# BIGPATS_DOC_STORE

CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, April 9, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Kenny returns to the renal transplant program today for his biweekly post transplant visit.  He has been well with no complaints of headaches, morning edema or abdominal pain.  Since Kenny's recent weight gain Kenny and his mother state that he has been much more careful about his diet and has begun exercising on a stationary bicycle which he seems to enjoy.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 12 mg b.i.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 250 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     P 84   R 16  HT 162.3cm   WT 63.2kg   
     General: Kenny appeared well and in no apparent distress
     Skin: no rash or petechiae, warm and well perfused
     HEENT: fundoscopic exam within normal limits, oropharynx with no signs of thrush and improving dental hygiene
     Neck: supple without nodes or masses
     Chest: clear to auscultation bilaterally
     Heart: regular rate and rhythm with no murmur 
     Abdomen: soft, right graft non-tender, no organomegaly, good bowel sounds 
     Extremities: no edema 
     Neurological: non-focal

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     N          
     PH UA       5               SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     GLUCOSE UA  50              WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          AST          12     U/L       MCV        86.1      FL    
          K           4.2  MMOL/L       MCH        30.6      PG    
          CA          9.3   MG/DL       MCHC       35.5    G/DL    
          CR          1.5   MG/DL (H)   RDW        16.0       % (H)
          CYA         269   MCG/L       HDW        2.93    G/DL    
          GLU         105   MG/DL       NF-2001    10.0      FL    
          PHOS        2.6   MG/DL (L)   PLT UNC     252   K/MM3    
          ALT          13     U/L       NEUT AB    8.97   K/MM3    
          BUN          29   MG/DL (H)   LYMPH A    1.58   K/MM3    
          URIC        7.3   MG/DL (H)   EOS ABS     .09   K/MM3    
          NA          139  MMOL/L       NEUT-A     78.6       % (H)
          CL          105  MMOL/L       LYMPH-A    13.8       % (L)
          CO 2         22   MEQ/L       MONO-A      5.4       %    
          BILI TO     0.9   MG/DL       EOS-A        .8       %    
          BILI DI     0.3   MG/DL       BASO-A       .4       %    
          WBC       11.40   K/MM3       ATYP LY     1.1       %    
          RBC        3.73   M/MM3 (L)   ANISO-A       +    
          HGB        11.4    G/DL (L)   MICRO-A       +    
          HCT.       32.1       % (L)   LEFT SH  ABSENT    

     Kenny appears to be doing well status post his transplant.  He is scheduled for a GFR scan this morning.  His creatinine remains slightly elevated although stable at 1.4 mg/dl, his blood pressure has been running stable in the 130's/mid 80's at home.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, April 16, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Michel is doing well.  He has had no fever, or pain around his graft site.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 12 mg b.i.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 250 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 128/82   HT 161.5cm   WT 62.2kg   
     General: Kenny appeared well hydrated and in no distress.
     Skin: without lesions.
     HEENT: within normal limits.
     Neck: supple without cervical lymphadenopathy.
     Chest: clear.
     Heart: without murmur 
     Abdomen: benign without pain over graft site.
     Extremities: warm and well perfused. 
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  N               WBC/HPF     N          
     PH UA       5               SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           4.0  MMOL/L       RDW        16.8       % (H)
          CA          9.2   MG/DL       HDW        2.88    G/DL    
          CR          1.8   MG/DL (H)   MPV         9.9      FL    
          CYA         275   MCG/L       PLT UNC     253   K/MM3    
          GLU          97   MG/DL       NEUT AB    7.52   K/MM3    
          PHOS        3.7   MG/DL       LYMPH A    1.85   K/MM3    
          BUN          42   MG/DL (H)   EOS ABS     .08   K/MM3    
          NA          141  MMOL/L       NEUT-A     73.8       % (H)
          CL          107  MMOL/L       LYMPH-A    18.1       % (L)
          CO 2         26   MEQ/L       MONO-A      5.5       %    
          WBC       10.19   K/MM3       EOS-A        .8       %    
          RBC        3.58   M/MM3 (L)   BASO-A       .3       %    
          HGB        10.6    G/DL (L)   ATYP LY     1.4       %    
          HCT.       30.9       % (L)   ANISO-A       +    
          MCV        86.4      FL       MICRO-A       +    
          MCH        29.6      PG       LEFT SH  ABSENT    
          MCHC       34.3    G/DL       

     Michel is doing well ten week post transplant.  Today creatinine is 1.8 mg/dl which is the most elevated it has been.  Because of this we will perform a renal biopsy to rule out acute rejection.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, April 23, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Kenny is here for his weekly visit.  He was recently discharged status post biopsy which showed chronic rejection.  He offers no complaints or tenderness along the graft site.

His current medications include:
     IMURAN 100 mg q.d.
     PREDNISONE 12 mg b.i.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 225 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 141/76   P 100   R 12    HT 161.8cm   WT 63.4kg   
     General: Kenny appears well hydrated in no distress.
     Skin: without lesions.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear.
     Heart: without murmur 
     Abdomen: benign without tenderness over the graft site.
     Extremities: no edema. 
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  1.013           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          AST          11     U/L       MCV        87.7      FL    
          K           4.1  MMOL/L       MCH        29.3      PG    
          CA          9.1   MG/DL       MCHC       33.4    G/DL    
          CL          103  MMOL/L       RDW        16.8       % (H)
          CR          1.8   MG/DL (H)   HDW        2.85    G/DL    
          CYA         268   MCG/L       MPV         9.8      FL    
          GLU          98   MG/DL       PLT UNC     281   K/MM3    
          PHOS        4.0   MG/DL       NEUT AB    8.13   K/MM3    
          ALT           9     U/L       LYMPH A    2.05   K/MM3    
          NA          142  MMOL/L       EOS ABS     .08   K/MM3    
          BUN          41   MG/DL (H)   NEUT-A     73.7       % (H)
          URIC        7.6   MG/DL (H)   LYMPH-A    18.6       % (L)
          BILI TO     1.1   MG/DL       MONO-A      5.8       %    
          BILI DI     0.3   MG/DL       EOS-A        .7       %    
          WBC       11.03   K/MM3       BASO-A       .3       %    
          RBC        3.55   M/MM3 (L)   ATYP LY      .9       %    
          HGB        10.4    G/DL (L)   ANISO-A       +    
          HCT.       31.1       % (L)   LEFT SH  ABSENT    

     Kenny has been stable.  He is now entering his eleventh week post transplant.  His transplant biopsy was essentually normal.  There was no sign of rejection.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, April 30, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Ken had two days of laryngitis.  This has spontaneously resolved.  He also has had occasional loose stools, these have been infrequent.  He currently has mild nasal congestion but has otherwise been feeling well.  Ken also had a transient pain in his right lower quadrant last night which spontaneously resolved.

His current medications include:
     IMURAN 100 mg q.d.
     PREDNISONE 12 mg b.i.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 225 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 127/73   P 108   R 20   HT 162.5cm   WT 64.1kg   
     HEENT: Pupils are equal and reactive to light.  Disk margins sharp.  Oropharynx is clear and moist.  Posterior oropharynx with minimal erythema.
     Neck: supple.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm.
     Abdomen: soft, no tenderness or bruit over the graft site.
     Extremities: without edema.
     Neurological: non-focal.

A urinalysis revealed:
     SPEC GR UA  1.016           WBC/HPF     0-2        
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    trace           WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   0-1        
     GLUCOSE UA  1+              WAXY CAST   N          
     RBC/HPF     0-3             BACTERIA    N     

Laboratory studies at this time include:
          K           3.9  MMOL/L       RDW        17.2       % (H)
          CA          8.8   MG/DL       HDW        2.81    G/DL    
          CR          1.8   MG/DL (H)   MPV         9.8      FL    
          CYA         208   MCG/L       PLT UNC     269   K/MM3    
          GLU         118   MG/DL (H)   NEUT AB    8.33   K/MM3    
          PHOS        3.3   MG/DL       LYMPH A    1.00   K/MM3    
          BUN          31   MG/DL (H)   EOS ABS     .10   K/MM3    
          NA          143  MMOL/L       NEUT-A     81.5       % (H)
          CL          106  MMOL/L       LYMPH-A     9.8       % (L)
          CO 2         27   MEQ/L       MONO-A      6.2       %    
          WBC       10.22   K/MM3       EOS-A       1.0       %    
          RBC        3.38   M/MM3 (L)   BASO-A       .3       %    
          HGB        10.8    G/DL (L)   ATYP LY     1.3       %    
          HCT.       29.8       % (L)   ANISO-A       +    
          MCV        88.2      FL       MICRO-A       +    
          MCH        32.0      PG       LEFT SH  ABSENT    
          MCHC       36.2    G/DL (H)   

     Ken has had a mild URI and occasional loose stools.  He has otherwise been feeling well.  His blood pressure is controlled on his current antihypertensive regimen.  His intake has been greater than 2500 cc/day with greater than 1700 cc output.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, May 7, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Ken is doing well.  He has been lifting weights.

His current medications include:
     IMURAN 100 mg q.d.
     PREDNISONE 12 mg b.i.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 225 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 144/78   P 96   HT 162cm   WT 64.4kg   
     General: comfortable alert
     Skin: no lesions
     HEENT: eyes, nose and throat clear
     Neck: supple no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm.
     Abdomen: soft, no tenderness or bruit over the graft site.
     Extremities: without edema.
     Neurological: no focal deficits or meningeal signs.

