasure of seeing Ingrid in the Renal Program on 11/10/94 for cloacal abnormality.

     This 5 year old girl with prior cloacal abnormality and post surgical repair with a present ureterostomy drainage of a single kidney presents for review of potential gastrocystoplasty as bladder reservoir a preparation for a future renal transplant.

Current medications include:
     PERINSOL  0.3 q.d.

Physical exam:
     BP 118/65   P 103   R 16    HT 96.1cm   WT 14.5kg
     General: Small thin active, cooperative female, well hydrated.
     Skin: Clear of lesions, rash
     HEENT: Within normal limits
     Neck: Supple, no cervical lymph adenopathy
     Chest: Clinically clear
     Heart: Clinically clear
     Abdomen: Mild excoriation around the gastroscopy tube site and a ureterostomy draining clear urine.
     Extremities: Free of rash or arthritis
     Neurological: No localizing signs

Urinalysis:
     SPEC GR UA  1.005           PH UA       7          
     PROTEIN UA  trace           BLOOD UA    trace      
     GLUCOSE UA  N               WBC/HPF     5-8        
     RBC/HPF     4-8             SQUAM EPI   num   
     CASTS       N               MUCUS STRANDS

Laboratory studies at this time include:
          CO 2         16   MEQ/L (L)   CA          9.5   MG/DL    
          CR          1.7   MG/DL (H)   PHOS        5.4   MG/DL    
          BUN          30   MG/DL (H)   NA          138  MMOL/L    
          K           4.1  MMOL/L       CL          102  MMOL/L    

     1)  Moderate renal insufficiency  2)  Cloacal anomaly post surgery  3)  Dysplastic kidneys  4)  Renal tubular acidosis  significant in the past.  Ingrid was off bicitra with recurrence of acidosis requiring return to therapy  5)  Borderline blood pressures  6)  Prior failure to thrive  7)  Consideration for gastrocystoplasty.

I discussed with the mother the plan to move to gastrocystoplasty at this stage while Ingrid is in good medical condition.

     We have asked Ingrid to return in three months.  Thank you for allowing us to share in Ingrid's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Luetta Shields, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Shields:

     We had the pleasure of seeing Ingrid in the Renal Program on 4/20/95 for cloacal abnormality/dysplastic kidneys.
     Ingrid is a 5 1/2 year old girl well known to us with cloacal abnormalities, status post surgical repair and moderate renal insufficiency secondary to dysplastic kidneys.  Ingrid is here for surgical clearance prior to her scheduled gastrocystoplasty on Monday to create a bladder reservoir in preparation for renal transplant.  From her last visit in November Ingrid had been placed back on Bicitra because of recurrence of acidosis.  Otherwise she has been well without any complaints.

Her current medications include:
     FERINSOL  0.3 ml q.d.

Ingrid's physical exam was notable for:
     BP 115/65   P 95   R    T    HT 97.3cm   WT 16.8kg
     General: Appears well in no distress, is very active and playful, well hydrated.
     HEENT: Within normal limits
     Neck: Supple, without cervical lymphadenopathy
     Chest: Clear
     Heart: No murmur.
     Abdomen: Mild irritation around the gastroscopy tube site without infection.  There is note of a ureterostomy tube.
     Genitourinary: Absence of genitalia.
     Extremities: No lesions

A urinalysis revealed:
     SPEC GR UA  1.003           RBC/HPF     0          
     WBC ENZ UA  N               WBC CAST    0          
     PH UA       7.0             RBC CAST    0          
     PROTEIN UA  N               GRAN CAST   0          
     BLOOD UA    N               WAXY CAST   0          
     GLUCOSE UA  N     mg/dl     SQUAM EPI   0          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:


     1.  Ingrid is a 5 1/2 year old girl with moderate renal insufficiency secondary to dysplastic kidneys.  Her creatinine has been stable at 1.7.
2.  She has renal tubular acidosis requiring reinstitution of Bicitra, we plan to recheck serum electrolytes before surgery.
3.  Borderline blood pressure which at present is 116/65.  
4.  Failure to thrive.
5.  Cloacal abnormality status post repair.
6.  Gastocystoplasty on Monday.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in We will be seeing Ingrid in the hospital during her surgical procedure.  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Joakuim Chef, MD           Mitsuko Khan, MD
               Fellow, Pediatric Nephrology Director, Clinical Services


CONTENT:
Luetta Shields, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Shields:

     We had the pleasure of seeing Ingrid in the Renal Program on 5/25/95 for cloacal abnormality/dysplastic kidneys.
     Ingrid is a 5 1/2 year old girl who has a cloacal abnormality, status post surgical repair and most recently had closure for ureterostomy, gastrostomy tube and a gastrocystoplasty.  She underwent the above surgery on April 24th and stayed in the hospital for three and a half weeks because of fever post-operatively.  There was no source of infection that was identified at that time.  She was discharged on the 19th of May with a suprapubic catheter and urethral catheter.  Since discharged six days ago she has been voiding clear urine through a suprapubic catheter and has been afebrile.  Since surgery she lost two pounds but mother that her appetite has been picking up very recently.  She remains active and playful and well hydrated.  She is also currently incontinent of stool although this was not a problem preoperatively.  On discharge her creatinine was 2.5 which went up from a baseline of 2 prior to surgery.  She had a creatinine level 5.1 immediately postoperatively which was assessed to be secondary to hydration status.  Her most recent bicarbonate was 27 on discharge.  She is also anemic with a hematocrit of 27.

Her current medications include:
     HYTAKEROL 0.125 mg po q.d.
     FERINSOL  0.3 ml q.d.
     BICITRA 5 cc po t.i.d.

Ingrid's physical exam was notable for:
     BP 127/77   P 123   R    T    HT 94.4cm   WT 14.9kg
     General: Ingrid lost 2 lbs. from her most recent visit four weeks ago.  Her blood pressure is borderline.  She appears active alert and well hydrated and very playful and pleasant.   
     Skin: no active lesion but note of slight hirsutism.
     Abdomen: soft and flat with no bruits.  Suprapubic and urethral catheters in place without signs of infection.  There is no tenderness of discharge. 
     Genitourinary: absent genitalia.
A urinalysis revealed:


Laboratory studies at this time include:
          CO 2         24   MEQ/L       CA          9.6   MG/DL    
          CR          2.1   MG/DL (H)   GLU          85   MG/DL    
          PHOS        6.0   MG/DL (H)   BUN          35   MG/DL (H)
          NA          139  MMOL/L       K           3.8  MMOL/L    
          CL          103  MMOL/L       PLT         347   K/MM3    
          WBC        7.01   K/MM3       RBC        3.35   M/MM3 (L)
          HGB         8.9    G/DL (L)   HCT.       27.4       % (L)
          MCV        81.7      FL       MCH        26.6      PG    
          MCHC       32.5    G/DL       RDW        14.8       %    
          HDW        3.39    G/DL (H)   PLT UNC     347   K/MM3    
          NEUT AB    2.92   K/MM3       LYMPH A    2.92   K/MM3    
          EOS ABS     .52   K/MM3 (H)   NEUT-A     41.7       %    
          LYMPH-A    41.7       %       MONO-A      5.2       %    
          EOS-A       7.4       % (H)   BASO-A       .8       %    
          ATYP LY     3.2       %       MICRO-A       +    
          HYPO-A        +               RET         2.3       % (H)

     1.  Ingrid is a 5 1/2 year old girl with cloacal abnormality status post repair.  Status post closure of ureterostomy and gastrocystoplasty in April 24 with the following problems:

1)  Previously stable renal insufficiency but most recent creatinine has gone up to 2.5.  We will repeat this today.
2)  Borderline elevated blood pressure which has been stable from before.  
3)  Proximal renal tubular acidosis and she is on Bicitra 5 cc t.i.d.  Her last bicarbonate was 27, and we will recheck this value today as she may need an increase of dose of Bicitra.
4)  Failure to thrive.  With a recent acute weight loss probably secondary to surgery.  Her current appetite appears okay but we will consider consulting with Nancy Spinozzi if her weight continues to fluctuate. 
5)  Anemia probably secondary to blood loss with a hematocrit of 27, we will start her on Fer-In-Sol today.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in One month after she goes to see Dr. Shields for a cystoscopy.  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Joakuim Chef, MD           Mitsuko Khan, MD
               Fellow, Pediatric Nephrology Director, Clinical Services


CONTENT:
Luetta Shields, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Shields:

     We had the pleasure of seeing Ingrid in the Renal Program on 7/19/95 for dysplastic kidney.
     Ingrid is a 5-3/4 year old female with a cloacal abnormality  status post repair, dysplastic kidney and RGA Type IV secondary to  ureteral obstruction.  She was seen in clinic today for follow-up of her  repair of April, 1995.  Since then she has had no hematuria except for  after cystoscopy.  She has had no dysuria.  She has had good appetite  and no fever, nausea, vomiting or diarrhea since her surgery.

Her current medications include:
     Bicitra .5 cc's b.i.d.
     Vitamin D 0.125 mg. q.d.
     Fer-In-Sol 0.5 cc q.d.

Ingrid's physical exam was notable for:
     BP 133/82   P 103   R    T    HT 99cm   WT 168kg
     General:  Ingrid appeared healthy.
     Skin: No rashes 
     HEENT:  Within normal limits except for teeth which showed evidence of iron  supplementation. 
     Neck: Supple.  Her lymph nodes were not palpable.  
     Chest: Clear to auscultation 
     Heart:  Regular rate with a normal S1 and S2.  She had a II/VI systolic murmur at the left sternal border. 
     Abdomen: She had good bowel sounds, her abdomen was soft, nontender, nondistended.  She had a surgical scar and a suprapubic catheter. 
     Genitourinary:  She has a repaired persistent cloaca and a urethral catheter.  She had breakdown in the course of her perineal scar.  She has no genitalia.
     Extremities:  Full range of motion.
     Neurological: She had 2+ reflexes in upper and lower extremities with no focal signs.
A urinalysis revealed:


Laboratory studies at this time include:
          ALKP        237     U/L       OSMO        293  MOSMKG    
          MG          2.3   MG/DL (H)   PHOS        5.4   MG/DL    
          CO 2         23   MEQ/L       BUN          42   MG/DL (H)
          CA         10.2   MG/DL       NA          138  MMOL/L    
          CR          2.0   MG/DL (H)   K           4.1  MMOL/L    
          GLU          87   MG/DL       CL          101  MMOL/L    

     This is a 5-3/4 year old female with dysplastic kidneys,  renal tubular acidosis Type IV secondary to ureteral obstruction, and a  cloacal abnormality status post repair in April of 1995.  She currently  has suprapubic and urethral catheters.  Her urine output is good.  She  has no hematuria.  She does have some breakdown in the course of her  perineal scar and is otherwise doing well.  Suggested salt water  dressings every night and petroleum jelly to the area when she swims.   In addition, we are getting electrolytes, BUN and creatinine.  She is to  be seen in Renal Clinic in 2 months.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in Two months.  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Luetta Shields, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Shields:

     We had the pleasure of evaluating Ingrid in the Renal Program on 9/6/95 for dysplastic kidney.
     Poor appetite and intake associated with slow weight gain.

Her current medications include:
     Ferinsol 0.3 ml q.d.
     Dihydrotachysterol 0.125 mg. q.d.
     Bicitra 5cc p.o. t.i.d.
     Equinox 1 q.d.

Past medical history:
     Well-known for complex issues of cloacal repair, renal dysplasia, and renal insufficiency.

Review of systems:
     There has been a steady decline in appetite and a patchy intake over the past 1 to 2 months following her gastric patch to the bladder augmentation.

There also appears to be less bowel control with fecal incontinence now readily present.

Ingrid's physical exam was notable for:
     BP 95/65   P 108   R 22   T    HT 99.9cm   WT 16.3kg
     General Appearance:  A thin, active, cooperative  patient.  
     HEENT:  Normal.  
     Neck:  Supple.  
     Lymph Nodes: Not palpable.   
     Chest: Clinically clear.  
     Heart:  Rate and rhythm regular without murmurs.  
     Abdomen:  Multiple past areas of operative scarring and a superpubic tube noted.  
     GU:  Reconstructed cloacal repair.  
     Extremities:   No edema.  
     Skin:  Intact.  
     Neurological:  No focalizing signs.
A urinalysis revealed:


Laboratory studies at this time include:
          CO 2         27   MEQ/L       RDW        13.5       %    
          CR          2.0   MG/DL (H)   HDW        2.54    G/DL    
          GLU         110   MG/DL       PLT UNC     307   K/MM3    
          BUN          37   MG/DL (H)   NEUT AB    6.41   K/MM3    
          NA          141  MMOL/L       LYMPH A    3.66   K/MM3    
          K           3.8  MMOL/L       EOS ABS     .15   K/MM3    
          CL           97  MMOL/L (L)   NEUT-A     57.3       %    
          WBC       11.18   K/MM3       LYMPH-A    32.7       %    
          RBC        4.67   M/MM3       MONO-A      5.4       %    
          HGB        12.2    G/DL       EOS-A       1.3       %    
          HCT.       36.6       %       BASO-A       .9       %    
          MCV        78.4      FL       ATYP LY     2.3       %    
          MCH        26.1      PG       MICRO-A       +    
          MCHC       33.3    G/DL       

     1.  Cloacal repair with now good drainage and stable metabolic status on present supplementation.  
2.  Renal dysplasia.  
3.  Renal insufficiency-stable after recent gastrocystoplasty.  

No changes in present supplement.  

Ingrid is due for a repeat review by Dr. Shields and, at that stage,  closer review of the change in bowel control will be further  investigated.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in Two months.  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Luetta Shields, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Shields:

     We had the pleasure of evaluating Ingrid in the Renal Program on 9/6/95 for dysplastic kidney.
     Poor appetite and intake associated with slow weight gain.

Her current medications include:
     Ferinsol 0.3 ml q.d.
     Dihydrotachysterol 0.125 mg. q.d.
     Bicitra 5cc p.o. t.i.d.
     Equinox 1 q.d.(natural vitamin)

Past medical history:
     Well-known for complex issues of cloacal repair, renal dysplasia, and renal insufficiency.

Review of systems:
     There has been a steady decline in appetite and a limited intake over the past 1 to 2 months following her gastric patch to the bladder augmentation.

There also appears to be less bowel control with fecal incontinence now readily present.

Ingrid's physical exam was notable for:
     BP 95/65   P 108   R 22   T    HT 99.9cm   WT 16.3kg
     General Appearance:  A thin, active, cooperative  patient.  
     HEENT:  Normal.  
     Neck:  Supple.  
     Lymph Nodes: Not palpable.   
     Chest: Clinically clear.  
     Heart:  Rate and rhythm regular without murmurs.  
     Abdomen:  Multiple past areas of operative scarring and a superpubic tube noted.  
     GU:  Reconstructed cloacal repair.  
     Extremities:   No edema.  
     Skin:  Intact.  
     Neurological:  No focalizing signs.
A urinalysis revealed:


Laboratory studies at this time include:
          CO 2         27   MEQ/L       RDW        13.5       %    
          CR          2.0   MG/DL (H)   HDW        2.54    G/DL    
          GLU         110   MG/DL       PLT UNC     307   K/MM3    
          BUN          37   MG/DL (H)   NEUT AB    6.41   K/MM3    
          NA          141  MMOL/L       LYMPH A    3.66   K/MM3    
          K           3.8  MMOL/L       EOS ABS     .15   K/MM3    
          CL           97  MMOL/L (L)   NEUT-A     57.3       %    
          WBC       11.18   K/MM3       LYMPH-A    32.7       %    
          RBC        4.67   M/MM3       MONO-A      5.4       %    
          HGB        12.2    G/DL       EOS-A       1.3       %    
          HCT.       36.6       %       BASO-A       .9       %    
          MCV        78.4      FL       ATYP LY     2.3       %    
          MCH        26.1      PG       MICRO-A       +    
          MCHC       33.3    G/DL       

     1.  Cloacal repair with now good drainage and stable metabolic status on present supplementation.  
2.  Renal dysplasia.  
3.  Renal insufficiency-stable after recent gastrocystoplasty.  

No changes in present supplement.  

Ingrid is due for a repeat review by Dr. Shields and, at that stage,  closer review of the change in bowel control will be further  investigated.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in Two months.  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Mitsuko Khan, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. :

     We had the pleasure of evaluating Ingrid in the Renal Program on 12/13/95 for followup of elevated blood pressure.
     
Ingrid returns today for review of an elevated blood pressure noted  during her recent hospitalization and for which she required nifedipine  5 mg six hourly prn. Her home blood pressures have shown significant  variation and because of this, the mother has had difficulty in the measurement  and administration of nifedipine at 5 mg dosage. Ingrid has been  inadequately covered and has had blood pressures ranging between 120/80  to 138/85.

Her current medications include:
     HYTAKEROL 0.125 mg q.d.
     BICITRA SUGAR FREE 5 cc t.i.d.
     NIFEDIPINE 5 mg q 6 hr prn

Past medical history:
     

Past medical history:  Well known for multiple surgical intervention in  an ongoing repair of a cloacal extrophy.

Review of systems:
     
     

Review of systems: Presently asymptomatic and with labile blood  pressure.

Ingrid's physical exam was notable for:
     BP 107/83   P 126   R 16   T    HT 100.7cm   WT 17.2kg
     
     Physical examination:  Well hydrated, well covered, cooperative child.   HEENT: normal limits. Neck: supple. Lymph nodes: not palpable. Chest:  clinically clear.  Heart: regular rate and rhythm with both heart sounds  audible and no bruit.  Abdomen: scars from prior surgery and presence of  a suprapubic tube.  Genitourinary: undergoing reconstruction.  Extremities: no edema or rash. Skin: intact.  Neurologic: no focal sign.
A urinalysis revealed:
                            

Laboratory studies at this time include:


     
Assessment:  Blood pressure inadequately controlled on nifedipine,  possibly secondary to the difficulty in administration of dosage for  mechanical reasons, since Ingrid was well controlled in the hospital  setting.  We will make a change to hydralazine 10 mg b.i.d., and  continue home monitoring.  Ingrid will return in three weeks for  further review.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in .  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stella Piggy, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Piggy:

     We had the pleasure of seeing Ingrid in the Renal Program on 1/31/96 for follow up of her hypertensive regime.
     
Ingrid is a 6 year old girl with a cloacal malformation with genital and renal dysplasia.  Her most recent surgery was a neourethral construction (November, 1995) following the gastrocystoplasty in April 1995.  She has  stable renal insufficiency, renal tubular acidosis, and continuing failure to thrive with short stature.  Her most active medical problem  is hypertension control.

Her current medications include:


Review of systems:
     
Review of Systems:  Ingrid had several episodes of emesis yesterday  and her blood pressure was 141/100 at the time.  She has had no  diarrhea, abdominal pain, or dysuria.  She and her family perform straight catheterization four times a day with no difficulty.

Ingrid's physical exam was notable for:
     BP 140/79   P 148   R    T    HT 102.3cm   WT 17kg
     
     On physical examination, she is a very active, cheerful and talkative  child.  Her head and neck exam is within normal limits.  Her oropharynx  shows no erythema, edema or exudate.  Her neck is supple with no  prominent adenopathy.  Her chest is clear to auscultation bilaterally.   Her cardiac exam shows a regular rate and rhythm with a I/VI systolic  murmur at the left upper sternal border.  Her abdomen is soft and  non-tender.  She has a suprapubic catheter - there is granulation tissue but  no acute inflammation at the exit site.  There is scant serous drainage on  the dressing.  There are no palpable masses, liver or spleen.  Her GU  exam reveals a urethral opening with no inflammation.  She has no  obvious perineal and diaper area rash.
A urinalysis revealed:
     SPEC GR UA             







Laboratory studies at this time include:
          K           3.5  MMOL/L       RBC        3.95   M/MM3    
          CA          9.4   MG/DL       HGB        10.2    G/DL (L)
          CR          2.4   MG/DL (H)   HCT.       30.7       % (L)
          PHOS        5.0   MG/DL       MCV        77.7      FL    
          BUN          48   MG/DL (H)   MCH        25.8      PG (L)
          NA          143  MMOL/L       MCHC       33.2    G/DL    
          CL          103  MMOL/L       RDW        12.9       %    
          CO 2         28   MEQ/L       HDW        2.55    G/DL    
          WBC        6.53   K/MM3       PLT UNC     271   K/MM3    

     

Assessment:  This 6 year old girl post cloacal extrophy repair shows chronic hypertension which has been poorly controlled at times.  The use of nifedipine probably has contributed to the variation in blood pressure and now on change to hydralazine for stabilization the dose is still under titration.  We asked her to increase the hydralazine dose to 10 mg tid, to monitor a.m. and p.m.   B.P. and call the results to our unit for potential modification, if necessary.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in .  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stella Red, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Red:

     We had the pleasure of seeing Ingrid in the Renal Program on 4/4/96 for cloral extremitis.
     Ingrid returns for follow up and stabilization of her blood pressure.   Her past medical history is well known for multiple surgical  interventions and an ongoing repair of cloacal extrophy. She remains with a  suprapubic tube drainage and intermittent catheterization as a mode of  clearing of her urinary tract.

Her current medications include:
     DIHYDROTACHYSTEROL 0.125 mg q.d.
     FERINSOL 0.5 ml q.d.
     BICTRA 5 ml t.i.d.

Review of systems:
     Over the interim 2-3 months, she has had  intercurrent viral episodes associated with cough, nausea, vomiting,  which has limited intake and slowed her ability for growth.

Ingrid's physical exam was notable for:
     BP 116/74   P 119   R    T    HT 101.5cm   WT 16.9kg
     General appearance, a well hydrated mildly overactive child.  
     HEENT:  Normal limits. 
     Neck:  Supple.  
     Lymph nodes:  Not palpable.  
     Chest:  Clinically clear.  
     Heart:  Rate and rhythm regular without bruit. 
     Abdomen:  Numerous operative sites and a  suprapubic catheter with the stoma in good clinical order.   
     Genitourinary:  In the process of reconstruction.  
     Extremities:  No  edema.  
     Skin intact.  
     Neurological:  Intact reflexes to the lower  extremities.
A urinalysis revealed:
     SPEC GR UA  1.012           GLUCOSE UA  neg        
     PH UA       7               RBC/HPF     2-5        
     WBC ENZ UA  neg             SQUAM EPI   occ.       
     BLOOD UA    trace           GRAN CAST   fine  
     PROTEIN UA  1+              BACTERIA    neg   
     WBC/HPF    clumps with mucus
CASTS      rare hyaline

Laboratory studies at this time include:


     ASSESSMENT: 1.  Poor growth over the past six month period.   2.  Improved but still mildly elevated blood pressures despite hydralazine therapy.   3.  Reasonable chemical control. 

It is disappointing that Ingrid shows a decrease in growth rate and whether this is associated with her viral episode, with decreased caloric intake or with the early onset of growth insufficiency secondary to decreased renal function is not clear.  Her chemistries remain stable with creatinine 2.6 mg./DL, BUN 43 mg./DL, with a mildly decreased  chloride, and with a borderline elevated bicarbonate consistent with her Bicitra intake.  Hematocrit 31.5% is slightly better than on previous occasions, but borderline also.   

My impression would be that this actually represents the commencement of a growth failure secondary to renal insufficiency.  My present aim would  be to maximize calorie intake, increase the chloride intake slightly (since chloride deficiency is associated with a hold up in growth rate) and to monitor her growth carefully over the next 2-3 months.  Should the hematocrit not continue to rise to 35% or above, consideration of erythropoietin therapy would be reasonable, and should growth not be re-established with a slightly better diet and caloric increase, that we consider the use of recombinant human growth hormone (Nutropin), which  has been now approved for use in chronic renal insufficiency patients.  We should aim at maintaining her growth at or close to more normal rate.  I would suggest that we maximize her blood pressure medication control by adding propranolol 5 mg. twice daily at this stage.   

I asked to have her pressures checked at home with mother and school, and to return here in four weeks so that we can balance and commence a more vigorous program of watching and assessment for the potential need of growth hormone, or erythropoietin therapy.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in 4 weeks.  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stella Piggy, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Piggy:

     We had the pleasure of seeing Ingrid in the Renal Program on 5/1/96 for follow up blood pressure control.
     Ingrid returns on hydralazine and propranolol therapy for control of her blood pressure.   She continues on Bicitra and Hytakerol for her  persisting renal insufficiency.   

Her past medical history is well known. 

Ingrid's home blood pressure are within a reasonable range, 115/70-80 with a pressure measured here in the Renal Program  review at 129/70.   

Ingrid continues with a suprapubic tube and a review with Dr. Hendrin  that is pending.

Her current medications include:
     HYDRALAZINE 10 mg q.i.d.
     PROPRANOLOL HCL 5 mg po b.i.d.
     HYTAKEROL .125 mg po q.d.
     BICITRA 5 cc t.i.d.
     FER-IN-SOL .6 cc q.d.

Ingrid's physical exam was notable for:
     BP 129/70   P 106   R 18   T    HT 102cm   WT 17.4kg
     General appearance: a well hydrated, well covered female with a suprapubic drainage in place.  
     Head, ears, eyes, nose, and  throat normal.  
     Neck: supple.  
     Lymph nodes: non-palpable.  
     Chest:  clinically clear.  
     Heart: regular rate and rhythm.  
     Abdomen: multiple surgical scars from genitourinary system in the presence of  reconstruction for post coital repair.  
     Extremities: no edema.  
     Skin:  intact.  
     Neurological: no focalizing signs.
A urinalysis revealed:
     SPEC GR UA  1.014           GLUCOSE UA  neg        
     PH UA       7.5             RBC/HPF     0-4        
     WBC ENZ UA  neg             WBC/HPF     5-8        
     BLOOD UA    trace           BACTERIA    neg   
     PROTEIN UA  1+         
     CASTS: rare, fine, granular
SQUAM EPI: occassional mucus strands

Laboratory studies at this time include:


     It is pleasing to see that Ingrid has shown resumption of linear  growth over the past one month.  Her blood pressure is barely acceptable and I thought it reasonable to recheck her chemistries.   A chemical profile showed stable renal function and correction of her acidosis.   Her creatinine is at 2.6 mg./dl. and BUN 43 mg./dl., both in a  relatively stable range.  The acidosis has been corrected and her present  dosage of Bicitra is adequate.  CO2 at 30 mEq per liter probably  represents some mild decrease in chloride intake.   We will need to watch carefully since serum chloride at 94 mEq per liter is mildly decreased.   Adjustment to her supplementation will be made to allow for the chloride losses with her gastric augmentation.   Hypochloremic alkalosis has been associated with hold up in growth rate,  but certainly at this time Ingrid is showing resumption of growth and this suggests that it is reasonable to continue the present routine.

     Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in 4 weeks.  In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stella Piggy, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Piggy:

We had the pleasure of seeing Ingrid in the Renal Program on 9/26/96 for obstructive uropathy and follow up blood pressure control.
Since our last interval review, Ingrid has remained relatively well  apart from an episode of urethral obstruction secondary to a renal calculus and  with the need for surgical removal and dilatation.  Her hypertension has  remained in variable control though the mother has not been taking her  pressures regularly and she has not been seen to have her pressure taken  by the school nurse.   

Systemic review reveals a continuing poor appetite but better sleeping,  increased activity, and no fever or recent abdominal pain.

Her current medications include:
     HYDRALAZINE 10 mg t.i.d.
     PROPRANOLOL HCL 5 mg b.i.d.
     BICITRA SUGAR FREE 5 ml t.i.d.
     DIHYDROTACHYSTEROL 0.125 mg b.i.d.
     FER-IN-SOL 0.6 ml q.d.

Ingrid's physical exam was notable for:
     BP 100/60   P 86   R 20   T    HT 103.3cm   WT 18.1kg
     Ingrid is a thin well hydrated girl.  
     HEENT: within normal limits.  
     Neck: supple. 
     Lymph nodes: not palpable.   
     Chest: clinically clear.  
     Heart: regular rate and rhythm.  
     Abdomen: showing multiple post operative scars and no overt mass, viscous or  tenderness was elicited.  
     Genitourinary: deferred (still in a  reconstruction from a cloacal extrophy).  Extremities: no edema or rash.   
     Skin: intact.  
     Neurological: no focalizing signs.
Laboratory studies at this time include:
          ALKP        283     U/L       MCHC       35.5    G/DL    
          K           3.8  MMOL/L       RDW        13.0       %    
          ALB         4.1    G/DL       HDW        2.60    G/DL    
          CA          9.7   MG/DL       MPV         8.7      FL    
          CR          3.7   MG/DL (H)   PLT UNC     334   K/MM3    
          GLU          81   MG/DL       NEUT AB    4.08   K/MM3    
          PHOS        7.6   MG/DL (H)   LYMPH A    2.90   K/MM3    
          TP          8.2   GM/DL       EOS ABS     .08   K/MM3    
          BUN          57   MG/DL (C)   NEUT-A     53.1       %    
          NA          135  MMOL/L       LYMPH-A    37.7       %    
          CL           90  MMOL/L (L)   MONO-A      4.3       %    
          CO 2         31   MEQ/L (H)   EOS-A       1.1       %    
          WBC        7.68   K/MM3       BASO-A      1.1       %    
          RBC        3.69   M/MM3 (L)   ATYP LY     2.6       %    
          HGB        10.1    G/DL (L)   MICRO-A       +    
          HCT.       28.5       % (L)   LEFT SH PRESENT    
          MCV        77.2      FL       PTH1       1246   pg/mL (H)
          MCH        27.4      PG       

Ingrid has shown a continuing steady decrease in renal function.  She also shows a decrease in growth rate and I would urge one monthly growth reviews with the consideration of growth hormone therapy.   Ingrid needs reinforcement of the need for  caloric supplementation to maximize growth potential and this needs stabilization before growth hormone therapy is considered.  

We will have her decrease her Bicitra supplementation to 5 ml b.i.d. since her present C02 is elevated.  With rising serum phosphorous we will have Ingrid commence TUMS (calcxium carbonate) 500 mg tabs t.i.d. in an attempt to balance her calcium/phosphorus metabolism while trying to maximize growth.

Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in one month. In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Hugo, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Hugo:

We had the pleasure of seeing Ingrid in the Renal Program on 11/6/96 for cloacal extrophy post augmentation procedure.
Ingrid returns for an interval review for check on growth, correction  of acidosis and hypertensive control.  She has remained asymptomatic in  the interval.   

Her past medical history is well known for extrophy repair and post  gastric augmentation procedure.

Her current medications include:
     BICITRA SUGAR FREE 5 ml b.i.d.
     PROPRANOLOL HCL 5 mg b.i.d.
     HYDRALAZINE 10 mg t.i.d.
     FER-IN-SOL 0.6 ml b.i.d.
     DIHYDROTACHYSTEROL 0.125 mg q.d.

Ingrid's physical exam was notable for:
     BP 117/61   P 111   R    T    HT 104.4cm   WT 18.4kg
     Her last set of chemistries showed significant hypochloremic alkalosis  and a marked hyperparathyroidism likely secondary to poor intake, slowed growth and to a vomiting illness at that time.  
     
     She is now doing better with slightly better caloric intake at this time.  
     rowth continues to be slow, general appearance with a thin, small statured seven year old.  
     HEENT: normal limits.  Neck supple, lymph nodes not  palpable.  
     Chest: clinically clear.  
     Heart: regular rate and rhythm with  a soft systolic bruit.  
     Abdomen: nontender.  
     Genitourinary: under  reconstruction with need for catheterization and drainage.  
     Extremities:  no edema.  
     Skin: intact.  
     Neurological: no focalizing signs.
Laboratory studies at this time include:
          AST          30     U/L       OSMO        302  MOSMKG (H)
          ALKP        413     U/L (H)   PHOS        5.4   MG/DL    
          K           3.8  MMOL/L       TP          8.3   GM/DL (H)
          ALB         4.3    G/DL       BUN          44   MG/DL (H)
          CA          9.6   MG/DL       NA          139  MMOL/L    
          MG          3.0   MG/DL (H)   CL           97  MMOL/L (L)
          CR          3.5   MG/DL (H)   CO 2         26   MEQ/L    

Ingrid remains mildly hypertensive and an increase in  propranolol dosage was made at this review.  Her calcium has been at the lower limits  of normal and her parathyroid level is extremely high despite  dihydrotachysterol dosage.  A change from dihydrotachysterol to  Rocaltrol 0.25 mcg every other day will be made.  

I suggest that Ingrid continue review at one monthly intervals with correction of her  electrolytes, maximizing her calories and consider growth hormone therapy if growth does not recurr.

Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in one month. In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Tuba Benise, M.D.          RE: Ingrid Percy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/89

Dear Dr. Benise:

We had the pleasure of seeing Ingrid in the Renal Program on 12/26/96 for follow up of growth retardation in the setting of chronic renal insufficiency.
Ingrid returns for follow-up of growth retardation and a continuing relatively poor caloric intake.  Her chemistries recently have remained in stable range without change in growth rate (in fact a flattening of the growth rate over the past 2 months).  

Past medical history is well-known for cloacal extrophy  and a dysplastic kidney with  renal tubular acidosis type IV secondary  to the ureteral obstruction.  

Controlled hypertension is present.

Her current medications include:
     BICITRA SUGAR FREE 5 mg b.i.d.
     PROPRANOLOL HCL 5 mg q.a.m.
     PROPRANOLOL HCL 10 mg q.p.m.
     HYDRALAZINE 10 mg t.i.d.
     FER-IN-SOL 0.6 b.i.d.

Ingrid's physical exam was notable for:
     BP 104/62   P 94   R    T    HT 104.6cm   WT 18.4kg
     She was well hydrated and free of edema.
I would fee the most appropriate course that we attempt should be treatment with erythropoietin for her anemia. If control of anemia does not allow an increase in wellbeing and better intake, we will push for growth at this stage with calcium-phosphorus metabolism and acidosis are fully  corrected.  

Michele will return for review after 3 weeks on erythropoietin  and hopefully we will have been able to commence on appropriate growth hormone therapy soon.

Thank you for the opportunity to participate in Ingrid's care.  We would like to review her in three weeks. In the interim, we would be happy to discuss or review Ingrid should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
W. Hardy Hendren, M.D.
Chief of Surgery
Fegan 3
Children's Hospital


Dennis P. Lund, M.D.
Surgery, Fegan 3
Children's Hospital


CONTENT:
Fai Pluto, M.D.          RE: Milt Westcott
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/17/84

Dear Dr. Pluto:

We had the pleasure of seeing Milt in the Endocrine Program on 2/12/92 for  .

History: I most recently saw Milt in Endocrinology at the Children's Hospital Specialty Care Center in Lexington on February 12th, 1992.  As you know, he is a 7 and 2/12 year old boy who has had Type I diabetes since April of 1989.  He is currently maintained on pure pork insulin, receiving 2 units of Regular and 8 units of NPH in the morning, and 1 unit of Regular and 5 units of NPH before dinner, giving him a total daily dose of 0.68 units/kg/day.  Although he is not following a specific ADA exchange list diet, he does have 3 meals and 3 snacks per day, and mother reports fairly good consistency in his meal pattern.  Since his last visit, he has had no significant illnesses.  He is on nutritional supplements supplied by a chiropractor.  Since his last visit,  Milt has had no severe hypoglycemia and experiences about one mild hypoglycemic episode per week.  He is still not good at recognizing his hypoglycemia.  Review of systems reveals continued enuresis, without any change.  Results of home glucose monitoring revealed blood sugars between 50 and 180 before breakfast, and between 70 and 180 before dinner.

Physical exam:  
Weight: 24 kg           BP: 100/                
Fundoscopic exam was benign.  There was no thyromegaly.  The insulin sites were without hypertrophy.

Laboratory studies:  revealed a random urine with negative glucose, negative ketones and negative protein.  A random blood sugar was 63.  A hemoglobin A1 was not drawn because of lab error, but a hemoglobin A1 last November was 6.9%, which is in the normal range.

In summary: Milt continues to do very well with his diabetes.  He is probably making some insulin on his own, explaining his excellent control.  Since the family is experiencing some difficulties with lack of insurance and the father being laid off from work, I have referred them to speak to our diabetes social worker, Ellen Goodman, for some advice.  I plan to see Milt again in 3 months time in order to follow his course.  

Thank you for allowing me to participate in Milt's care.  Please don't hesitate to call if you have any specific questions.


Thank you for letting us share in the care of Milt.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Fai Pluto, M.D.          RE: Milt Westcott
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/17/84

Dear Dr. Pluto:

We had the pleasure of seeing Milt in the Endocrine Program on 2/23/93 for follow-up of Type I diabetes mellitus.

History: As you know, Milt is an 8 year old boy who has had insulin dependent diabetes since April of 1989. He is maintained on Pure Pork insulin, receiving 2.5 regular and 12 of NPH before breakfast, and 1.5 Regular, 7.5 NPH before dinner, giving him a total daily dose of 0.84 units/kg/day. Although he is not on a specific meal plan, his diet is fairly consistent with three regular meals and snacks. Milt is in the second grade, where he is doing well. There are no specific struggles with his diabetes. He still has persistent enuresis. Milt experiences 1-2 mild hypoglycemic episodes per week, and has had no severe hypoglycemia since his last visit. Results of home glucose monitoring reveal blood sugars between 60 and 200 before breakfast and before dinner.

Physical exam:  
Height: 128.9 cm        Weight: 27.8 kg         BP: 122/72              
There was no thyromegaly.  The insulin sites looked normal. The remainder of the exam was unremarkable.

Laboratory studies:   Hemoglobin-A1 8.7%, random blood sugar 77.

Impression: Milt's diabetic control continues to be excellent. At this point, he is on a larger dose of insulin, and so is out of his honeymoon period. I encouraged the mother to check blood sugars before lunch and before bedtime occasionally. I plan to see Milt again in three months time in order to follow his course.

Thank you for letting us share in the care of Milt.

Sincerely,




Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Chunbo Pluto, M.D.          RE: Bridget Connolly
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/89

Dear Dr. Pluto:

We had the pleasure of seeing Bridget in the Endocrine Program on 2/14/94 for vitamin d intoxication.

History: Bridget is doing very well.   She is now 4 years and 6 months old.  She drinks only about a half a cup of milk per day in her cereal (2% milk from Garelick Farms).   She eats a lot of cheese, yogurt, and ice cream, and  some fish, poultry and red meat.   She does not eat a lot of vegetables but likes fruit.   She is in preschool and enjoys it.

Current medications: Medications:  None.

Physical exam:  
BP: 90/60               Pulse: 100              Breast: Tanner I        
Pubic hair: Tanner I    
Height 103.3 cm (just at one standard deviation below the mean).  Weight 15.1 (between one standard deviation and the delayed curve).
General:  Well developed, well nourished.  No apparent distress.
Skin:  Normal.   
HEENT:  Normocephalic, atraumatic.   Pupils are equal, round and reactive to light.  Bilateral red reflex.  
Neck:  No masses.   
Chest:  Clear.
Cardiac: Regular rate and rhythm.  
Abdomen:  No masses.  
GU:  Pre-pubertal female.
Extremities:  Normal.
Neurologic:  Deep tendon reflexes are 2+ and equal.

Laboratory studies:  1/6/94:  Calcium 9.7, sodium 140, potassium 4.1, chloride 103, bicarbonate 21, BUN 7, creatinine 0.7, glucose 115, 125 vitamin D 50 pg/mL, 25 vitamin D 38 mg/mL, PTH 13 pg/mL.  Urine calcium 3.2, urine creatinine 30.3, urine calcium to creatinine ratio 0.1, 

Renal ultrasound done.  "Moderate amount of diffuse bilateral nephrocalcinosis.  This may be very slightly less dense when compared to the immediate prior exam.  However, this is not definite.  Both kidneys appear to be growing and the renal cortical mantle appears normal."

Impression: Bridget continues to do very well.  Her vitamin D levels are now completely within the normal range, and urine calcium to creatinine ratio is normal.  There is no need to continue to follow Bridget's vitamin D level since she is not taking excessive vitamin D and her levels are normal.

Disposition: Follow up in the Renal Clinic.
Thank you for letting us share in the care of Bridget.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Chunbo Pluto, M.D.          RE: Bridget Connolly
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/89

Dear Dr. Pluto:

We had the pleasure of seeing Bridget in the Endocrine Program on 2/16/95 for history of vitamin d intoxication.

History: Bridget is now 5 years and 6 months old.   She has been taking milk without any vitamin D, but only takes about one half to one cup per day.  She likes cheese, ice cream and milk, and takes these quite frequently.   She is overall quite healthy and doing well.   She tends to vomit easily but not particularly frequently.   She has no polydipsia or polyuria.

Current medications: None.

Physical exam:  
Height: 110.2 cm        Weight: 16.9 kg         BP: 100/80              
Pulse: 84               Breast: Tanner I        Pubic hair: Tanner I    
General: Well developed, well nourished, no apparent distress.    
Skin: Normal.   
HEENT: Normocephalic, atraumatic, pupils equal, round and reactive to light.   Bilateral red reflexes present.   Teeth appear normal.   
Neck: No thyromegaly.   
Chest: Clear.  
Heart: Regular rate and rhythm without a murmur.   
Abdomen: Soft without masses.  
Genitourinary: Prepubertal female external genitalia.   
Neurological: I was unable to elicit deep tendon reflexes, but neurologically she seems grossly intact.   

Laboratory studies done on 2/6/95, 25 hydroxyvitamin D = 21 ng/mL, 1.25 dihydroxyvitamin D = 50 pg/mL,  lead was less than 5, the ferritin was 22.0, PTH 19, urine calcium 9.6, urine creatinine 22.2, sodium 139, potassium 4.2, chloride 102, bicarb 27, BUN 11, ferritin 65 (normal 50-120), bilirubin 0.2, albumin 4.0, alkaline phosphotase 180, magnesium 2.1, calcium 9.0.   An ultrasound done today showed the nephrocalcinosis has improved over the past two years.

Impression: Bridget continues to do well.   It is encouraging that her nephrocalcinosis has improved somewhat.   Her urine calcium to creatinine ratio is 0.43 but this may be related to her resolving nephrocalcinosis.   Her PTH, vitamin D levels, calcium, phosphorous and alkaline phosphotase were all normal.

Disposition: Will continue to follow yearly.
Thank you for letting us share in the care of Bridget.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Chunbo Pluto, M.D.          RE: Bridget Connolly
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/89

Dear Dr. Pluto:

I saw Bridget in the Endocrine Program on 2/1/96 for vitamin D intoxication.

History: Bridget is now 6 years and 6 months old.  She has been doing quite well.  She is in school, and enjoys it.  She has had no medical problems since she was last seen.  She is growing and developing normally.

Current medications: None.

Physical exam:    Height : 17.1 cm    Weight: 17.7 kg
BP: 100/70              Pulse: 100              
Breast: Tanner I        Pubic hair: Tanner I    
Height  is 1 standard deviation below the mean.  Weight is just below 1 standard deviation below the mean.   
General:  Well-developed, well-nourished in no apparent distress.  Skin:  normal.  HEENT:  normocephalic, atraumatic, pupils equal, round and reactive to light, fundi benign.  Neck:  no thyromegaly.  Lungs:  clear.  Breasts:  Tanner I.  Heart:  regular rate and rhythm without a murmur.  Abdomen:  benign.  GU:  pre-pubertal.  Extremities:  normal.

Laboratory studies:  12/19/95:  albumin = 4.0, alkaline phosphatase = 233, magnesium = 2.2, bicarbonate level = 23, urine calcium = 19.5. urine creatinine = 91.3, ALT = 15, ALT = 30, phosphate = 5, calcium = 8.9, sodium = 137, potassium = 4.0, chloride = 103, creatinine = 0.5, BUN = 15, glucose = 97, platelets = 325K, hematocrit = 38.7, 25-hydroxy vitamin D = 22, 1,25-dihydroxy vitamin D = 44.   

An abdominal ultrasound showed no change in her nephrocalcinosis over the past year.  Kidneys are slightly increased in size from the 1 year ago.  In reviewing the ultrasounds over the past 5 years, there appears to have been a decrease in the amount of nephrocalcinosis from 1993 to 1995.  The nephrocalcinosis appears more prominent in 1993 compared to 1990, but it is difficult to determine if this is real or not, since the technique changed from 1992 to 1993.  The growth in the kidneys does not appear to account for the decrease in the nephrocalcinosis.

Impression: Bridget is doing well.  Her nephrocalcinosis has decreased over the past 3 years, and her kidneys have grown slightly, consistent with Bridget's growth.  Her renal function is normal at this time, and her metabolic bone parameter's are normal.

Disposition: Continue to follow her yearly to monitor her nephrocalcinosis and vitamin D status.



Sincerely,




Penelope Hagen, MD              
Attending in Endocrinology   


cc:  Mr. and Mrs. Connolly  34 Rawson Rd  Brookline , MA  02146

     Kathy Jabbs, MD Nephrology Division Hunnewell 3


CONTENT:
Chunbo Pluto, M.D.          RE: Bridget Connolly
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/89

Dear Dr. Pluto:

We had the pleasure of seeing Bridget in the Endocrine Program on 11/7/91 for evaluation of vitamin d toxicity.

History: As you know, she is a 2 year and 3 month old female with a history of vitamin D intoxication and nephrocalcinosis.  She has been doing quite well, and is currently in preschool.  Her diet is very low in calcium, as she eats very few dairy products.  She drinks quite a bit of fluid during the day, about 20 oz or more, mostly juices.  She is " a normal, finicky 2 year old eater" according to her parents.  Bridget has also had vaginitis since birth and was seen by Dr. Emmans in March of 1991.  She is currently getting A & D ointment applied to her vaginal area, and this seems to have improved her vaginitis.

Physical exam:  
BP: 90/60               Pulse: 66               
She had no thyromegaly, breast development, or axillary hair.  She had a 1/6 systolic murmur. Bridget had a normal prepubertal external genitalia including a normal red and shiny vaginal mucosa, and no vaginal discharge. 

An ultrasound was done today which showed no change in Bridget's' nephrocalcinosis.  In addition, it was noticed that her uterus is 3 cm in length and her ovaries are slightly enlarged.  She had a right ovarian cyst of 7-8 mm.

In summary: Bridget's last vitamin D levels were normal.  In 7/24/91 Bridget had a 25 hydroxy vitamin D level of 76 mg/ml (normal 9-74) and a 1 25-dihydroxy vitamin D level of 59 pg/ml (normal being 15-60).  At that time her PTH was 21 pg/ml (normal being 10-65), and her calcium was 9.3.  She had a urine creatinine of 5.4, urine calcium of 3.3, and thus a urine calcium creatinine ratio of about 0.6.  From a hormonal point of view, Bridget has been doing quite well. We continued to be concerned that her nephrocalcinosis has not improved. We have arranged for Bridget to be seen in Renal Clinic. Today her calcium=10.0 mg/dl, phosphorous=5.5 mg/dl, BUN=11 mg/dl, creatinine=0.4 mg/dl, and alkaline phosphatase=1298 mU/ml, which may be a laboratory error since her last alkaline phosphatase was 127 or a transient idiopathic hyperphosphatasemia.  We would recommend repeating the alkaline phosphatase level.  No urine for calcium and creatinine was received by the lab.  It will be important to monitor these values because of the previously abnormal ratio.  we plan to see Bridget back in our clinic in 6 months.

Disposition: 

Thank you for letting us share in the care of Bridget.

Sincerely,


Penelope Hagen, MD              Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Chunbo Pluto, M.D.          RE: Bridget Connolly
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/89

Dear Dr. Pluto:

We had the pleasure of seeing Bridget in the Endocrine Program on 05/21/92 for follow-up evaluation of vitamin d intoxication.

History: Bridget is now two years and 10 months old.  She has been doing well and has had only a few colds this winter.  She is currently in pre-school.  She is toilet-trained during the day, but wears a diaper at night.  She has no polyuria or polydipsia. She eats well, and drinks about half a cup of 2% milk a day.  The parents buy either Garelick Farms or Hood from milk.  Bridget likes cheeses which she eats almost every day.

Current medications: No over-the-counter vitamins.

Physical exam:  
Height: 90.2 cm         Weight: 11.9 kg         BP: 95/65               
Pulse: 105              Breast: Tanner I        Pubic hair: Tanner I    
Skin: Small 3 mm mole on the back of the forehead that has been noted over the past six months.  
HEENT: Normal. Pupils equal, round and reactive to light.
Neck: No thyromegaly.
Chest: Clear.
Heart: Regular rate and rhythm. II/VI systolic murmur heard best at the left sternal border.
Abdomen: No organomegaly.
Genitourinary:  Pre-pubertal female.
Extremities: Normal.
Neurological: Grossly intact.

Laboratory studies:  Ultrasound done today showed no change in nephrocalcinosis, the uterus was normal, and there were no ovarian cysts.  Labs from 5/7/92 showed PTH 31 pg/mL; calcium 9.5 mg/dL; 125 D 58 pg/dL; urine calcium 3.6; urine creatinine 17.2; urine calcium/creatinine ratio 0.2; urine phosphorus 24.5; albumin 4.2; phosphorus 5.0; alkaline phosphatase 125; hematocrit 36.9; white count 8.8; platelets 336,000; ALT 38, AST 29, LDH 31; cholesterol 159; bicarbonate 26.

Impression: Andrienne is doing quite well.  Her nephrocalcinosis is unchanged, but her calcium/creatinine ratio has been 0.2 or less for over a year.  The vitamin D has only been normal for the last year, and this may account for the fact that her nephrocalcinosis is unchanged.  Bridget has been seen by Dr. Kim in the Renal Service.

Disposition: We would like to see Bridget back in the Endocrinology Clinic in six months.

Laboratory studies pending at this time include: 25-dihydroxy vitamin D.  No other studies ordered.
Thank you for letting us share in the care of Bridget.

Sincerely,


Penelope Hagen, MD              Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Chunbo Pluto, M.D.          RE: Bridget Connolly
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/89

Dear Dr. Pluto:

We had the pleasure of seeing Bridget in the Endocrine Program on 1/25/93 for a history of vitamin d intoxication.

History: Bridget is now 3 and 6/12 years old. She does not have polyuria or polydipsia. She takes between 0 and 1/4 cup of milk a day, but eats about 2 oz. of cheese a day and yogurt. Mom's feels that Bridget looks  pale. Otherwise, Bridget has been healthy. She goes to preschool three days a week.

Current medications: None.

Physical exam:  
Height: 95.6 cm         Weight: 13.3 kg         BP: 110/70              
Pulse: 114              Breast: Tanner I        Pubic hair: Tanner I    
General: She is well developed, well nourished and in no apparent distress. 
Skin: Normal with a slight grayish tint circumorally. HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Oropharynx normal. Neck:  No thyromegaly. Chest: Clear.  Heart: Regular rate and rhythm. 1/6 systolic murmur at the left, lower sternal border radiating to the apex.  Abdomen: Soft without masses.  Genitourinary: Prepubertal female.  Extremities: Normal. Neurological: Grossly intact.

Laboratory studies:  Renal ultrasound showed no change in the nephrocalcinosis, urine calcium 12.5, urine creatinine 43.4, calcium 10.1 mg/dL, creatinine 0.4, BUN 11.

January 28, 1993:  Repeat urine calcium=6.6 mg/dL, urine creatinine=43.4 mg/dL, PTH=20 pg/mL (normal 10-65).  1,25 D=40 pg/mL (normal 15-60), 25 D=40 pg/mL (normal 9-74).

Impression: Bridget is still has nephrocalcinosis.  She has no evidence of continued vitamin D intoxication. Her vitamin D levels have been normal since last summer, and continue to be normal.  Her urine calcium/creatinine ratio is also normal..

Disposition: Return to clinic in one year.
Thank you for letting us share in the care of Bridget.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Khan, M.D.          RE: Joan Seligman
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/86

Dear Dr. Khan:

We had the pleasure of seeing Joan in the Endocrine Program on 12/05/91 for evaluation of follow up of her premature thelarche.

History: Since last seen on 06/24/91 Joan has been well, her parents did not notice any undue growth spurt, acne or vaginal discharge.  She had no intercurrent illness.

Physical exam:  
Height: 117.8 cm        Weight: 27.3 kg         
She was large for age but proportionate.  She had no acne and no hirsutism.  Breasts were 6.0 cm in diameter but consisted more of adipose rather than glandular tissue, the areolae were 2.0 cm each.  The vaginal mucosa was non-estrogenized.  The rest of the examination was normal.

In summary: Joan's linear growth does not seem to be accelerating at present.  We will reassess her in six months and obtain a bone age then.


Thank you for letting us share in the care of Joan.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Khan, M.D.          RE: Joan Seligman
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/86

Dear Dr. Khan:

We had the pleasure of seeing Joan in the Endocrine Program on 06/01/92 for follow-up of premature thelarche.

History: Joan has been well since last seen on 12/05/91.  She has no intercurrent illness.  Her mother complained that Joan has a very good appetite and eats a lot.  She also thinks that she has had some growth of her breasts.

Physical exam:  
Height: 120.5 cm        Weight: 29.9 kg         
BP: 100/64              Pulse: 82               
Joan was tall but proportionate.  Skin:  Dry, particularly overt the wrists  posteriorly.  HEENT:  has two permanent lower incisors, otherwise negative.  Neck:  Thyroid not enlarged.  Chest:  Breasts measure about 8 cm in diameter but consists mostly of adipose subcutaneous tissue rather than glandular tissue.  Areolae each 2.0 cm.  Cor:  Rhythmic and regular.  NOS a I/VI ejection systolic murmur at LSB.  Abdomen:  Soft, no masses, no hepatosplenomegaly.  GU Vaginal mucosa not estrogenized.  Extremities:  Normal.

Impression: Joan is growing at a normal rate and the bone age advanced appropriately  (BA 7 10/12 years, CA 5 11/12 years); both are reassuring that she does not have excess estrogen production.  Joan will return to clinic in six months for re-evaluation.

Thank you for letting us share in the care of Joan.

Sincerely,




Kendell Simpson, MD             
Clinical Director


CONTENT:
Tinisha Khan, M.D.          RE: Zebulon Clark
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/02/85

Dear Dr. Khan:

     We had the pleasure of evaluating Zebulon in the Renal Program on 8/30/95 for hypertension.
     Zebulon is a 10-year old boy with a history of possible hypertension for approximately 5 years.  He has had several blood pressure readings in the ER with systolic measurements of greater than 120.  His routine blood pressures have been in the 100-120/70-80 range.

His current medications include:
     

Past medical history:
     Significant for no history of upper respiratory tract infections, no surgeries, no allergies.

He was hospitalized at the age of 1 for a parasite infection in the Virgin Islands.

Review of systems:
     Unremarkable. 

Family history:
     Significant for his mother who has medullary sponge kidneys with kidney stones.  She requires lithotripsy one to four times per year.  Her last treatment was in August of 1994.  He also has a family history of hypertension on both his maternal and paternal sides.   There is no family history of cardiac disease.  There is no family history of any other diseases.

Zebulon's physical exam was notable for:
     BP /   P 72   R 16   T    HT 147.5cm   WT 49.3kg
     General:  He is an alert and cooperative male.  
     HEENT:  Within normal limits.  
     Neck:  Supple.  
     Lymph Nodes:  No lymphadenopathy.  His chest exam was clear to auscultation.  Cardiac:  Without  murmurs.  
     Abdomen:  Soft, nontender, no hepatosplenomegaly.   
     GU: Revealed Tanner I. 
     Extremities: Without clubbing, cyanosis, or edema.  
     Skin: Intact with no rashes.  
     Neurological:  Grossly intact, reflexes were 2+ with toes downgoing.   
     
     Four extremity blood pressures done here in the Clinic:  Right arm: 120/52, 
     left arm: 121/60,  Right leg: 119/65, left leg: 110/51.
A urinalysis revealed:
     SPEC GR UA  1.025           GLUCOSE UA  N          
     PH UA       N               RBC/HPF     N          
     BLOOD UA    N               WBC/HPF     N     
     PROTEIN UA  N          

Laboratory studies at this time include:


     This is a 10-year old male with a body habitus of approximately a 12-year old whose blood pressures are appropriate for a 12-year old age.  He has no history of any proteinuria or hematuria.   His renal function is normal and he has had a normal renal ultrasound in the past.  At this point, we would not advise further diagnotic or therapeutic intervention.  His blood pressure should be checked routinely as part of his health care maintenance.

     Thank you for the opportunity to participate in Zebulon's care.  We would like to review him in .  In the interim, we would be happy to discuss or review Zebulon should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Instructor in Pediatrics


CONTENT:
Mitsuko DeNiro, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. DeNiro:

We had the pleasure of seeing Remy in the Endocrine Program on 3/28/94 for follow-up of congenital adrenal hyperplasia.

History: Remy is a 10 and 9/12 year old with congenital adrenal hyperplasia.  He complains less of fatigue than previosuly.  He is doing very well in school.  Remy manages to sleep through most nights.  He denies nocturia, or headaches, nor acne or progression of pubic hair.

Current medications: Hydrocortisone 7.5 mg qAM, 2.5 mg in mid-PM< 2.5 mg qHS.  Flutamide 250 mg BID, Florinef 0.05 mg BID.

Physical exam:  
Height: 137.6 cm        Weight: 41.5 kg         Pulse: 98               
R. testis: 2.4 x 1.2 cm L. testis: 2.0 x 1.0 cm Phallus length: 9.0 cm  
Mid-shaft diam.: 2.3 cm 


Laboratory studies:  December 16, 1994:  17-ketosteroids 22.4 mg/IU 145 mg creatinine.  June 14, 1993: Bone age 12 years.

Impression: Remy is no longer showing a drop off in height since lowering his hydrocortisone dose in AM.  There is a slight increase in testicle size but remains largley pre-pubertal.  The current hydrocortisone dosing appears adequate.


Laboratory studies pending at this time include: 17-OH progestereone, 17-OH pregnanelone, PRA.
Disposition: Repeat bone age in three months.  I plan to see Remy again in five months.
Thank you for letting us share in the care of Remy.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Bonaparte, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. Bonaparte:

I saw Remy in the Endocrine Program on 5/20/96 for management of congenital adrenal hyperplasia.

History: Remy is a 12 and 11/12 year old with congenital adrenal  hyperplasia. His interval history is unremarkable.  He has a little bit of fatigue in the afternoon, he sleeps through the night and denies nocturia. He also denies salt craving, constipation and any changes in his vision.

Current medications: Flutamide 250 mg b.i.d., hydrocortisone 7.5 mg q.a.m., 2.5 mg q.p.m., 2.5 mg q.h.s.

Physical exam:
Height: 148.2 cm    Weight: 42.3 kg
BP: 95/60               Pubic hair: Tanner I    R. testis: 3.2 x 1.9 cm 
L. testis: 3.1 x 1.8 cm Mid-shaft diam.: 2.9 cm 
Comfortable male in no apparent distress.  Skin: warm, no hyperpigmentation.  Chest: clear to auscultation.  GU: pubertal genitalia.  Neurological: 2+ deep tendon reflexes bilaterally.

Impression: Remy is doing well and is apparently going through puberty at this time.

Disposition: I have elected to obtain screening tests for which I have sent a lab form for Remy to have filled at HCHP.  In particular, I am interested in his ACTH level to see whether we have adequately suppressed him on this low dose of 12.5 mg per day.



Sincerely,




Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Gleide Bonaparte, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. Bonaparte:

Remy is a 13 and 6/12 year old with congenital adrenal hyperplasia.  He recently was diagnosed with strep throat and has been somewhat fatigued in the last week.  Otherwise, he his history has been unremarkable and he has not been fatigued.

Current medications: Hydrocortisone 7.5 mg q.a.m., 2.5 mg q.p.m., and 2.5 mg q.h.s. Flutamide 250 mg b.i.d., Florinef 0.1 mg q.d.

Physical exam:    HT: 153 cm    WT: 42.9 kg
BP: 108/47              Pulse: 91               Pubic hair: Tanner V    
R. testis: 4.2 x 2.4 cm L. testis: 4.2 x 2.5 cm Mid-shaft diam.: 3 cm   
Comfortable male in no apparent distress, slightly pale.  Skin: warm. Neck: no thyromegaly.  Lungs: clear.

Impression: Remy is growing very well and is clearly going through sexual development of puberty. It is unclear whether he requires any more Flutamide and I will discontinue the Flutamide if his bone age continues to be not significantly advanced beyond the last one.

Disposition: I recommend obtaining a bone age as well as adrenal hormone levels as specified on the laboratory sheet which I gave to Remy and his father.


Sincerely,



Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Agustin Capulet, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. Capulet:

We had the pleasure of seeing Remy in the Endocrine Program on 8/26/91 for evaluation of congenital adrenal hyperplasia.

History: Remy is an 8 2/12 year old male with Congenital Adrenal Hyperplasia who has been treated with Hydrocortisone and  Florinef.  Since his last visit he has unremarkable, enjoyable summer and his mother notes that he has had less emotional lability than in the past.  She also reports no change in hair pattern.  He denies having to use deodorant or having acne.  He has daily bowel movements, denies nocturia and denies headaches.  He eats three meals a day and drinks one glass of milk a day.  He is about to start the third grade.

Current medications: Hydrocortisone 5mg in the morning, 2.5mg at 3:00PM and 2.5mg at 7:00PM and Florinef 0.1mg in the morning and .05mg in the evening.

Physical exam:  
Height: 129.6 cm       Weight: 27.7 kg        BP: 90/72
Pulse: 70              Breast Tanner: 1       Pubic hair Tanner: 1
R. testis: 2.3 x 1.1 cm            L. testis: 2.3 x 1.3 cm 
Penile stretch length: 10.2 cm     Mid-shaft diam.: 2.1 cm 
General: comfortable male with no apparent distress
Skin: no acne or axillary hair 
HEENT: fundi benign
Neck:no thyromegaly 
Chest: clear to auscultation, and no gynocomatia
Heart: regular rate and rhythm
Abdomen: no hepatosplenomegaly
Genitorurinary: few isolated terminal hairs
Extremities: no cyanosis, edema or clubbing noted
Neurological: unremarkable

In summary: Remy is up on the medium curve for height and has no evidence of further virilization on physical exam.  He has a slight increase in a systolic blood pressure compared to prior visits.

Disposition: Given his prior suppression of plasma renin activity on his prior visit as well as his slight increase in ? blood pressure, we feel comfortable  in reducing his Florinef  dose to 0.05 mg. twice a day.  We do not feel that any change in Hydrocortisone dosage is necessary.

Laboratory studies pending at this time include: 17 OH Progesterone and DHEA.  At the time of this visit, bone age was 12.5 years, androstenedione 33ng/dl, 17 OH Pregnenolone was 14ng/dl, and 24-hour urinary 17 ketosteroids were 2.4mg/24.  These preliminary results are consistant with adequate suppression of androgen production.

Thank you for letting us share in the care of Remy.

Sincerely,


Lancelot Blue, MD                   Bernardo Red, MD
Fellow in Endocrinology            Chief, Director of Endocrinology


CONTENT:
Agustin Capulet, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. Capulet:

We had the pleasure of seeing Remy in the Endocrine Program on 2/6/92 for  congenital adrenal hyperplasia.

History: Remy is an 8 and 8/12 year old male with congenital adrenal hyperplasia who is being treated with Hydrocortisone and Florinef.  Since his last visit, he has some occasional episodes of emotionalism.  He denies headaches, enuresis, onset of body odor or use of deodorant.  He has one bowel movement per day and denies heat or cold intolerance.  He drinks a least one glass of milk a day.  He is currently in the third grade and is doing well.

Current medications: Hydrocortisone 5 mg in the morning, 2.5 mg at 3:00PM and 2.5 mg at 7:00PM.  Florinef 0.05 mg at 7:00AM and 0.05 mg at 7:00PM.

Physical exam:  
Height: 131.8 cm        Weight: 29.5 kg         BP: 108/85              
Pulse: 70               Pubic hair Tanner: 1    R. testis: 2.3 x 1.3 cm 
L. testis: 2.5 x 1.3 cm Phallus length: 9.9 cm  Mid-shaft diam.: 2.6 cm 
General: Comfortable appearing male. Skin: No hyperpigmentation.  HEENT: Pupils equal, round and reactive to light, extraocular movements intact.  Neck: No thyromegaly.  Chest: Clear to auscultation.  Heart: Regular rate and rhythm, no murmur.  Abdomen: No hepatosplenomegaly.  Bowel sounds present. Genitourinary: Prepubertal exam.   Neurological: Deep tendon reflexes 2+ in the patella and biceps.

In summary: Impression:  Remy has shown no changes in the size of his genitalia and his height velocity appears to have further decreased and consequently it appears that he is well suppressed on the present dose of Hydrocortisone and Florinef.

Disposition: We obtained urinary 17 ketosteroids, plasma DHEA, androstenedione, plasma renin activity, and 17  hydroxyprogesterone.  We would very much like to see Remy in four months for follow-up.

Thank you for letting us share in the care of Remy.

Sincerely,


Lancelot Blue, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Mitsuko DeNiro, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. DeNiro:

We had the pleasure of seeing Remy in the Endocrine Program on 6/4/92 for congenital adreanl hyperplasia.

History: Remy is a 9 year old with congenital adrenal hyperplasia, treated with hydrocortisone and Florinef.  He has no specific complaints currently and Remy  denies nocturia or insomnia.  He goes  to bed at 9PM.  He is active and does not tire easily.  He has bowel movements once a day.  He denies acne but does note increased body odor over the last few months.

Current medications: Hydrocortisone 5 mg  qam, 2.5 mg at 3:00PM and 2.5 mg at 7PM; Florinef 0.05 mg q 7AM and 0.05 mg q 7PM.

Physical exam:  
Height: 132.9 cm        Weight: 30.4 kg         BP: 96/62               
Pulse: 84               Pubic hair: Tanner I    R. testis: 2.4 x 1.2 cm 
L. testis: 2.6 x 1.11 cmPhallus length: 11 cm   Mid-shaft diam.: 2.7 cm 
General: 
Skin: Warm.
HEENT: PERRL, EOMI. 
Neck: No thyromegaly.
Chest: Clear to auscultation, no gynecomastia.
Heart: Regular rate and rhythm.
Abdomen: No hepatosplenomegaly.
Genitourinary: Prepubertal.
Extremities: No cyanosis, clubbing or edema.
Neurological: Non-focal, deep tendon reflexes 2+.

Laboratory studies:  were notable for an increased DHEA of 74 ng/dL, and increased 17 ketosteroid of 6.8 mg/24 hours.  17 hydroxyprogesterone seemed to be moderately elevated at 564 ng/dL, a bone age that was unchanged, 17 hydroxyprogesterone 1520 ng/dL, DHEA 112 ng/dL, DS 31 mcg/dL,  androstenedione 89 ng/dL and PRA 0.9 ng/L/hr.  We have also asked the parents to obtain an 24 hour urine collection for 17 ketosteroids two months after this visit.

Impression: Remy is doing well clinically.  However, his recent onset of body odor and the rise in his adrenal androgens suggest that he requires increased suppression of his adrenal axis.

Disposition: We have decided to increase Remy' dose of hydrocortisone to a total of 15 mg a day divided 10 mg in the morning, 2.5 mg in the mid-afternoon and 2.5 mg at bedtime.  We have also added a anti-androgen to his therapy, namely Flutamide 500 mg a day given as two capsules of 125 mg each twice a day.  We hope to see Remy in three months.
Thank you for letting us share in the care of Remy.

Sincerely,


Lancelot Blue, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director            


Problem list to date:
21-HYDROXYLASE-DEFICIENCY    Start: 06/22/83  End:          Invalid: 
CONG.-ADRENOCORTICAL-HYPERPLAStart: 02/06/92  End:          Invalid: 
ADRENAL-DISORDERS            Start: 06/04/92  End:          Invalid: 

Transcribed by DeNiro


CONTENT:
Mitsuko DeNiro, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. DeNiro:

We had the pleasure of seeing Remy in the Endocrine Program on 2/1/93 for congenital adrenal hyerpplasia.

History: Remy is a 9 and 8/12 year old male with congenital adrenal hyperplasia who has responded well to treatment with decreased growth velocity and no further progression of bone age.  Laboratory studies on the last visit showed adequate adrenal suppression.  Remy denies body odor, hirsutism, nocturia, constipation.  He requires a new prescription for eye glasses.  He continues to do well in school and his parents have not noted significant behavioral problems.

Current medications: Hydrocortisone 10 mg qAM 12,5 mg in mid-PM, 12.5 mg at 7PM, Flutamide 250 mg bid, Florinef 0.05 mg bid.

Physical exam:  
Height: 133.8 cm        Weight: 35.4 kg         BP: 90/56               
Pulse: 82               R. testis: 2.6 x 1.1 cm L. testis: 2.2 x 1.0 cm 
Phallus length: 10.5 cm Mid-shaft diam.: 2.3 cm 
General: Well developed,well nourished.  Skin: No hyperpigmentation.  HEENT: Mucous membranes moist.  Neck: No thyromegaly.  Chest: Clear to auscultation.  Genitourinary: Prepubertal.  Extremities: No edema.  Neurological: Non-focal.

Laboratory studies:  November 2, 1992:  17OH progesterone <10 ng/dL, DHEAS <1 mcg/dL, androstenedione <10 ng/dL.

Impression: Remy appears to be doing very well.   His growth curve is consistent with adequate control of the CAH and he also has shown a deceleration in his weight gain.  Since he took his medication late today, we will defer blood tests until the next visit.

Disposition: Return to the Endocrine clinic in four months for blood test and bone age.
Thank you for letting us share in the care of Remy.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Mitsuko DeNiro, M.D.          RE: Remy Grotius
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/83

Dear Dr. DeNiro:

We had the pleasure of seeing Remy in the Endocrine Program on 10/4/93 for follow-up of congenital adrenal hyperplasia.

History: Remy is a 10 and 3/12 year old male with congenital adrenal hyperplasia who has shown good suppression of androgen production while on a total of 15 mg/day of hydrocortisone.  However, his appetite has been increasing, as has his weight, as his height velocity has diminished.  He reports increased fatigue and takes naps in the late afternoon and sleeps from 10PM to 3:30AM.  He denies nocturia, frequent headaches, constipation or diarrhea.  He denies acne or progression of pubic hair.

Current medications: Hydrocortisone 10 gm QAM, 12.5 mg in mid-PM, 12.5 mg at 7PM.  Flutamide 250 mg BID, Florinef 0.05 mg BID.

Physical exam:  
Height: 153.4 cm        Weight: 40.1 kg         BP: 110/65              
Pulse: 80               Pubic hair: Tanner I    R. testis: 2.0 x 1.0 cm 
L. testis: 2.1 x 1.1 cm Phallus length: 7.5 cm  Mid-shaft diam.: 2.1 cm 
General: Slightly chubby comfortable male.  Skin: No lesions.  HEENT: PERRL.  Neck: No thyromegaly.  Chest: No gynecomastia.  Heart: Regular rate.  Abdomen: Protuberant,  no hepatomegaly.  Genitourinary: Prepubertal. Extremities: No edema.

Impression: Remy is a 10 and 3/12 year old boy with CAH who has a falling centile in height and increasing weight for height.  This suggests that Remy may be overtreated with glucocorticoids.

Disposition: I have decreased the AM hydrocortisone to 7.5 mg and suggested that Remy decrease his intake of fruit juices.  I plan to see Remy again in six months.

Laboratory studies pending at this time include: DHEA, androstenedione, CBC, ESR.
Thank you for letting us share in the care of Remy.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 3/7/94 for follow up of diabetes mellitus.

History: Ivan is now 7 years and 2 months old.  He has not been sick over the last several months.  He has had no changes in has school, but is undergoing another evaluation.  There is some feeling at the school that he is hyperactive.  Mom is requesting a neurology second opinion for Ivan.  His insulin dose is currently 17 units NPH 4 units Regular Porcine insulin in the morning, which gives him 0.9 units/kg/day.  He receives his insulin at all areas.  Recently his blood sugars have been somewhat high in the AM, and he has had polyuria, nocturia and has had polydipsia in the mornings.  He is a 1500 calorie diet and seems to be doing adequately.

Physical exam:  

General: Well developed, well nourished but not terribly cooperative.
Skin: No atrophy or hypertrophy at the injection sites.
HEENT: PERRL.  
Neck: Thyroid as not palpable.
Chest: Lungs clear.
Heart: 
Abdomen: Benign.

Impression: Ivan's blood sugars have been high in the am.  He may at some point some NPH in the evening prior to dinner.


Laboratory studies pending at this time include: Hemoglobin A1C and random plasma glucose.
Disposition: We will try starting a small amount of NPH (1 unit) in the evening and see if he tolerates that.  If he does, we will continue him on it.  If he does not, we will go back to the previous regimen.
Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology   


Problem list to date:
INSULIN-DEPENDENT-DM                         08/04/93  
Transcribed by Sullivan_ma


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 6/21/94 for diabetes mellitus.

History: Ivan has been doing well.  He started on Ritalin on May 5, 1994, taking 5 mg twice a day,for hyperactivity.  According to the school, Ivan is more focused on Ritalin, but mom does not see much of a difference.   Ivan is currently on 17 units of NPH and 4 units of Regular Porcine insulin in the morning.   He gets his shots between 6-6:30 in the morning.  He occasionally has reactions, usually due to activity or refusing snacks.  He is on a 1,600 calorie diet and this seems to be adequate.  His blood sugars have been running approximately 65 and 200 prior to all meals, and there is a far amount of variability in his blood sugar readings.

Physical exam:  

General: Well developed, well nourished, no apparent distress.   
HEENT: Pupils are equal, round and reactive to light.   
Neck: Thyroid is not palpable.  
Chest: Lungs are clear.  
Heart: Regular rate and rhythm without a murmur.  
Abdomen: Benign.  
Extremities: There is no stiffness in his joints.   There is no atrophy or hypertrophy of his injection sites.

Laboratory studies:  Hemoglobin A1C=9.9%and glucose=102 mg/dL.

Impression: We do not plan to change Ivan's insulin dose at this time, since he is in a reasonably good range although he has quite a variability in his blood sugar readings.

Disposition: Return to clinic in three months.
Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 6/27/95 for diabetes mellitus.

History: Ivan is now 8 years and 6 months old.  He has been healthy, except for a bout with the flu about a month ago, during which time his insulin requirement decreased.  He steals food occasionally, leading to high blood sugars before dinner.  He currently gets 18 units of NPH and 5-6 units of regular insulin (porcine) prior to breakfast, and rarely requires insulin during the day.  However, he tends to have elevated blood sugar readings before bed time.  On the other hand, when mom gives him NPH prior to dinner, he tends to be low in the middle of the night.

Current medications: 18 U NPH porcine insulin and 5-6 U Regular porcine insulin prior to breakfast (23-24 U/day = 1 U/kg/day)

Physical exam:  
Height: 119.7 cm        Weight: 24.5 kg         BP: 110/80              
Pulse: 102              Breast: Tanner I        Pubic hair: Tanner I    
Weight is at the 25%
Height is at the 5%
General:  Well-developed, cooperative, not interactive
HEENT:  Normocephalic, atraumatic.  Unable to visualize fundi.  PERRL
Neck:  Papable thyroid gland, not enlarged
Chest:  Clear
Heart:  No murmur
Abdomen:  Grossly benign
GU:  Prepubertal
Extremities:  No hypertrophy or atrophy
Neuro:  DTR's slightly brisk.  Repeats words said to him, but does not engage in conservation.

Impression: Ivan is running high blood sugars in the morning, and in general is somewhat erratic in his blood sugar readings.  He may be more stable in his blood sugar readings if he was on humulin insulin with twice a day injections.  Ultralente before dinner would be less likely to give him low blood sugars in the middle of the night, and would carry him through breakfast.  When going from porcine to humulin, most people require a 10% increase in dose.  I will be a bit more conservative to  start with, but may need to go up on the total daily dose.  I will be in contact with the family as we start this regimen to fine tune it to Ivan's needs.  Ivan's thyroid gland is palable, and thus I obtained thyroid function tests today.


Laboratory studies pending at this time include: TFTs, HbA1C
Disposition: Start humulin insulin:  15 U NPH and 3 U Regular before breakfast, 5 U Ultralente and 2 U regular before dinner (25 U/day).  Return to clinic in 4 months, at which point Ivan will see the Nutritionist.
Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 2/28/92 for  follow-up evaluation of diabetes mellitus.

History: Ivan has been doing fairly well.  He had bilateral otitis about a month ago,  but otherwise has been healthy.  He has been in a good mood recently, and his blood sugars have been in the 70 to 180 range.  The parents are quite pleased with his blood sugars as they have been lower recently.  He is currently on 15 units of NPH and 2 units of Regular in the morning, giving him 17 units a day (0.76 units/kg/day).

Physical exam:  
Weight: 22.4 kg         
Physical examination was within normal limits.  Height was not measured because Ivan was not cooperative.

Impression: Ivan continued to do quite well.  His blood sugars have been lower recently and he seems to be in a better mood with the lower blood sugars.

Disposition: Return to Clinic in three months.  The plan is to continue with 15 units of NPH and 2 units of Regular in the morning.

Laboratory studies pending at this time include: Blood sugar and hemoglobin A1C.

Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 6/5/92 for follow-up  of  diabetes.

History: Ivan has been doing quite well. He is now 5 years and 5 months old. He had chicken pox in May, but tolerated that quite well. He is currently in school from 9 a.m. to 12:30 and will soon be in school until 3:30 in the afternoon. He is getting 15 units of NPH in the morning and 2 units of regular with no insulin in the evening. He is overall, doing very well.

Physical exam:  
Weight: 21 kg           
General: We were unable to record Ivan's height and blood pressure due to lack of cooperation. In general, he is well developed and well nourished.
Skin: no evidence of hypertrophy or atrophy.
HEENT: pupils equal, round and reactive to light. 
Neck: thyroid not palpable.
Chest: lungs clear.
Heart: no murmur.
Abdomen: benign.

Laboratory studies:  Hemoglobin A1C = 10.3% and glucose level = 118 mg/dL.

Impression: Ivan is doing fairly well with blood sugars in a very good range, between 90-190.

Disposition: Return to diabetes clinic in three months.
Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology   


Problem list to date:
                             

Transcribed by Sullivan


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 9/1/92 for follow-up of diabetes mellitus.

History: Ivan is 5 and 8/12 years old, and has been doing quite well. He has been in a special school all summer as he is a special needs child. He is beginning to toilet train. Ivan is currently on 15 units of NPH and 2 units of regular Porcine insulin in the morning giving him 0.77 units/kg/day. He occasionally has reactions usually after he takes a walk or has excessive activity. His blood sugars have been running in the 75-150 range prior to breakfast, 120-180 prior to lunch and 70-130 prior to dinner.

Physical exam:  
Height: 108.9 cm        Weight: 22.2 kg         

General: Ivan is quite uncooperative with the examination. 
Skin: Normal. 
HEENT: Eyes are equal, round and reactive to light. 
Neck: Thyroid not palpable.  
Chest: Lungs clear. 
Heart: No murmur. 
Abdomen: Soft.  
Neurological: Grossly intact.

Impression: Ivan is doing quite well on the current regimen of insulin. Our plan is to continue his current 15 NPH and 2 regular in the morning.

Disposition: Return to clinic in three months.

Laboratory studies pending at this time include: Glucose, Hemoglobin-A1C,  and a C-Peptide.
Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology   


Problem list to date:
                             

Transcribed by Cassells


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 3/2/93 for follow-up of diabetes mellitus.

History: Ivan continues to do well. He was sick last week, with temperatures up to 104 and ketones in his urine. Mom was in touch with the endocrine fellow on call, and appropriately gave Ivan more insulin as needed. Ivan continues to be in school and seems to like it quite a bit. His speech is improving. He is on 15 units of NPH and 2 units of regular in the morning giving him 17 units a day. This is approximately .8 units/kg/day of porcine insulin. Ivan sometimes has reactions, the major symptom which is crankiness and the reasons are sometimes, but not always, known. His diet is adequate and he is taking in 1500 calories a day. Ivan's blood sugars have been running in the 100-200 range in the morning, 150-250 at lunch, and 100-150 prior to dinner.

Physical exam:  

General: Well developed and well nourished.  Uncooperative with the exam. 
Skin: Injection sites were without atrophy or hypertrophy.  HEENT: Pupils equal, round and reactive to light. Lens clear.   Neck: Thyroid edges palpable.  Chest:  Lungs clear.   Heart:  Normal.  No murmur.  Abdomen:  Normal.

Impression: Ivan's blood sugars are running on the high side prior to lunch, but are otherwise within a reasonable range. Our plan is to increase to 3 units of regular in the morning. I am considering increasing to 16 units NPH if he tolerates the increased amount of regular insulin in the morning.

Disposition: Return to clinic in four months.

Laboratory studies pending at this time include: Hemoglobin-A1C  = 12% and glucose = 338 mg/dL.

Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 7/6/93 for follow-up of diabetes mellitus.

History: Ivan is now 6 6/12 years old.   Mom reports that he sometimes takes foot from other peoples plates at the evening meal, usually when he eats too quickly.   This appears to be a behavior problem, not a lack of adequate caloric intake.  Otherwise, his diet has been appropriate, and he takes in 1,800 calories a day.   He is in school this summer, is talking more, and becoming more social.   Ivan is currently getting 16 units of NPH and 3 units of Regular Porcine insulin in the morning.   His blood sugars have remained in the 70-250 range, though mostly the low 100s.   He has reactions, about twice a week, and mom usually knows why and when they occur.   He is growing well.   He exercises daily and occasionally mom will adjust his food for exercise.   Mom monitors his blood sugars three times a day, and checks his ketones 3-4 times a week.

Physical exam:  
Height: 111.5 cm        Weight: 22.3 kg         
His height is at about the 10th percentile. His weight is just above the 50th percentile. General: Well developed, well nourished and in no apparent distress. HEENT: PERRL. Neck:  Thyroid is not palpable. Chest: Lungs clear.
Heart: No murmur. Abdomen: Normal. Extremities: There is no stiffness, hypertrophy or atrophy on any of his extremities.

Impression: Ivan continues to do well and I will continue his current dosage regimen.

Disposition: Return to clinic in three months.

Laboratory studies pending at this time include: Hemoglobin-A1C and glucose.
Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Ivan Bonnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/86

Dear Dr. Brezny:

We had the pleasure of seeing Ivan in the Endocrine Program on 12/7/93 for follow up of diabetes mellitus.

History: Ivan has been doing well.  He was sick over Thanksgiving weekend with ketones in his urine, vomiting, and decreased eating.  He was managed well at home.  Ivan continues to be in "Kids are People" school.  He appears to be speaking more and paying attention and has had a lot of improvement over the last several years.  Insulin dose currently is 16 units of NPH and 3 units of Regular in the morning, giving him 19 units per day, which is somewhat less than 1 unit/kg/day.  He receives Porcine insulin and gets his injections at 7:00AM.  Mother is the only one at home who is giving him his insulin injections, though his sister is planning to learn.

Physical exam:  
Breast: Tanner I        Pubic hair: Tanner I    
General: Well developed, well nourished HEENT: PERRL, clear lenses. Neck: Thyroid was palpable and smooth.   Chest: Lungs are clear. Heart: Normal.
Abdomen: Normal. Genitourinary:  Extremities: Injections sites have no atrophy or hypertrophy. Neurological: Grossly intact.

Impression: Ivan is doing well. He needs a little bit more Regular insulin in the morning, and we will increase his morning insulin to 4 units a day.

Disposition: His blood glucose was 102, HbA1C was drawn in the wrong tube and therefore not performed.  He is  return to clinic in three months.
Thank you for letting us share in the care of Ivan.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Benji DeNiro, M.D.          RE: Dean Masaryk
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/26/89

Dear Dr. DeNiro:

We had the pleasure of seeing Dean in the Endocrine Program on 11/7/91 for evaluation of crypotorchidism.

History: Dean is a 2 and 2/12 year old black male with undescended tests, born at 42 weeks via cesarean section for failure to progress to an 18 year old G2 P0-1 black female.  He was delivered at the Beth Israel Hospital and did well at birth.  He was home at day of life 6 feeding with Similac with iron.  The first year of life he had 3-4 episodes of otitis media but was otherwise well, and had good growth.  He has had no previous hospitalizations.  Based upon exam by his physician he was referred to the Boston City Hospital for undescened testes at about approximately the age of 1.  Because of no health insurance, he was not operated upon at that time.  He was then referred to Children's Surgical Clinic and was seen there in late October; the Endocrine service was called and it was discovered that he indeed did have cryptorchidism.  A plan for orchidopexy was deferred until after evaluation by Endocrine was completed for possible HCG therapy.

Past medical history:  As above.

Family history:  The mother is 4' 11" 18 years old and has asthma but is otherwise well.  The father is 21 years old, 6' tall, and healthy.

Physical exam:  
Height: 82.7 cm         Weight: 13.2 kg         Pulse: 100              
Arm span: 84            Breast Tanner: 1        Pubic hair Tanner: 1    
Phallus length: 5.8 cm  Mid-shaft diam.: 1.4 cm 
Right testes was palpable slightly below the inguinal ligament but was not measurable based on its location.  It felt normal, prepubertal in size.  Left testes was not felt.  
Alert, vigorous black male no acute distress.  HEENT exam revealed normal cephally, equal, round reactive pupils, and a benign pharynx, with 20 teeth.  Chest was clear.  Abdomen was without hepatosplenomegaly or masses, and the extremities were normal.  Neurological exam was non-focal with bilaterally downgrowing toes.

In summary: Dean is a 2 old black male with a left undescended testicle, and a right testes that which below the inguinal ligament.  We think that it would be worthwhile to try 10 doses of HCG therapy prior to surgery to see if indeed we can achieve testicular descent without surgery.  Secondly,, with HCG stimulation, we will prove by a good testosterone response, that he has normally functioning testicular tissue.  Our plan then is to check a testosterone level today, and to arrange for him to receive HCG injections, twice a week for 5 weeks, and to see him back at that time to draw another testosterone level to see response.  Should the testes both descend into the scrotum prior to the tenth dose, therapy can be discontinued.

Disposition: 

Thank you for letting us share in the care of Dean.

Sincerely,


Antonio Capulet, MD             Etta Kramer, MD           
Fellow in Endocrinology


CONTENT:
Benji DeNiro, M.D.          RE: Dean Masaryk
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/26/89

Dear Dr. DeNiro:

We had the pleasure of seeing Dean in the Endocrine Program on 11/7/91 for evaluation of crypotorchidism.

History: Dean is a 2 and 2/12 year old black male with undescended testes, born at 42 weeks via cesearean section for failure to progress to an 18 year old G2 P0-1 black female.  He was delivered at the Beth Israel Hospital and did well at birth, discharged home at day 6 of life feeding Similac with iron.  The first year of life he had a few episodes of otitis media but was otherwise well, demonstrating good growth, and needing no hospitalizations.  He was referred to the Boston City Hospital for undescended testes at the age of 1; because of no health insurance, surgery was not performed.  He was then referred to the surgical clinic at Children's Hospital and was seen in late October; the Endocrine service was called, and a plan for orchidopexy was deferred until after evaluation by Endocrine (for possible HCG therapy).

Past medical history:  As above.

Family history:  The mother is 4' 11", 18 years old and has asthma but is otherwise well.  The father is 21 years old, 6' tall, and healthy.

Physical exam:  
Height: 82.7 cm  Weight: 13.2 kg  Pulse: 100              
Arm span: 84   Breast: Tanner 1   Pubic hair: Tanner 1    
Phallus length: 5.8 cm  Mid-shaft diameter: 1.4 cm 
Alert, vigorous black male no acute distress.  HEENT exam revealed normocephaly and equal, round, reactive pupils.  The oropharynx was benign, with 20 teeth.  Chest was clear.  Abdomen was without hepatosplenomegaly or masses, and the extremities were normal.  GU exam revealed a testis below the right inguinal ligament (normal prepubertal size),  but no testis palpable on the left.  Neurological exam was non-focal, with normal Babinskis.

In summary: Dean is a 2 old black male with a left undescended testis, and a right testes that which is palpable below the inguinal ligament.  We think that it would be worthwhile to try 10 doses of HCG therapy prior to surgery to see if indeed we can achieve testicular descent without surgery.  Secondly, if with HCG stimulation, we can demonstrate a good testosterone response, he is very likely to have functional Leydig cells in the testes. 
     Our plan today is to check a testosterone level, and to arrange for him to receive HCG injections, 500 units IM twice weekly for 5 weeks. After this therapy is complete, we would like to see him again,  and another testosterone level will be drawn to monitor the response.  Should the testes both descend into the scrotum prior to the tenth dose, therapy can be discontinued.   Should he fail to respond, we will refer him back to the surgical clinic for orchidopexy.
 

Thank you for letting us share in the care of Dean.

Sincerely,


Antonio Capulet, MD             Etta Kramer, MD           
Fellow in Endocrinology      Assistant in Endocrinology


CONTENT:
Brooke Stalin, M.D.          RE: Luther Guizot
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/10/90

Dear Dr. Stalin:

We had the pleasure of seeing Luther in the Endocrine Program on 3/20/92 for  rule out diabetes.

History: Luther is a 22 month old, former 6 lb 10 oz infant born by a spontaneous vaginal delivery at term to a 21 year old primiparous mother.  He was born at the Brigham Hospital due to a concern about a cerebellar cyst seen on a prenatal ultrasound.  He appeared well at birth, and was followed with serial head CTs, and is now discharged from the Neurosurgery Clinic, as they feel his cerebellar cyst is benign.  Luther was bottle fed during the first year and then switched to regular milk; his weight gain was excellent the first 6 months of life but has since fallen off.    His developmental milestones have been normal.  The current concern relates to the fact that Luther drinks large amounts of fluids daily.  His mother brought his cup into the office and it appears to be a 20-24 oz cup.  She claims he drinks 6 of these during the course of the day.  However, he goes to bed at 8:00PM, does not have to waken to drink or urniate, and arises at 8:00AM. The night before his evaluation here he went to bed at 9:00PM and was fasting until his bloods tests were drawn at 10:00AM (13 hours).  At that time the sodium was 139 mEq/L, the rest of the electrolytes, BUN and creatinine were all normal.  Fasting blood sugar was 81; two hours after a large meal, a repeat blood sugar was 113 mg/dl.

Current medications: None.

Past medical history:  Six bouts of otitis media and no other major medical problems.  Right inguinal hernia repair at Falmouth Hospital.

Review of systems:  Remarkable only for occasional mild constipation.

Family history:  Luther is an only child.  His father is 23 years old, 6'3" tall, and healthy.  Two paternal uncles had Attention Deficit Disorder.  Mother is 21 years old, healthy and 5'8 1/2" tall.  A maternal uncle has progressive hearing loss as does the maternal great-uncle.  There is no history of calcium metabolism problems or other fluid abnormalities in the family.   There are a few family members distantly related to the father who have adult onset diabetes.

Physical exam:  
Height: 88.2 cm         Weight: 13.5 kg         Pulse: 88               
Breast Tanner: 1        Pubic hair Tanner: 1    R. testis: 2 x 1 cm     
L. testis: 2 x 1 cm     
General: Alert, pleasant white male in no acute distress.
Skin: Unremarkable.
HEENT: Extraocular movements and pupillary reflexes were normal.  Fundi were not well visualized. Facies were normal.  Oropharynx was benign.
Neck: Supple, with no thyromegaly or adenopathy.
Chest: Clear.
Heart: Regular rate and rhythm with a 1/6 flow murmur.
Abdomen: Soft and nontender.  No hepatosplenomgaly noted.
Genitourinary: Normal prepubertal male.
Extremities: Warm and well-perfused.
Neurological: Nonfocal with normal deep tendon reflexes.

Impression: Luther is a 22 month old boy with polydipsia.  Differential diagnosis would include diabetes insipidus, diabetes mellitus, renal failure, or other renal concentrating defects (to include hypercalcuiria).  Finally, a diagnosis of exclusion at this age would by psychogenic polydipsia.  The fact that his fasting blood sugar and two hour post prandial blood sugar are both normal is reassuring; furthermore, that he sleeps overnight without awakening to drink is also reassuring.  His sodium of 139 mEq/L after a 13 hour fast, and this makes diabetes insipidus extremely unlikely.  Finally, we obtained a calcium, magnesium, and phosphorous which were all normal, essentially ruling out hypercalcemia-induced hypercaluria.  The one study we were unable to get today, which we would recommend, is a fasting morning urine specific gravity, also checking a calcium/creatinine ratio in that urine specimen.  Should this return normal, we are left with a most likely diagnosis of habit polydipsia.  I do not think that any intervention at this time is necessary, but if weight gain is of concern given his lack of appetite with the excessive drinking, a trial of fluid restriction might be indicated.


Thank you for letting us share in the care of Luther.

Sincerely,


Antonio Capulet, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Rui Plato, M.D.          RE: Russel Muybridge
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/18/89

Dear Dr. Plato:

We had the pleasure of seeing Russel in the Endocrine Program on 12/19/94 for a question of early puberty.

History: As you may remember the patient is a 5 and 10/12 year old black male referred to us for questionable early puberty with large phallus noticed by you in October of 1994.   The patient is otherwise healthy with no medical problems.   The father reports denies recnet rapid growth  or weight gain.   The patient has no specific symptoms.  He eats a regular diet.    Mother reports that she had noticed pubic hair growth about 5-6 months ago but really didn't think much of it because everybody on her side of the family had developed pubic hair at a young age.

Social History:  The patient is in kindergarten with "average" performance.

Current medications: None.

Past medical history:  Pregnancy was uncomplicated and delivery was by normal spontaneous vaginal delivery.  Growth and development have been within normal limits.   Nutrition: the patient has a history of lead poisoning at about a year of age treated with oral medication.   Infectious disease: the patient had frequent otitis media in the past.   He had no hospitalizations.   The patient suffered mild head trauma in 1990.

Review of systems:  Completely negative.

Family history:  There is no short stature,  infertility,  cancers.  No diabetes or thyroid problems noted.  Her mom is 38 years old and she had menarche at 10 years of age.   Dad is 40 years of age and he had adrenarche at 15-16 years of age.   The patient has an 8 year old male sibling who mom reports has pubic hair about Tanner II and starting about 6-6.5 years of age.   Mom's height is 5'2".  Father's height is 5'6".  The target height for the patient is 66.5 inches.

Physical exam:  
Height: 120.2 cm        Weight: 23.7 kg         BP: 92/54               
Pulse: 72               U/L ratio:  1.04        Arm span: 126           
Pubic hair: Tanner II   R. testis: 1.5 x 1.0 cm L. testis: 1.6 x 1.0 cm 
Phallus length: 9.5 cm  Mid-shaft diam.: 2.1 cm 
General: Alert, active male in no acute distress.    
Skin: Warm and dry, no rashes or cafe au lait spots.   
HEENT: Normocephalic, atraumatic.  Pupils equal and reactive to light.  Extraocular movements intact.  Fundi sharp.   Oropharynx was clear.  Tympanic membranes were clear.   
Neck: Supple with no thyromegaly.   Lymph nodes had no adenopathy.  
Chest: Clear to auscultation.   
Heart: Regular rate and rhythm.  
Abdomen: Soft.  No hepatosplenomegaly or mass.   
Genitourinary: Pubic hair Tanner II with increased penis size but no testicular enlargement.   
Extremities: Warm and well perfused with no cyanosis, clubbing or edema.   
Neurological: The patient was alert and oriented x3.    The exam was grossly nonfocal.

Laboratory studies:  17OHpregnanelone 66 ng/dL, 17OHprogesterone 15 ng/dL, DS 60 ug/dL,    DHA 80 ng/dL, testosterone <10 ng/dL

Impression: The patient is a 5 and 10/12 year old male with Tanner II pubic hair, increased phallus size but prepubertal testes.   These findings are most consistent with idiopathic premature adrenarche but also non-classical adrenal hyperplasia.

Disposition: The patient is to return to clinic in three months.   We will call the parents with the results of the tests and at the time of the follow up appointment depending on what the studies ordered today show, will consider if it is necessary evaluating the 8 year old sibling.  The tests resuls however, support the diagnosis of idiopathic premature adrenarche.
Thank you for letting us share in the care of Russel.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Addendum: Stefania Natalone, M.D.
Resident in Pedaitrics
Boston City Hospital


CONTENT:
Gleide McPherson, M.D.          RE: Benedict Giddings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/13/90

Dear Dr. McPherson:

We had the pleasure of seeing Benedict in our Endocrine Program on 07/11/91 for evaluation of osteopetrosis.

History: As you know, Benedict is now a 16 month old boy with ectodermal dysplasia, an X-linked immunodeficiency, and probable osteopetrosis, here for follow-up.  Since his last visit, he has been doing quite well, except for recurrent pseudomonas otitis, which has been treated with Tobrex and Decadron drops.  He had a fever yesterday to 101.2, but has subsequently defervesced.  His developmental progression has been considerable, currently being able to roll for the last three to four weeks and saying one word and frequent babbling.  He has had no vomiting, constipation, or diarrhea and has been very alert and active.  Benedict's diet continues to be Prosobee 24 calories per oz for a total of 1000 cc's per day plus a small amount of additional solid po intake.