A urinalysis revealed:
     SPEC GR UA  1.017           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     GLUCOSE UA  30              WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     
     URATE CRYSTALS  1+

Laboratory studies at this time include:
          AST          12     U/L       MCH        29.7      PG    
          K           3.6  MMOL/L       MCHC       33.9    G/DL    
          CA          9.1   MG/DL       RDW        17.0       % (H)
          CL          105  MMOL/L       HDW        2.87    G/DL    
          CR          2.0   MG/DL (H)   MPV         9.8      FL    
          CYA         291   MCG/L       PLT UNC     275   K/MM3    
          GLU          85   MG/DL       NEUT AB    6.75   K/MM3    
          PHOS        3.9   MG/DL       LYMPH A    1.49   K/MM3    
          ALT          11     U/L       EOS ABS     .06   K/MM3    
          NA          142  MMOL/L       NEUT-A     73.6       % (H)
          BUN          37   MG/DL (H)   LYMPH-A    16.2       % (L)
          URIC        8.0   MG/DL (H)   MONO-A      8.1       % (H)
          BILI TO     1.0   MG/DL       EOS-A        .7       %    
          BILI DI     0.2   MG/DL       BASO-A       .3       %    
          WBC        9.17   K/MM3       ATYP LY     1.0       %    
          RBC        3.43   M/MM3 (L)   ANISO-A       +    
          HGB        10.2    G/DL (L)   MICRO-A       +    
          HCT.       30.1       % (L)   LEFT SH  ABSENT    
          MCV        87.7      FL       

     Ken has stable renal function.  The rise is his creatinine may be secondary to cyclosporine which we will be decreasing today.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, May 14, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Kenny is doing well three months post transplant.  His weight is up slightly today by 1.5 kilos.  His last creatinine was slightly elevated at 2.0 mg/dl.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 24 mg q.d.
     PREDNISONE 24 mg q.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 200 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 122/64   P 105   R 16   HT 162.8cm   WT 66kg  
     General: comfortable, alert
     Skin: no lesions
     HEENT: eyes, nose and throat clear
     Neck: supple no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: S1 S2 normal, no murmur.
     Abdomen: soft, no organomegaly, no tenderness over the graft site.
     Extremities: no edema.
     Neurological: no focal deficits or meningeal signs.

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     1-2        
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           4.0  MMOL/L       RDW        17.0       % (H)
          CA          9.3   MG/DL       HDW        2.88    G/DL    
          CR          1.7   MG/DL (H)   MPV         9.9      FL    
          CYA         270   MCG/L       PLT UNC     270   K/MM3    
          GLU         105   MG/DL       NEUT AB    6.75   K/MM3    
          PHOS        3.3   MG/DL       LYMPH A    3.36   K/MM3    
          BUN          27   MG/DL (H)   EOS ABS     .11   K/MM3    
          NA          141  MMOL/L       NEUT-A     60.3       %    
          CL          103  MMOL/L       LYMPH-A    30.0       %    
          CO 2         25   MEQ/L       MONO-A      5.3       %    
          WBC       11.19   K/MM3       EOS-A       1.0       %    
          RBC        3.44   M/MM3 (L)   BASO-A       .3       %    
          HGB        10.7    G/DL (L)   ATYP LY     3.0       %    
          HCT.       31.6       % (L)   ANISO-A       +    
          MCV        92.0      FL       MACRO-A       +    
          MCH        31.1      PG       LEFT SH  ABSENT    
          MCHC       33.8    G/DL       

     Michel is clinically stable.  His cyclosporine levels have continued to be high with reductions in dosage.  We will make further adjustments based on his levels.

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, May 21, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.
     Michel is now three months post transplant and is doing very well.  At his last visit his creatinine had gone down from 2 to 1.7 mg/dl after increasing his fluid intake.  Over the last few days he has taken in about 3500 cc.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 24 mg q.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 137/71   P 86   R    T    HT 162.3cm   WT 67kg   HC cm
     General: comfortable, alert
     Skin: no lesions
     HEENT: eyes, nose and throat clear.
     Neck: supple no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: S1 S2 normal, no murmur.
     Abdomen: soft, no tenderness over the graft site.
     Extremities: no edema.
     Neurological: no focal deficits or meningeal signs.
A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           3.5  MMOL/L       MCHC       34.6    G/DL    
          CA          9.4   MG/DL       RDW        16.6       % (H)
          CR          1.7   MG/DL (H)   HDW        2.94    G/DL    
          CYA         194   MCG/L       MPV        10.0      FL    
          GLU          90   MG/DL       PLT UNC     255   K/MM3    
          PHOS        4.1   MG/DL       NEUT AB    4.70   K/MM3    
          BUN          23   MG/DL (H)   LYMPH A    3.20   K/MM3    
          NA          142  MMOL/L       EOS ABS     .10   K/MM3    
          CL          104  MMOL/L       NEUT-A     53.6       %    
          CO 2         27   MEQ/L       LYMPH-A    36.5       %    
          WBC        8.77   K/MM3       MONO-A      6.1       %    
          RBC        3.09   M/MM3 (L)   EOS-A       1.2       %    
          HGB         9.7    G/DL (L)   BASO-A       .6       %    
          HCT.       28.0       % (L)   ATYP LY     2.0       %    
          MCV        90.6      FL       LEFT SH  ABSENT    
          MCH        31.4      PG       

     Michel is clinically stable.  His blood pressure has been good.  We have told him that he should continue maintaining good oral intake, especially in this heat, so that he does not dry out because of increased insensible losses.

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

               Sincerely,


               Neal Sanders, MD       Mitsuko Khan, MD
               Renal Fellow                 Director, Clinical Services


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, June 4, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Kenny is currently doing well.  He has no symptoms.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 24 mg q.d.
     PROCARDIA XL 30 mg b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 138/70   P 95   R 14    HT 162.3cm   WT 68.1kg   
     General: comfortable, alert
     Skin: no lesions
     HEENT: eyes, nose and throat clear.
     Neck: supple no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: S1 S2 normal, no murmur.
     Abdomen: soft, no tenderness over the graft site.
     Extremities: no edema.
     Neurological: no focal deficits or meningeal signs.

A urinalysis revealed:
     SPEC GR UA  1.007           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           3.4  MMOL/L       MCHC       34.7    G/DL    
          CA          8.9   MG/DL       RDW        15.0       %    
          CR          1.7   MG/DL (H)   HDW        2.89    G/DL    
          CYA         183   MCG/L       MPV        10.2      FL    
          GLU         105   MG/DL       PLT UNC     253   K/MM3    
          PHOS        3.0   MG/DL       NEUT         56       %    
          BUN          16   MG/DL       LYMPH        39       %    
          NA          142  MMOL/L       MONOS         2       %    
          CL          105  MMOL/L       EOS           3       %    
          CO 2         26   MEQ/L       CELLS C     100    
          WBC        7.71   K/MM3       ABS NEU    4.32   K/MM3    
          RBC        3.33   M/MM3 (L)   ABS LYM    3.01   K/MM3    
          HGB        10.6    G/DL (L)   ABS EOS     .23   K/MM3    
          HCT.       30.5       % (L)   MORPH    NORMAL    
          MCV        91.7      FL       BASO ST    RARE (*)
          MCH        31.8      PG       

     Michel is currently 3 1/2 months post transplant and is clinically stable.  We have advised him not to be so concerned about his weight gain.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

     We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, June 18, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

     Since his last visit with us Kenny has been doing well without complaints.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 15 mg po q.d.
     PROCARDIA 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 132/58   P 86   R 12    HT 161.6cm   WT 68.5kg   
     General: comfortable, well hydrated in no distress.
     Skin: no lesions.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear.
     Heart: without murmur.
     Abdomen: soft, without tenderness nor over the graft site.
     Extremities: no edema.
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   few        
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          AST          14     U/L       MCV        90.3      FL    
          K           3.5  MMOL/L       MCH        31.7      PG    
          CA          8.8   MG/DL       MCHC       35.1    G/DL    
          CL          104  MMOL/L       RDW        13.7       %    
          CR          2.1   MG/DL (H)   HDW        2.80    G/DL    
          CYA         210   MCG/L       MPV        10.3      FL    
          GLU         100   MG/DL       PLT UNC     242   K/MM3    
          PHOS        3.9   MG/DL       NEUT AB    4.05   K/MM3    
          ALT          10     U/L       LYMPH A    3.07   K/MM3    
          NA          143  MMOL/L       EOS ABS     .13   K/MM3    
          BUN          23   MG/DL (H)   NEUT-A     49.9       %    
          URIC        8.6   MG/DL (H)   LYMPH-A    37.8       %    
          BILI TO     0.7   MG/DL       MONO-A      6.7       %    
          BILI DI     0.3   MG/DL       EOS-A       1.6       %    
          WBC        8.13   K/MM3       BASO-A       .5       %    
          RBC        3.25   M/MM3 (L)   ATYP LY     3.5       %    
          HGB        10.3    G/DL (L)   LEFT SH  ABSENT    
          HCT.       29.3       % (L)   

     In summary Kenny has had stable renal function during the past three visits with us.  He is continuing to gain weight although this has decreased compared to his previous weight gains.  We have continued to reassure him regarding the decrease in weight gain with continuing tapering of his Prednisone.  We will repeat his serum creatinine next week after good hydration.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

    We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, July 2, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

    Kenny is continuing to have weight gain.  We have reassured him that his gains in weight will decrease with continuing tapering of his Prednisone.  He is complaining of some redness of his eyes possibly due to eye strain.  We reminded him to continue follow up with ophthalmology because of the possibility of lenticonus associated with Alports disease.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 13 mg PO q.d.
     PROCARDIA XL 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) 1 M-W-F
     KPHOS NEUT 2 tablets t.i.d.

Michel's physical exam was notable for:
     BP 135/70   P 90   R 12   HT 163cm   WT 70.8kg 
     General: comfortable, well hydrated in no distress.
     Skin: no lesions.
     HEENT: TM's not injected, clear disk borders on fundoscopic exam.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: without murmur.
     Abdomen: soft, without tenderness nor bruits over the graft site.
     Extremities: no edema.
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  1.004           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   few        
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          AST          11     U/L       HCT.       31.1       % (L)
          K           3.7  MMOL/L       MCV        89.6      FL    
          CA          9.2   MG/DL       MCH        31.4      PG    
          CR          2.0   MG/DL (H)   MCHC       35.1    G/DL    
          CYA         147   MCG/L       RDW        13.2       %    
          GLU         103   MG/DL       HDW        2.73    G/DL    
          PHOS        3.7   MG/DL       MPV        10.5      FL    
          ALT           7     U/L       PLT UNC     224   K/MM3    
          BUN          22   MG/DL (H)   NEUT AB    4.93   K/MM3    
          URIC        8.7   MG/DL (H)   LYMPH A    2.88   K/MM3    
          NA          141  MMOL/L       EOS ABS     .11   K/MM3    
          CL          104  MMOL/L       NEUT-A     55.9       %    
          CO 2         26   MEQ/L       LYMPH-A    32.6       %    
          BILI TO     0.7   MG/DL       MONO-A      7.5       %    
          BILI DI     0.1   MG/DL       EOS-A       1.3       %    
          WBC        8.81   K/MM3       BASO-A       .6       %    
          RBC        3.47   M/MM3 (L)   ATYP LY     2.1       %    
          HGB        10.9    G/DL (L)   LEFT SH  ABSENT    

    We have reassured Kenny regarding his weight gain.  We have also discussed the fluctuations in his creatinine.  At present if his labs are stable we will space out his visits to three weeks in the near future.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, July 23, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.
Michel complained of a slight increase in his temperature to 38 last week.  He offers no complaints today and he is back to his baseline temperature.  He also saw ophthalmology who thought that he has no evidence of lenticonus at present.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) 1 M-W-F
     KPHOS NEUT 2 packs t.i.d.
     PREDNISONE 15mg/9mg q.o.d.

Michel's physical exam was notable for:
     BP 134/66   P 85   HT 162.6cm   WT 70.7kg  
     General: well developed, and well nourished in no distress.
     Skin: no lesions
     HEENT: positive for moist mucus membranes.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm with no murmur noted.
     Abdomen: soft without bruits or tenderness at graft site.
     Genitourinary: deferred
     Extremities: no edema.
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  1.002           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     
0-1 hyaline cast

Laboratory studies at this time include:
          AST          18     U/L       MCV        88.2      FL    
          K           3.8  MMOL/L       MCH        30.6      PG    
          CA          8.8   MG/DL       MCHC       34.6    G/DL    
          CL          105  MMOL/L       RDW        13.3       %    
          CR          2.0   MG/DL (H)   HDW        2.85    G/DL    
          CYA         200   MCG/L       MPV        10.7      FL    
          GLU         104   MG/DL       PLT UNC     246   K/MM3    
          PHOS        4.0   MG/DL       NEUT AB    4.80   K/MM3    
          ALT           8     U/L       LYMPH A    3.08   K/MM3    
          NA          139  MMOL/L       EOS ABS     .33   K/MM3    
          BUN          20   MG/DL (H)   NEUT-A     53.1       %    
          URIC        8.1   MG/DL (H)   LYMPH-A    34.0       %    
          BILI TO     0.8   MG/DL       MONO-A      6.6       %    
          BILI DI     0.2   MG/DL       EOS-A       3.6       %    
          WBC        9.05   K/MM3       BASO-A       .6       %    
          RBC        3.60   M/MM3 (L)   ATYP LY     2.1       %    
          HGB        11.0    G/DL (L)   LEFT SH  ABSENT    
          HCT.       31.8       % (L)   

Michel has been stable over the past several weeks.  His weight has also stabilized.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, July 23, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.
Michel complained of a slight increase in his temperature to 38 last week.  He offers no complaints today and he is back to his baseline temperature.  He also saw ophthalmology who thought that he has no evidence of lenticonus at present.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) 1 M-W-F
     KPHOS NEUT 2 packs t.i.d.
     PREDNISONE 15mg/9mg q.o.d.

Michel's physical exam was notable for:
     BP 134/66   P 85   HT 162.6cm   WT 70.7kg   
     General: well developed, and well nourished in no distress.
     Skin: no lesions
     HEENT: positive for moist mucus membranes.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm with no murmur noted.
     Abdomen: soft without bruits or tenderness at graft site.
     Genitourinary: deferred
     Extremities: no edema.
     Neurological: no lateralizing signs.
A urinalysis revealed:
     SPEC GR UA  1.002           WBC/HPF     N          
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     
0-1 hyaline cast

Laboratory studies at this time include:
          AST          18     U/L       MCV        88.2      FL    
          K           3.8  MMOL/L       MCH        30.6      PG    
          CA          8.8   MG/DL       MCHC       34.6    G/DL    
          CL          105  MMOL/L       RDW        13.3       %    
          CR          2.0   MG/DL (H)   HDW        2.85    G/DL    
          CYA         200   MCG/L       MPV        10.7      FL    
          GLU         104   MG/DL       PLT UNC     246   K/MM3    
          PHOS        4.0   MG/DL       NEUT AB    4.80   K/MM3    
          ALT           8     U/L       LYMPH A    3.08   K/MM3    
          NA          139  MMOL/L       EOS ABS     .33   K/MM3    
          BUN          20   MG/DL (H)   NEUT-A     53.1       %    
          URIC        8.1   MG/DL (H)   LYMPH-A    34.0       %    
          BILI TO     0.8   MG/DL       MONO-A      6.6       %    
          BILI DI     0.2   MG/DL       EOS-A       3.6       %    
          WBC        9.05   K/MM3       BASO-A       .6       %    
          RBC        3.60   M/MM3 (L)   ATYP LY     2.1       %    
          HGB        11.0    G/DL (L)   LEFT SH  ABSENT    
          HCT.       31.8       % (L)   

Michel has been stable over the past several weeks.  His weight has also stabilized.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, August 20, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

Michel today has no complaints, he has been loosing weight because he has remained more active and we are currently continuing to wean his steroid dose.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) 1 M-W-F
     KPHOS NEUT 2 packs t.i.d.
     PREDNISONE 15mg/5mg q.o.d.

Michel's physical exam was notable for:
     BP 128/70   P 88   R 12   HT 162.7cm   WT 68kg   
     General: he looks great in no distress.
     Skin: positive for hirsutism.
     HEENT: moist mucus membranes.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm with no murmur.
     Abdomen: soft without bruits or tenderness at graft site.
     Genitourinary: deferred
     Extremities: no edema, warm and well perfused.
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  1.008           WBC/HPF     0-1        
     PH UA       5.0             SQUAM EPI   few        
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   occ.       
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          AST          14     U/L       HCT.       30.7       % (L)
          K           4.1  MMOL/L       MCV        86.1      FL    
          CA          8.7   MG/DL       MCH        30.3      PG    
          CR          2.3   MG/DL (H)   MCHC       35.2    G/DL    
          CYA         153   MCG/L       RDW        13.8       %    
          GLU          92   MG/DL       HDW        2.80    G/DL    
          PHOS        4.7   MG/DL (H)   MPV        10.4      FL    
          ALT           4     U/L       PLT UNC     240   K/MM3    
          BUN          19   MG/DL (H)   NEUT AB    3.88   K/MM3    
          URIC       10.3   MG/DL (H)   LYMPH A    2.65   K/MM3    
          NA          141  MMOL/L       EOS ABS     .22   K/MM3    
          CL          105  MMOL/L       NEUT-A     52.6       %    
          CO 2         24   MEQ/L       LYMPH-A    35.9       %    
          BILI TO     0.8   MG/DL       MONO-A      5.6       %    
          BILI DI     0.1   MG/DL       EOS-A       3.0       %    
          WBC        7.37   K/MM3       BASO-A       .7       %    
          RBC        3.56   M/MM3 (L)   ATYP LY     2.1       %    
          HGB        10.8    G/DL (L)   LEFT SH  ABSENT    

Michel continues to do well.  His creatinine is elevated slightly.  We will re-check his labs and re-evaluate.

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

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, September 24, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

Michel and his father report no complaints, he has been doing well at home.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) 1 M-W-F
     KPHOS NEUT 2 packs t.i.d.
     PREDNISONE 15mg/1mg q.o.d.

Michel's physical exam was notable for:
     BP 132/66   P 85   HT 163.4cm   WT 67.7kg   
     General: alert and attentive in no distress.
     Skin: hirsute.
     HEENT: normal.
     Neck: lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm with 2/6 systolic ejection murmur heard loudest at the left upper sternal border.
     Abdomen: soft, nontender and nondistended.  The graft is not tender to palpation.
     Genitourinary: deferred
     Extremities: normal without edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.005           WBC/HPF     N          
     PH UA       5               SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          AST          14     U/L       HCT.       31.9       % (L)
          K           4.2  MMOL/L       MCV        86.6      FL    
          CA          9.2   MG/DL       MCH        29.9      PG    
          CR          2.1   MG/DL (H)   MCHC       34.5    G/DL    
          CYA         134   MCG/L       RDW        14.6       %    
          GLU         103   MG/DL       HDW        2.81    G/DL    
          PHOS        3.9   MG/DL       MPV        10.7      FL    
          ALT           4     U/L       PLT UNC     260   K/MM3    
          BUN          19   MG/DL (H)   NEUT AB    3.19   K/MM3    
          URIC        8.3   MG/DL (H)   LYMPH A    2.63   K/MM3    
          NA          137  MMOL/L       EOS ABS     .19   K/MM3    
          CL          101  MMOL/L       NEUT-A     47.3       %    
          CO 2         25   MEQ/L       LYMPH-A    39.0       %    
          BILI TO     1.2   MG/DL       MONO-A      6.6       %    
          BILI DI     0.3   MG/DL       EOS-A       2.8       %    
          WBC        6.74   K/MM3       BASO-A       .8       %    
          RBC        3.68   M/MM3 (L)   ATYP LY     3.4       %    
          HGB        11.0    G/DL (L)   LEFT SH  ABSENT    

Michel is doing well.  He will taper his prednisone to 15 mg q.o.d. starting tomorrow.  His renal function is stable.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, November 26, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

Michel has been doing very well.  He has had one episode of rhinorrhea without fever.  He has not been complaint with his KPhos supplements over the past two months.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) 1 M-W-F
     PREDNISONE 15mg q.o.d.

Michel's physical exam was notable for:
     BP 143/54   P 94   HT 162.7cm   WT 64kg
     General: alert and attentive in no distress.
     Skin: normal.
     HEENT: normal.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation bilaterally.
     Heart: regular rate and rhythm without gallops, murmurs or rubs.
     Abdomen: soft, non-tender without hepatosplenomegaly.
     Genitourinary: deferred
     Extremities: warm and well perfused without edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.002           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       6.0             WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   sever 
     MICROSCOPC             

Laboratory studies at this time include:
          K           3.9  MMOL/L       MCHC       33.0    G/DL    
          CA          8.2   MG/DL (L)   RDW        15.0       %    
          CR          2.4   MG/DL (H)   HDW        2.73    G/DL    
          CYA         105   MCG/L       MPV        10.2      FL    
          GLU          96   MG/DL       PLT UNC     287   K/MM3    
          PHOS        5.3   MG/DL (H)   NEUT         68       %    
          BUN          26   MG/DL (H)   LYMPH        19       % (L)
          NA          135  MMOL/L       MONOS         5       %    
          CL           98  MMOL/L       EOS           2       %    
          CO 2         24   MEQ/L       ATYP LY       5       %    
          WBC        9.00   K/MM3       BAND          1       %    
          RBC        3.79   M/MM3 (L)   CELLS C     100    
          HGB        11.3    G/DL (L)   ABS NEU    6.21   K/MM3    
          HCT.       34.3       % (L)   ABS LYM    1.71   K/MM3    
          MCV        90.4      FL       ABS EOS     .18   K/MM3    
          MCH        29.8      PG       MORPH    NORMAL    

Michel's creatinine is mildly elevated and we will check this in one week.  We have instructed him to discontinue the K-Phos supplements as his phosphate levels are within normal limits.  He will also discontinue his bactrim.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Michel Evans
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/78

Dear Dr. Pulanski:

We had the pleasure of seeing Michel in the Renal Transplant Program on Tuesday, November 26, 1996.  He has chronic renal failure secondary to Alport's Syndrome.  He had a renal transplant on 2/8/96.