Current medications: IV gamm 7.5gm every 3 weeks, Valproate 625mg twice a day, Bactrim 5cc daily and vitamins and iron.

Physical exam:  HR: 120, BP: 84/, weight: 12 kg, height: 78.2 cm, right testicle: 1 x 1.5 cm, left testicle: 1 x 1.2 cm
Benedict is very alert and active.  Head circumference was 46cm.  Skin complexion was pale and there was abundant fine hair on the scalp.  HEENT exam was notable for two pointed central incisors, a most orapharynx and intact extra ocular movements.  Chest was clear to ausciltation and there was one out of six ejection systolic murmur.  Abdomen was soft with liver 2cm below the right costal margin.  Extremities were without clubbing, cyanosis, or edema.  Genital exam was Tanner stage 1 with phallus measuring 1.3 by 4.5cm.  Neurologic exam still showed 3+ and equal deep tendon reflexes with normal relaxation time.

Laboratory studies:
VPA 156, Calcium 9.6 ml/dl, Phos 5.3 ml/dl, Creatinine 0.2, AST 47, ALT 19, HCT 37.0, WBC 10.3, PTH: 40pg/ml (nl 10-65), 250HD: 29ng/ml (nl 9-74), Urine calcium <3mg/dl.  Repeat bone films obtained today revealed stable bone changes, namely abnormal tubulation of the long bones, stippled femoral epiphyses, bone-within-bone appearance of the ribs with splaying of the antinin ribs and diminished mineralization.

In summary: Since his last visit, Benedict has shown excellent growth for length and somewhat excessive growth for weight.  He is currently at the 25th percentile for length and up to the 75th for weight.  We would probably recommend decreasing his formula to 20 calories per oz, but leave this at your discretion.

To follow Benedict for any possible evidence of hearing dysfunction through bone impingement on his acoustic nerve brainstem audio evoked potentials, are planned for the near future and we will contact you with these results when they are available.

Laboratory studies pending at this time include: 1,25(OH)2D.

Thank you for letting us share in the care of Benedict.

Sincerely,


Maureen Shields, MD                      Kendell Simpson, MD
Fellow in Endocrinology               Clinical Director

LM/SN/smp


CONTENT:
Gleide Daley, M.D.          RE: Benedict Giddings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/13/90

Dear Dr. Daley:

We had the pleasure of seeing Benedict in the Endocrine Program on 11/18/91 for evaluation of rule out osteopetrosis.

History: When we saw Benedict last he had a 1,25 di-hydroxy level of approximately 220 pg/ml which on repeat evaluation 1 1/2 months ago through your office was down somewhat at 140 pg/ml but still markedly elevated.  According  to his mother, Benedict has been doing quite well with only transient diarrhea associated with switching to Pediasure.  He still had mild diarrhea on return to Prosobee 24 calorie per oz formula, but has had no fever or vomiting.  Benedict's feeds currently consist of 900 cc daily of Prosobee plus a small amount of table food.  Benedict has begun to roll and attempts to crawl and pull to standing.

Current medications: Bactrim 5cc QD, Valproate 5 tablets q AM and Pm, and IV gram 10 gm every 3 weeks.

Physical exam:  
Height: 81.8 cm         Weight: 12.2 kg         BP: 80/                 
Pulse: 120              R. testis: 1.4 x 0.7 cm L. testis: 1.4 x 0.7 cm 
Phallus length: 4.2 cm  Mid-shaft diam.: 1.2 cm 
General: Happy appearing boy
Skin: Pale but had good turgor.  Fine hair on the scalp was unchanged.
HEENT: Pointed incisors and intact extraocular movements and equally responsive pupils.
Chest: Clear to ausculation.
Heart: No cardiac murmurs.
Abdomen: Soft, without hepatosplenomegaly.
Extremities: Hand splints bilaterally. No cyanosis or edema.
Neurological: Mild hypertenicity unchanged from previously and 1+ and equal deep tendon reflexes.

In summary: Since his last visit, Benedict has exhibited a normal pattern of growth.  He has normalized in terms of weight gain velocity and continues to grow along the 25th percentile for length.  Because of his still elevated 1,25 di-hydroxy vitamin D levels, we have repeated them today as well as general assessment of calcium and phosphorus metabolism.  Also we plan on repeating bone films which will be done on mother's return visit to ORL Clinic on December 7th.  We have made no changes in Benedict's regimen currently, and will notify you of the results when they are available.


Thank you for letting us share in the care of Benedict.

Sincerely,


Maureen Shields, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Gleide Daley, M.D.          RE: Benedict Giddings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/13/90

Dear Dr. Daley:

We had the pleasure of seeing Benedict in the Endocrine Program on 4/13/92 for evaluation of  amino deficiency, possible osteopetrosis.

History: We had the pleasure of seeing Benedict in the Endocrine Program on April 13, 1992 and follow-up of abnormal bone films and elevated 125 dihydroxy Vitamin D levels. As you know Benedict is now a 25 month old with x-linked amino deficiency, ectodermal dysplasia and markedly abnormal bones. Benedict was recently hospitalized for three weeks centering a gastrointestinal work of four bloody stools. His evaluation included a  CT Scan of the abdomen showing fatting infiltration of the liver and proof culture positive for mycobacterium avium intracellulare. He has been made NPO and now is maintained on total ? nutrition a total volume of 1300 ccs/day with approximately 20% glucose by report from the mother. Since being made NPO Benedict has had continued mucousy and watery stools. His platelet count has improved since his initiation of therapy for MAI as well as caminterferon injections. He has intermittent fevers as well. His last laboratory evaluation in December 1991 included a 25 hydroxy Vitamin D of 38 ng/ml, 125 dihydroxy Vitamin D 123 pg/ml decreased from its previous value of 218 pg/ml in July. PTH 62 pg/ml and calcium 9g/dl.

Current medications: Rifamton 150 mg QD, Phenabarbitol 30 mg BID, Clorithamycene 125 mg BID, Ethanbutol 1 1/2 QD, INH 2 tabs QD, Amikacin 130 mg QD, Bachtlin 5cc QD.

Physical exam:  
Height: 85 cm           Weight: 12.43 kg        BP: 100/                
Pulse: 100              Pubic hair Tanner: 1    R. testis: 1.2 x 0.5 cm 
L. testis: 1.2 x 0.5 cm Phallus length: 4.8 cm  Mid-shaft diam.: 1.0 cm 
Benedict was a somewhat irritable boy. Skin turgor was good, texture was normal. Alopecia remained unchanged. HEENT revealed pointed inscissors with no additional erupted teeth, or moisture of the pharnax , intact extraocular movements.???? The neck was without a palpable thyroid, the chest was cleared up. Cardiac exam revealed regular, rate and rhythm, 106, murmur, lower edge was palpable 3cm below the right coastal margin with no additional masses or tenderness in the abdomen. Neurologic exam revealed 3+ deep tendon reflexes, spontaneous clonos of the right leg and unchanged hyperkinicity.

Impression: Our impression is that since his last visit Benedict has been diagnosed with MAI secondary to his amino deficiency. Though no discrete granuloma were observed on bone marrow biopsy or his additional GI work-up, it is conceivable that his elevated 125 levels may in part be due to subclinical granuloma or activated macrophages. These 125 levels prove a useful marker to follow his body burden of MAI but may be complicated by his gamma interferon  therapy which may further elevate levels. Also, we wish to continue to monitor Benedict closely for development of possible hypercalcimia, both with his entral replacement and possibly continued elevation in 125 levels. We will review Benedict's films from his hospitalization to determine if any significant change in bone appearance has occurred but by report they are similar in nature to his previous studies. We instructed the mother to obtain for us repeat Vitamin D metabolites, parathyroid hormone and urine, calcium phosphorous and creatinine at the time of Benedict's PN profile and appreciate your help in obtaining these. Please let us know if we can be of any further assistance in Benedict's care. We hope to see him again in four months time or when hospitalized next time, should that be more convenient.

Thank you for letting us share in the care of Benedict.

Sincerely,


Maureen Shields, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus              


Problem list to date:
                             

Transcribed by Cassells


CONTENT:
Gleide Daley, M.D.          RE: Benedict Giddings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/13/90

Dear Dr. Daley:

We had the pleasure of seeing Benedict in the Endocrine Program on 4/13/92 for evaluation of  immuno deficiency and possible osteopetrosis.

History: We had the pleasure of seeing Benedict in the Endocrine Program on April 13, 1992 in follow-up of abnormal bone films and elevated 1,25 d-hydroxy vitamin D levels. As you know Benedict is now a 25 month old with an X-linked immuno deficiency, ectodermal dysplasia and markedly abnormal bones. Benedict was recently hospitalized for three weeks centering on a gastrointestinal work of bloody stools. His evaluation included a  CT Scan of the abdomen showing fatting infiltration of the liver and proof culture positive for mycobacterium avium intracellular. He has been made NPO and now is maintained on total parenteral nutrition, a total volume of 1300 ccs/day with approximately 20% glucose by report from the mother. Since being made NPO Benedict has had continued mucousy and watery stools. His platelet count has improved since his initiation of therapy for MAI as well as alpha interferon injections.  His last laboratory evaluation in December 1991 included a 25 hydroxy Vitamin D of 38 ng/ml, 1,25 dihydroxy vitamin D 123 pg/ml, decreased from its previous value of 218 pg/ml in July, PTH 62 pg/ml and calcium 9 mg/dl.

Current medications: Rifampin 150 mg qd, Phenobarbitol 30 mg bid, Clorithamycene 125 mg bid, Ethambutol 1 1/2 qd, INH 2 tabs qd, Amikacin 130 mg qd, Bactrim 5 cc qd.

Physical exam:  
Height: 85 cm           Weight: 12.43 kg        BP: 100/                
Pulse: 100              Pubic hair: Tanner I    R. testis: 1.2 x 0.5 cm 
L. testis: 1.2 x 0.5 cm Phallus length: 4.8 cm  Mid-shaft diam.: 1.0 cm 
Benedict was a somewhat irritable boy.  Skin:  Turgor was good, texture was normal. Alopecia remained unchanged. HEENT:  Pointed incisors with no additional erupted teeth, a moist oropharynx , intact extraocular movements and responsive pupils. Neck:  Without a palpable thyroid.  Chest: Clear to auscultation. Cardiac: Regular rate and rhythm, I/VI ejection murmur.  Abdomen:  Liver edge was palpable 3 cm. below the right coastal margin with no additional masses or tenderness in the abdomen. Neurologic: 3+ deep tendon reflexes, spontaneous clonus of the right leg and unchanged hyperkinicity.

Impression: Our impression is that since his last visit, Benedict has been diagnosed with MAI secondary to his immuno deficiency. Though no discrete granulomata were observed on bone marrow biopsy or his additional GI work-up, it is conceivable that his elevated 1,25 levels may in part be due to subclinical granuloma or activated macrophages. These 1,25 levels may prove a useful marker to follow his body burden of MAI, but may be complicated by his gamma interferon therapy which may further elevate levels. Also, we wish to continue to monitor Benedict closely for development of possible hypercalcemia, since he is at increased risk secondary to both parenteral calcium replacement and possibly continued elevation in 1,25 levels. We will review Benedict's films from his hospitalization to determine if any significant change in bone appearance has occurred but by report they are similar in nature to his previous studies. We instructed the mother to obtain for us repeat vitamin D metabolites, parathyroid hormone and urine calcium, phosphorous, and creatinine at the time of Benedict's PN profile and appreciate your help in obtaining these. Please let us know if we can be of any further assistance in Benedict's care. We hope to see him again in four months time or when hospitalized next time, should that be more convenient.

Thank you for letting us share in the care of Benedict.

Sincerely,


Maureen Shields, MD             Mitsuko Simpson, MD             
Attending in Endocrinology   Chief, Emeritus


CONTENT:
Gleide McPherson, M.D.          RE: Benedict Giddings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/13/90

Dear Dr. McPherson:

We had the pleasure of seeing Benedict in the Endocrine Program on 11/19/92 for follow-up of osteopetrosis.

History: We have followed Benedict because of increased bone density on previous films and elevated 125-dihydroxy vitamin-D levels. As you know, Benedict is a now 2 and 8/12 years old with an x-linked immunodeficiency and MAI infection.  His feeds currently are Prosobee 20 cals,  150 ccs q three hours around the clock. He has been vomiting relatively frequently through the day though has had no diarrhea or fevers. He has had no weight change over the past several months according to his mother. His mother reports that he has been quite alert with increased vocalization and has begun rolling and using his left hand more than previously.

Current medications: Biaxin, Cipro, Rifampin, Barbitol, Bactrim, Zantac, Nystatin and Beta-interferon 3 x weekly.

Physical exam:  
Height: 90 cm           Weight: 13.35 kg        BP: 104/                
Pulse: 108              Pubic hair: Tanner I    R. testis: 1.2 x 0.6 cm 
L. testis: 1.2 x 0.6 cm Phallus length: 5 cm    Mid-shaft diam.: 1 cm   
Skin: Pale coloration though turgor was good. There were no cutaneous lesions.  HEENT: Intact extraocular movements, equally responsive pupils, and flat optic discs. Neck: Without thyromegaly.  Chest: Clear to auscultation.  Heart: Regular rate and rhythm.  Abdomen: Soft, with a clean g-tube site.  Neurological: Normal for diffuse hypertonia.

Laboratory studies:  10/19 elevated alkaline phosphatase at 476, 9/92 25-hydroxy vitamin-d level 15.

Impression: Benedict has had marked difficulty over the prior several months with MAI infections. His current status overall though appears relatively stable. Of note is an elevated alkaline phosphatase while he was hospitalized approximately one month ago. Associated with this are slowly declining 25-hydroxy vitamin d levels. This may represent early vitamin-d deficiency which can be managed with enteral supplementation. In order to assess this more accurately, we are requesting   vitamin-d metabolites today as well as alkphos, calcium, phosphate, PTH at the time of Benedict's next blood draw at your office. Should his vitamin d level prove markedly low, we would consider starting him approximately 1000 units of vitamin d enterally daily.

Thank you for letting us share in the care of Benedict.

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Brezny, M.D.          RE: Edgar Harris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/80

Dear Dr. Brezny:

We had the pleasure of seeing Edgar in the Endocrine Program on 4/1/92 for .

History: This letter will serve to summarize Edgar' visit with me on April 1st, 1992 in Endocrinology at the Children's Hospital Specialty Care Center in Lexington.  You Harris want to pass a copy of this letter along to Edgar' pediatrician.  As you know, Edgar was brought to see me because of concerns about short stature and poor growth velocity.  His past medical history has been unremarkable.

Physical exam:  

On exam, Edgar had a weight of 40.3 kg and a height of 144.4 cm.  Blood pressure was 110/70.  His thyroid gland was slightly enlarged.  He was showing evidence of just beginning puberty.  The remainder of his exam was unremarkable.

Laboratory studies:  Laboratory studies revealed a state of hypothyroidism (underactive thyroid), with hormonal measurements showing a T4 of 2.6 mcg/dl, TBGI 0.88, TT3 94. ng/dl, and TSH 310 mcU/ml.  Microsomal and thyroglobulin antibodies were both positive, consistent with a diagnosis of chronic thyroiditis, also known as Hashimoto thyroiditis, which is an indolent auto-immune thyroid disease which is fairly common in the adult population.   Other evaluation showed a bone age of approximately 11 1/2 years, which give Edgar a predicted adult height of approximately 68-70".  For treatment, Edgar will be started on Synthroid, receiving 75 mcg every other day for two weeks, then becoming 75 mcg each day.  I would like to see Edgar in June to repeat his thyroid functions, and reassess his growth.  

Please feel free to call if you have any questions.


Thank you for letting us share in the care of Edgar.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology   


Problem list to date:
ACQUIRED-HYPOTHYROIDISM      Start: 04/22/92  End:          Invalid: 
HASHIMOTO'S-THYROIDITIS      Start: 04/22/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Sabie Shields, M.D.          RE: Edgar Harris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/80

Dear Dr. Shields:

We had the pleasure of seeing Edgar in the Endocrine Program on 6/10/92 for follow-up of acquired hypothyroidism.

History: As you know, he is a nearly 12 year old boy whom  I am following for acquired hypothyroidism. He is currently maintained on Synthroid, receiving 75 mcg/day. Since his Synthroid has started, he has noticed that he is sleeping less, but that his activity pattern and appetite are unchanged. His intercurrent history and review of systems are otherwise unremarkable.

Physical exam:  
Height: 146.2 cm        Weight: 40 kg           BP: 110/65              
Pulse: 75               

The thyroid was barely palpable, being smooth and symmetric. Deep tendon reflexes were +2 throughout. The remainder of the exam was unremarkable.

Laboratory studies:  T4 9.2 mcg/dL, TBG Index 1.04, Total 168 ng/dL, and a slightly high TSH of 10.6 mcu/mL.

Impression: On clinical assessment, Edgar is euthyroid. In light of the slight elevation in TSH, I have increased his dose, so that he will receive 75 mcg alternating on a daily basis with 100 mcg. Since his last visit, Edgar's growth velocity has increased somewhat, and he has grown 1.8 cm since the beginning of April.

Disposition: I plan to see Edgar again in four months time in order to follow his course.
Thank you for letting us share in the care of Edgar.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology   


Problem list to date:
ACQUIRED-HYPOTHYROIDISM      Start: 04/22/92  End:          Invalid: 
HASHIMOTO'S-THYROIDITIS      Start: 04/22/92  End:          Invalid: 

Transcribed by Cassells


CONTENT:
Sabie Shields, M.D.          RE: Edgar Harris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/80

Dear Dr. Shields:

We had the pleasure of seeing Edgar in the Endocrine Program on 6/10/92 for follow-up of acquired hypothyroidism.

History: I most recently saw Edgar in Endocrinology on June 10, 1992.  As you know, he is a nearly 12 year old boy whom  I am following for acquired hypothyroidism. He is currently maintained on Synthroid, receiving 75 mcg/day. Since his Synthroid was started, he has noticed that he is sleeping less, but that his activity pattern and appetite are unchanged. His intercurrent history and review of systems are otherwise unremarkable.

Physical exam:  
Height: 146.2 cm        Weight: 40 kg           BP: 110/65              
Pulse: 75               

The thyroid was barely palpable, being smooth and symmetric. Deep tendon reflexes were +2 throughout. The remainder of the exam was unremarkable.

Laboratory studies:  T4 9.2 mcg/dL, TBG Index 1.04, Total 168 ng/dL, and a slightly high TSH of 10.6 mcu/mL.

Impression: On clinical assessment, Edgar is euthyroid. In light of the slight elevation in TSH, I have increased his dose, so that he will receive 75 mcg alternating on a daily basis with 100 mcg. Since his last visit, Edgar's growth velocity has increased, and he has grown 1.8 cm since the beginning of April.

Disposition: I plan to see Edgar again in four months time in order to follow his course.

Thank you for allowing me to participate in Edgar' care.  Please don't hesitate to call if you have any specific questions.
Thank you for letting us share in the care of Edgar.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology   


Problem list to date:
ACQUIRED-HYPOTHYROIDISM      Start: 04/22/92  End:          Invalid: 
HASHIMOTO'S-THYROIDITIS      Start: 04/22/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Sabie Shields, M.D.          RE: Edgar Harris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/80

Dear Dr. Shields:

We had the pleasure of seeing Edgar in the Endocrine Program on 12/1/92 for .

History: I most recently saw Edgar in Endocrinology on December 1, 1992.  As you know, he is a 12 1/2 year old boy whom I am following for Hashimoto's thyroiditis.  He is currently maintained on Synthroid, receiving 100 mcg/day.  Since his last visit, he has no signs or symptoms suggestive of hyper- or hypothyroidism.

Physical exam:  
Height: 148.2 cm        Weight: 42.2 kg         BP: 115/58              
Pulse: 72               
Examination of the neck revealed a fairly palpable thyroid, which was smooth, symmetric, and nontender.  He had Tanner II pubic hair and genitalia.  Deep tendon reflexes were 2+ throughout.  The remainder of the exam was unremarkable.

Laboratory studies:  Thyroid functions revealed a T4 of 9.1 mcg/dL, TBGI 1.04, TT3 138 ng/dL, and TSH 12.2 mcU/mL.

Impression: Edgar is clinically euthyroid, and although his T4 and T3 are normal, his TSH is slightly elevated.  Accordingly, I will increase his Synthroid dose, to a schedule of 100 mcg alternating on a daily basis with 112 mcg.  I plan to see Edgar again in four months time in order to follow his course.

Thank you for allowing me to participate in Edgar' care.  Please don't hesitate to call if you have any specific questions.

Thank you for letting us share in the care of Edgar.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Sabie Shields, M.D.          RE: Edgar Harris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/80

Dear Dr. Shields:

We had the pleasure of seeing Edgar in the Endocrine Program on 3/9/93 for follow-up  of  hashimoto's thyroiditis.

History: I most recently  saw Edgar in the Endocrine Program on March 9, 1993.

As you know, he is a 12 8/12 year old boy whom I am following for Hashimoto's Thyroiditis. Since his last visit, his intercurrent history and review of systems are unremarkable. There are no signs or symptoms suggestive of hyper- or hypothyroidism. He is currently maintained on Synthroid, receiving 100 mcg alternating on a daily basis with 112 mcg.

Physical exam:  
Height: 148.9 cm        Weight: 42.8 kg         BP: 110/65              
Pulse: 66               
Examination of the neck revealed a thyroid which was barely palpable, being smooth and symmetric. He had Tanner II pubic hair and genitalia. The remainder of the exam was unremarkable.

Laboratory studies:  T4 8.0 mcg/dL, TBG index 1.02, total T3 125 ng/d, TSH 8.4 mcu/mL. Thyroid microsomal and thyroglobulin antibodies were both positive.

Impression: By both clinical and laboratory assessment, Edgar is euthyroid on his current Synthroid dose. However, given the slight elevation in his TSH, I will increase his Synthroid to 112 mcg each day. I plan to see Edgar again in four months time in order to follow his course.

Thank you for letting us share in the care of Edgar.

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Norma Walpole
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/77

Dear Dr. Meisner:

We had the pleasure of seeing Norma in the Endocrine Program on 5/22/95 for follow-up of graves disease.

History: Norma is an 18 year old with Graves disease, last seen on 10/93.  She has been off of PTU for at least 2 months. She has daily bowel movements.  She reports headaches "when she does not eat".  Mother thinks she has been more irritable recently.

She recently saw an ophthalmologist and reportedly was given a clear bill of health.

Current medications: none.

Physical exam:  
Height: 157.3 cm        Weight: 62.1 kg         Pulse: 78               
Skin: warm.
HEENT:  no lid lag; mucous membranes moist.
Neck:  1x2 cm. on right, 1x1.5 cm on the left.
Neurological:  no resting tremor.

Laboratory studies:  TSI 84%, TBGI 0.98, T4 9.4 ug/dL, TT3 130 ng/dL, TSH 0.40   uU/mL

Impression: Norma appears to be doing well off of PTU but her weight loss is of some concern.

Disposition: Return to clinic in six months.
Thank you for letting us share in the care of Norma.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Norma Walpole
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/77

Dear Dr. Meisner:

I saw Norma in the Endocrine Program on 12/4/95 for Graves' disease.

History: Norma is an 18 and 7/12 year old with a history of Graves' disease.  She is currently doing well off of thyroid medication.  She denies headaches, reports daily bowel movements and reports a "good" energy level.  She also denies heat or cold intolerance.  She does, however, report that she has nocturia once or twice a night.  She is currently working in a deli and reports that she eats all the time.

Current medications: Oral contraceptive pill once a day.

Physical exam:
HT: 156.5 cm    WT: 70.8 kg      BP: 90/60       Pulse: 84               
On physical examination, she is a slightly chubby female in no apparent distress.    Skin: warm.  HEENT:  no lid lag, PERRL.  Neck:  a 2 x 1 cm lobe on the right and a barely palpable lobe on the left.  Extremities:  2+ patellar reflexes bilaterally and no clubbing, cyanosis or edema.

Laboratory studies:  T4 11.6 ug/dL, TSH 1.50 uU/mL, TBGI 0.77,glycosylated hemoglobin 5.4%

Impression: Norma appears to be doing well although she has put on an impressive amount of weight in the last 7 months.  She is aware of this and is now attempting to institute a diet. Also, there is some concern in the asymmetry of her goiter, and if this persists, I will consider obtaining a repeat thyroid scan.

Disposition: No thyroid medications are indicated at this time, and I obtained a repeat set of thyroid function tests, and a glycosolated hemoglobin.



Sincerely,




Lancelot Blue, MD             
Attending in Endocrinology   


cc: Mr. & Mrs. Joseph Walpole  258 Arlington Street  West Medford , MA  02155


CONTENT:
Valdeci Meisner, M.D.          RE: Norma Walpole
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/77

Dear Dr. Meisner:

I saw Norma in the Endocrine Program on 6/17/96 for Grave's disease.

History: Norma is a 19 and 1/12 year old with a history of Grave's disease.  She is currently on no medication for her Grave's disease and has not noted any changes in her neck size in the past six months.  She continues to have daily bowel movements and denies fatigue or hyperactivity.  She does note that she has gained weight significantly in the past year.  She eats 2-3 meals per day and has three snacks.  She has regular menses while on oral contraceptives.  She denies headaches, night thirst or nocturia.

Current medications: She takes Ovicon 1 tablet per day.

Physical exam:
HT: 166.6 cm    WT: 75.5 kg       BP: 109/55       Pulse: 79               
Cheerful female in no apparent distress.  Skin: warm.  Neck: enlarged thyroid bilaterally, smooth.  No bruit, no thrill.  Lymph nodes: no lymphadenopathy noted.  Extremities: 2+ deep tendon reflexes on patellae and ankle bilaterally.

Laboratory studies:  T4 11.6 ug/dL, TSH  0.90 uU/mL, TPO AB <0.3 U/mL, TBGI 0.70, TG AB 1.2 U/mL

Impression: Norma appears to be in full remission from her Grave's and off of medication.  Her weight gain is nonetheless impressive although it does not appear to be related to a thyroid disorder.

Disposition: I have counseled Norma to go see a nutritionist to help her control her intake of calories.  I have also recommended that she obtain a thyroid function tests to make sure that she is indeed euthyroid now that she has been off of medication for a substantial period.



Sincerely,




Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Norma Walpole
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/77

Dear Dr. Meisner:

We had the pleasure of seeing Norma in the Endocrine Program on 7/20/92 for evaluation of thyromegaly.

History: Norma is a 15 year old white female referred for the evaluation of an enlarged thyroid discovered by her primary care pediatrician on routine examination in May of 1992. Notably her most recent exam prior to this in June of 1990 revealed no thyromegaly. She has not noticed any neck mass or goiter herself. She denies dysphasia or dizziness even with position changes. Her weight has increased 8 lbs. in the past two months which she attributes to increased oral intake after school was dismissed. Her overall weight has increased 20 lbs. in the past two years. Her appetite is good. She denies changes in her skin or hair, daytime sleepiness, palpitations, excessive sweating, heat or cold intolerance, tremor,  anxiety, or change in her usual bowel habits (1 bowel movement/day). She denies significant headaches, change in her visual field, or nocturia, or previous radiation therapy to her neck. Her last menstrual period began on July 12, 1992. Menses have been regular every 28 days lasting one week, associated with cramps and heavy bleeding during the first two days. Her menarche was at age 12. She grew up in Medford, MA.

Current medications: None.

Past medical history:  During pregnancy Norma's  mother was diagnosed with Grave's disease and treated with radioactive iodine treatment  at two years following Norma's birth. Delivery was two weeks premature. Norma weighed 6 lbs 4 oz at delivery. Growth and development normal, except for significant breast asymmetry. 1990 left breast was noted to be Tanner V and the right breast was Tanner I. Despite growth of both breasts asymmetry remains. Nutrition: Norma snacks on high fat and high calorie foods. Hospitalizations or surgeries: none.

Review of systems:  Negative except for occasional achy pains in knees at night, not associated with activity.

Family history:  Negative for diabetes, adrenal disease, vitiligo. Mother has hypertension. Father has degenerative arthritis of hips and back as well as reflex esophagitis. A paternal uncle had leukemia. A paternal grandmother died of breast carcinoma at age 65. Paternal grandfather died of cirrhosis secondary to alcohol abuse. Mother's height was 5'2.5", father's height 5'4".

Physical exam:  
Height: 156.9 cm        Weight: 69 kg           BP: 110/60              
Pulse: 78               Pubic hair Tanner: 5    

General: Healthy appearing female in no acute distress. 
Skin: Normal.  
HEENT: Abscence of lid lag or exopthalamus. No stare. Tonsils mildly enlarged bilaterally. 
Neck: Diffusly enlarged thyroid with a soft and fleshy texture. No nodules, no bruit. The gland was non tender. 
Chest: Tanner breast stage on the right was IV and on the left V. Breast tissue palpable on the left with a diameter of 17 cm and on the right 7 cm. This compares with previous exam in 11/90 measuring 16 cm on the left and 7 cm on the right. No mass or nipple discharge. Axillary hair was present.
Heart: Lungs clear. 
Abdomen: No hepatomegaly  or mass palpable. 
Extremities: Normal.
Neurological: Reflexes were +2 without delay and there was no tremor.

Laboratory studies:  6/90 normal thyroid hormones and negative antithyroid and antimicrosomal antibodies. 
5/92 Antithyroid and antimicrosomal antibodies negative, T4 8.4, T3 27.4, TSH 0.8 (all normal).

Impression: Norma is a 15 year old female who is clinically and biochemically euthyroid who has asymptomatic diffuse thyromegaly on exam. Her family history is notable for Grave's disease in her mother. Diagnostic concerns include Hashimoto's thyroiditis, early Grave's disease, colloid goiter, iodine deficiency, and dishormonogenesis. Hashimoto's disease is somewhat less likely due to the absence of antithyroid and antimicrosomal antibodies on two occasions but would be a common cause of goiter in the teenage woman. Early Grave's disease is a possibility as well particularly given her family history and fleshy texture of her goiter. A colloid goiter due to the presence of thyroid growth stimulating immunoglobulins is also a concern and would be a relatively common cause of goiter. Iodide deficiency is unlikely as she has grown up in MA. Finally, dishormonogenesis is a possibility. In order to clarify the cause of her thyromegaly we will order thyroid growth stimulating immunoglobulin, thyroid binding inhibitory immunoglobulin and repeat her thyroid function tests. These studies will be reviewed.

Disposition: Return to clinic in one year for reevaluation. If she develops any symptoms she should return to clinic sooner.
Thank you for letting us share in the care of Norma.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Addendum: Mary Elizabeth Patti, MD
Fellow in Endocrinology
Beth Israel Hospital

The immunoglobulin studies results include TBSI 72% (0-129), TSI 124%, TBII 11.7%.  Also, T4 10.7 mcg/dL, TT3 122 ng/dL, TSH 0.6 mcU/mL.  It therefore appears that Norma might have early, asymptomatic Graves disease, although the immunoglobulin levels are barely above normal.  At this point she bears close monitoring with TFTs every six months and both she and her parents should be asked to watch for symptoms of thyrotoxicosis.


CONTENT:
Valdeci Meisner, M.D.          RE: Norma Walpole
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/77

Dear Dr. Meisner:

We had the pleasure of seeing Norma in the Endocrine Program on 3/1/93 for graves disease.

History: Norma is a 15 and 9/12 year old female with thyromegaly, absence of clinical thyrotoxicosis and with normal thyroid function tests but rheumatological evidence of autoimmune thyroid disease.  Since her last visit, Norma continues to have regular menses.  She denies headaches, nocturia, palpitations.  Her mother notes that she is much less cold intolerant than her colleagues.  She has not changed her diet (3 meals per day and multiple snacks).

Current medications: None.

Physical exam:  
Height: 156.9 cm        Weight: 65 kg           BP: 98/65               
Pulse: 88               Breast: Tanner V        
General: Well developed, well nourished.  Skin: No lesions, no striae.  Neck: 2x3 cm on the left and 3x4 cm. lobe on the right.  Heart: Asymmetrical breasts.

Laboratory studies:  T4 11.3 and TSH 0.3 mcU/mL.

Impression: Norma has lost 4 kg. since her last visit, and has both a larger thyroid and and a higher resting heat ate.  It may be then that Norma is now entering clinical thyrotoxicosis.

Disposition: We will consider therapy for Graves disease once we obtain the thyroid function tests.  Norma is to return to the Endocrine program in three months.