Michel has been doing very well.  He has had one episode of rhinorrhea without fever.  He has not been complaint with his KPhos supplements over the past two months.

His current medications include:
     IMURAN 100 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 30 mg po b.i.d.
     CYCLOSPORINE STUDY #073-C 175 mg b.i.d.
     BACTRIM DS (Trimethoprim 160 mg, Sulfamethoxazole 800 mg) 1 M-W-F
     PREDNISONE 15mg q.o.d.

Michel's physical exam was notable for:
     BP 143/54   P 94   HT 162.7cm   WT 64kg   
     General: alert and attentive in no distress.
     Skin: normal.
     HEENT: normal.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation bilaterally.
     Heart: regular rate and rhythm without gallops, murmurs or rubs.
     Abdomen: soft, non-tender without hepatosplenomegaly.
     Genitourinary: deferred
     Extremities: warm and well perfused without edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.002           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       6.0             WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   several 
     MICROSCOPC             

Laboratory studies at this time include:
          K           3.9  MMOL/L       MCHC       33.0    G/DL    
          CA          8.2   MG/DL (L)   RDW        15.0       %    
          CR          2.4   MG/DL (H)   HDW        2.73    G/DL    
          CYA         105   MCG/L       MPV        10.2      FL    
          GLU          96   MG/DL       PLT UNC     287   K/MM3    
          PHOS        5.3   MG/DL (H)   NEUT         68       %    
          BUN          26   MG/DL (H)   LYMPH        19       % (L)
          NA          135  MMOL/L       MONOS         5       %    
          CL           98  MMOL/L       EOS           2       %    
          CO 2         24   MEQ/L       ATYP LY       5       %    
          WBC        9.00   K/MM3       BAND          1       %    
          RBC        3.79   M/MM3 (L)   CELLS C     100    
          HGB        11.3    G/DL (L)   ABS NEU    6.21   K/MM3    
          HCT.       34.3       % (L)   ABS LYM    1.71   K/MM3    
          MCV        90.4      FL       ABS EOS     .18   K/MM3    
          MCH        29.8      PG       MORPH    NORMAL    

Michel's creatinine is mildly elevated and we will check this in one week.  We have instructed him to discontinue the K-Phos supplements as his phosphate levels are within normal limits.  He will also discontinue his Bactrim.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Nekia Blue, M.D.          RE: Sammy Hart
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/28/79

Dear Dr. Blue:

We had the pleasure of seeing Sammy in the Endocrine Program on 12/9/93 for follow-up of possible hypothyroidism.

History: He had elevated TSH three months ago.  Mother reports no illness for the last three months.  He has been very active playing football.  He denies any intercurrent illness, no constipation.  His review of systems is completely normal.

Physical exam:  
Height: 170 cm          Weight: 87.8 kg         BP: 120/80              
Pulse: 72               Pubic hair: Tanner IV   R. testis: 4.5 x 2.5 cm 
L. testis: 4.0 x 2.5 cm 
The remainder of his exam was unremarkable except to note that Sammy is obese.

Impression: My impression is that Sammy is clinically euthyroid even with the past history of elevated TSH.  I elected not to treat him at the present time.  I did obtain thyroid function tests which are pending.  If the TSH shows elevation to a certain degree I would like to start him on Synthroid.  Otherwise, I will continue to observe him and see him again in six months. I discussed in great detail with Sammy and his mother about the overweight problems and they seem to be interested in watching his diet.

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

Sincerely,


Elmo Domingo, MD                 
Attending in Endocrinology   


Addendum: T4 5.6, TSH 5.1.


CONTENT:
Nekia Blue, M.D.          RE: Sammy Hart
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/28/79

Dear Dr. Blue:

We had the pleasure of seeing Sammy in the Endocrine Program on 9/23/93 for evaluation of elevated tsh.

History: He had been in his usual health until a year before his clinic visit when he was noted to gain weight excessively.  Thyroid function tests were obtained showing elevated TSH 6.8 with upper limit of normal being 4.3  otherwise the T4 and TT3 are normal.  There fore hew as referred to the Endocrine Clinic for further management.

On review of systems Sammy states that he is very active and no illness in the past.  He is eating well with a good appetite.  He has no problems swallowing, no constipation or diarrhea.  He denies any dry skin or coarse hair.

Physical exam:  
Height: 169.8 cm        Weight: 85.7 kg         BP: 110/80              
Pulse: 60               Arm span: 179           Pubic hair: Tanner IV   
R. testis: 4.5 x 2.5 cm L. testis: 4.0 x 2.5 cm 
The remainder of his exam was completely normal.

Impression: My impression is that Sammy had elevated TSH however, he showed no clinically signs or symptoms of hypothyroidism, therefore I elected to wait for three months and evaluate him again.  If you have any concerns please contact us.

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

Sincerely,


Elmo Domingo, MD                 
Attending in Endocrinology


CONTENT:
Bird, M.D.          RE: Bernard Ruth
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/77

Dear Dr. Bird:

We had the pleasure of seeing Bernard in the Endocrine Program on 10/25/94 for .

History: I have seen Jeffrey Ruth on the 23rd of August and again on the 25th of October 1994 at the Diabetes clinic at Children's Hospital.   He is involved in some sports but he is now working at Osco Drug store 15-20 hours per week.  He does complain of some highs and occasional lows.   He is not testing very often.    

At his first visit his insulin dose was 14 of Regular and 28 of NPH in the morning with 9 Regular and 20 NPH before dinner.   He does use extra insulin if he is high or for extra food.   It was noticed at that time that he was testing very rarely and this was apparently due to having a broken meter.   Prescriptions were given for a new meter at that time.   At this second visit he was still on the same dose of insulin and had not yet obtained a blood glucose meter.   

Review of systems is negative for diabetes related symptoms.  He does have occasional reactions and these happen at night, usually when he has taken less food or skipped meals or snacks and then added exercise.   He  complains of bleeding gums.   His diet is absolutely inconsistent in terms of the timing of meals and the content of meals but he does obtain three meals a day.   He drinks a small amount of alcohol at parties.  He is sexually active and uses condoms.

Physical exam:  
Height: 178.3 cm        Weight: 70.4 kg         BP: 108/70              
His height is 178.3 cm and his weight is 70.4 kg.  His blood pressure is 108/70.   He is a healthy appearing, mature young man.  His eye exam is normal.   His thyroid exam is normal.   The lungs are clear and the heart has a normal sinus rhythm with no murmur.   The abdominal exam is benign.   There is 1+ and equal DTR's.   The skin is normal except for cracked and broken skin on the sole of the right foot.  There is hypertrophy at insulin injection sites.    

Laboratories obtained at the August visit included a glycohemoglobin of 9.6%, the glycohemoglobin in October was 10.7%, random glucose was 40 mg%.   Urine microalbumin done in October was 10 mg per gram of creatinine, which is normal.

Impression: 1.  It is our impression that his diabetes is in only fair control.  He is taking insulin regularly but he is not always matching his insulin to his meals.   We have again asked him to obtain a glucose meter and to start testing and reviewed adapting insulin for his school and work schedule.   
2.  He has gingivitis and he should be seeing a dentist.   In the meantime, we talked to him about brushing regularly and flossing.   
3.  He has quamation of the sole of his right foot for which we recommended cleaning, good drying and application of lotion such as Vaseline Intensive Care on a regular basis.

Disposition: Thank you for letting us share in Freddie's care.   I would like to see him back in three months.
Thank you for letting us share in the care of Bernard.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Bird, M.D.          RE: Bernard Ruth
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/77

Dear Dr. Bird:

We had the pleasure of seeing Bernard in the Endocrine Program on 7/18/95 for .

History: Your patient Bernard Ruth continues to be followed at the Diabetes clinic at Children's Hospital at approximately 3-6 month intervals.  At this visit,  (July 18, 1995), he was 18 7/12 years old.  He felt well and denied symptoms referable to the diabetes except for an occasional nocturnal hypoglycemia.  His consistency with diet was less then optimal, but it appears that he takes all his insulin.  

His reported blood sugars were nill.  His energy level is good and he plays basketball regularly.

He reported however, that he had been seen 6/28/95 by an anesthesiologist prior to dental surgery and was found to have a murmur and arrhythmia.

Current medications: His insulin dose as of his last visit was 14 Regular and 28 NPH in the morning, 9 Regular and 20 NPH in the evening for a total of 1 unit/kg/day.

Physical exam:  
Height: 178.6 cm        Weight: 70.4 kg         
He has no problems at the injection sites.
Cardiac exam is normal except for a low pitched II/VI murmur at the left sternal border, radiating to the apex.

Laboratory studies:  Labs included a urine glucose which was traced positive with negative ketones and protein.  His glucose was 98 mg% and his glycohemoglobin 10.8% (norms 5.2-7.8).  Microalbumin is normal at 4 mg/g creatinine.

Impression: Overall it appears that his diabetes is in fair control, probably more due to consistently taking insulin and physical activity then anything else.  I have made no changes and I have encouraged him to check his blood sugar more often so he stays out of trouble.  I hope to see Bernard again in three or four months.  I have offered him the opportunity of moving on to an adult clinic but he says he prefers to come to Children's for the time being.


I have referred him to Cardiology Clinic early next week for evaluation of his murmur.

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

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 6/8/94 for .

History: I saw Marcus, age 15 years 4 1/2 months, in follow up for growth hormone deficiency.

He is currently on Protropin 2.5 mg daily (0.05 mg/kg/dose).  

In addition to growth hormone deficiency, he has a congenital heart defect (ventricular septal defect and a transverse septum in the right atrium).  Apparently, he has had no hemodynamic effects from the heart defect and he is not on specific treatment.  He denies any symptoms of dyspnea with exertion or palpitations.  He does use antibiotics prophylacticly prior to dental procedures.  

He has a large appetite and has three meals and two snacks daily.  Bowel movements are normal. Vision and hearing are normal;  he has occasional headaches none of which are severe.  He is in the ninth grade and does well in school  He sleeps well, usually without disturbance from 10:00 p.m. until 6:00 a.m.

Physical exam:  
Height: 157.4 cm        Weight: 48.2 kg         BP: 170/78              
Pulse: 84               Breast: Tanner II       Pubic hair: Tanner IV   
R. testis: 4.0 x 2.5 cm L. testis: 4.0 x 2.8 cm Phallus length: 12.0 cm 
Mid-shaft diam.: 2.8 cm 
General: Well developed, well -nourished, with good color and hydration.  
Skin: Normal texture.
HEENT: Unremarkable.
Neck: No thyromegaly.
Chest: (gynecomastia)  Clear to percussion and auscultation.
Heart: Grade IV-V/Vi pansystolic murmur, maximally heard at the 4th left intercostal space.
Abdomen: Liver, spleen and kidney not palpable.
Genitourinary: 
Extremities: Normal muscle tone and mass.
Neurological: PERRL, EOMI; cranial nerves intact fundi were normal.   DTR's 2+ symmetric in the lower extremities and he had intact vibratory sensation.

Laboratory studies:  Bone age 13 1/2 to 14  years.

Impression: Growing well; growth velocity 5.8 cm/year form July 1993 to the present time.  His cardiac status is apparently unchanged.  Puberty has progressed.

Disposition: Continue Protropin 2.5 mg daily.  Return to clinic in three months.
Thank you for letting us share in the care of Marcus.

Sincerely,


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


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 9/26/94 for .

History: I saw Marcus, age 15 years 8 months, in follow-up for growth hormone  deficiency.

Medications: Protropin 2.5 mg daily (0.049 mg/kg). 

He has enjoyed good health; he has no complaints.  He has a good appetite and eats three meals plus snacks.  Bowel movements are normal.  His sleep is undisturbed.  He has an active social life and is doing well academically.

Physical exam:  
Height: 159.2 cm        Weight: 50.9 kg         BP: 126/76              
Pulse: 72               Breast: Tanner I        Pubic hair: Tanner IV   
R. testis: 4.5 x 2.6 cm L. testis: 4.3 x 2.2 cm 
General:  Well developed, well nourished, good color and hydration.  
Skin: Smooth and warm.
HEENT: Unremarkable.
Neck: No thyromegaly.
Chest: Clear.
Heart: Grade IV/VI pansystolic murmur heard best at the lower left sternal border; no third heart sound and normal S2.
Abdomen: No organ enlargement or masses.
Genitourinary: Normal adult genitalia as noted above.
Extremities: Normal.
Neurological:  Cranial nerves intact; PERRL; EOMI; intact visual fields, normal fundi.

Impression: His annualized growth velocity is 6.9 cm/yr and rate of weight gain 10.1 kg/yr.  

I have recommended that he continue growth hormone therapy in the same dose.  I would appreciate the opportunity to see him again in three months at which time I will repeat his thyroid function tests.

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

Sincerely,


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


Problem list to date:
SEXUAL-PRECOCITY                             12/08/92  
SHORT-STATURE                                03/17/92  
GH-DEFICIENCY                                07/21/83  
Transcribed by Sullivan_ma


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I saw Marcus, age 15 years 11 months, in follow-up for growth hormone deficiency.

Medications: Protropin (growth hormone) 2.5 mg daily or 0.046 mg/kg/dose.

He feels well and has no complaints.  General health has been good.  He does well in school.

Physical exam:  
Height: 161.2 cm     Weight: 53.8 kg      BP: 128/84    Pulse: 93               
He looked well and had good color and hydration.  Skin was smooth and warm.  No thyromegaly.  Grade IV/VI systolic murmur over the precordium.  He has 2+ axillary hair; increased sebacous gland activity on the nose and in nasolabial grooves; occasional facial comedones and blackheads.  Fundi were normal.

Laboratory studies:  Serum thyroxine 7.2 5g/dl, TBGI 0.99, TSH 1.10 5U/ml, all normal.

Impression: He has grown 2.0 cm. and gained 2.9 kg in three months, an annualized growth velocity of 8 cm/yr.  I have increased his dose of growth hormone slightly to 2.7 mg/dose (0.05 mg/kg).  

Overall, Marcus is doing extremely well.  I plan to see him again in four months.

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

Sincerely,


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


CONTENT:
, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Fenns,

I received a report from Good Samaritan Medical Center from tests dated 6/22/95:

T4 8.1 ug/dl
rT3 uptake 33%
TSH 12.97 uU/ml (Increased and suggestive of hypothyroidism)

According to my records Holly is taking 0.0625 mg of L-thyroxine daily. If the dose is being reliably taken then it is not sufficient. She should move up to the 0.075 mg dose.


Sincerely,




Norman Spack MD
Associate in Endocrinology

cc: Peter Rappo MD, 1047 No. Main St., Brockton 02401


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I saw Marcus, age 16 years 9 months, for follow-up of growth hormone deficiency.   

He feels well and is doing well in school.  He reports normal vision and no  headaches.  He is moderately active and has a part-time job.  He sleeps without disturbance and has a good energy level.  Bowel movements are normal.  He shaves less than once per week.

Current medications: Human growth hormone 2.7 mg. (0.044 mg/kg) daily.

Physical exam:
HT: 164.8 cm            WT: 60.6 kg
BP: 130/78              Breast: Tanner I        Pubic hair: Tanner IV   
He looked well, had smooth and warm skin.  He has a grade III-IV/VI systolic murmur.  Remainder of the examination was normal.

Impression: He has grown 1.3 cm. and gained 3.0 kg. in 3 months.  He is  continuing to respond to growth hormone.  His annualized growth velocity is 5.3 cm. per year since September 26, 1994.

Disposition: I have recommended that he continue growth hormone therapy at the same dose.


Sincerely,





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


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I saw Marcus, age 16 years 5 months, for follow-up of growth hormone  deficiency. 

Medications:  Protropin 2.7 mg daily. 

He has enjoyed good health and currently has no complaints.  He has a  good appetite and normal bowel movements.  He sleeps well without  disturbance.  He reports no headaches, visual disturbance or hearing  impairment.  He has good coordination and abundant energy. 

He does use a deodorant but has not yet begun to shave.

Physical exam:
HT: 163.6 cm    WT: 57.6 kg
BP: 126/78              Pulse: 70               
He looked well, had good color and hydration.  Skin was  smooth and warm.  There was no thyromegaly.  Fundi revealed normal disc  vessels.  The neurologic exam was grossly normal. 

His bone age was approximately 14 years (standard deviation 15 months).

Impression: He has grown 0.9 cm and gained 2.0 kg in 3 months, an  annualized growth velocity of 3.6 cm per year.  In the past 13 months,  his annualized growth velocity was 5.9 cm per year.  At a bone age of 14  years, the average boy has achieved approximately 92.7% of his mature  height,  Based on his current height and bone age, Marcus's predicted  adult height is 69.5 inches.



Sincerely,




Bernardo Bird, MD         
Clinical Director


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I saw Marcus, age 17 years, for follow up of growth hormone deficiency.   

Medications:  Human growth hormone 2.7 mg (0.047 mg/kg/dose).  He takes all doses in the upper extremity and omits approximately one dose per week.   

He feels well and had no complaints.  He has been more active and has a busier schedule.  His meals are not as regular as in the past, and he usually only has two meals daily.  He sleeps well without disturbance.  He is doing well in school.  He reported no headaches or visual changes.

Current medications: None.

Physical exam:
HT: 165.4 cm            WT: 57.3 kg
BP: 120/74              Pulse: 72               Pubic hair: Tanner V    
He is a slender, healthy appearing youth.  Skin was smooth and warm.  His murmur was unchanged.  He has adult male genitalia.  Neurologic exam, including visualization of the fundi, was normal.

Laboratory studies: T4 6.5 ug/dL, TBGI .98, TSH 1.6 uU/mL, all normal.

Impression: He has grown 1.6 cm in three months (growth velocity 2.4 cm per year) and has lost 3.3 kg.  His growth is slowing, but has not stopped.  His ventricular septal defect seems to be unchanged.

Disposition: I will repeat his bone age in three months and make a decision whether or not to stop growth hormone therapy at that time.  Meanwhile, he should continue growth hormone therapy at the same dose.


Sincerely,






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


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I saw Marcus, age 17 years 2 months, for follow up of growth hormone insufficiency.   

Medications:  Protropin human growth hormone 2.7 mg daily (0.045 mg/kg). 

He has felt well and has a good appetite.  He is moderately active.  He sleeps well without disturbance and had no complaints.  He shaves once per week.

Current medications: None.

Physical exam:
HT: 166.2 cm            WT: 60.2 kg
BP: 120/80              Pulse: 72               Pubic hair: Tanner V    
He looked well, had smooth and warm skin.  HEENT was unremarkable.  Physical exam revealed an unchanged heart murmur.  Secondary sexual development was complete.  Neurologic exam was normal.
Bone age: 16 years

Impression: Based on his height on 4-17-95, he has grown 3.5 cm in the past year.  My reading of his bone age was 16 years (SD is 13 months).  I have advised him to continue growth hormone therapy in the same dose until growth is complete.


Sincerely,






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


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I saw Marcus, age 17 6-1/2 months, for follow-up of growth hormone insufficiency.   

Medications:  Protropin 2.75 mg (0.044 mg/kg) daily.   

He had no specific complaints.  He has a good appetite, no gastrointestinal symptoms.  He reported no headaches or visual disturbance.  He shaves approximately twice per week.  He will be entering senior year in high school.  During the summer, he is working approximately 60 hours per week.

Physical exam:
HT: 167.4 cm            WT: 63 kg
BP: 138/84              Pulse: 79               Pubic hair: Tanner V    
He looked well.  The skin was smooth and warm.  No thyromegaly.  Chest clear.  There was a pansystolic murmur heard across the precordium.  The remainder of the exam was unremarkable.