Laboratory studies pending at this time include: T3, TBGI.
Thank you for letting us share in the care of Norma.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Addendum: The T4 is just outside the normal range.  It would be advisable to start therapy in the coming month given the clinical correlates of hyperthyroidism she manifests (weight loss, larger thyroid and higher resting heat ratio).


CONTENT:
Valdeci Meisner, M.D.          RE: Norma Walpole
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/77

Dear Dr. Meisner:

We had the pleasure of seeing Norma in the Endocrine Program on 6/14/93 for follow-up of graves disease.

History: Norma is a 16 and 1/12 year old with Graves disease who has not required medication thus far.  Since her last visit, Norma has lost another 1.1 kg. (added to the 7 kg. by weight loss of the last visit).  Her menses continue to be regular and only had headaches during menses.  Norma complains of heat more than her friends.  She denies nocturia, constipation or diarrhea.  She continues to have a "hearty appetite" which appears to be increasing.

Current medications: None.

Physical exam:  
Height: 157.0 cm        Weight: 63.9 kg         BP: 108/78              
Pulse: 90               
General: Well developed, and well nourished. Skin: Warm. HEENT: No lid lag or exophthalmus. Neck: 2x3 cm. lobe on right; 2x4 cm lob on left. Heart: Regular rate and rhythm.

Laboratory studies:  March 1, 1993: T4 was 11.3 mcg/dL, TSH was 0.3 mcU/mL.

Impression: Norma's continued weight loss and increasing heart rate and increasing T4 all suggest overt clinical hyperthyroidism.  We recommend starting PTU dosing.  If she develops any sort of infectious illness, even a mild cold, Norma should have her CBC checked for a granulocytosis secondary to the PTU.

Disposition: Return to the Endocrine Program in two months.

Laboratory studies pending at this time include: T4, TSH, CBC with differential.
Thank you for letting us share in the care of Norma.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Problem list to date:
GRAVE'S-DISEASE              Start: 03/01/93  End:          Invalid: 

Transcribed by Blue


CONTENT:
Valdeci Meisner, M.D.          RE: Norma Walpole
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/77

Dear Dr. Meisner:

We had the pleasure of seeing Norma in the Endocrine Program on 10/4/93 for follow-up of graves disease.

History: Norma is a 16 and 4/12 year old with Graves disease s/p implant of breast due to asymmetry of breast.  She has gained 0.6 kg since her last visit.  Her menstrual cycle continues to be regular.  She denies constipation, headaches, or nocturia.

Current medications: PTU 100 mg TID.

Physical exam:  
Height: 157.1 cm        Weight: 64.5 kg         Pulse: 72               
General: Cheerful girl.  Skin: Warm.  HEENT: EOMI, no lid lag.  Neck: 2x3 cm. lobe on right; 2x2 cm lobe on left.  Chest: Clear.  Heart: Regular rate.  Abdomen: No hepatomegaly.  Neurological:  Reflexes brisk.

Laboratory studies:  T4 10.0 mcg/dL, TSH 1.7 mcU/mL.

Impression: Norma is currently euthyroid, both clinically and biochemically.

Disposition: I have made no changes in Norma's medication.
Thank you for letting us share in the care of Norma.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Mitsuko Matlock, M.D.          RE: Mabel Barclay
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/13/87

Dear Dr. Matlock:

We had the pleasure of seeing Mabel in the Endocrine Program on 7/29/93 for evaluation of possible endocrinological dysfunction.

History: As you may well know, Mabel is a 6 year old girl with a history of reactive airway disease and allergies which has been followed at the Pulmonary Clinic at Children's Hospital.  Her mother has some concerns that she may have a chemical imbalance.  Mother reports that she had an abnormal LH/FSH ratio with amenorrhea prior to the conception of Mabel. There was a question during this period as to whether she had hypothyroidism. She was only transiently started on thyroid supplementation.  Since the delivery of the child, she has been asymptomatic.  Mabel has otherwise been growing well without any evidence of thyroid or adrenal dysfunction.  There have been no complaints of pubertal changes, no breast buds or pubic hair has been noted by the family.  

She is currently on no medications and she has no known drug allergies.

Past medical history:  Significant for the reactive airway disease and recent allergies to numerous agents.

Family history:  She has a sister who is 14 1/2 years old who has not reached menarche yet, but is showing signs of puberty.  There is a question of thyroid dysfunction in one of the maternal aunts.  Otherwise there is no history of endocrinological disorder in other family members.

Physical exam:  
Height: 114.9 cm        Weight: 21.8 kg         BP: 95/66               
Pulse: 102              Breast: Tanner I        Pubic hair: Tanner I    
Mabel's growth has been charted over the last two years and she appears to be following normal growth for both weight and height.   General: Well appearing child in no apparent distress. Skin: No rashes. HEENT: Negative.
Neck: No neck masses. Chest: Clear breath sounds with no wheezing. Heart: Regular rate and rhythm. Abdomen: Soft, no organomegaly. Extremities: Well developed, no evidence of delayed growth. Neurological: Normal.

Impression: It is our impression that Mabel is a well child with no apparent hormonal dysfunction at this time.  Both the history and the physical exam do not show any evidence of thyroid or adrenal dysfunction.  There is also no evidence of precocious puberty and she appears to be growing well.  We reassured the family that at this stage that no further testing would be required to rule out any hormonal dysfunction.  We encouraged the family to feel free to raise their concerns if there are any problems at the time of puberty.

Thank you for letting us share in the care of Mabel.

Sincerely,


Brett Meisner, MD               Kendell Simpson, MD             
                             Clinical Director


CONTENT:
Clotilde Montague, M.D.          RE: Bela Tubman
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/15/86

Dear Dr. Montague:

We had the pleasure of seeing Bela in our Endocrine Program on 07/29/91 for evaluation of delayed development and short stature.

History: This is a 5 and 6/12 year old male with a long and complicated history.  Of note, antenatally, his mother had viral gastroenteritis and stomatitis at approximately 35 weeks of pregnancy.  At 36 weeks she went into premature labor and was successfully treated.  She then delivered at approximately 38 weeks.  The delivery was notable for thick meconium and a nuchal cord, but the patient had Apgars of 7 and 9.  Early development was normal until approximately 8 months.  At this time, it was evident that there was significant motor problems.  Patient would not sit until he was approximately 10 1/2 months and would fall over.  He did not walk until 15 1/2 months and began cruising at 12 months.  His mother described crawling backward and diffuse motor delays.  She also noted a decrease in his speech.  He still doesn't ride a tricycle.  He was referred today for new onset of growth retardation.  By report, he has been in the 10 percentile and has had the absence of linear growth for 1 1/2 years.  He has required little new clothes in the past year and a half.  His shoe size has increased 1/2 size in the past year.

Current medications: Ventolin nebulizer and Intal.

Past medical history:  Frequent ear and respiratory infections.  He has had a tonsillectomy and adenoidectomy in 1991 and had speech regression at that time.  He also had a Myringotomy.  He is also known to have a low IgG2 subtype.

Family history:  His mother is 5'7" with an underdeveloped optic nerve with no other developmental problems.  His father is 5'10" tall.  He had orthopedic problems with his feet as a child.  Recently he has had Bipolar Disease with significant depression, as well as back and disc problems preventing him from pursuing his occupation.  Both brothers are developing mentally normal, although one has asthma and the same immuno deficiency.  His sister is younger and has an underdeveloped optic nerve.

Physical exam:  
Height: 108.3 cm        Weight: 17 kg           BP: 100/70
Pulse: 82               Pubic hair Tanner: 1    
On exam, he had significantly delayed speech.  His skin shows no lesions.  His HEENT exam is benign.  His neck shows no thyromegaly or adenopathy.  His chest was clear.  Cardiac exam shows no murmurs or gallops.  His abdomen was benign.  His genital exam was normal with bilaterally descended testes.  His extremities were normal.  There was no focal neurologic lesion.

Laboratory studies:
Normal chromosomes with no evidence of fragile X.  He had a normal EEG.  He had a normal cranial MRI approximately 1 year ago.  A bone age done 6/4/91 showed a delay at approximately 4 1/2 years for the hand and 3 years for the wrist.  CBC, electrolytes, bicarbonate, BUN, CREAT, calcium phosphorous and albumin were normal.  He had normal thyroid function tests.  Somatomedin C was normal at 0.40.  Stool O & P was negative.  Anti-endomysial, anti-gliadin, anti-reticulin antibodies were negative.  A d-Xylose test was normal.  ESR was normal.

In summary: This is a 5 1/2 year old male with diffuse speech and developmental delay.  He appears to have had a recent onset of growth retardation.  An MRI scan one year ago was normal.  He was scheduled to have a neuroendocrine work-up on August 14, 1991.

Thank you for letting us share in the care of Bela, I will let you know of the results of the various skin tests as soon as they become available.

Sincerely,


Elizabeth Stewart, MD                     Kendell Simpson, MD
Fellow in Endocrinology, BWH              Clinical Director

ES/SN/smp


CONTENT:
Clotilde Montague, M.D.          RE: Bela Tubman
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/15/86

Dear Dr. Montague:

We had the pleasure of seeing Bela in the Endocrine Program on 03/24/92 for follow-up of his short stature..

History: Bela has been well since last seen on 07/29/91.  He did not have an excessive number of upper respiratory infections, had only one bout of asthma and few episodes of mild diarrhea.  His appetite has been capricious and his weight gain has varies accordingly.  Recently he had become incontinence and his school work has deteriorated, this coincided with the parents separating.

Review of systems:  negative.

Physical exam:  
Height: 112.5 cm        Weight: 18.2 kg         BP: 80/50               
Pulse: 88               Phallus length: 4.0 cm  Mid-shaft diam.: 1.2 cm 
Overactive boy with speech retardation. Lost two deciduous lowered central incisors.  He had mildly injected conjunctivae.  He had no hepatosplenomegaly.  The genitalia were prepubertal.  The remainder of the examination was non-revealing.

Impression: Bela grew well (4.2 cm in eight months), this further substantiates the normal hormonal studies obtained on his last visit.  He presently is on the 20th centile in height and on the 10th centile in weight (on the 30th centile weight for height).  No further endocrine studies are indicated at present.

Thank you for letting us share in the care of Bela.

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Problem list to date:
SHORT-STATURE                Start: 03/24/92  End:          Invalid: 

Transcribed by Nortonsh


CONTENT:
Clotilde Montague, M.D.          RE: Bela Tubman
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/15/86

Dear Dr. Montague:

We had the pleasure of seeing Bela in the Endocrine Program on 03/01/93 for evaluation of his growth.

History: Since last seen on 03/14/92 Bela had been very well.  On October 15, 1992, he had repair of the velopharyngeal flap and since then his speech has greatly improved.  He is in first grade and likes best his gym class.  He is active, does not seem to to tire easily.  He is on Amoxicilln prophylaxis.  He had no asthmatic attacks.

Current medications: Amoxicillin prophylaxis.

Physical exam:  
Height: 118.1 cm        Weight: 20.4 kg         
Bela was thin but healthy looking.  His speech has greatly improved. Skin:  Normal texture.  HEENT:  Koryza, Tubes in the ears..  Neck:  Thyroid normal.  Lymph nodes:  No lymphadenopathy.  Chest:  Clear lungs.  Cor:  Normal S1 and S2, no murmurs.  Abdomen:  Soft, no hepatosplenomegaly.  GU:  Prepubertal.  Extremities:  Normal.  Neurological:  DTR 2+ symmetrical, Cranial nerves II-XII intact.

Impression: Bela continues to grow at a normal rate.  He obviously has no endocrine deficiency.

Thank you for letting us share in the care of Bela.

Sincerely,





Kendell Simpson, MD             
Clinical Director


CONTENT:
Mandy Hammer, M.D.          RE: Andie Zhou
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/23/90

Dear Dr. Hammer:

We had the pleasure of seeing Andie in the Endocrine Program on 6/6/94 for .

History: As you know, Andie is now 3 and 10/12 year old white female who was diagnosed at birth with Turner's Syndrome.   In addition to her characteristic phenotype, Andie has had associated aortic stenosis, partial anomalous pulmonary venous return and a mild aortic coarctation.   She was referred to our clinic by her cardiologist, Dr. Carl Lear, for further evaluation of the possibility of instituting growth hormone therapy.   In addition,  to Andie's cardiac defects, she also has a history of chronic otitis requiring myringotomy tubes several times.

She is developing well.   The mother's  primary concern is Andie's short stature and hearing deficits.

Current medications: None.
Allergies:  She developed a rash with Suprax.

Past medical history:  Notable for cardiac deficits described above.  She is status post catheterization with aortic valve dilatation.  She has also had a history of GU reflux detected in the presence of a urinary tract infection.   The parents state that this has now resolved.   Parents say developmentally she has been more or less on target, sitting at six months, walking at 12 months.  They state that she is toilet trained although is still having episodes of nocturnal enuresis and occasional incontinence of stool.

Review of systems:  Notable for no evidence of congestive heart failure at this time.   She is an active child without fatigue.

Family history:  She is the middle child of three.   She has an older brother who is 6 years old and well and a three month old sister who is also doing well.   There are no other family members with chromosome abnormalities.  No mental retardation.   Family history is only positive for adult onset diabetes.   Mother is adopted and there is little known of her biological family.

Physical exam:  
Height: 89 cm           Weight: 13.8 kg         
Andie is a pleasant, active three year old with Turner's phenotype who is in no acute distress.   She has a height at this time at 89 cm.  Weight of 13.8 kg.
SKIN:  Notable for two 3 mm hypopigmented macules on her back.  She has dysmorphic toenails.
HEENT: She was normocephalic.  Pupils were equal, round and reactive.  There was no strabismus.   Her oropharynx was benign.
NECK: Webbed and supple.  There was no goiter.  She has mild, shotty, right anterior cervical nodes.
CHEST: She did have a shield deformity with small nipples and a nipple distance of 12.5 cm.
LUNGS:  Clear bilaterally.  No rales or wheeze.
CARDIAC:  Notable for mild tachycardia and a III/VI systolic ejection murmur at the right upper sternal border, radiating to the carotid but heard throughout the precordium.
ABDOMEN: Benign, soft with good bowel sounds and no hepatosplenomegaly.
GU: The patient was Tanner I.  External anal exam was normal.
EXTREMITIES:  Revealed nearly normal carrying angle and short metacarpals bilaterally.
NEUROLOGIC:  Nonfocal. 

Review of the patient's growth data reveals a height less than the 5th percentile and weight at the 10th percentile with height for weight approximately 75th percentile on the NCHS chart.  When plotted on the Turner's growth chart, she has grown just below the 50th percentile with good interval growth between age of 2 and11/12 and 3 and 10/12.

Impression: Andie is a 3 and 10/12 year old with Turner syndrome with characteristic phenotype and short stature.  Her growth velocity has been along the 50th percentile on the Turner growth chart.   She has associated aortic stenosis and mild aortic coarctation which is being followed by Dr. Carl Lear in cardiology clinic at Children's Hospital.   There does not seem at this time to be any contraindication to growth hormone treatment.   As the parents are somewhat reluctant to begin thearpy at this time, we have planned to see Andie back in six months both to check interval growth and to have an opportunity to discuss further with the cardiologist any reason not to pursue growth hormone therapy.   The patient's cardiac defects are structural and so far as we know are no contraindication to growth hormone therapy.

Disposition: RECOMMENDATIONS:
1.  A bone age at this time to assess skeletal maturation.
2.  Baseline FSH and LH studies.
3.  The patient is to return to the Endocrine Program in six months time for follow up evaluation of growth and institution of growth hormone therapy if there are no cardiac contraindications.
Thank you for letting us share in the care of Andie.

Sincerely,


Yale Lear, MD            Mitsuko Simpson, MD             
                             Chief Emeritus               


Addendum: Senior Resident


CONTENT:
Ellastine Hammer, M.D.          RE: Andie Zhou
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/23/90

Dear Dr. Hammer:

We had the pleasure of seeing Andie in the Endocrine Program on 4/6/95 for turner's syndrome.

History: As you know, Andie is a 4 9/12 year old white female who was diagnosed at birth with Turner's syndrome.  In addition to her characteristic phenotype, Andie has had associated aortic stenosis and a mild aortic coarctation.  She also has a history of chronic otitis requiring myringotomy tubes several times.  

Andie is overall doing well.  There is no history of headaches or fevers.  She has an otitis at the present time for which she is receiving 
Pediazole.  Nasal congestion is a chronic issue.  She has an excellent energy level and good appetite.  She is in preschool and doing well.  There is no history of temperature intolerance, constipation or diarrhea.  She also has no vomiting or abdominal pain.  She has no rashes or dry skin.  She is also developing well.

Current medications: Pediazole.

Physical exam:  
Height: 92.5 cm         Weight: 15 kg           BP: 98/60               
Pulse: 90               U/L ratio:  1.26        Arm span: 96            
Breast: Tanner I        Pubic hair: Tanner I    
General: Pleasant in no acute distress.   
Skin: Clear.  Dysmorphic toenails.
HEENT: Normal suphalic.  PERRL, EOMI.  low lying hairline.  
Neck: Slightly webbed.  No thyromegaly or lymphadenopathy.  
Chest: Widely spaced nipples, clear to auscultation.
Heart: Regular RR, 3/6 systolic injection murmur throughout precordium.
Abdomen: Soft, no masses or hepatosplenomegaly.
Genitourinary: Normal female genitalia.
Extremities: No clubbing, cyanosis or edema.
Neurological: Nonfocal, reflexes 2+ and toes bilaterally downgoing.

Laboratory studies:  June, 1994:  Bone age 2 9/12 years with a chronologic age of 3 10/12 years (standard dev. is 8.9 months).  FSH 11.7, LH 0.13.

Laboratories: (4/6/95) T4 12.4 mcg/dL, TSH 4.1 mcU/mL (normal).  Bone age - 3 3/12 years (CA - 4 9/12).  SD=11 months.

Impression: This is a 4 9/12 year old with short stature and  a setting of Turner's syndrome.  She has fallen one channel on the growth curve and currently is at the 25%ile.  Her growth velocity is 5.4 cm per year, having grown 4.5 cm over the past ten months.  We feel that Andie is a good candidate for growth hormone therapy.  We know of no contraindication to growth hormone therapy as this child's cardiac defects are only structurall.  However, we will discuss this issue with the patient's cardiologist before we make a formal recommendation.  As hypothyroidism occurs with increased incidence in patients with Turner's syndrome, we will check TFT's today to be sure that hypothyroidism is not the cause of her decreased height velocity.

Disposition: 1.  We repeated a bone age to access skeletal maturation.   The bone age is delayed.
2.  We discussed the issue of growth hormone therapy with this patient's cardiologist.  Andie will have a repeat ECHO in July, 1995, then a reevaluation in the Endocrine Clinic this September.  
3.  We called Andie's mother following this discussion with Dr. Sadler regarding growth hormone therapy.  We will reconsider this option in September. 
4.  The patient is euthyroid and hypothyroidism is not the cause of fall off on the growth curve.  
5.  We would like to see Andie again in the clinic in one year for follow-up asessment or sooner if the decision is made to begin growth hormone therapy.
Thank you for letting us share in the care of Andie.

Sincerely,


Sotiria Bonaparte, MD         Ariel Adler, MD           
                             Attending in Endocrinology


CONTENT:
Mandy Hammer, M.D.          RE: Andie Zhou
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/23/90

Dear Dr. Hammer:

Andie is now 5 10/12 years old and was last seen in our clinic in 4/95.   As you know, I have been following her for short stature and a diagnosis of Turner's syndrome.  Andie also has aortic stenosis and a  mild aortic coarctation.  Other issues include chronic otitis and chronic nasal congestion and chronic rhinitis. 

Andie has been bothered by increased diaphoresis and a decreased energy  level.  Her parents have noted decreased exercise tolerance, but no complaints of shortness of breath or chest pain.  Over the past few weeks, she has had profuse sweating with exercise.  Last Thursday, 5/16/96, she had an episode of diaphoresis and hypertension  while undergoing a stress test in the Cardiology Division here.

Current medications: None.

Review of systems:  A further review of systems reveals that Andie has had no headaches or visual changes.  She has a good appetite and has had no weight loss.   Her stools are occasionally watery but she typically has one normal  bowel movement per day with occasional episodes of diarrhea.  She sleeps  throughout the night.  She still has chronic congestion, but no fevers.  She has had no  syncopal episodes or no complaints of dizziness.  Her mother has noted  an increased thirst in the recent weeks but no polyuria.  She has  primary enuresis as before.

Physical exam:
HT: 97.9 cm    WT: 16.6 kg    Arm span: 97 cm    U/L ratio:  1.13
Breast: Tanner I        
General appearance is happy. alert and no acute distress.  Skin is dry and clear.  Dysmorphic toenails.  HEENT:  PERRL, EOMI.  Low lying hairline  and webbed neck.  No thyromegaly or lymphadenopathy noted.  Lungs are  clear to auscultation.  Breast are Tanner I.  Heart rate is 90 with  III-IV/VI systolic ejection murmur noted throughout the precordium.  The  abdomen is soft without organomegaly.  Extremities are warm and well  perfused.  Neuro is nonfocal; the reflexes are 2+ and the toes are  bilaterally down going.

Laboratory studies:  K  4.1 mmol/L,  NA 13 mmol/L, glucose 103 mg/dL, Cl 104 mmol/L, CO2 24 mEq/L, BUN 12 mg/dL< Cr 0.3 mg/dL.   T4 9.8  ug/dL, TBGI 0.84, TSH 4.80 uU/mL.  Random urinalysis:  no microalbumin, ketones - negative, glucose - negative, blood - negative, nitrite - negative, protein - negative, pH  7.5. SPEC GR 1.022

Impression: This is a 5 10/12 year old with Turner's syndrome and short stature.  Now with intermittent episodes of perfuse diaphoresis of unclear etiology.  We sent baseline electrolytes as well as a  urinalysis that were normal. Thyroid function tests were also normal.

Disposition: We have called Dr. Carol Satler of Cardiology and the patient's mother with these results.  At this time, unless issues arise before, we would like to see her again in a year to reassess her growth.  Given the extent of her cardiac disease, it was decided with the cardiologists that growth hormone therapy is not a reasonable option at this time.  Thank you for letting us continue to share in her care.



Sincerely,




Sotiria Bonaparte, MD            Rahul Ibsen, MD                
Fellow in Endocrinology         Attending in Endocrinology


CONTENT:
Laura Steinbeck, M.D.          RE: Norm Boyd
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/23/87

Dear Dr. Steinbeck:

We had the pleasure of seeing Norm in the Endocrine Program on 7/6/95 for delayed a growth rate.

History: Norm is a 7 and 11 1/2 year old who was referred for evaluation of a delayed growth rate.  Norm was diagnosed with high risk ALL in September of 1990, and received 6 months of induction chemotherapy before bone marrow and CNS remission was achieved.  Subsequently, he underwent a matched unrelated bone marrow transplant in May of 1991.  For the transplant, he received a conditioning regimen which included: 1,000  RAD to the whole brain followed by total body radiation of 1400 RAD.  His total cranial dose of radiation was 2400 RAD.  He has had no GVHD to date, and, he has remained in remission since his transplant.

Norm is now referred for evaluation of a decrease in his growth rate noted in the past year.  His height has crossed from the 50th to the 25th percentile during this period.  His mother reports that he has remained well during this period and that his appetite has not changed.  He has had normal bowel movements, with no blood or fat noted in the stools.  He has had no vomiting or diarrhea,  nor significant illness during this period.  Of note, he did have a bone age performed at a chronological age of 7 and 2 1/2 years which was read as 7 and 6/12 years, plus/minus 10 months.

He is also referred to evaluate a TSH level which has been noted to be elevated since May 18, 1993 in the Jimmy Fund Clinic.  Of note, the patient's T4, free thyroxine, and T3 uptake have remained within normal limits for the vast majority of this period of time.  He has shown no other clinical evidence of hypothyroidism.  At the time of the visit, he was on no medications, and he has no known drug allergies.  His immunizations are up to date.

Past medical history:  It is notable for the high risk ALL and MUDBMT noted above.

Review of systems:  Unremarkable except for bilateral posterior subcapsular cataracts secondary to therapy he received for his high risk ALL.  He has also undergone neuropsychiatric evaluation for some school difficulties.

Family history:  Remarkable only for a history of an inflamed thyroid in his maternal grandmother.  His mother's height was 5 ft 9 in, and father's 6 ft at the time of this visit.

Physical exam:  
Height: 123.7 cm        Weight: 25.7 kg         BP: 100/65              
Pulse: 80               U/L ratio:  0.93        Arm span: 125           
R. testis: 2.1 x 1.2 cm L. testis: 2.1 x 1.3 cm Phallus length: 8 cm    
Mid-shaft diam.: 1.6 cm 
General: Well developed boy.  
Skin: No rash or petechiae.
HEENT: PERRL, EOMI, fundi flat with sharp discs, tympanic membranes pearly with normal light reflex and mobility, oropharynx without exudate.
Neck: Supple with no evidence of thyromegaly.  Shotty cervical adenopathy.
Chest: Clear to auscultation.
Heart: Regular rate and rhythm, no murmurs.
Abdomen: Normoctive bowel sounds.  Soft, nondistended, nontender, no hepatosplenomegaly.
Genitourinary: Normal Tanner 1 male genitalia, testes were descended bilaterally.  
Neurological: Nonfocal.

Laboratory studies:  WBC 4.66 K/mm3, Hgb 12.1 g/dL, Hct 34.5%, MCV 86.4 Fl, platelets 246 k/mm3, TBGI 1.02, T4 6.5 ug/dL, TT3 113 ng/dL, TSH 3.40 uU/mL. IGF-1 pending.

Bone age prelimary rading 9 year 6 months.

Impression: This is a 7 and 11 1/2 year old, status post, matched  unrelated donor bone marrow transplant for high risk acute lymphoplastic leukemia, who received 2400 RAD of total cranial radiation, and now has a slowed growth rate and a history of an elevated TSH in the setting of normal T4, free thyroxine, and T3 uptake values.  Given the patient's history and lack of delayed bone age growth hormone deficiency and hypothyroidism are less likely to be the cause of this child's slowed growth rate.  TFTs are WNL and IGF-1 as screeen for GH is pending.  His growth and weight will be followed closely over time and he will follow up in the endocrine clinic in 4-6 months.

Thank you for letting us share in the care of Norm.

Sincerely,


Victor Romanov, MD         Leif Pavarotti, MD             
                             Attending in Endocrinology   


Addendum: Resident in Pediatrics

Problem list to date:
SHORT-STATURE                                08/09/95  
ACUTE-LYMPHOBLASTIC-LEUKEMIA                 08/09/95  
CRANIAL-IRRADIATION                          08/09/95  
Transcribed by Sullivan_ma


CONTENT:
Icilda Ibsen, M.D.          RE: Norm Boyd
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/23/87

Dear Dr. Ibsen:

I saw Norm in the Endocrine Program on 3/21/96 for follow up of decreasing growth velocity.

History: Norm is now 8 and 8/12 years old.  Since his last visit,  he has had no  illnesses nor change in his energy level.   He continues to be a picky eater and receives supplemental instant breakfast.  He has dry skin and brittle fingernails.  He complains of a diffuse abdominal pain that is intermittently achy.  He  did vomit once, and it may have occurred after being hit with a ball.   He denies hair loss, coarse hair, constipation, diarrhea, or cold  intolerance.

Current medications: None.

Physical exam:
HT: 125.7 cm    WT: 26.5 kg   Arm span: 126 cm    U/L ratio:  0.9
BP: 90/56               Pulse: 80               Breast: Tanner I        
R. testis: 2.1 x 1.3 cm L. testis: 2.2 x 1.4 cm Phallus length: 8 cm    
Mid-shaft diam.: 1.5 cm 
General appearance: alert and cooperative.  Skin: normal texture.  HEENT: PERRL, EOMI, discs not visualized.  Neck: no thyromegaly.  Lungs: clear.  Back: left shoulder appears elevated compared to right consistent with a mild scoliosis.  Heart:  regular rate and rhythm  without murmur.  Abdomen: soft, nontender, no hepatosplenomegaly or masses.  Extremities:  well perfused.  Neurological: normal patellar deep tendon reflexes.

Laboratory studies:  Norm underwent provocative testing on  02/28/96.  His growth hormone level rose to only 3.2 ng/ml after insulin-induced hypoglycemia.  Growth hormone rose to 7.9 ng/ml after glucagon stimulation.  FSH and LH responses were consistent with early puberty with maximal values of 6.1 IU/L and 9.3 IU/L respectively.  Cortisol levels were adequate.  After TRH stimulation, the TSH level did not return to baseline and the prolactin response was exaggerated, consistent with  hypothalamic damage.  At today's visit, IGF-1 39 ng/ml and IGFBP-3 1.7 mg/L.

Impression: Norm's provocative testing was consistent with hypothalamic damage, presumably secondary to cranial irradiation.  His GH response was inadequate, although not deficient.  He has grown only 0.9 cm. over the past four months and only 2 cm over the past 8 months since I started seeing him.  This very poor growth velocity with low IGF-1 and IGFBP-3 levels confirms GH inadequacy, and I think we should consider treatment with recombinant human growth hormone.  We have limited time, as biochemically, he is entering puberty.  I would, however, like to delay discussion until he has his further assessment in May which will consist of an EKG, echocardiogram, and pulmonary function tests.  If these are within  normal limits, then benefits of the growth hormone treatment should outweigh the risks.

Disposition: I would encourage Norm to improve his nutritional intake and to take a multivitamin with Zinc.  I would consider referral to Steven Lipshultz, M.D. in Cardiology, as he follows several of the patients s/p chemotherapeutic regimens with cardiac toxicity who are receiving growth hormone treatment.  I would like to see Norm back in Endocrine clinic in 4 months.

Thanks you for letting me share in Norm's care.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc:  Clare Twist, M.D. Jimmy Fund Clinic   Dana-Farber Cancer Institute

     Zoe Boyd  5 Old Slab Bridge Road  Assonet, MA  02702


CONTENT:
Icilda Ibsen, M.D.          RE: Norm Boyd
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/23/87

Dear Dr. Ibsen:

I saw Norm in the Endocrine Program on 10/17/96 for growth hormone deficiency.

History: Norm is a 9-2/12 year old with growth hormone deficiency status post treatment of acute lymphocytic leukemia.  On 3/21/96, his height was 125.7 cm.  He started treatment with Humatrope (recombinant human growth hormone).  In the end of July, it was initially being injected in the morning, but has now been given at night for 1 week.  He denies cold intolerance, constipation or dry skin.  However, he has had an increase in urination.  By mother's report, a  urinalysis and culture were normal.  He also has nocturia x 2 and occasional enuresis.

Current medications: Humatrope 0.60 mg subcu q.day which is equal to 0.21 units/kg per day.

Physical exam:
HT: 128.4 cm    WT: 29 kg
BP: 118/54              Pulse: 97               R. testis: 2.1 x 1.2 cm 
L. testis: 2.2 x 1.3 cm Phallus length: 7 cm    Mid-shaft diam.: 1.8 cm 
General appearance:  alert.  Skin:  normal texture.  HEENT:  PERRL, EOMI.  Neck: no thyromegaly.  Lungs:  clear.  Heart:  regular rate and rhythm without murmur.  Abdomen:  soft without hepatosplenomegaly or masses.  Extremities:  warm and well perfused.

Laboratory studies:  Na 143 mmol/L, serum osm 292 mosmkg, urine osm 1218 mosmkg, TSH 3.86 5U/mL, hemoglobin A1C 5.4%.   Bone age: 10.6 years

Impression: Norm has grown 2.7 cm over the past 7 months.  He has only been on growth hormone for the past 3 months, so my expectation is that most of this growth was since starting growth hormone.  I increased his dose to 0.7 mg subcu q.day to keep his total dose at 0.025 mg/kg per day.

His enuresis does not appear to be due to a urinary tract infection, diabetes insipidus, or diabetes mellitus.  Therefore, it may be behavioral, and he might benefit from a trial of an alarm system.

Disposition: I would like to see Norm back in Endocrine clinic in 4-5 months.  Thank you for letting me share in his care.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc:   Clare Twist, M.D.  Jimmy Fund Clinic  Dana-Farber Cancer Institute  
      44 Binney Street  Boston, MA 02115

      Zoe Boyd   5 Old Slab Bridge Road   Assonet, MA  02702


CONTENT:
Herman Stalin, M.D.          RE: Ali Jervis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/05/77

Dear Dr. Stalin:

We had the pleasure of seeing Ali in the Endocrine Program on 09/05/91 for evaluation of short stature.