Laboratory studies: Serum thyroxine 5.8 5g/dL, TBGI .95, TSH 1.2 5U/mL, normal; IGF-1 pending.

Impression: He has grown 1.2 cm and gained 2.8 kg in 3.5 months.  His annualized growth velocity in the interval since July 17, 1995, was 3.8 cm and weight gain 5.4 kg.  He is continuing to respond to growth hormone; accordingly, I have reniewed his prescription for an additional 4 months.  At his next visit, we will obtain a bone age to determine whether his epiphyses have fused.


Sincerely,





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


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I saw Marcus, age 17 years 10-1/2 months, for follow-up of growth hormone  insufficiency.   

Medications:  Protropin 2.7 mg daily (0.043 mg/kg or 0.3 mg/kg/week). 

He feels well and has normal energy.  He sleeps without disturbance. He reported no headaches or visual disturbance.  He is a senior doing well in school and applying to college.  He is moderately active and has a normal social life. 

He shaves 2-3 times weekly.

Physical exam:
HT: 167.8 cm            WT: 62.6 kg
BP: 129/80              Pulse: 66               Pubic hair: Tanner V    
Physical exam revealed a healthy appearing youth who has completed secondary sexual development.  Thyroid gland was not enlarged.  The physical exam was unchanged.  

Bone age was 17 years (standard deviation 13 months).

Impression: He has continued to grow slowly.  With a bone age of 17 years, he has attained approximately 99% of his adult height.

Disposition: I recommended discontinuing growth hormone after he has used his current supply.  We discussed the possibility of re-testing his growth hormone-IGF-1 axis in six months time to determine whether his growth hormone insufficiency is permanent.  If it is, it will be important in the future to address the question of whether Marcus should continue to receive growth hormone at a lower maintenance dose throughout adult life.  

There is emerging clinical research data that suggests that adults with GH insufficienct who receive GH replacement are healthier, have increased muscle and bone mass, more favorable lipid profiles, and better quality of life.  No decisions were made at this time.

Sincerely,




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


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 11/18/91 for evaluation of response to growth hormone.

Since last seen on 08/24/91 he has been well, had no intercurrent illness and review of systems was negative.

Physical exam:  
Height: 141.5 cm        Weight: 33.7 kg         BP: 90/70               
R. testis: 2.0 x 1.2 cm L. testis: 2.0 x 1.2 cm Phallus length: 7.0 cm  
Mid-shaft diam.: 1.8 cm 
The skin was of normal texture, he had no acne.  The cardiac murmur was unchanged.  He had pubic or axillary hair. The rest of the examination was negative.

In summary: Marcus grew 2.3 cm in four months, an above average rate of growth.  He does not show any evidence of early puberty.  His bone age on 07/91 was 12.5 years which gives him a predicted adult height of 5'6".

The dose of Protropin was increased to 1.87 mg daily six days a week to adjust for his present weight.  Blood was obtained for Thyroid function tests, LH, FSH, Testosterone, and DHEAS.  The results are pending.

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

Sincerely,




Kendell Simpson, MD                          
Clinical Director


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 03/17/92 for  follow-up evaluation of his response to growth hormone therapy.

History: Since last seen on 11/18/91 Marcus has been well.  He had no intercurrent illness.  He has been doing very well in school.   He had no headaches, polyuria or or polydipsia.  The review of systems was negative.

Physical exam:  
Height: 143.7 cm        Weight: 35.5 kg         BP: 90/60               
Pulse: 72               Pubic hair Tanner: 1    R. testis: 2.0 x 1.2 cm 
L. testis: 2.0 x 1.2 cm Phallus length: 6.5 cm  Mid-shaft diam.: 1.6 cm 
The skin was of normal with no acne.  The thyroid was not palpable.  His heart murmur was unchanged.  He  had no axillary or pubic hair. The remainder of the examination was normal.

Impression: Marcus continues to grow at an accelerated rate without any significant pubertal development.  He is to continue on the same dose of Protropin (1.87 mg daily six days a week) which is equivalent to 0.045 mg/kg/day.


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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

I had the pleasure of seeing Marcus in the Endocrine Program on 07/14/92 for evaluation of his response to growth hormone therapy.

History: Marcus has been well since last seen on 03/17/92.  He had no intercurrent illness and review of systems was negative.  He did very well in school.

Current medications: Protropin 1.87 mg daily x 6/week

Physical exam:  
Height: 145.6 cm        Weight: 36.7 kg         
BP: 110/60              Pulse: 78               
R. testis: 2.8 x 1.7 cm L. testis: 2.8 x 1.5 cm 
Phallus length: 7.5 cm  Mid-shaft diam.: 2.0 cm 
Marcus was healthy looking.  Skin:  Normal texture.  No acne.  HEENT:  Normal Fundi.  EOM intact.  Neck:  Supple. Thyroid not enlarged.  Chest:  Lungs are clear.  Cor:  Grade IV/VI pansystolic harsh murmur best heard over LSB  Abdomen:  Soft.  No masses.  No tenderness. No hepatosplenomegaly.  GU:  Few hairs over the scrotum. Extremities:  Normal.

Laboratory studies pending at this time include: Bone age.

Impression: Marcus shows very very early signs of puberty.  He again grew 2.0 cm in four months.  He is to continue on the same dose of Protropin and will be reassessed in four months.

Thank you for letting me share in the care of Marcus.

Sincerely,





Kendell Simpson, MD             
Clinical Director


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 12/8/92 for follow up of his response to growth hormone therapy.

History: Marcus has been well since last seen on July 14, 1992.  He had a head trauma in August which needed sutures but he did not lose consciousness nor did he become dizzy, subsequently he had no headaches.  He is doing very well in school.  Review of systems was negative.

Current medications: Protropin 1.87 mg 6X/week.

Physical exam:  
Height: 147.4 cm        Weight: 39.4 kg         BP: 110/60              
Pulse: 82               Pubic hair: Tanner II   R. testis: 3.0 x 2.0 cm 
L. testis: 3.0 x 1.8 cm Phallus length: 8.0 cm  Mid-shaft diam.: 1.8 cm 
Marcus was healthy looking in no distress.  Skin: Normal texture, has multiple nevi.  HEENT: Negative.  Neck: Thyroid not enlarged.  Chest: Clear lungs.  Heart: Pansystolic murmur unchanged.  Abdomen: Soft, no masses, no hepatosplenomegaly.  Genitourinary: Few hair over the scrotum, there has been some increase in the size of the testicles.  Extremities: Normal.  Neurological: Non-focal.

Impression: Isolated GH deficiency - VSD.  Marcus grew 1.8 cm. in 5 months, a slower rate than previously, he also has further pubertal development.

Disposition: Increase the dose of Protropin to 2. mg. and administer it daily to adjust for his weight gain.  Marcus is to return to the Endocrine clinic in four months.

Laboratory studies pending at this time include: TFT, DS, LH, FSH, testosterone.
Thank you for letting us share in the care of Marcus.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 03/23/93 for follow up of his response to growth hormone therapy.

History: Since last seen on 12/08/92 Marcus has been well.  He had no intercurrent illness and the review of systems was negative.  He continues to do well in school.

Current medications: Protropin 2.0 mg daily.

Physical exam:  
Height: 149.0 cm        Weight: 39.0 kg         BP: 110/70              
Pulse: 78               Pubic hair: Tanner II   R. testis: 3.0 x 2.0 cm 
L. testis: 3.0 x 2.0 cm Phallus length: 8.0 cm  
The physical examination was essentially negative except for the persistent pan-systolic murmur.

Laboratory studies:  (12/08/92) DHEAS 164 mcg/dL, Testosteone 52 mg/dL, T4 7.1 mcg/dL, TBGI 1.07, TT3 153, TSH 1.20 mcU/mL, LH 1.0 U/L, FSH 1.7 U/L.

Impression: Marcus grew 1.8 cm in 3 1/2 months, a normal rate of growth.   His pubertal devleopment has not progressed significantly.

Disposition: He is to continue the same dose of Protropin and return to clinic in four months.
Thank you for letting us share in the care of Marcus.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 7/13/93 for follow-up of his response to growth hormone therapy.

History: Marcus has been well since last seen on March 23, 1993.  He had a "strep throat" and developed a skin rash attributed to a Penicillin allergy.  He just came back from camp where he did not like the food.  Review of systems was negative.  He recently started using a deodorant.

Current medications: Protropin 2l0 mg/day 6 days a week.

Physical exam:  
Height: 151.9 cm        Weight: 39.1 kg         BP: 110/70              
Pubic hair: Tanner II   R. testis: 3.5 x 2.0 cm L. testis: 3.5 x 2.0 cm 
Phallus length: 8.0 cm  Mid-shaft diam.: 2.2 cm 
Marcus was healthy looking.  Skin: Normal texture.  HEENT: Normal fundi.  Neck: Thyroid not enlarged.  No lymphadenopathy.  Chest: Clear lungs.
Heart: Normal S1 and S2.  Pansystolic V/VI murmurs best heard at 4th LCS at LSB.  Abdomen: Soft, no tenderness, no hepatosplenomegaly.  Extremities: Normal.  Neurological: Nonfocal.

Impression: Marcus continues to grow well and to progress in his pubertal developmetn.  He has, however, not gained any weight.

Disposition: Marcus will continue on the same dose of Protropin.  He will try to increase his caloric intake.  I plan to see him in four months for follow-up.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Cavinder Pavarotti, M.D.          RE: Marcus Thompson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/25/79

Dear Dr. Pavarotti:

We had the pleasure of seeing Marcus in the Endocrine Program on 12/7/93 for evaluation of his response to growth hormone therapy.

History: Since last seen on 07/13/93 Marcus has been well.  He has developed a very good appetite.  He did not complain of headaches, polyuria, or polydipsia.  The review of systems was negative.

Current medications: Protropin 2.1 mg daily six days a week.

Physical exam:  
Height: 153.4 cm        Weight: 44.1 kg         BP: 90/60               
Pulse: 78               Pubic hair: Tanner II   R. testis: 4.0 x 2.5 cm 
L. testis: 4.0 x 2.0 cm Phallus length: 8.0 cm  Mid-shaft diam.: 2.3 cm 
Marcus was healthy looking.  Skin:  Normal texture. He has a few axillary hairs.  HEENT:  Normal fundi. Neck:  Thyroid not enlarged.  Chest:  Clear lungs.  Cor:  Normal S1 and S2 grade V/VI pansystolic murmur best heard at the 4th ics to the LSB.  Abdomen:  Soft, no tenderness, no hepatosplenomegaly.  Extremities:  Normal.  Neurological: DTR 2+ symmetrical, cranial nerves II - XII intact.

Laboratory studies:  (12/07/93) TBGI .91, T4 7.1 mcg/dL,  TSH mcU/mL, TT3 pending.

Impression: Marcus continues to grow (1.5 in four months) though not as fast as on the previous visit.  He also gained quite a bit of weight (5 kg in four months).

Disposition: The Protropin dose was increased to 2.5 mg daily to adjust for his weight increase.
Thank you for letting us share in the care of Marcus.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Saurabh Hugo, M.D.          RE: Eric Hanno
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/78

Dear Dr. Hugo:

We had the pleasure of seeing Eric in our Endocrine Program on 07/25/91 for evaluation of delayed onset of puberty, decreased PTH, elevated T4, and isolated insulin antibody.

History: 13 year old male with Thalassemia Major and short statue, delayed onset of puberty, decreased parathyroid hormone, elevated T4, and isolated positive anti-insulin antibody.  Patient has Thal Major with iron overload, serum irons 294, TIBC 236, and Ferritin 2,317, on chelation therapy.

Summary of endocrine abnormalities:  1) Delayed onset of puberty.  Patient is still pubescent with LH, FSH, and testosterone levels being prepubertal, most recently measured 1/26/91; 2) Short Stature.  No growth curves are available.  Mother reports normal growth until age 5 with decreasing growth.  Now is 151cm (25% centile); 3) Decreased parathyroid hormone.  On 1/26/91 he had the following measurements, calcium 9.9., PTH less than 10, 25 OH D 32 (9-74 normal), 1,25 (OH)2 D 86 (15-60 normal).  Patient reports no symptoms of hypocalcemia.  4) Increased T4.  On 1/26/91, the patient had the following measurements, T4 15.3, TBGI 0.83, T3 210, TSH 1.7.  The patient reports no symptoms of hypo or hyperthyroidism.  5) Screening for diabetes.  On 8/10/90, patient had an IV glucose tolerance test which was normal.  On two occasions, patient anti-islet cell antibody test done which were negative.  On 8/10/90, patient had anti-insulin antibody tests which was reported as 71 being positive.  These were repeated on 1/91 with a value of -19, which is negative.

Physical exam:  
Height: 150.6 cm        BP: 120/80              Pulse: 70               
U/L ratio:  0.83        
Arm span of 155cm.  Skin is tanned.  No goiter.  Lungs were clear.  Cardiac exam was normal, S1S2.  Abdomen with splenectomy scar.  Extremities were without edema and deep tendon reflexes were normal.

In summary: By problem:  1) Delayed onset of puberty.  He is delayed in onset of puberty, but it is still at the 20 or 30 percentile, meaning that 20-30% of the male population will enter puberty after his age.  Plan, no studies are planned, but we will see him again in 6 months and initiate work-up at that time if puberty hasn't begun; 2) Short stature.  Patient is concerned about this but he is only 1 standard deviation below norm.  We will not initiate any work-up at this time, but will follow him; 3) Decreased PTH.  It is hard to believe this isolated decreased parathyroid hormone level when calcium and vitamin D metabolites are normal.  We will repeat PTH and calcium measurements today; 4) Increased T4.  This is probably due to increased TBG, given the low normal TBGI and normal TSH.  No further work-up is being done for this; 5) Isolated insulin antibody.  This was first found to be positive and then later negative with a normal IV glucose tolerance test.  The isolated elevated glycosylated hemoglobin probably represents an increased level of fetal hemoglobin associated with his Thalassemia.  The plan to follow-up on this, we will repeat the Insulin antibody again and most likely confirm that it is again negative and the positive was a susperious result.

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

Sincerely,


Brad Lowell, MD                      Kendell Simpson, MD
Fellow in Endocrinology              Clinical Director

BL/SN/smp


CONTENT:
Beaker, M.D.          RE: Sammy Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/05/79

Dear Dr. Beaker:

We had the pleasure of seeing Sammy in the Endocrine Program on 6/9/94 for .

History: As you know, he is a 15 year old boy who has congenital anorchia.  He is currently receiving Testosterone Enanthate, 100 mg every three weeks.  

His intercurrent history is unremarkable.  His sexual function is described as normal.

Physical exam:  
Height: 183.2 cm        Weight: 67.5 kg         BP: 120/70              
General:  He had facial hair above his upper lip and had axillary hair.   
Neck:  His thyroid was barely palpable, being smooth and symmetric.  
GU: Revealed Tanner V pubic hair and normal phallic develop.

Laboratory studies:  Lab studies revealed a T4 of 8.1 mcg/dL, TSH 0.90 mcU/mL,  LH <0.10 mIU/mL, FSH 2.2 mIU/mL, DHEA sulfate 52 mcg/dL, Testosterone 553 ng/dl - all normal.  Sammy's bone age was 15 years.

Impression: Sammy continues to do well on his replacement therapy.   I have increased his Testostereone dose to 100 mg every two weeks, which is a normal adult replacement dose.

Disposition: I plan to see Sammy again in six months time in order to follow his course.   

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

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Zylpha Plato, M.D.          RE: Sammy Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/05/79

Dear Dr. Plato:

We had the pleasure of seeing Sammy in the Endocrine Program on 2/13/92 for  .

History: I most recently saw in Sammy n Endocrinology on February 3rd, 1992.  As you know, he is a 12 and 8/12 year old boy whom I am following for anorchia.  He was started on Testosterone Enanthate in August of 1991, receiving 25 mg IM each month.  The father reports giving the injections without any difficulties.  At this point, Sammy is fairly content with the effects of the testosterone therapy.  His intercurrent history and review of systems are entirely unremarkable.

Physical exam:  
Weight: 43.6 kg         BP: 110/60              Arm span: 169           
Upper/lower segment ratio: 1.06.
Fundoscopic exam was benign.  There was no thyromegaly.  There was no axillary hair.  He had trace facial hair above his upper lip.  G.U. exam revealed Tanner II pubic hair, a phallus measuring 2.5 x 7.5 cm, and testicular prostheses in place.  The remainder of the exam was unremarkable.

In summary: Sammy has displaced a good biologic response to testosterone, with pubertal changes and an increase of growth velocity to 8.3 cm per year.  After a discussion with Sammy and his father, we have decided to change his testosterone dose to 25 mg IM every 3 weeks.

Disposition: Addendum:  FSH 55 mIU/ml, LH 3.7 mIU/ml, DHEA-S 62 mcg/dl. Testosterone is pending.

Laboratory studies pending at this time include: FSH, LH, DS and testosterone.  We will obtain a bone age at the next visit.

I plan to see Sammy again in 4 months time in order to follow his course.  Thank you for allowing me to participate in Sammy's care.  Please don't hesitate to call if you have any specific questions.

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

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology   


Problem list to date:
HYPOGONADISM                 Start: 02/13/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Beaker, M.D.          RE: Sammy Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/05/79

Dear Dr. Beaker:

We had the pleasure of seeing Sammy in the Endocrine Program on 4/6/93 for .

History: I most recently saw Sammy in Endocrinology on April 6, 1993.  As you know, he is a 13 and 10/12 year old boy whom I am following for anorchia.  He is currently maintained on Testosterone Enanthate, receiving 50 mg IM every three weeks.  Since his last visit, his intercurrent history and review of systems are unremarkable.

Physical exam:  
Height: 174.6 cm        Weight: 56.2 kg         Arm span: 178           
Pubic hair: Tanner IV   Phallus length: 10.0 cm Mid-shaft diam.: 3.0 cm 
U/L 0.90
Fundoscopic exam was benign.  There was trace facial above his upper lip.  He had mild bilateral gynecomastia.  He had testicular prosthesis in place.  The remainder of the exam was unremarkable.

Impression: Sammy continues to do well on his therapy, progressing with normal pubertal changes.  He is currently growing at an impressive rate of 12.1 cm/yr.  As I understand laboratory tests must be obtained locally, I gave Sammy's father a lab slip to obtain blood work for FSH, LH, DHEAS, testosterone, and estradiol levels, with blood to be drawn 1-2 days before Sammy's next Testosterone dose.  In addition a plain film of his left hand and wrist would be helpful for a bone age.  I have increased Sammy's Testosterone dose to 75 mg every three weeks.  I plan to see Sammy again in six months time, when I will then again probably increase his Testosterone dose.

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

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

Sincerely,


Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Darlene Brando, M.D.          RE: Ingrid Elytis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/24/70

Dear Dr. Brando:

We had the pleasure of seeing Ingrid in the Endocrine Program on 2/7/92 for  .

History: I saw Ingrid, age 21 years 3 months, in follow-up for insulin dependent diabetes mellitus.

She is currently on pure pork insulin, 12 units of Regular and 33 of NPH before breakfast, 12 units of Regular at supper, and 16 of NPH before bedtime.  She stated that she has not taken the presupper insulin dose for the past 2-3 months and also skips the bedtime injection at least once per week.  

She discontinued the Plaquenil prescribed for Lupus.  

She complained of pain in her back and neck and had red blotches on her feet and dry, red patches on her knees.  She reported that her skin changes color with the cold weather; her hands become re,d and her feet become red and white.  

Her diet has been unsatisfactory.  She does not have proper meals or snacks and does not follow a meal plan.  There have been no episodes of severe hypoglycemia.  She has nocturia and intermittent polyuria and polydipsia.  There has been no blood glucose monitoring.

Physical exam:  
Weight: 56.1 kg         BP: 118/76              Pulse: 104              
She was well-developed and well-nourished.  She had good color and hydration.  Mucus membranes were pink.  She had a malar flush.  Thyroid gland was not palpable.  Chest was clear and the heart was normal.  She had a tender liver edge approximately 1-2 finger breadths below the right costal margin.  She had telangiectasiae and redness of the scar on her left knee.  She had an erythematous, reticular rash on the toes of both feet and heels.  Her feet were cool.  Her distal extremity pulses were normal.