History: Ali is a now 14 and 8/12 year old Hispanic male here for follow-up of short stature.  Ali work-up in the Endocrine Program has been notable for normal growth hormone response to provocative stimuli and bone films that have not yielded a diagnosis of a specific congenial dysplasia.  Ali was seen in the Ortho clinic on 6/10/91 at which time lengthening braces were entertained and according to the family are planned for approximately November.  Since his last visit here, Ali has been doing fairly well, though does have headaches once to twice weekly.  He denies constipation or vomiting, but does have occasional loose stools.

Current medications: None.

Physical exam:  
Height: 140 cm          Weight: 40.5 kg         BP: 110/70
Pulse: 72               
Skin was without lesions and of good turger.  Examination of the neck revealed no thyromegaly.  HEENT exam showed flat optic discs and a moist orapharynx.  Chest was clear to auscultation.  Abdomen was soft.  GU exam was notable for 2.8 x 9.0cm phallus, Tanner stage III to IV pubic hair, and testes measuring 2.2 x 4.0cm bilaterally.  Neurologic exam showed 2+ and equal deep tendon reflexes with normal relaxation.

In summary: Ali continues to grow at a near normal rate, though significantly below the 3rd percentile.  His last bone age was approximately 18 months ago which was too near chronological age to be consistent with a diagnosis of constitutional delay growth in puberty.  We are repeating a bone age today to again determine a predicted adult height.  In addition, we sent an IGH binding protein 3 as an indicator of growth hormone status.  We hope to see Ali again in approximately one year's time to review his growth.

Thank you for letting us share in the care of Ali.

Sincerely,


Maureen Shields, MD                      Kendell Simpson, MD
Fellow in Endocrinology               Clinical Director

LM/SN/smp


CONTENT:
Herman Stalin, M.D.          RE: Ali Jervis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/05/77

Dear Dr. Stalin:

We had the pleasure of seeing Ali in the Endocrine Program on 09/05/91 for evaluation of short stature.

History: Ali is a now 14 and 8/12 year old Hispanic male here for follow-up of short stature.  Ali's work-up in the Endocrine Program has been notable for a normal growth hormone response to provocative stimuli and bone films that have not yielded a diagnosis of a specific chondro-dysplasia.  Ali was seen in the Ortho clinic on 6/10/91 at which time lengthening braces were entertained and according to the family are planned for approximately November.  Since his last visit here, Ali has been doing fairly well, though does have headaches once to twice weekly.  He denies constipation or vomiting, but does have occasional loose stools.

Current medications: None.

Physical exam:  
Height: 140 cm          Weight: 40.5 kg         BP: 110/70              
Pulse: 72               
Skin was without lesions and of good turgor.  Examination of the neck revealed no thyromegaly.  HEENT exam showed flat optic discs and a moist oropharynx.  Chest was clear to auscultation.  Abdomen was soft.  GU exam was notable for a 2.8 x 9.0cm phallus, Tanner stage III to IV pubic hair, and testes measuring 2.2 x 4.0cm bilaterally.  Neurologic exam showed 2+ and equal deep tendon reflexes with normal relaxation.

In summary: Ali continues to grow at a near normal rate, though significantly below the 3rd percentile.  His last bone age was approximately 18 months ago which was too near chronological age to be consistent with a diagnosis of constitutional delay growth in puberty.  We are repeating a bone age today to again determine a predicted adult height.  In addition, we sent an IGF BP3 as an indicator of growth hormone status.  We hope to see Ali again in approximately one year's time to review his growth.

Disposition: 

Thank you for letting us share in the care of Ali.

Sincerely,


Maureen Shields, MD                      Kendell Simpson, MD


CONTENT:
Renske McPherson, M.D.          RE: Johanna Witte
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/10/88

Dear Dr. McPherson:

We had the pleasure of seeing Johanna in the Endocrine Program on 4/6/92 for familial short stature.

History: Johanna is a 3 adn 10/12 year old girl with familial short stature.  Over the winter, her only medical problems were two ear infections (much decreased over previous year).  She has had a recent gatroenteritis, as did the rest of the family, since which she has had a decrease in her appetite.  Since discontinuing lactose containing foods, her diarrhea has resolved.  She seems to be growing well according to her mother, and is developing normally.

Current medications: Bactrim 1 1/2 teaspoons bid (for otitis media).

Review of systems:  Positive for fatigue which has come on since her gastroenteritits and the aforementioned decreased appetite.

Physical exam:  
Height: 91.7 cm         Weight: 13.2 kg         BP: 90/60               
Pulse: 92               U/L ratio:  1.08        Arm span: 93            
Breast Tanner: 1        Pubic hair Tanner: 1    
(U/L ratio: 1.08)
General: Aside from the recently diagnosed otitis media, was normal.  Since we last saw her eight months ago, she has grown 4.1 cm, or a rate of 6.15 cm per year.  This is an entirely normal growth velocity for her age.

Impression: Johanna is a 3 and 10/12 year old girl with familial short stature, with possibly a component of constitutional growth delay.  As her growth velocity in the last eight months has been normal for age, we feel it very unlikely for her to have a pathologic cause for her short stature.  We do not need to see her again, but would be glad to do so should further questions arise.

Thank you for letting us share in the care of Johanna.

Sincerely,


Antonio Capulet, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Kurt Frog, M.D.          RE: Sara Sedgwick
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/01/89

Dear Dr. Frog:

We had the pleasure of seeing Sara in the Endocrine Program on 9/22/94 for to rule out cushing's syndrome.

History: Her mother reports that she has always been plump and she has always been tall compared with other children.  She does eat a lot of fattening foods but apparently not in excessive quantities.  There are no symptoms to suggest Cushings in terms of skin changes, hypertension, fall off in growth.   She has no history of headaches or abdominal pain.   

She has one sister, age 11 who is of average height and who is thin but who apparently eats more than Sara.  There is no family history of obesity.   

Her health has always been good, otherwise, with normal early growth and development.   She takes multiple vitamins (Flintstone type).   

Mother's height 4'8", father's height 6 feet.

Physical exam:  
Height: 111.2 cm        Weight: 27 kg           BP: 98/67               
Pulse: 84               
General: This is a plump-cheeked, healthy looking girl with generalized distribution of fat.   There are no stigmata of Cushing's disease.    Skin: Good quality.   Neck: No thyromegaly.     Neurological: Fundoscopy was normal.

Laboratory studies:  Laboratory tests that we received done elsewhere showed her to be biochemically euthyroid.

Impression: Our impression is that she is overweight, but growing normally, and there is no underlying endocrinopathy, and we don't need to investigate further for Cushing's.

Disposition: Our final recommendation to Sara's mother is that she seek the help and advice of a nutritionist at the East Boston Clinic and try and develop good eating habits at this point.   We won't need to see her back unless further problems develop.
Thank you for letting us share in the care of Sara.

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology   


Addendum: Karen McCowen, M.D.
Fellow in Endocrinology
Joslin Diabetes Center


CONTENT:
Leif Steinbeck, M.D.          RE: Mickey Dewar
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/08/84

Dear Dr. Steinbeck:

     We had the pleasure of seeing Mickey in the Renal Program on 6/9/94 for follow-up of P.U.V..

     Mickey has had several problems since his last visit.  He was hospitalized for three days during April for intravenous antibiotics for his urinary tract infection.  He received intravenous antibiotics in May as an outpatient for the same indication.  Apparently he has not been catheterizing himself as well as he should. Apparently this is a behavioral issue with him.

Current medications include:
     ROCALTROL .25 mcg b.i.d.
     DITROPAN 5 mg q.d.
     BACTRIM 1 tablet q.h.s.

Physical exam:
     BP 123/69   P 76   R 12   HT 134.5cm   WT 34.7kg
     General: Appears well, no distress
     Skin: Clear no rashes
     HEENT: Benign, fundi normal
     Neck: Supple, lymph nodes no adenopathy
     Chest: Clear to percussion and auscultation
     Heart: S1 normal, S2 split, grade 1/6 systolic ejection murmur left sternal border, no S3 S4
     Abdomen: Benign, no masses or tenderness
     Extremities: No edema

Urinalysis:
     SPEC GR UA  1.008           PH UA       6          
     PROTEIN UA  3+              BLOOD UA    N          
     GLUCOSE UA  N               WBC/HPF     2-3   
     RBC/HPF     0-1             SQUAM EPI   N     
     CASTS       N

     Mickey seems reasonably stable.  We discussed again the importance of adequate catheterization.  His mother will be working on behavioral modification in this regard.  I will not do any further lab tests now.  His PTH, however, last time was elevated and therefore I will increase the Rocaltrol now.

     We have asked Mickey to return in four months.  Thank you for allowing us to share in Mickey's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Leif Steinbeck, M.D.          RE: Mickey Dewar
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/08/84

Dear Dr. Steinbeck:

     We had the pleasure of seeing Mickey in the Renal Program on 12/1/94 for P.U.V..
     Mickey Fortan has not done well since his last visit here.  He saw Dr. Baur in September.  At that time his renal function was improved and everything looked well.  He, however, has discontinued his self catheterizations and has not taken his medications in over two months.  He said that he does not want to take the medication because he doesn't understand what they are doing for him.  He also said that he stopped the self catheterization because it seemed to cause urinary tract infections.  He has also has stopped seeing his psychologist because the psychologist felt that they were not getting anywhere.

Current medications include:
     ROCALTROL .25 mcg b.i.d.
     DITROPAN 5 mg q.d.
     BACTRIM 1 tablet q.h.s.

Physical exam:
     BP   127/65   P 85   R 16   T    HT 136.9cm   WT 34.1kg
     General: Appears slightly pale in no distress
     HEENT: Negtative
     Neck: Supple 
     Lymph Nodes:  No adenopathy
     Chest: No rales or wheazes
     Heart: S1 normal, S2 split, no S3, S4 or murmur
     Abdomen: Benign, no masses or tenderness
     Extremities: No edema
Urinalysis:
     SPEC GR UA  1.008           PH UA       7          
     PROTEIN UA  2+              BLOOD UA    0          
     GLUCOSE UA  0          WBC/HPF     o     
     RBC/HPF     0     

Laboratory studies at this time include:
          ALKP        202     U/L       CO 2         24   MEQ/L    
          CA          8.9   MG/DL       CR          2.0   MG/DL (H)
          PHOS        5.5   MG/DL       BUN          46   MG/DL (H)
          NA          143  MMOL/L       K           4.5  MMOL/L    
          CL          110  MMOL/L       WBC        4.01   K/MM3 (L)
          RBC        3.73   M/MM3       HGB        11.1    G/DL    
          HCT.       33.2       % (L)   MCV        88.9      FL    
          MCH        29.8      PG       MCHC       33.5    G/DL    
          RDW        12.4       %       HDW        2.37    G/DL    
          PLT UNC     241   K/MM3       

          CASTS       N

     Mickey is obviously not doing well.  He should restart his medications and he should start the catheterizations.  He will be seeing Dr. Bauer today.  I will discuss possible alternatives with Dr. Bauer.  We can have him seen by Behavioral Medicine here.  In any case, we have to make sure that he doesn't have further infections or further obstruction.

     We have asked Mickey to return in .

     Thank you for allowing us to share in Mickey's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
, M.D.          RE: Marietta Saussure
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/11/83

Dear Mrs. Saussure,

I was reviewing some of my charts and failed to find a copy of a letter which I had thought was sent to you following Marietta's evaluation Endocrine Clinic in February.

The essence of those results is that I cannot exclude some deficiency of growth hormone production, but I think this is unlikely given some of the normal test results, such as her IGF-1 level of 277 ng/mL and a random post-exercise growth hormone of 4.6 ng/mL.  Her thyroid function tests were also normal.

The areas of concern relate to the ovarian hormonal function which will be necessary for initiation of puberty and maintenance of normal female hormonal function, including menstruation.  The tests indicate that Marietta's previous treatment, so necessary to save her from leukemia, had an adverse effect on her ovarian function.  This happens frequently in cancer treatment, since the gonadal tissue normally divides rapidly and is sensitive to radiation and to chemotherapy.

The therapeutic decision at hand is when to initiate some estrogen therapy to cause some pubertal changes.  There is no immediate rush on this, but Marietta is 11 years old now and her friends are probably beginning to bud their breast tissue and to commence some growth spurt, and she shouldn't be left behind.

I am not sure when we decided Marietta's next visit with me would be, but I would like to have the chance to sit down with you and Marietta to go over some of this and to remeasure her height approximately 6 months after her first visit with me.  This would mean around August or September.  Hopefully, we can schedule heW visit to Endocrine Clinic to coincide with other appointments you may have at the hospital.  A few months later wouldn't matter much.

Have a good summer.


Sincerely,





Nilto Carter MD
Attending in Endocrinology

cc:  Dr. Lee, Pediatric Clinic, Dana Farber Institute, 44 Binney Street


CONTENT:
Guy Romanov, M.D.          RE: Marietta Saussure
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/11/83

Dear Dr. Romanov:

We had the pleasure of seeing Marietta in the Endocrine Program on 8/11/94 for .

History: I had the pleasure of seeing Marietta in follow up in the Endocrine clinic on 8/11/94.   She is now 11 and 3/12 years old and was seen here initially in February for evaluation of growth rate.  I have had the benefit of looking at growth data begining at the time of her radiation  (age 6 and a half; she has definitely shown a reduction in rate of growth since the time of her transplant at age 8.   She has however, increased 2.1 cm and 1.8 kg in the past 6 months.   Her normal IGF-1 and thyroid function tests at that time were reassuring.   It is unlikely that she has significant growth hormone deficiency based on the IGF-1 level.  Of concern at that time was the elevated LH and FSH with unmeasurable estradiol production.   This suggests that not only does she have ovarian insufficiency with respect to ovulation but she is hypogonadal with respect to estrogen production.   She will, therefore, require estrogen replacement treatment to enable her to enter puberty.   She is not particularly interested in this at this time and being only 11 and 3/12, it is not an immediate issue.   As time goes on, it will be both a social issue and a medical issue as she would be at risk for osteopenia should estrogen treatment be delayed.

Current medications: None currently.

Physical exam:  
Height: 146.6 cm        Weight: 45 kg           U/L ratio:  0.89        
Arm span: 158           Breast: Tanner I        Pubic hair: Tanner I    


Impression: The implications of the above laboratory studies were discussed and I will see Marietta and her mother again in six months to rediscuss the issue.   I anticipate that she will be needing to start low dose estrogen in the form of Premarin 0.3 mg daily no later than her 13 birthday and possibly earlier depending on her interest.

Thank you for letting us share in the care of Marietta.

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology


CONTENT:
Laura Steinbeck, M.D.          RE: Marietta Saussure
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/11/83

Dear Dr. Steinbeck:

I was pleased to see Marietta in follow up in the Endocrine Program on 5/21/96 for assessment of pubertal response to estrogen in the context of her previous ovarian failure secondary to ALL treatment.  She was begun on a very small dose of 5 mcg a day of estradiol in 3/95 and now 14 months later she has shown some progression in development with an obvious increase in growth rate without a concomitant increase in weight however at presently 13 and 0/12 years of age.  She has had some breast  development, she has also developed some apocrine odor and some pubic hair and she has had some vaginal discharge and a somewhat pruritic discharge suggestive of recent yeast infection.  There have been no untoward effects and I realize from laboratory results done at her last visit with you in November, that her bone age at 12 and 6/12 chronologically was 10 and 6/12, and at that time she had thyroid function tests that suggested a very slightly elevated TSH of 5.5 mU/ml with a T4 of 9 mcg/dl and a resin T3 uptake of 21%.  She could be developing acquired hypothyroidism so this needs to be checked out.

Physical exam:
HT: 154.1 cm    WT: 49.3 kg    Arm span: 165 cm    U/L ratio:  0.83
BP: 100/50              Breast: Tanner II       Pubic hair: Tanner II   
Bone age is pending.  The exam was otherwise unremarkable

I have drawn a follow up LH (17.2 IU/L), FSH (43.90 IU/L), thyroid functions (T4 8.3 ug/dl, TBGI 0.75, TSH 3.1 uU/ml - normal) and a bone age and I have switched her over to 0.3 mg a day of Premarin and will see her again in approximately six months.  At that time or possibly six months later, I will increase her to 0.625 mg a day.  After a year of therapy from this point I may Saussure to cycle her with Progestin.  

Thanks for allowing me to share in her care.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Brett Benise, M.D.          RE: Marietta Saussure
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/11/83

Dear Dr. Benise:


Marietta looked very well when I saw her today at 13-6/12 years of age in follow-up for pubertal response to estrogen for primary ovarian failure secondary to ALL treatment. 

She has been on 0.3 mg a day of Premarin for the past 18 months and has not had the remarkable growth spurt that she had hoped.  She has had further progression of breast maturation however and has had one vaginal flow, although I don't expect her to have any regularity of cycles on this low dose treatment.   

Otherwise she is doing well, taking martial arts and in the eighth grade and is a good student.

Physical exam:
HT: 155.4 cm    WT: 50.6 kg    Arm span: 166.5 cm    U/L ratio:  0.87
BP: 107/45              Pulse: 69               
Breast: Tanner II       Pubic hair: Tanner III  
Upper to lower ratio still of eunuchoidal proportions of 0.87 upper to lower segment ratio.  A bone age was 13 years today.

Impression: I have recommended that she increase to 0.625 mg a day of Premarin and then I will see her in six months.  At that time I will switch her to a combination estrogen-progestin such as a birth control pill combination with a 28 day pill pack.  If she starts to develop problems, frequent or excessive vaginal bleeding on this current Premarin dose then we may have to move towards the estrogen-progestin combination somewhat sooner.

Disposition: I have asked her to get a TSH, LH and FSH when she comes in to the Jimmy Fund Clinic next month and a bone age will be done today. 

Thanks for allowing me to share in her care.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   


cc:  Clare Twist, M.D.  Jimmy Fund Clinic  Dana-Farber Cancer Institute  
     44 Binney Street  Boston, MA 02115

     Merilyn Gustafson   92 No Pond Road   Amston , CT  06231


CONTENT:
Nilberto Rolf, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Rolf:

We had the pleasure of seeing Alban in the Endocrine Program on 6/20/94 for evaluation of obesity.

History: As you know Alban is a 3 year old with multiple medical issues including asthma, spina bifida at S3 with neurogenic bladder, seizure disorder, s/p hyaline membrane disease, s/p right infarcted kidney, s/p tethered cord, here for evaluation of increased weight and abnormal thyroid function studies.  According to his mother, Alban has always been chubby and with a higher weight percentile than height percentile.  According to mother, he was doing well until  mid-April when he started "ballooning out".  He gained ~ 10 lbs in two weeks.  He had thyroid studies done at that time that were "slightly abnormal".  Alban has always had a good appetite, however, his mother states that he never seems to get full. She notes an increased amount of aggression in the patient over the last month or so.

Current medications: Depakote, Neuronsten, Carnitine, Vanceril, Intal, multi-vitamin.  PRN medications include Valium, Albuterol, Motrin.

Past medical history:  Hyaline membrane disease despite 38 week gestation.  Post-natal course remarkable for a right infarcted kidney.  The patient has a significant past surgical history  remarkable for his initial back surgery, VP shunt placement, VP shunt revision, bronchoscopy, circumcision, untethering of his spinal cord in October 1992 and bilateral hernia repair.  He also is straight catheterized QID for residual urine in the bladder and has a seizure disorder with significant language delays as well fine motor and gross motor skill delay.

Family history:  Asthma as well hypoparathyroidism. and "slight hypothyroidism" on the mother's side.  Father's family history is remarkable for hypertension.

Physical exam:  
Height: 93.2 cm         Weight: 22.4 kg         Phallus length: 4 cm    
Mid-shaft diam.: 1.2 cm 
General: Chubby, active boy.
Skin: Unremarkable.
HEENT: 
Neck: No palpable thyroid.
Chest: Mild expiatory wheezing however good aeration throughout.
Heart: Unremarkable. 
Abdomen: Obese.
Genitourinary: Normal.  Testes descended bilaterally.
Extremities: Chubby.
Neurological:

Laboratory studies:  6/10/94: TBGI 0.91, T4 6.6 mcg/dl slightly decreased, TT3 178, TSH 7.8 
CBC hemoglobin 10.9, hematocrit 32.6, white count 6.67 and platelets 306, MCV 93.8, remarkably high.

Impression: Alban is a patient with spina bifida and multiple medical problems who has d significant weight gain of late.  Thyroid tests were not significantly abnormal.  We suspect that hyperphagia may be part of this picture of increased weight gain.  We suggested that mother keep a food diary for three Hayakawas and take this to a nutritionist.  We asked that the nutritionist send us a report of the calorie count.  We will also obtain thyroglobulin antibodies as well as calcium and phosphorous to rule out pseudohypoparathyroidism.  Due to mother's request we will also obtain a B12 and a folate for your office to work up his anemia.  We have asked mother to return to clinic within six months so that we can follow Alban's care.

Thank you for letting us share in the care of Alban.

Sincerely,


Khabira Benise, MD            Lancelot Blue, MD             
                             Attending in Endocrinology   


Addendum: Fellow in Endocrinology


CONTENT:
Nilberto Rolf, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Rolf:

     We had the pleasure of seeing Alban in the Renal Program on 8/24/94 for renal infarct/hypertension.

     Alban comes in today with his mother.  He was hospitalized approximately eight weeks ago for two weeks for a urinary tract infection.  At that point, he was febrile to 103 degrees and had a significant decline in his renal function with serum creatinine values peaking at approximately 2.5 mg/dl.  Alban slowly responded to intravenous antibiotics and ultimately received a two week course of ceftriaxone with a one week course of gentamicin.  Renal ultrasound was unchanged.  A nuclear DMSA scan revealed no cortical defects and a nuclear cystogram was negative .  Since his discharge, Ronnie has been doing well off of antibiotics.

Current medications include:
     DEPAKOTE 375 mg t.i.d.
     NEURONTIN  200 mg-100 mg-300 mg

Physical exam:
     BP 112/72   P 115   HT 98.3cm   WT 22.6kg
     General: Active, alert, easily irritated child
     Skin: Remarkable for some areas of erythematous irritated skin on the lower extremities.  These are scattering in four locations.  They are the size of small peas.  Some of them are somewhat vesicular inn nature however there is some honey crusting.  Appearance compatible with a contact dermatitis
     HEENT: Palpable shunt
     Neck: Supple.  No adenopathy
     Chest: Clear throughout
     Heart: Without murmur.  S1 and S2 are normal
     Abdomen: Soft, multiple well healed surgical scars.  No organomegaly or mass
     Genitourinary: Tanner 1
     Extremities: Well formed, without edema


     Clinically, Alban continues to do well.  His most recent laboratory evaluation revealed normal renal function and unremarkable urinalysis.  At this point, I have asked Mrs. Hayakawa to continue having Alban's blood pressure done on a very sporadic basis.  In addition, I told her that we should probably check surveillance urine cultures on Ronny every six to eight weeks.  Certainly his urine should be checked sooner if he has a febrile illness of unknown etiology or if his urine appears to be infected when his mother catheterizes him.  

I spent some time discussing with the family why we would not recommend a nephrectomy at this point.  I explained to them that this is major surgery and that unless Alban were having repeated episodes of infection, the risks of surgery would certainly outweight such a drastic intervention.  They appeared to understand our rationale.

     We have asked Alban to return in six months.  Thank you for allowing us to share in Alban's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Antonio Khan, MD
               Instructor in Pediatrics


CONTENT:
Nilberto Rolf, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Rolf:

     We had the pleasure of seeing Alban in the Renal Program on 2/9/95 for hypertension/renal infarct.

     Alban comes in today with his mother and a nurse.  It has been 6 months since his last Renal Program evaluation.  During that time, Alban has been doing quite well.  His mother continues to intermittently catheterize him at home.  She reports no problems with the procedure.  She has been obtaining urine cultures periodically all of which have been negative.  She does state that Alban's urinary residuals vary from a few ccs to 100 cc.  Overall, she believes that the amount is on the lower side.

Alban was last seen in the myelodysplasia clinic 1 month ago.  At that point they had no new recommendations.  He is scheduled to have his annual renal ultrasound in the spring.

Otherwise, Alban is being enrolled in an intervention program through the Framingham public schools.  His mother is anxious for this to begin in March.  She believes that this may prove useful, especially now that Alban's seizure problem has been well controlled on his present combination of medications.

Current medications include:
     CLONIDINE HCL 1 mg b.i.d.
     DITROPAN 1 tsp b.i.d.
     DEPAKOTE 250 mg q.a.m., 250 mg q.p.m., 315 mg q.h.s.
     NEURONTIN  200 mg q.a.m., 200 mg q.p.m., 300 q.h.s.

Physical exam:
     BP 112/67   P 100   HT 99.9cm   WT 25.6kg
     General: Alert, active, easily irritated child
     Skin: Free of rash
     HEENT: Palpable shunt.  Otherwise benign
     Neck: Supple, without adenopathy
     Chest: Clear throughout
     Heart: Without murmur.  S1 and S2 are normal.  
     Abdomen: Soft.  There are multiple well healed surgical scars.  There is no organomegaly or mass
     Genitourinary: Tanner 1
     Extremities: Well formed, without edema

Laboratory studies at this time include:
          ALB         3.7    G/DL       CR          0.3   MG/DL    
          PB           <5  MCG/DL       VPA       114.7  MCG/ML (H)


     Clinically, Alban continues to do quite well.  His blood pressure measurements which have been obtained as an outpatient have all been in an acceptable range.  In addition, Alban recently had a 24 hour ambulatory blood pressure recording.  Although this is somewhat technically difficult in children in Alban's age group, the exam did proceed somewhat better than expected.  The majority of Alban's blood pressures were within normal limits, although he did have a few high readings, especially when he was due for doses of his seizure medication.  In addition, some of his higher blood pressure measurements are related to flares of his temper.  I do not believe that this study gives us objective evidence to consider anti-hypertensive therapy at this point.

I have asked Mrs. Hayakawa to continue to intermittently bring in urine samples for urine cultures.  In addition, she should keep track of Ronny's blood pressures when it is obtained on an outpatient basis and notify me if she has concerns.

     We have asked Alban to return in six months.  Thank you for allowing us to share in Alban's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Antonio J.G. Khan, MD
               Instructor in Pediatrics


CONTENT:
Hugo, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Hugo:

We had the pleasure of seeing Alban in the Endocrine Program on 2/17/95 for obesity.

History: Alban is a an almost 4 years old male with spina bifida, asthma, seizures and obesity.  He was last seen 6/20/94 at which time his thyroid function was in the low normal range.  In the interim, he has had intermittent poor appetite.  His mother notes he is thirsty "all the time".  He does not get up at night for drinking but he is immediately thirsty on awakening.  He has two bowel movements Hayakawa and is intermittently constipated.  He has gained 4 kg in the last 8 months.

Current medications: Clonidine, Carnitine, Depakote, Neuronsten, multivitamin.

Physical exam:  
Height: 99.3 cm         Weight: 26.4 kg         Pulse: 90               
General: Obese, active male.
Skin:  Cold skin, dry.
HEENT: Dry lips.
Neck: No thyromegaly.   No adenopathy.
Abdomen: Liver 3 cm below right costal margin.

Laboratory studies:  urine osmolality 503 mOsm/k, K 4.1 mmol/L, NA  142 mmol/L, urine sodium 90 mmol/L, T4 10.9 ug/dL, TSH 6.10 uU/mL, prolactin 6.80 ng/mL,  glycosylated hemoglobin 6.7%

Impression: Continued obesity with high caloric intake, especially from frequent fruit juice.  Frequent thirst is of concern and we obtained screening studies.  

I am also screening again for hypothyroidism, given prior borderline values.

Disposition: If all studies are normal, we only need to recheck Alban's status in one year.
Thank you for letting us share in the care of Alban.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Addendum: Alban's thyroid function studies are still within the normal range.   Since he was not given a formal water deprivation test, we cannot rule-out diabetes insipidus as a cause of his increased thirst and if it progresses, we should consider such testing.


CONTENT:
Gayla Brezny, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Brezny:

     We had the pleasure of seeing Alban in the Renal Program on 8/24/95 for renal inferct.
     Alban comes in today with his mother.  It has been approximately six months since his last Renal Program evaluation.   During that time, Alban has been doing well.  He continues in an intervention program and his mother is quite pleased with his progress.   This summer, he has been also attending a camp and has been doing lots of swimming and water activities.  He was seen in Myelo Clinic last week.  His checkup was unremarkable including a serum creatinine of 0.5,  a BUN of 14, and a negative urine culture.  Alban had an interval renal ultrasound done one month ago which showed his left kidney was 9.8 cm. and his right kidney was unchanged in its diminutive size of 3.5 cm.   There was no evidence of hydronephrosis or obstruction.

His current medications include:
     Clonidine 1mg patch q.d.
     Clonidine 0.1mg -1/4 pill b.i.d.
     Ditropan b.i.d.
     Neurontin 200 q a.m., 200 q p.m., 300 q h.s.
     Depakote 250 q a.m., 250 q p.m., 315 q h.s.

Alban's physical exam was notable for:
     BP 107/77   P 91   R    T    HT 103.2cm   WT 27.3kg
     General: Alert, active child in no distress.   
     HEENT:  Remarkable for a palpable shunt.  Alban is also wearing glasses.  
     Neck:  Supple without thyromegaly or adenopathy.   
     Chest: Configuration excursion is normal.  
     Lungs:  Clear to auscultation.  
     Cardiac:  Without murmur.  S1 and S2 are normal.  Pulses are full.  
     Abdomen:  Soft.  There is no organomegaly or mass.  
     GU:   Tanner 1.  
     Extremities:  Well formed.  
     Skin:  Remarkable for multiple surgical scars which are healed on the upper chest, abdomen, and the lumbar spine.
A urinalysis revealed:
     SPEC GR UA  1.022           RBC/HPF     0          
     PH UA       6               WBC/HPF     0          
     BLOOD UA    Neg.            SQUAM EPI   0          
     PROTEIN UA  Tr             BACTERIA    Neg.  
     GLUCOSE UA  Neg.       

Laboratory studies at this time include:


     Overall, Alban continues to do well.  He is maintaining normal renal function and has normal blood pressure.  His renal ultrasound shows good parenchyma on his normal left kidney and no significant changes in theright kidney.   

At this point, I would recommend no changes with Alban's regimen.   He needs to continue to be intermittently monitored.   I did discuss with his mother that the clonidine which is being used for Alban's behavior may have a  blood pressure effect.  If the clonidine were to be discontinued by the behavioral therapist, it would probably be best if it were slowly weaned to minimize the potential for rebound hypertension.

     Thank you for the opportunity to participate in Alban's care.  We would like to review him in Six months.  In the interim, we would be happy to discuss or review Alban should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Instructor in Pediatrics


CONTENT:
Gayla Brezny, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Brezny:

I saw Alban in the Endocrine Program on 8/21/95 for follow up of obesity.

History: Alban is a 4-5/12 year old male last seen  on 02/17/95 for evaluation of obesity.  He has not had any seizures in  the last year and has had an uneventful interval history.  He is still  not toilet-trained and is said to have a neurogenic bladder.  His mother  notes that she has been using less undiluted fruit juice.

Current medications: Clonidine patch, carnitine, Depakote, Neurontin,  multivitamins, Ditropan, Vanceril inhaler.

Physical exam:  
Height: 103.2 cm        Weight: 27.2 kg         
BP: 105/70              Pulse: 88               
General appearance:  Active, slightly overweight child.  Skin  warm.  HEENT:  Pupils equal, round and reactive to light.  Neck:  No  thyromegaly.  Chest clear.  Heart:  Regular rate and rhythm.  Abdomen:   Liver down 2 cm below the right costal margin.  Genitourinary:   Prepubertal exam.  Extremities:  No edema.

Impression: Alban's weight gain has decelerated with the last dietary  change.  This is very encouraging.  Consequently there is no need for a  repeat thyroid function test at this visit.

Disposition: I would like to see Alban in 12 months to follow his  growth and possibly to obtain another thyroid function test.


Sincerely,




Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Gayla Brezny, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Brezny:

     We had the pleasure of seeing Alban in the Renal Program on 2/8/96 for hypertension/ renal infarct.
     
Alban comes in today with his mother and home health care provider.  It  has been approximately 6 months since his last Renal program evaluation.   During that time, Alban has generally been doing well.  He has had no  episodes of urinary tract infection.  He continues being intermittently  catheterized during the Hayakawa.  He has maintenance urine cultures done  every 2 to 4 weeks, all of which have been normal.  His blood pressures  at home have been in the 120 to 130/60 to 70 range.  Mrs. Hayakawa tells me  that these readings have been consistent since the enalapril was  initiated. 

Alban was last seen in the Myelodysplasia Clinic approximately 3 months  ago.  At that point, intravesicular installation of Ditropan was  initiated on a twice-a-Hayakawa schedule to see if changes in the bladder  function could be accomplished.  Mrs. Hayakawa has noticed that Alban seems  to be somewhat drier at times.  The frequency of the Ditropan has just  been increased to 3 times a Hayakawa. 

Otherwise, Alban has had several exacerbations of his asthma.  He has  been on several short bursts of steroids.  He uses albuterol frequently  as well.  While he is on the albuterol steroids the family has noticed  that his blood pressures tend to be somewhat higher but still in the  aforementioned range.

His current medications include:
     ENALAPRIL MALEATE 5 mg po b.i.d.
     DEPAKOTE  250-125-250
     NEURONTON 300-200-300
     DITROPAN  5 mg-2.5 mg--5 mg intravesically
     VANCERIL 3 puffs t.i.d.
     CARNITINE 50 mg b.i.d.
     RITALIN 5 mg up to t.i.d.

Alban's physical exam was notable for:
     BP 134/68   P 123   R    T    HT 107.3cm   WT 26.3kg
     General:  Alert, active child sitting in his stroller.   
     HEENT: remarkable for a palpable external shunt.  The TM's are clear.  The oropharynx is unremarkable.  
     Neck: supple without  thyromegaly or adenopathy.  
     CHEST: The configuration and excursion of the chest is normal.  Lungs show occasional rhonchi, there are no rales or wheezes.  
     Cardiac: with soft Grade I/VI systolic murmur without radiation.  S1 and S2 appear normal.  
     Abdomen: soft.   There are small healed surgical scars.  There is no hepatosplenomegaly or mass.  
     Extremities: without edema.
A urinalysis revealed:

     Did not void.

Laboratory studies at this time include:
          AST          12     U/L       RDW        14.0       %    
          CR          0.3   MG/DL       HDW        2.96    G/DL    
          FE           85  MCG/DL       PLT UNC     409   K/MM3 (H)
          NH3          34  MCG/DL       NEUT AB    7.69   K/MM3    
          ALT          12     U/L       LYMPH A    1.98   K/MM3    
          BUN          11   MG/DL       EOS ABS     .02   K/MM3    
          VPA       123.0  MCG/ML (H)   NEUT-A     73.6       % (H)
          WBC       10.44   K/MM3       LYMPH-A    19.0       % (L)
          RBC        4.24   M/MM3       MONO-A      5.4       %    
          HGB        13.2    G/DL       EOS-A        .2       %    
          HCT.       38.1       %       BASO-A       .2       %    
          MCV        89.9      FL       ATYP LY     1.6       %    
          MCH        31.1      PG       LEFT SH  ABSENT    
          MCHC       34.6    G/DL       NEURONT    2.50  MCG/ML    

     Alban appears to be doing well clinically.  His blood pressures are much better controlled on his current dose of enalapril.  He does tend to run a somewhat high systolic pressure but I do not believe that we need to change his medication regimen at this point.  If his systolics were to consistently run greater than 140, then I ask the family to contact me so we could discuss our options. 

I would like to see Mrs. Hayakawa to continue doing intermittent urine culture maintenance screens.  She should continue checking Alban's blood pressure on a regular basis.

     Thank you for the opportunity to participate in Alban's care.  We would like to review him in six months.  In the interim, we would be happy to discuss or review Alban should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Gayla Brezny, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Brezny:

Alban is a 5 and 6/12 year old boy who has seizure disorder, neurogenic bladder and bowel.  In August 1996 he had appendicostomy to irrigate his bowel.  He has had several seizures over the past year.  He has also been noted to have renal stenosis with hypertension for which he has been started on enalapril.  Otherwise his interval history is unremarkable.  The mother notes that he has not changed his appetite or eating pattern since his last visit, but is  perhaps more active.

Current medications: Clonidine p.r.n., Ritalin 1-3x a Hayakawa, Depakote, Neurontin,  Ditropan, enalapril.

Physical exam:
WT: 25.2 kg      BP: 120/70              
This is a comfortable male in no apparent distress.  Skin is warm.  HEENT shows pupils were equal, round, and reactive to light.  Neck has no thyromegaly.  Chest clear to auscultation.  Abdomen without hepatosplenomegaly.  GU is prepubertal.

Impression: Alban appears to be doing reasonably well.  Of note, he has lost 2 kg. since his last visit a year ago which is quite surprising given the fact that he has not changed in his eating pattern.  This might be due to changes in his bowel habits.

Disposition: I would like to recheck his thyroid function tests and to see him again in one year.



Sincerely,




Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Gayla Brezny, M.D.          RE: Alban Hayakawa
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/91

Dear Dr. Brezny:

We had the pleasure of seeing Alban in the Renal Program on 1/2/97 for hypertension.
Alban comes in today with his mother and visiting nurse.  Since his  last renal program evaluation, Alban had generally been doing well.   Approximately one month ago, he did develop a urinary tract infection  which was treated with Bactrim.  A subsequent urine culture was  negative.  Since that time, however, Alban has had some fluctuations in  his blood pressure.  He has had lots of systolic blood pressures in the  130-140 range.  The majority of his diastolic pressures have been in the  60-70 range although for a short period of time he was actually running  diastolics that were persistently in the 80-90 range.  At that point,  his morning dose of Enalapril was increased to 7.5 mg and the family  believes there may have been a slight response since then.  

Alban has had several episodes where he has become quite flush and this  is concomitant with very high blood pressure readings of  150-180/100-120.  He has responded slightly to sublingual nifedipine when these episodes have occured. 

Otherwise, there have been no significant changes in Alban's medical  profile.  He continues to take his anti-convulsant medications and has  had good levels on recent exams. His appendiceal stoma is functioning  quite nicely and the family is happy with his bowel cleanout regimen.  The mother continues to intermittently catheterize Alban but he dribbles in between catheterizations.

His current medications include:
     DEPAKENE 250 mg b.i.d.
     DEPAKENE 125 mg q.p.m.
     DITROPAN 5 mg t.i.d.
     ENALAPRIL MALEATE 7.5 mg q.a.m.
     ENALAPRIL MALEATE 5 mg q.p.m.
     CLONIDINE HCL 0.1 mg q.h.s.
     RITALIN SR 20 q.d.
     CARNITINE 1/2 tsp b.i.d.
     INTAL inhaler b.i.d.
     NEURONTIN 400 mg t.i.d.

Alban's physical exam was notable for:
     BP /   P    R    T    HT 111.8cm   WT 24.9kg
     On physical examination, Alban was an alert and active child in no  distress.  
     HEENT exam was unremarkable.  
     Neck was supple.  Shunt tubing  is palpable in the right neck.  
     Chest was clear throughout.  
     Cardiac  exam was without murmur.  
     Abdomen was soft without organomegaly or  mass.  There was a bandage present over the right upper quadrant.   
     Extremities were normal.
The etiology of Alban's increased blood pressure is somewhat unclear to  me.  It may all be related to his recent urinary tract infection and we  are just seeing a flare which can sometimes occur.  Generally, this is  the case when there is a pyelonephritis but Alban did not have symptoms  completely compatible with an upper tract infection one month ago.  His  dose of Enalapril has been the same for some time but he has not had  significant weight gain, so it is unlikely that he has outgrown his dose  of medication.  His blood pressures have responded somewhat to  increasing his Enalapril dose and I did advise his mother to increase  the dose to 7.5 mg twice a Hayakawa and to assess his blood pressures on a  daily basis.   

In addition, I believe it would be worthwhile for us to re-assess the parenchyme of Alban's left kidney with a renal ultrasound.  The  angiography which was performed approximately two years ago did reveal  an area of probable stenosis in the non-infarcted kidney.  I doubt that  there has been a significant change in this finding, but we would like to be able to document a continued normal echo appearance of this kidney.   

Moreover, since the family has described several episodes of flushing  accompanied by very high blood pressure readings, I believe it would be  worthwhile for us to obtain a urine collection for catecholamines and VMA.  Although I believe it is unlikely that Alban has a  pheochromocytoma, his symptoms may be suggestive of such a process and a urinary collection could help us eliminate this diagnosis as a concern.   

I spent some time discussing my advice regarding increasing the  Enalapril therapy and obtaining these further tests with Alban's  mother.  She is going to attempt to do the collection within the next two weeks and also to obtain the ultrasound during an interval visit to the hospital scheduled in one week's time.  In the meantime, I have  asked her to contact me if Alban's blood pressure were to show diastolic pressures significantly greater than 90.

Thank you for the opportunity to participate in Alban's care.  We would like to review him in six months. In the interim, we would be happy to discuss or review Alban should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


cc:
Nedda Hobbs, M.D.
Birth Defects, Fegan 10
Children's Hospital
Boston, MA 02115


CONTENT:
Montse Simpson, M.D.          RE: Eddie Swinton
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/29/79

Dear Dr. Simpson:

We had the pleasure of seeing Eddie in the Endocrine Program on 10/12/92 for evaluation of gynocomastia.

History: Eddie is a 13 year old white male who presents today with increased development of both breasts which began approximately 3-4 years ago. Eddie's mother states that she was not concerned of her breast development initially, attributing it to Eddie's obesity, but now she has become more concerned. Eddie admits to having mild tenderness to the breast area but denies any pain or discharge.  Eddie's gynecomastia appears to be causing him some psychological distress.

Current medications: None.

Past medical history:  Eddie has fractured his left tibia and fibula during a motor vehicle accident approximately two years ago, has no other past medical history. He is the product of a  full term, normal spontaneous vaginal delivery. His mother states that his growth was normal till approximately 6-7 years of age, but since then Eddie has always been over the 95th percentile in both height and weight.

Review of systems:  There is no history of headaches, diarrhea, or constipation. Mrs. Swinton states that Eddie drinks lots of fluids but denies any polyuria. He does not use or need deodorant at this time.

Family history:  There is no family history of gynecomastia, delayed or precocious puberty. His maternal grandfather has a history of hyperparathyroidism. Mother's height is 5'6.5". Father's height is 6'1".

Physical exam:  
Height: 167.9 cm        Weight: 76.8 kg         BP: 120/62              
Pulse: 75               U/L ratio:  0.82        Arm span: 175           
Breast: Tanner III      Pubic hair: Tanner II   R. testis: 3.2 x 1.4 cm 
L. testis: 3.1 x 1.4 cm Phallus length: 6.5 cm  Mid-shaft diam.: 2 cm   
General:  Eddie is a well developed, well nourished white male. 
Skin:  No lesions. 
HEENT: Atraumatic, normocephalic. Pupils were equally reactive to light. His fundi were sharp bilaterally. His visual fields were grossly intact. 
Neck: Supple, no thyromegaly. 
Chest: Clear to auscultation. 
Heart: Regular rate, and rhythm. Negative murmurs, gallops, or rubs. S1, S2 normal. 
Abdomen: Soft, mildly obese. No tenderness, positive bowel sounds. No hepatosplenomegaly.
Genitourinary: Negative testicular masses noted. 
Extremities: Free range of motion. Good tone. 
Neurological: Alert and active, no focal deficits. 
Breast Exam: Enlarged bilateral breast tissue. His left breast measured 5 cm x 5 cm. His right 4 x 4. Nipple diameter approximately 5 mm.

Impression: Our impression is that Eddie's gynecomastia is due to pubertal changes.  However, it is important to rule out other possible causes of his breast development.  This includes estrogen producing tumors, Klinefelter's and partial testicular feminization.  These causes are highly unlikely but laboratory studies including estrogen, estradiol, testosterone, FSH, T4 and DHEA were drawn to exclude these possibilities.

One other aspect of Eddie's problem must also be addressed.  He appears to be having some psychological difficulties because of his accelerated breast development and this may cause long lasting stresses.  This was discussed with Eddie and his mother.  His mother appeared to diminish this aspect of his problem but Eddie appeared concerned and receptive to correction of his gynecomastia.  The surgeons at Children's Hospital have considerable experience in performing corrective surgery in his age group.

Thank you for letting us share in the care of Eddie.

Sincerely,


Mitsuko Leary, MD           Lancelot Blue, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Hamud Swartzenegger, M.D.          RE: Howie Burgess
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/25/85

Dear Dr. Swartzenegger:

We had the pleasure of seeing Howie in our Endocrine Program on 07/29/91 for evaluation of gynecomastia.

History: Howie is a 6 and 4/12 year old white male last seen on 4/11/91 for right sided gynecomastia.  At that time, he had had acne for one month with no changes in body odor and had also complained of mild constipation.  Since his visit, the gynecomastia has varied in size, but overall, has shown regression.  Howie has daily bowel movements, is very active, and does not complain of heat or cold intolerance, nor does he complain of nocturia.

Current medications: None.

Family history:  In addition to the history revealed to us on the initial visit, his mother reports that there are two paternal great aunts, one paternal grandmother, a maternal grandmother and two maternal great aunts, all who have unspecified forms of thyroid disease.

Physical exam:  
Height: 123.7 cm    Weight: 24.8 kg         BP: 98/60
Pulse: 79           Pubic hair Tanner: 1    
R. testis: 2.1 x 1.1 cm           L. testis: 2.1 x 1.1 cm 
Penile stretch length: 6.8 cm     Mid-shaft diam.: 1.9 cm 
Active male in no apparent distress.  Skin without lesions.  HEENT two missing front incisors.  Neck no thyromegaly.  Chest pectus excavatum.  Right sided nipple was "pouted" and the breast tissue measured 1.1 x 1.2cm.  The nipple was slightly hyperpigmented.  There was no breast tissue palpable on the left.  Heart exam regular rate and rhythm and no murmur.  Abdominal exam no hepatosplenomegaly.  GU exam was unremarkable.  Extremities were without deformity or cyanosis, clubbing, or edema.  Neurologic exam was unremarkable.

Laboratory studies:
On 4/11/91 IGF-1 0.66u/ml, 17 OH Progesterone 25ng/dl, 17 OH Pregnenolane 25ng/dl, DHEAS 10mcg/dl, DHA 10ng/dl, androstenedione less than 10ng/dl, LH less than 0.12MIU/ml, FSH 1.1mIU/ml, prolactin 4.3ng/ml, estrone 1ng/dl, estradiol less than 2pg/ml, testosterone less than 20pg/ml, and a bone age at that time was 6 years.  All are normal prepubertal levels.

In summary: Howie is a 6 and 4/12 year old with right sided gynecomastia, which has regressed somewhat since the last visit.  His testicular size has somewhat decreased and his mid-shaft diameter and stretch penile length have somewhat increased since his last visit.  The variations in these measurements suggest that it is possible that there is intermittent centrally driven process which is causing his testicles to intermittently produce sex steroids.  Given his normal endocrine values, it is clear that, even if this process is intermittent, it was not operating at the time these values were obtained.

Disposition: Unless Howie shows signs of pubertal progression, we would like to see him in three months for further evaluation.  If he shows any progression prior to that time, or at the time of that visit, if he shows further development of gynecomastia or phallic enlargement, we will organize a imaging study of his central nervous system.

Thank you for letting us share in the care of Howie.

Sincerely,


Lancelot Blue, MD                      Mitsuko F. Simpson, Jr., MD
Fellow in Endocrinology               Chief, Emeritus

IK/JFC/smp


CONTENT:
Hamud Swartzenegger, M.D.          RE: Howie Burgess
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/25/85

Dear Dr. Swartzenegger:

We had the pleasure of seeing Howie in the Endocrine Program on 11/7/91 for evaluation of gynecomastia.

History: Howie is a 6 and 7/12 year old male who has been followed in our clinic for gynecomastia.  He was last seen on 7/29/91.  At that time his adrenal hormone profile as well as his gonadotropins had been prepubertal.  Since his last visit, his gynecomastia has further regressed such as that it is currently barely conceptual according to the parents.  There has been no onset of body odor nor has there been acne.  Patient also denies nocturia, headaches or constipation.

Physical exam:  
Height: 125.8 cm        Weight: 26.5 kg         BP: 95/55               
Pulse: 90               Pubic hair Tanner: 1    R. testis: 2.3 x 1.0 cm 
L. testis: 2.3 x 1.1 cm Phallus length: 6.7 cm  Mid-shaft diam.: 1.8 cm 
General: 
Skin: No lesions.  
HEENT: Two front upper incisors have errupted since the last visit.
Chest: Gynecomastia is no longer appreciable.
Genitourinary: Prepubertal.
Extremities: No deformities.
Neurological: Nonfocal.

In summary: Howie has shown complete resolution of his gynecomastia.  There has been no further increase in the size of his genitalia, and his growth shows no further acceleration.  Therefore, it seems likely that whatever process caused him to have gynceomastia and possibly some acceleration of height is no longer active.

Disposition: We do not feel that he requires any specific testing at this time and would very much like to monitor him at 6 month intervals to ensure that he does have reactivation of whatever process was causing his transient gynecomastia

Thank you for letting us share in the care of Howie.

Sincerely,


Lancelot Blue, MD             Etta Kramer, MD           
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Hamud Swartzenegger, M.D.          RE: Howie Burgess
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/25/85

Dear Dr. Swartzenegger:

We had the pleasure of seeing Howie in the Endocrine Program on 11/7/91 for evaluation of gynecomastia.

History: Howie is a 6 and 7/12 year old male who has been followed in our clinic for gynecomastia.  He was last seen on 7/29/91.  At that time his adrenal hormone profile as well as his gonadotropins had been prepubertal.  Since his last visit, his gynecomastia has further regressed such that it is currently barely noticeable according to the parents.  There has been no onset of body odor nor has there been acne.  Patient also denies nocturia, headaches or constipation.

Physical exam:  
Height: 125.8 cm        Weight: 26.5 kg         BP: 95/55               
Pulse: 90               Pubic hair Tanner: 1    R. testis: 2.3 x 1.0 cm 
L. testis: 2.3 x 1.1 cm Phallus length: 6.7 cm  Mid-shaft diam.: 1.8 cm 
General: 
Skin: No lesions.  
HEENT: Two front upper incisors have errupted since the last visit.
Chest: Gynecomastia is no longer appreciable.
Genitourinary: Prepubertal.
Extremities: No deformities.
Neurological: Nonfocal.

In summary: Howie has shown complete resolution of his gynecomastia.  There has been no further increase in the size of his genitalia, and his growth shows no further acceleration.  Therefore, it seems likely that whatever process caused him to have gynceomastia and possibly some acceleration of height is no longer active.

Disposition: We do not feel that he requires any specific testing at this time and would very much like to monitor him at 6 month intervals to ensure that he does have reactivation of whatever process was causing his transient gynecomastia

Thank you for letting us share in the care of Howie.

Sincerely,


Lancelot Blue, MD             Etta Kramer, MD           
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Hamud Swartzenegger, M.D.          RE: Howie Burgess
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/25/85

Dear Dr. Swartzenegger:

We had the pleasure of seeing Howie in the Endocrine Program on 05/18/92 for follow-up evaluation of gynecomastia.

History: Howie is a seven and 2/12 year old male who was last seen on 11/07/91 for follow-up of evaluation of gynecomastia.  Since his last visit there has been further regression of his gynecomastia such that it is now almost imperceptible.  Since his last visit, his weight has increased by about 2 kg and his mother does note increased appetite.  Bowel movements are daily.  He occasionally has nocturia, and rare headaches.  He denies body odor, pubic hair or acne.

Current medications: None.

Family history:  Howie's father was recently found to have Gilberts syndrome.

Physical exam:  
Height: 129 cm          Weight: 28.3 kg         BP: 100/75              
Pulse: 80               Pubic hair: Tanner I    R. testis: 2.3 x 1.2 cm 
L. testis: 2.2 x 1.1 cm Phallus length: 7.2 cm  Mid-shaft diam.: 1.9 cm 
General: Comfortable male in no acute distress.
Skin: Unremarkable. 
HEENT: No thyromegaly.
Chest: Residual 0.7 cm mass behind right nipple.
Heart: Regular rate and rhythm. 
Abdomen: No hepatosplenomegaly.
Genitourinary: Prepubertal to early pubertal male.  
Neurological: Non-focal exam.

Laboratory studies:  hCG < 5 mIU/mL;  bone age 6 years (essentially unchanged from nine months ago).

Impression: Howie is a 7 and 2/12 year old male with minimal gynecomastia that waxes and wanes.  Given the prior workup and lack of height acceleration, we feel that it is unlikely that Howie has an endocrinopathy such as precocious puberty.

Disposition: We would like to see Howie back in the Endocrinology Clinic in six months.
Thank you for letting us share in the care of Howie.

Sincerely,


Lancelot Blue, MD             Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology   


Problem list to date:
GYNECOMASTIA                 Start: 05/18/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Consuelo Romanov, M.D.          RE: Mill Ruth
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/01/91

Dear Dr. Romanov:

We had the pleasure of seeing Mill in the Endocrine Program on 7/15/93 for evaluation of obesity.

History: Mill is a 2 year and 5 month old boy who born after a normal pregnancy at 39 weeks gestation and weighed 9 lbs. 1 oz at birth.  He has always been overweight.  For the last month, he had been following a diet suggested by a nutritionist without much appreciable weight change.  Mill has had a number of other medical problems which have raised the diagnosis of Bardet-Biedl syndrome.  These include polydactyly with a extra finger on the lateral side of both hands and an extra toe on his right foot laterally; and developmental delay.  He has been seen at the Birth Defects Clinic.  His other past medical history includes chronic otitis media for which he will undergo surgery, sleep apnea with adenotonsillar hypertrophy and asthma.  He has only taken intermittent Ventolin for his asthma.

Family history:  He has two siblings ages 5 and 13 years old, both whom are well.  His family history is significant for polydactyly in a paternal great-aunt and in a maternal cousin.  He also has some paternal relatives who are obese, one of whom has diabetes.  His mother's height is 5'4", father's height is 5'6".

Physical exam:  
Height: 103.2 cm        Weight: 29.4 kg         BP: 105/                
Pulse: 98               U/L ratio:  0.97        Arm span: 103           
R. testis: 1.9 x 0.9 cm L. testis: 1.9 x 1.1 cm Phallus length: 5.4 cm  
Mid-shaft diam.: 1.2 cm 
General: Obese young boy who was very irritable and somewhat difficult to exam.  His obesity is generalized. Skin: He had some acanthosis nigricans at the base of his neck. HEENT: Head circumference:  53.5 cm.  Fundoscopic exam was unable to be performed.   Neck: No thyromegaly. Chest: Clear. Heart: Regular rate. Abdomen: No hepatomegaly. Genitourinary: Prepubertal male. Extremities: Extra finger adjacent to the 5th finger bilaterally and an extra toe on the lateral side of his foot.

Impression: Our impression is that his obesity is most likely part of his overall syndrome, possibly Bardet-Biedl syndrome which is associated with obesity, developmental delay and polydactyly.  It is most unlikely that the obesity be due to other endocrine causes such as hypothyroidism or Cushing disease as his height has been progressing.  However, insulin resistance can be associated with the above syndrome and today a glycosylated hemoglobin was ordered as well as thyroid function tests to rule out hypothyroidism.  His parents were advised to continue as best as they could with keeping him on a strict diet and continue to be followed by a nutritionist.  Insulin resistance should be watched for over the following years.  No further endocrine follow-up is planned unless any abnormalities should show on the investigations ordered.

Thank you for letting us share in the care of Mill.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Addendum: Jackie Center, M.D.
Fellow in Endocrinology

Laboratories studies were unremarkable.


CONTENT:
Owen Brezny, M.D.          RE: Eric Games
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/89

Dear Dr. Brezny:

As we discussed on the phone, I have reviewed the data which was sent ton Eric Games from the Emergency Room on November 18, 1991.  As I explained to you, the Endocrine Service was not consulted while he was in the Emergency Department but rather labs were obtained and an oral glucose tolerance test was arranged for his history of glycosuria.  The test results are as follows:

                                       time         glucose    insulin
1. oral glucose tolerance test:     -30 minutes       62          9.3
                                     -1 minute        51          7.3
                                     -0 minutes   1.75 g/kg of glucose po
                                    +15 minutes       97         15.6
                                    +30 minutes      144         23.3
                                    +45 minutes      163         50.2
                                    +60 minutes      155         44.4
                                    +90 minutes      114         23.1
                                    +120 minutes      91         45.5

Interpretation:  This is a normal oral glucose tolerance test.

2.  glycosylated hemoglobin  was 8.2% (normal range 5.6-7.6%).  
    Interpretation:  This is slightly elevated; given his normal oral 
    gluocse tolerance test, further work-up should be undertaken including 
    a hemoglobin electropheresis.
3.  Anti-islet cell and anti-insulin antibodies: pending.
4.  Urine amino acids:  There was a mild increase in serine valine,   
    tyrosine, phenylalaline, histidine.  These were felt to be quite mild 
    and nonspecific and probably normal.  
5.  Urine studies to rule out a proximal tubular defect: 
    a) calcium to creatinine ratio was .24 (upper limit of normal
       for age);
    b) tubular resorption of phosphorus: 77% (this is at the lower limit 
       of normal, suggesting high normal phophaturia); 
    c) serum calcium was 10.6, serum phosphorus was 5.5, and serum 
       creatinine was 0.4 on the day of his evaluation.
           
In summary it seems that Eric has normal metabolic studies including oral glucose tolerance test, urine amino acids, and calcium and phosphorus metabolism.  However, his total glycosylated hemoglobin is a very mildly elevated; therefore we suggest further work-up of this abnormality including a hemoglobin electropheresis.  

Thank you very much and I hope that this summary is helpful.

Sincerely,


Antonio Capulet, MD                    Kendell Simpson, MD             
Fellow in Endocrinology             Clinical Director


CONTENT:
Yan Plato, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Plato:

We had the pleasure of seeing Maxine in the Renal Transplant Program on May 10, 1994.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on September 3, 1992.

Maxine is doing well and has no new problems.

Current medications include: CYCLOSPORINE 60 mg t.i.d., IMURAN 25 mg q.d. and
PREDNISONE 6 mg q.o.d.


Physical exam:
     BP 123/69     P 114     R 20   HT 92cm     WT 13.9kg
     HEENT: mouth was clear.  TM's were normal.
     Neck: supple with no adenopathy
     Chest: clear
     Heart: regular rate and rhythm
     Abdomen: soft nontender
     Extremities: no edema

Urinalysis:
          SPEC GR UA  1.018                PH UA       5          
          PROTEIN UA  N                    GLUCOSE UA  N     mg/dl
          BLOOD UA    N                    WBC ENZ UA  N          
          RBC/HPF     0     /HPF           WBC/HPF     0     /HPF 
          WBC CAST    0     /LPF           RBC CAST    0     /LPF 
          GRAN CAST   0     /LPF           WAXY CAST   0     /LPF 
          Squamous Epithelial 0-1
          Leucocyte Esterase N


Laboratory studies at this time include:
          BUN 40       Cr 0.4       K 4.9        Ca 10.2       PO4 4.7
          Na 138       Cl 106       GLUC 81      CYA 90
          WBC 7.89     HGB 11.1     HCT 33.4     MCV 82.2      PLT 454
          N 77.4       L 17.9       B .3         ABS N 6.11
         
Maxine continues to do well post transplant.  Due to her increased weight we will increase her Prednisone to 7 mg q.o.d.

She will return in one month.

Thank you for allowing us to assist in the care of Maxine.

Sincerely,


Kinze Brando, MD               
Assistant in Nephrology


CONTENT:
Yan Plato, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Plato:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, June 14, 1994.  She has chronic renal failure secondary to .  She had a renal transplant on .
     Maxine has been feeling well since her last visit here to our clinic.  She currently has no complaints.

Current medications include:
     CYCLOSPORINE 60 mg t.i.d.
     IMURAN 25 mg q.d.
     PREDNISONE 7 mg po q.o.d.


Physical exam:
     BP 121/82   P 114   R 20   T    HT 92.7cm   WT 14.2kg   HC cm
     HEENT: oropharynx is clear and moist.  Her nares has some clear rhinnohrea 
     Neck: supple without masses
     Chest: clear to auscultation
     Heart: regular rate and rhythm
     Abdomen: soft with no tenderness or bruit over the graft site
     Extremities: no peripheral edema.

Urinalysis:
     SPEC GR UA  1.020           PH UA       5          
     PROTEIN UA  N               GLUCOSE UA  N     mg/dl
     BLOOD UA    N               WBC ENZ UA  N          
     RBC/HPF     0     /HPF      WBC/HPF     0     /HPF 
     WBC CAST    0     /LPF      RBC CAST    0     /LPF 
     GRAN CAST   0     /LPF      WAXY CAST   0     /LPF 


Laboratory studies at this time include:
          BUN 32  Cr 0.3  K  4.8  Ca 9.6  PO4 5.0  
          Na 138        Cl 106       GLUC 82        CYA 138 
          WBC 8.99      HGB 11.5       HCT 32.0       MCV 80.5      PLT 439
          N 46.3            L 44.4           B .3           ABS N 4.16
          HYALINE CAST 2-5

     Maxine has been feeling well since her last visit here, she continues to have a mild URI symptoms.

     We have asked Maxine to return in .

     Thank you for allowing us share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Thilo Beaker, MD            Kinze Brando, MD
               Renal Fellow                 Assistant in Nephrology


CONTENT:
Yan Plato, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Plato:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, July 19, 1994.  She has chronic renal failure secondary to .  She had a renal transplant on .
     Maxine has done well since her last visit.  She has no complaints.

Current medications include:
     CYCLOSPORINE 60 mg   t.i.d.
     IMURAN 25 mg   q.d.
     PREDNISONE 7 mg   q.o.d.


Physical exam:
     BP 115/75   P 76   R 20   T    HT 93.4cm   WT 14.7kg   HC cm
     General: mildly hirsute
     HEENT: normal 
     Neck: supple no masses, lymph nodes not palpable
     Chest: clear
     Heart: two heart sounds with no murmurs
     Abdomen: soft, kidney nontender with no murmur.
     Extremities: no edema

Urinalysis:
     SPEC GR UA  1.015           WBC ENZ UA  N          
     PH UA       5               PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N          
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   1+              BACTERIA    N     


Laboratory studies at this time include:
          BUN 37    Cr 0.5   K 5.2    Ca 9.7    PO4 4.5
          Na 138    Cl 106    GLUC 70    ALB 3.8    CYA 137
          WBC 5.70    HGB 11.3    HCT 32.2    MCV 81.2    PLT 363
          N 53.4    L 37.8    B .4    ABS N 3.05

     Maxine is doing well.  Her renal function is stable and her growth is excellent.

     We have asked Maxine to return in .

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Giancarlo Piggy, MD        Clotilde Goldwater, MD


CONTENT:
Yan Plato, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Plato:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, August 16, 1994.  She has chronic renal failure secondary to glomerulocystic disease.  She had a renal transplant on September 3, 1992.
     Maxine has done well since her last visit.  She had fever and upper respiratory tract symptoms last week.  These seem to be resolving without treatment.

Current medications include:
     CYCLOSPORINE 60 mg   t.i.d.
     IMURAN 25 mg   q.d.
     PREDNISONE 7 mg   q.o.d.


Physical exam:
     BP 118/59   P 86   HT 93.9cm   WT 14kg
     General: active and playful
     Skin: warm and well profused
     HEENT: moist mucous membranes.  Positive nasal congestion.  Mildly hirsute.
     Chest: clear 
     Heart: regular rate and rhythm without murmurs, gallops, or rubs
     Abdomen: soft non-tender and non-distended without organomegaly or graft tenderness.
     Extremities: no clubbing cyanosis or edema

Urinalysis:
     SPEC GR UA  1.013           WBC ENZ UA  N          
     PH UA       6.5             PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N          
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
     BUN 45 CR 0.7 NA 139 K 3.8 CL 105
     GLU 100 CA 9.2 PO4 3.9 CYA 99
     WBC 5.59 HCT 34.7 HGB 11.5 MCV 84.1 PLT 335
     N 46 L 40 ABS N 2.68

     Maxine is doing well.  Her URI symptoms are resolving.  No major complaints since last visit.  Repeat BUN and creatinine on 8/18/94 were lower at 27 and 0.6 respectively.  The increase likely reflected volume depletion with her intercurrent illness.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Yan Plato, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Plato:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Thursday, August 18, 1994.  She has chronic renal failure secondary to glomerulocystic disease.  She had a renal transplant on September 3, 1992.
     Maxine has had a persistent upper respiratory tract infection since last weekend.  The parents were concerned because she has decreased po intake and more concentrated looking urine.  She also had a fever to 102 at home.  Activity has been pretty good in the morning although she has decreased activity at night.  There has been no history of vomiting or diarrhea.

Current medications include:
     CYCLOSPORINE 60 mg   t.i.d.
     IMURAN 25 mg   q.d.
     PREDNISONE 7 mg   q.o.d.


Physical exam:
     BP 112/73   P 148     T 37      WT 14.1kg   
     General: healthy and active
     HEENT: moist mucous membranes.  Positive nasal congestion.  TM's clear bilaterally.  Throat clear without exudate.
     Chest: clear 
     Heart: regular rate and rhythm without murmurs, gallops, or rubs
     Abdomen: soft non-tender and non-distended without any masses
     Extremities: warm and well profused

Urinalysis:
     SPEC GR UA  1.021           WBC ENZ UA  N          
     PH UA       6.0             PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N          
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
     BUN 27 CR 0.6 NA 136 K 5.3 CL101
     GLU 97 CA 9.4 PO4 4.0 CYA   CO2 24
     WBC 8.53 HCT 35.4 HGB 12.2 MCV 84.0 PLT 338
     N 58.8 L 29.3  B .3 ABS N 5.02

     Maxine is doing well but currently has an upper respiratory tract infection.  Her laboratory studies show that her dehydration status is improving.  We will have the parents obtain a creatinine level locally on Monday.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Yan Plato, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Plato:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, September 13, 1994.  She has chronic renal failure secondary to glomerulocystic disease.  She had a renal transplant on September 3, 1992.
     Maxine has had no problems since her last visit with us.

Current medications include:
     CYCLOSPORINE 60 mg t.i.d.
     IMURAN 25 mg q.d.
     PREDNISONE 7 mg q.o.d.
     FLINSTONES 1 q.d.
     WESTCORT CREAM apply to affected area b.i.d.

Physical exam:
     BP 108/62     P 96    HT 95.4 cm    WT 14.8 kg 
     General:  active and healthy
     HEENT: moist mucous membranes without exudate or masses.  She has a bilateral contact dermatitis around the angles of her mouth
     Chest: clear
     Heart: regular rate and rhythm without murmurs, gallops, or rubs
     Abdomen: soft non-tender and non-distended without masses.  There is no tenderness or bruits over the graft site.
     Extremities: warm and well perfused
     Neurological: non-focal
Urinalysis:
     SPEC GR UA  1.008           WBC ENZ UA  N          
     PH UA       6.5             PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   few             BACTERIA    N     


Laboratory studies at this time include:


     Maxine has done well since her last visit.  We will continue to follow her creatinine closely.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, October 18, 1994.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on September 3, 1992.
     Maxine returned today to the renal transplant clinic.  She had an ear infection which was treated with Amoxicillin for ten days.  For the last three days she has had a persistent upper respiratory tract infection with a moist cough.

Current medications include:
     CYCLOSPORINE 60 mg t.i.d.
     IMURAN 25 mg q.d.
     PREDNISONE 7 mg q.o.d.
     FLINSTONES 1 q.d.

Physical exam:
     BP 70/40   P 80   R 16     HT 96.8cm   WT 14.9kg   
     General: she had a runny nose but was bright and active 
     HEENT: red throat, ears normal  
     Neck: lymphadenopathy, lymph nodes 
     Chest: clear
     Heart: 2 heart sounds, no murmurs
     Abdomen: soft, non-tender, central graft 
     Genitourinary: tanner 1
     Extremities: no edema

Urinalysis:
     SPEC GR UA  1.020           WBC ENZ UA  N          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          CA          9.7   MG/DL       CR          0.7   MG/DL    
          CYA         123   MCG/L       GLU          77   MG/DL    
          PHOS        4.6   MG/DL       BUN          38   MG/DL (H)
          NA          142  MMOL/L       K           4.6  MMOL/L (H)
          CL          107  MMOL/L       WBC        7.58   K/MM3    
          RBC        4.03   M/MM3       HGB        11.9    G/DL    
          HCT.       34.7       %       MCV        86.1      FL    
          MCH        29.5      PG       MCHC       34.2    G/DL    
          RDW        13.6       %       HDW        2.40    G/DL    
          PLT UNC     396   K/MM3       NEUT AB    3.87   K/MM3    
          LYMPH A    2.86   K/MM3       EOS ABS     .23   K/MM3    
          NEUT-A     51.0       % (H)   LYMPH-A    37.8       % (L)
          MONO-A      4.7       %       EOS-A       3.0       %    
          BASO-A       .7       %       ATYP LY     2.7       %    


     Maxine is doing well since her last visit.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Mitsuko Khan, MD
               Director of Clinical Services


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, November 15, 1994.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on September 3, 1992.
     Maxine has been well since her last visit.  She has had pain behind the left knee for one week and has occasionally had to be carried by her father.  She has had this once before one year ago and it cleared spontaneously.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 7 mg po q.o.d.
     DAILY MULTIVITAMIN 1 cc po q.d.


Physical exam:
     BP 90/65   P 80   R 18    HT 96.5cm   WT 15.2kg   
     Skin: normal
     HEENT: normal
     Neck: supple without masses. Lymph nodes not palpable. 
     Chest: clear, moist cough
     Heart: 2 heart sounds no murmurs
     Abdomen: soft, non-tender, left sided graft 
     Genitourinary: Tanner
     Extremities: no edema, knees normal to examination

Urinalysis:
     SPEC GR UA  1.014           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          CO 2         25   MEQ/L       CA          9.1   MG/DL    
          CR          0.6   MG/DL       CYA         107   MCG/L    
          GLU          74   MG/DL       PHOS        4.0   MG/DL (L)
          BUN          28   MG/DL (H)   NA          137  MMOL/L    
          K           4.8  MMOL/L (H)   CL          103  MMOL/L    
          WBC        7.32   K/MM3       RBC        3.86   M/MM3    
          HGB        10.9    G/DL       HCT.       32.5       % (L)
          MCV        84.2      FL       MCH        28.2      PG    
          MCHC       33.5    G/DL       RDW        13.3       %    
          HDW        2.53    G/DL       PLT UNC     393   K/MM3    
          NEUT         46       % (H)   LYMPH        43       % (L)
          MONOS         7       %       EOS           2       %    
          ATYP LY       1       %       BAND          1       %    
          CELLS C     100               ABS NEU    3.44   K/MM3    
          ABS LYM    3.15   K/MM3       ABS EOS     .15   K/MM3    
          MORPH    NORMAL       


     Maxine appears well.  Her growth is excellent and her renal function is stable.  The knee x-rays were normal.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, December 13, 1994.  She has chronic renal failure secondary to glomerulocystic disease.  She had a renal transplant on September 3, 1992.
     Maxine is two years status post living related transplant and has been doing very well.  About one month ago she contracted a cold with nasal congestion and non-productive cough.  About two weeks ago she presented to her pediatrician who prescribed a ten day course of Ampicillin which she completed yesterday.  Immediately after the Ampicillin was completed she started experiencing her symptoms again without fever, chills, night sweats, headaches, abdominal pain, vomiting, nausea or diarrhea.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 7 mg po q.o.d.


Physical exam:
     BP 110/70   P 110     HT 96.6cm   WT 15.3kg   
     General: appeared well.
     HEENT: normal. 
     Neck: supple with no masses, lymph nodes not palpable
     Chest: clear
     Heart: two heart sounds.
     Abdomen: soft non-tender with non-tender graft.
     Genitourinary: Tanner 1
     Extremities: no edema

Urinalysis:
     SPEC GR UA  0               WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     0               RBC/HPF     0          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          CA          9.7   MG/DL       CR          0.6   MG/DL    
          CYA         148   MCG/L       GLU          68   MG/DL    
          PHOS        4.1   MG/DL (L)   BUN          32   MG/DL (H)
          NA          140  MMOL/L       K           4.6  MMOL/L (H)
          CL          107  MMOL/L       WBC       15.84   K/MM3    
          RBC        4.11   M/MM3       HGB        11.9    G/DL    
          HCT.       35.2       %       MCV        85.6      FL    
          MCH        29.0      PG       MCHC       33.8    G/DL    
          RDW        13.9       %       HDW        2.50    G/DL    
          PLT UNC     381   K/MM3       NEUT AB   10.48   K/MM3    
          LYMPH A    3.49   K/MM3       EOS ABS     .64   K/MM3 (H)
          NEUT-A     66.2       % (H)   LYMPH-A    22.0       % (L)
          MONO-A      5.9       %       EOS-A       4.0       %    
          BASO-A       .5       %       ATYP LY     1.4       %    


     Maxine continues to do well post transplant.  This is her first year attending school and she is experiencing multiple respiratory infections.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, January 10, 1995.  She has chronic renal failure secondary to glomerular cystic diasease.  She had a renal transplant on September 3, 1992.
     Maxine has done well since her last visit with us.  She has no new complaints.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 7 mg po q.o.d.


Physical exam:
     BP 114/65   P 117   R 22     HT 97.7cm   WT 15.7kg   
     General: healthy
     HEENT: moist mucous membranes without exudates or masses 
     Chest: clear 
     Heart: regular rate and rhythm without murmurs, gallops or rubs
     Abdomen: soft, non-tender, non-distended without pain or bruit over the graft site
     Extremities: warm and well perfused 
     Neurological: non-focal
Urinalysis:
     SPEC GR UA  1.015           WBC ENZ UA  N          
     PH UA       5               PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          CA         10.0   MG/DL       CR          0.6   MG/DL    
          CYA         120   MCG/L       GLU          87   MG/DL    
          PHOS        4.2   MG/DL (L)   BUN          38   MG/DL (H)
          NA          139  MMOL/L       K           5.0  MMOL/L (H)
          CL          108  MMOL/L       WBC        9.27   K/MM3    
          RBC        4.02   M/MM3       HGB        11.6    G/DL    
          HCT.       34.2       %       MCV        85.1      FL    
          MCH        28.9      PG       MCHC       34.0    G/DL    
          RDW        13.8       %       HDW        2.52    G/DL    
          PLT UNC     392   K/MM3       NEUT AB    5.00   K/MM3    
          LYMPH A    3.35   K/MM3       NEUT-A     54.0       %    
          LYMPH-A    36.1       %       MONO-A      5.2       %    
          EOS-A       2.3       %       BASO-A       .3       %    
          ATYP LY     2.1       %       


     Maxine has done extremely well since her last visit with us.  Her renal function is stable and her growth is excellent.  We will increase her Prednisone to 8 mg qod, so that the dose is 0.5mg/kg/qd.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, January 17, 1995.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on September 3, 1992.
     Maxine returned today for review following a recent cold and asthma attack.  She has been on Ventolin Inhaler over the weekend, 2 puffs every 4 hours.  She has improved considerably.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.
     AMOXICILLIN 250 mg t.i.d.
     VENTOLIN INHALER q 4 hours

Physical exam:
     BP 110/55   P 110   R 28     WT 15.7kg   
     General: appeared well.
     Skin: normal
     HEENT: normal. 
     Neck: supple with no masses, lymph nodes not palpable.
     Chest: prolonged expiration, soft expiratory wheeze heard throughout the chest.
     Heart: two heart sounds.
     Abdomen: soft with non-tender graft.
     Genitourinary: Tanner 1
     Extremities: no edema

Urinalysis:
     SPEC GR UA  1.015           WBC ENZ UA  N          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          CO 2         20   MEQ/L       CA         10.0   MG/DL    
          CR          0.7   MG/DL       CYA          95   MCG/L    
          GLU          91   MG/DL       PHOS        3.6   MG/DL (L)
          BUN          45   MG/DL (H)   NA          138  MMOL/L    
          K           5.6  MMOL/L (H)   CL          106  MMOL/L    
          PLT         384   K/MM3       WBC        4.90   K/MM3 (L)
          RBC        4.37   M/MM3       HGB        12.3    G/DL    
          HCT.       36.6       %       MCV        83.6      FL    
          MCH        28.1      PG       MCHC       33.6    G/DL    
          RDW        13.4       %       HDW        2.74    G/DL    
          PLT UNC     384   K/MM3       NEUT         79       % (H)
          LYMPH        17       % (L)   MONOS         1       %    
          BAND          3       %       CELLS C     100    
          ABS NEU    4.02   K/MM3       ABS LYM     .83   K/MM3    
          ABS EOS     .00   K/MM3       MICRO        1+    
          OVALO        1+       


     Maxine has improved on the Ventolin.  She now has a moist cough and some scattered wheezes.  She will continue on the Ventolin.  Her renal function is stable.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, February 14, 1995.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on September 3, 1992.
     Maxine is doing well.  She has had a small cold with a dry cough and runny nose but otherwise has been well.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.


Physical exam:
     BP 136/72   P 120   R 20     HT 97.5cm    WT 15.5kg  
     General: Bright and cheerful.
     HEENT: Throat and ears clear. 
     Neck: No cervical lymphadenopathy
     Chest: Clear.
     Heart: Two heart sounds.
     Abdomen: Non-tender graft.
     Genitourinary: Tanner 1
     Extremities: No edema
     Neurological: Normal
Urinalysis:
     SPEC GR UA  1.020           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     2-3             RBC/HPF     2-3        
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   1+              BACTERIA    N     


Laboratory studies at this time include:
          CA          9.9   MG/DL       CR          0.6   MG/DL    
          CYA         147   MCG/L       GLU         100   MG/DL    
          PHOS        4.0   MG/DL (L)   BUN          31   MG/DL (H)
          NA          139  MMOL/L       K           5.2  MMOL/L (H)
          CL          107  MMOL/L       WBC        9.70   K/MM3    
          RBC        4.30   M/MM3       HGB        12.1    G/DL    
          HCT.       35.9       %       MCV        83.4      FL    
          MCH        28.1      PG       MCHC       33.7    G/DL    
          RDW        14.1       %       HDW        2.74    G/DL    
          PLT UNC     373   K/MM3       NEUT AB    8.13   K/MM3    
          LYMPH A    1.08   K/MM3       EOS ABS     .08   K/MM3    
          NEUT-A     83.8       % (H)   LYMPH-A    11.1       % (L)
          MONO-A      2.2       %       EOS-A        .9       %    
          BASO-A       .2       %       ATYP LY     1.8       %    


     Maxine is doing well.

     We had planned to see Maxine in six weeks but required admission on 2/20/95 for a febrile course and elevated creatinine.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, March 7, 1995.  She has chronic renal failure secondary to glomerular cystic disorder.  She had a renal transplant on September 3, 1992.
     Maxine's mother reports a history of cold with a stuffy nose and ocassional nasal discharge, but denies any fever or cough.  Maxine appears to be in good spirits, and has a good appetite.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.

Physical exam:
     HT 98.1cm   WT 15.9kg    

     HEENT: benign, pharynx without lesions
     Neck: supple with no lymphadenopathy
     Chest: clear
     Heart: regular rate and rhythm, normal S1 S2
     Abdomen: non-tender, transplant non-tender
     Extremities: without edema

Urinalysis:
     SPEC GR UA  0               WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     0-1             RBC/HPF     0          
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    0     


Laboratory studies at this time include:
          CA          9.6   MG/DL       CR          0.6   MG/DL    
          CYA         191   MCG/L       GLU          95   MG/DL    
          PHOS        4.0   MG/DL (L)   BUN          35   MG/DL (H)
          NA          143  MMOL/L       K           5.0  MMOL/L (H)
          CL          110  MMOL/L       WBC        9.06   K/MM3    
          RBC        3.71   M/MM3       HGB        10.4    G/DL (L)
          HCT.       30.8       % (L)   MCV        82.9      FL    
          MCH        28.0      PG       MCHC       33.8    G/DL       
          PLT UNC     396   K/MM3       NEUT         50       %    
          LYMPH        45       %       MONOS         4       %    
          EOS           1       %       CELLS C     100      

     Maxine is doing well.  Her renal function is stable and her growth is excellent.

     We have asked Maxine to return in one month.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, April 11, 1995.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on September 3, 1992.
     We saw Maxine today for follow up in the renal transplant program.  Maxine is status post renal transplant 1 1/2 years ago.  She is doing very well and there are no complaints.

Current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.


Physical exam:
     BP 120/80   P 70   R 20    HT 98.7cm   WT 16.1kg   
     General: she is a charming four year old girl in no distress
     Skin: non tender
     HEENT: benign, pharynx without lesions
     Neck: supple with no lymphadenopathy
     Chest: clear
     Heart: regular rate and rhythm, normal S1 S2
     Abdomen: non-tender, transplant non-tender with no bruits
     Extremities: without edema
     Neurological: intact
Urinalysis:
     SPEC GR UA  1.015           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  0          
     BLOOD UA    0               GLUCOSE UA  0     mg/dl
     WBC/HPF     0               RBC/HPF     0          
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    0     


Laboratory studies at this time include:
          CA          9.7   MG/DL       CR          0.7   MG/DL    
          CYA         146   MCG/L       GLU          86   MG/DL    
          PHOS        4.2   MG/DL (L)   BUN          32   MG/DL (H)
          NA          141  MMOL/L       K           5.0  MMOL/L (H)
          CL          108  MMOL/L       WBC        6.79   K/MM3    
          RBC        3.92   M/MM3       HGB        10.8    G/DL    
          HCT.       32.1       % (L)   MCV        81.8      FL    
          MCH        27.6      PG       MCHC       33.7    G/DL    
          RDW        15.4       %       HDW        3.04    G/DL    
          PLT UNC     412   K/MM3 (H)   NEUT AB    3.89   K/MM3    
          LYMPH A    2.07   K/MM3       EOS ABS     .17   K/MM3    
          NEUT-A     57.3       %       LYMPH-A    30.4       %    
          MONO-A      6.0       %       EOS-A       2.4       %    
          BASO-A       .7       %       ATYP LY     3.2       %    
          MICRO-A       +       


     Maxine is stable.  Blood pressure is mildly elevated and will be checked at home to see labile.

     We have asked Maxine to return in two months.

     Thank you for allowing us to share in Maxine's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, June 13, 1995.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on 9/3/92.
     She appears to be doing well and has no complaints.

Her current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.


Maxine's physical exam was notable for:
     BP 120/78    HT 99.9cm   WT 16.6kg   
     General: she is a charming four year old girl in no distress
     HEENT: negative for cataracts.
     Neck: supple with no lymphadenopathy
     Chest: clear
     Heart: regular rate and rhythm with no murmurs
     Abdomen: soft and non-tender.
     Extremities: without edema
     Neurological: intact
A urinalysis revealed:
     SPEC GR UA  1.020           RBC/HPF     0          
     WBC ENZ UA  0               WBC CAST    0          
     PH UA       5               RBC CAST    0          
     PROTEIN UA  0               GRAN CAST   0          
     BLOOD UA    0               WAXY CAST   0          
     GLUCOSE UA  0     mg/dl     SQUAM EPI   0          
     WBC/HPF     0               BACTERIA    0     

Laboratory studies at this time include:
          CA          9.4   MG/DL       CR          0.7   MG/DL    
          CYA         161   MCG/L       GLU          67   MG/DL    
          PHOS        4.1   MG/DL (L)   BUN          33   MG/DL (H)
          NA          139  MMOL/L       K           4.8  MMOL/L (H)
          CL          108  MMOL/L       WBC        7.52   K/MM3    
          RBC        3.85   M/MM3       HGB        11.4    G/DL    
          HCT.       34.0       %       MCV        88.2      FL    
          MCH        29.6      PG       MCHC       33.6    G/DL    
          RDW        14.5       %       HDW        2.68    G/DL    
          PLT UNC     440   K/MM3 (H)   NEUT AB    3.25   K/MM3    
          LYMPH A    3.31   K/MM3       EOS ABS     .23   K/MM3    
          NEUT-A     43.2       %       LYMPH-A    44.1       %    
          MONO-A      5.9       %       EOS-A       3.1       %    
          BASO-A      1.7       %       ATYP LY     2.1       %    


     Maxine is a four year old girl who had a living related transplant and is doing well, clinically stable.

     Thank you for the opportunity to participate in Maxine's care.  We would like to review her in one month.  In the interim, we would be happy to discuss or review Maxine should you or the family wish it.

               Sincerely,


               Gleide Blue, MD
               Attending, Pediatric Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, July 18, 1995.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on September 3, 1992.
     Maxine is a four and a half year old girl status post renal transplant in 1992 has been doing well.  Her blood pressure is stable and she appears well.

Her current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.


Maxine's physical exam was notable for:
     BP 110/75   P 92   R 14    HT 100.9cm   WT 16.5kg   
     General: she is playful and active.
     Skin: no lesions
     HEENT: normal
     Chest: clear
     Heart: no murmurs
     Abdomen: no tenderness over graft site.
     Extremities: without edema
     Neurological: no lateralizing signs.
A urinalysis revealed:
     SPEC GR UA  1.018           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5               RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N     mg/dl     SQUAM EPI   N          
     WBC/HPF     rare            BACTERIA    N     
     occ Hyaline casts

Laboratory studies at this time include:
          CA          9.4   MG/DL       CR          0.6   MG/DL    
          CYA          84   MCG/L       GLU          87   MG/DL    
          PHOS        4.8   MG/DL       BUN          37   MG/DL (H)
          NA          136  MMOL/L       K           4.8  MMOL/L (H)
          CL          104  MMOL/L       WBC        5.74   K/MM3 (L)
          RBC        4.00   M/MM3       HGB        11.3    G/DL    
          HCT.       33.6       % (L)   MCV        84.1      FL    
          MCH        28.3      PG       MCHC       33.6    G/DL    
          RDW        13.5       %       HDW        2.61    G/DL    
          PLT UNC     350   K/MM3       NEUT AB    4.19   K/MM3    
          LYMPH A     .84   K/MM3       EOS ABS     .13   K/MM3    
          NEUT-A     72.9       % (H)   LYMPH-A    14.7       % (L)
          MONO-A      7.6       %       EOS-A       2.3       %    
          BASO-A       .6       %       ATYP LY     1.8       %    


     Maxine is a four and a half year old girl status post renal transplant doing well.  Maxine has been growing nicely on her growth curve.

     Thank you for the opportunity to participate in Maxine's care.  We would like to review her in three months.  Have pediatrician draw monthly bloods.  In the interim, we would be happy to discuss or review Maxine should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, October 17, 1995.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on 9/3/92.

     Maxine is doing very well.  She is now completely recovered since her last episode of pneumonia in September.

Her current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.


Maxine's physical exam was notable for:
     BP 120/70    HT 102.2cm   WT 17.6kg   
     General: she is joyful and very well appearing.
     Skin: no lesions
     HEENT: normal
     Neck: supple without lymph nodes.
     Chest: symmetric and clear breath sounds.
     Heart: regular rate without murmurs
     Abdomen: soft without hepatosplenomegaly.  There is no tenderness or bruit over graft site.
     Extremities: unremarkable except for some mild hirsutism.
     Neurological: symmetrical and appears normal.

A urinalysis revealed:
     SPEC GR UA  1.015           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5               RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           4.4  MMOL/L       MCH        28.4      PG    
          CO 2         21   MEQ/L (L)   MCHC       33.8    G/DL    
          CR          0.6   MG/DL       RDW        14.0       %    
          CYA         121   MCG/L       HDW        2.99    G/DL    
          GLU          70   MG/DL       PLT UNC     411   K/MM3 (H)
          PHOS        3.9   MG/DL (L)   NEUT AB    3.68   K/MM3    
          BUN          44   MG/DL (H)   LYMPH A    3.21   K/MM3    
          NA          140  MMOL/L       EOS ABS     .13   K/MM3    
          CL          107  MMOL/L       NEUT-A     48.9       %    
          WBC        7.53   K/MM3       LYMPH-A    42.7       %    
          RBC        3.88   M/MM3       MONO-A      4.4       %    
          HGB        11.0    G/DL       EOS-A       1.7       %    
          HCT.       32.6       % (L)   BASO-A       .3       %    
          MCV        84.0      FL       ATYP LY     2.0       %    

     Maxine is doing very well.

     Thank you for the opportunity to participate in Maxine's care.  We would like to review her in three months.  In the interim, we would be happy to discuss or review Maxine should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, January 23, 1996.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on 9/3/92.

     Maxine is currently doing well.  She was recently admitted to the hospital from the 1st to 3rd of January for a fever.  She has been well at home since then.

Her current medications include:
     CYCLOSPORINE 60 mg po t.i.d.
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.


Maxine's physical exam was notable for:
     BP 122/80   P 100   R 14    HT 104.1cm   WT 17.8kg   
     General: comfortable, alert, active
     Skin: no lesions
     HEENT: eyes, nose and throat clear
     Neck: supple, no significant lymphadenopathy
     Chest: clear to auscultation
     Heart: S1 S2 normal
     Abdomen: soft, no graft tenderness 
     Extremities: no edema
     Neurological: no focal deficits or meningeal signs

A urinalysis revealed:
     SPEC GR UA  1.012           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           4.5  MMOL/L       MCH        25.3      PG (L)
          CA          9.8   MG/DL       MCHC       30.4    G/DL    
          CR          0.8   MG/DL (H)   RDW        15.3       %    
          CYA         127   MCG/L       HDW        2.97    G/DL    
          GLU          97   MG/DL       PLT UNC     415   K/MM3 (H)
          PHOS        4.3   MG/DL (L)   NEUT AB    4.27   K/MM3    
          BUN          39   MG/DL (H)   LYMPH A    3.19   K/MM3    
          NA          140  MMOL/L       EOS ABS     .08   K/MM3    
          CL          106  MMOL/L       NEUT-A     50.6       %    
          CO 2         25   MEQ/L       LYMPH-A    37.8       %    
          WBC        8.44   K/MM3       MONO-A      7.1       %    
          RBC        3.84   M/MM3       EOS-A       1.0       %    
          HGB         9.7    G/DL (L)   BASO-A       .4       %    
          HCT.       31.9       % (L)   ATYP LY     3.1       %    
          MCV        83.1      FL       LEFT SH  ABSENT    

     Maxine is clinically stable at present.

     Thank you for the opportunity to participate in Maxine's care.  We would like to review her in three months.  In the interim, we would be happy to discuss or review Maxine should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

     We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, April 23, 1996.  She has chronic renal failure secondary to glomerulocystic disease.  She had a renal transplant on 9/3/92.

     Maxine is doing very well.  Since her last visit in January she had a brief episode of upper respiratory infection.  She has otherwise been extremely active and has had no interval complaints.

Her current medications include:
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.
     SANDIMMUNE 60 mg po t.i.d.


Maxine's physical exam was notable for:
     BP 124/51   P 103   R 28   HT 105.3cm   WT 18.8kg   
     General: well developed, well nourished child, extremely active, laughing, playing
     Skin: no rash
     HEENT: eyes, nose and throat clear
     Neck: soft, no lymphadenopathy
     Chest: clear to auscultation
     Heart: no murmur
     Abdomen: soft, non-tender 
     Extremities: no edema
     Neurological: grossly intact

A urinalysis revealed:
     SPEC GR UA  1.010           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           5.5  MMOL/L (H)   MCHC       33.9    G/DL    
          CA         10.0   MG/DL       RDW        14.3       %    
          CL          105  MMOL/L       HDW        2.80    G/DL    
          CR          0.8   MG/DL (H)   MPV         7.5      FL    
          CYA         156   MCG/L       PLT UNC     393   K/MM3    
          GLU          72   MG/DL       NEUT AB    2.93   K/MM3    
          PHOS        4.2   MG/DL (L)   LYMPH A    2.40   K/MM3    
          NA          138  MMOL/L       EOS ABS     .13   K/MM3    
          BUN          44   MG/DL (H)   NEUT-A     49.5       %    
          WBC        5.92   K/MM3 (L)   LYMPH-A    40.6       %    
          RBC        4.11   M/MM3       MONO-A      4.7       %    
          HGB        11.5    G/DL       EOS-A       2.2       %    
          HCT.       33.9       % (L)   BASO-A       .5       %    
          MCV        82.5      FL       ATYP LY     2.4       %    
          MCH        28.0      PG       LEFT SH  ABSENT    

     Maxine is continuing to do well.  Her renal function is stable.  We will switch from Sandimmune to Neoral within the next 2-3 months.  Her growth is fine.

     Thank you for the opportunity to participate in Maxine's care.  We would like to review her in three months.  In the interim, we would be happy to discuss or review Maxine should you or the family wish it.

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, July 30, 1996.  She has chronic renal failure secondary to glomerular cystic disease.  She had a renal transplant on .

Maxine had a cold last week and her symptoms have resolved.  Her parents have concerns regarding nocturnal enuresis which has never resolved.

Her current medications include:
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.
     SANDIMMUNE 60 mg po t.i.d.


Maxine's physical exam was notable for:
     BP 120/66   P 101   HT 108cm   WT 19.1kg  
     General: playful and alert
     Skin: hirsutism
     HEENT: normal
     Neck: normal, negative lymph nodes
     Chest: clear
     Heart: regular rate and rhythm with 2/6 systolic murmur
     Abdomen: soft, non-tender 
     Extremities: no edema

A urinalysis revealed:
     SPEC GR UA  1.018           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   few        
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           5.0  MMOL/L (H)   HGB        10.7    G/DL    
          CA          9.7   MG/DL       HCT.       31.0       % (L)
          CL          109  MMOL/L       MCV        80.7      FL    
          CR          0.8   MG/DL (H)   MCH        27.9      PG    
          CYA         127   MCG/L       MCHC       34.5    G/DL    
          PHOS        3.9   MG/DL (L)   RDW        14.3       %    
          NA          141  MMOL/L       HDW        2.98    G/DL    
          BUN          34   MG/DL (H)   MPV         7.7      FL    
          WBC        6.19   K/MM3       PLT UNC     460   K/MM3 (H)
          RBC        3.84   M/MM3       

Maxine is doing well.  We will plan for a VCUG to evaluate her bladder anatomy given her continuing enuresis.  If this is negative, we will consider behavioral and possibly pharmacologic treatment.  We will increase her Prednisone dose from 8 mg qod to 10 mg qod to keep up with her increase in weight.

Thank you for the opportunity to participate in Maxine's care.  We would like to review her in three months. In the interim, we would be happy to discuss or review Maxine should you or the family wish it.

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Maxine Warren
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/91

Dear Dr. Sanders:

We had the pleasure of seeing Maxine in the Renal Transplant Program on Tuesday, July 30, 1996.  She has chronic renal failure secondary to glomerular cystic disease.  

Maxine had a cold last week and her symptoms have resolved.  Her parents have concerns regarding nocturnal enuresis which has never resolved.

Her current medications include:
     IMURAN 25 mg po q.d.
     PREDNISONE 8 mg q.o.d.
     SANDIMMUNE 60 mg po t.i.d.


Maxine's physical exam was notable for:
     BP 120/66   P 101   HT 108cm   WT 19.1kg   
     General: playful and alert
     Skin: hirsutism
     HEENT: normal
     Neck: normal, negative lymph nodes
     Chest: clear
     Heart: regular rate and rhythm with 2/6 systolic murmur
     Abdomen: soft, non-tender 
     Extremities: no edema

A urinalysis revealed:
     SPEC GR UA  1.018           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   few        
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           5.0  MMOL/L (H)   HGB        10.7    G/DL    
          CA          9.7   MG/DL       HCT.       31.0       % (L)
          CL          109  MMOL/L       MCV        80.7      FL    
          CR          0.8   MG/DL (H)   MCH        27.9      PG    
          CYA         127   MCG/L       MCHC       34.5    G/DL    
          PHOS        3.9   MG/DL (L)   RDW        14.3       %    
          NA          141  MMOL/L       HDW        2.98    G/DL    
          BUN          34   MG/DL (H)   MPV         7.7      FL    
          WBC        6.19   K/MM3       PLT UNC     460   K/MM3 (H)
          RBC        3.84   M/MM3       

Maxine is doing well.  We will plan for a VCUG to evaluate her bladder anatomy given her continuing enuresis.  If this is negative, we will consider behavioral and possibly pharmacologic treatment.  We will increase her Prednisone dose from 8 mg qod to 10 mg qod to keep up with her increase in weight.

Thank you for the opportunity to participate in Maxine's care.  We would like to review her in three months. In the interim, we would be happy to discuss or review Maxine should you or the family wish it.

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