Laboratory studies:  Hemoglobin 12.9 g/dl, hematocrit 37.4%, MCV 86.6, MCH 29.8, MCHC 34.5, white cell count 8.43, RBC 4.32, platelets 257K, ESR 6 mm/hr.  AST, ALT, LDH, alkaline phosphatase were 14, 23, 66, 52 mU/ml, respectively.  Urinalysis had SG 1.18, pH 6.0, no protein, 3+ glucose, negative ketones and negative blood, negative white cells, and negative nitrite.  Plasma glucose 321 mg/dl, hemoglibn A1 13.3% (normal 5.2-7.8%).  Her diabetes mellitus is poorly controlled as a result of poor compliance.  She appears to have an exacerabation of lupus erythematosus.  I have encouraged her to return to see you and encouraged her to resume proper diabetes care.



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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr. Gorby:

     We had the pleasure of evaluating Anne in the Renal Program on 10/5/94 for renal transplant.

     Renal transplant doing well.  Anne shows no significant symptomatology from her kidney but does show a continuing intermittent musculoskeletal pain and almost constant headache syndrome.

Current medications include:
     PREDNISONE 5 mg q.d.
     IMURAN  75 mg/50 mg  q.d.

Past medical history:
     Focal segmental glomerulosclerosis  2)  Headaches seen by Dr. Charles S. Barlow and he is starting biofeedback for therapy.

Review of systems:
     Negative apart from the headaches and intermittent musculoskeletal pain with occasional lower abdominal and groin pain.  Some of these symptoms may be attributable to point shoe ballet dancing at her present weight.

Physical exam:
     BP 127/54   P 84   R 16   HT 150.8cm   WT 74.6kg
     Mildly obese girl with mild cushingoid features.  she shows no evidence for bruising or rash and there was no evidence for cataracts or O positive eye findings.  The kidney at this time was approximately 11 cm in length and to physical examination was without obvious bruit.  Reflexes in the lower limb and plantar reflexes were within normal limits and no there was no evidence for localized muscle pain or tenderness.

Urinalysis:
     SPEC GR UA  1.016           PH UA       6          
     PROTEIN UA  N               BLOOD UA    N          
     GLUCOSE UA  N               WBC/HPF     0-2        
     RBC/HPF     0-1             CASTS       N

     1)  Renal transplant living related donor (father) six years and ten months  2)  Intermittent musculoskeletal pain  3)  Headaches under investigation in biofeedback

     We have asked Anne to return in four months.  Thank you for allowing us to share in Anne'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:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr. Gorby:

     We had the pleasure of evaluating Anne in the Renal Program on 3/2/95 for renal transplant and recent surgery for gynecological problems and abdominal pain.

     Recent laparoscopic laborotomy for surgery lysis of adhesions and biopsy of area around the right ovary which was tethered behind the renal transplant.  2)  Endometriosis was found on the biopsy and will be treated through Dr. Mark Laufer of the Gynecological department.

Current medications include:
     PREDNISONE 5 mg q.o.d.
     IMURAN  75 mg/50 mg  q.d.

Past medical history:
     Well known for prior focal glomerulosclerosis and renal transplant.

Review of systems:
     Asymptomatic at this review.

Physical exam:
     BP 121/85   P 97    HT 150.9cm   WT 73.3kg
     General: Mildly overweight happy teenager (improved since her surgery)
     Skin: Intact
     HEENT: Normal
     Neck: Supple, lymph nodes not palpable
     Chest: Clinically clear
     Heart: Rate and rhythm normal 
     Abdomen: Non-tender
     Genitourinary: Deferred
     Extremities: No tenderness or edema
     Neurological: No localizing signs

Urinalysis:
     SPEC GR UA  1.006           PH UA       6          
     PROTEIN UA  N               BLOOD UA    N          
     GLUCOSE UA  N               WBC/HPF     0-2        
     RBC/HPF     0-2             SQUAM EPI   rare  
     HYALINE CAST   rare

     1)  Renal transplant with excellent function  2)  Endometriosis quiescent at this present time.  I recommend Lupron depot therapy per Dr. Laufer and Dr. Gorby.  This should not interfere with her ongoing immunosuppression, and  continue present Imuran and prednisone cover.

     We have asked Anne to return in three months.  Thank you for allowing us to share in Anne'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:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr. Gorby:

     We had the pleasure of seeing Anne in the Renal Program on 7/19/95 for renal transplant.
     Anne is a 15 year old status post a  living-related-donor renal transplant approximately 7-1/2 years ago for  focal segmental glomerulosclerosis.  The patient was most recently seen  in clinic in February of 1995.  She has been well in the interim and  reports no problems related to her transplant.  She has also been seen  by Dr. Laufer for her endometriosis which has been under good control on  Lupron.  However, the patient does continue to have headaches and does  not report significant improvement with biofeedback.

Her current medications include:
     Lupron 3.75 mg. q. month
     Prednisone 5 mg. q.d.
     Imuran75/50 mg. alt. q.d.

Anne's physical exam was notable for:
     BP 137/71   P 101   R    T    HT 150.8cm   WT 77.5kg
     General: The patient is a mildly obese girl in no acute distress.   The patient is also mildly Cushingoid.  Her head is normocephalic and  atraumatic.  Pupils are equally round and reactive to light.   Extraocular movements are intact.  Her fundi are flat and discs are  sharp.  Her tympanic membranes are pearly with a normal light reflex and  good mobility.  She has no sinus tenderness.  Her oropharynx is without  erythema or exudate.
     Skin: No rashes or bruises  
     Neck: Supple. Lungs are clear to auscultation bilaterally.  
     Heart: Benign with a regular rate and rhythm, normal S1 and S2 and no murmur.  She has normal active bowel sounds.
     Abdomen:  Soft, nondistended, nontender with no hepatosplenomegaly.  Her renal transplant is palpable but nontender.   She has no sign of clubbing or edema.   
     Neurological: Nonfocal.
A urinalysis revealed:
     SPEC GR UA  1.007           RBC/HPF     0          
     PH UA       5.0             WBC/HPF     0          
     BLOOD UA    Neg.            SQUAM EPI   0          
     PROTEIN UA  Neg.  mg/dl     BACTERIA    Neg.  
     GLUCOSE UA  Neg.       

Laboratory studies at this time include:
          CO 2         27   MEQ/L (H)   K           4.3  MMOL/L    
          CR          1.2   MG/DL (H)   BUN          21   MG/DL (H)

     Anne is a 15 year old status post renal transplant for  focal segmental glomerulosclerosis, who continues to have stable renal  function.  Her endometriosis is also under good control, although her  headaches continue to be an issue.  The patient will follow up in 3  months' time with Dr. Khan. 

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr Gorby:

     We had the pleasure of seeing Anne in the Renal Transplant Program on Tuesday, March 19, 1996.  

   Anne returns to the renal transplant program today three days after discharge from the hospital.  She has been admitted for surgery for ureteral reimplantation and laparoscopy for endometriosis.  Her hospital stay was characterized by post operative obstruction which lead to an increase in her creatinine.  She did reach a low creatinine of 1.4 mg/dl but was discharged with a creatinine of 1.8 mg/dl.  Since discharge she has been doing well.  She complains of occasional abdominal pain, but this is transient and subsides on its own.

Her current medications include:
     PREDNISONE 5 mg po q.d.
     IMURAN 75/50 alt. days
     ORTHOTICYCLINE 1 po q.d.

Anne's physical exam was notable for:
     BP 150/90   P 88   R 14   
     General: comfortable, alert
     HEENT: eyes, nose and throat clear
     Neck: supple, no significant lymphadenopathy 
     Chest: clear to auscultation
     Heart: S1 S2 normal, no murmur
     Abdomen: soft, no tenderness over the graft site 
     Extremities: no edema
     Neurological: no focal deficits or meningeal signs

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     occ.       
     PH UA       5.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    large           WBC CAST    N          
     PROTEIN UA  N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     RBC/HPF     10-15           BACTERIA    N     

Laboratory studies at this time include:
          K           4.1  MMOL/L       HGB        10.3    G/DL (L)
          CR          1.4   MG/DL (H)   HCT.       30.0       % (L)
          BUN          15   MG/DL       MCV        91.4      FL    
          NA          142  MMOL/L       MCH        31.4      PG    
          CL          104  MMOL/L       MCHC       34.4    G/DL    
          CO 2         31   MEQ/L (H)   RDW        13.5       %    
          WBC       17.41   K/MM3 (H)   HDW        3.03    G/DL    
          RBC        3.28   M/MM3 (L)   PLT UNC     407   K/MM3 (H)

     Anne's blood pressure continues to be slightly high today.  We will watch this until her next visit and if there is no improvement we will start her on a antihypertensive medication.

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

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr. Gorby:

     We had the pleasure of evaluating Anne in the Renal Program on 4/4/96 for renal transplant.
     At this stage Anne returns for review now with clearing of abdominal  pain, and although maintaining her bladder empty by frequent voiding,  has no dysuria, frequency, or fever.

Her current medications include:
     IMURAN 75/50 mgm alternating days
     PREDNISONE 5 mgm q.d.

Past medical history:
     Her past medical history is well known for focal glomerulo-sclerosis and renal transplantation from her father and for recent surgical reimplantation of a refluxing ureter to the transplant.

Review of systems:
     Anne has shown an excellent response to her surgery now after an  immediate post implantation surgery with edema and renal dysfunction  secondary to the edema.

Anne's physical exam was notable for:
     BP 123/74   P 97   R    T    HT 151.9cm   WT 74.5kg
     A happy, cooperative, teenager.  
     HEENT:  Normal.   
     Neck: supple.  
     Lymph nodes: not palpable.  
     Chest:  Clinically clear.   
     Heart:  Rate and rhythm regular.  
     Abdomen:  Nontender with no tenderness over the renal allograft.  
     Genitourinary: deferred.  
     Extremities:  No  edema.  
     Skin:  Intact.  
     Neurological:  No focalizing signs.
A urinalysis revealed:
     SPEC GR UA  1.014           GLUCOSE UA  neg        
     PH UA       5.5             RBC/HPF     0-1        
     WBC ENZ UA  neg             WBC/HPF     0-2        
     BLOOD UA    neg             SQUAM EPI   rare       
     PROTEIN UA  neg             BACTERIA    neg   
     CASTS  occasional fine granular

Laboratory studies at this time include:
          ALKP         88     U/L       RDW        13.8       %    
          K           4.9  MMOL/L (H)   HDW        2.81    G/DL    
          CA          9.7   MG/DL       PLT UNC     404   K/MM3 (H)
          CO 2         27   MEQ/L       NEUT         82       % (H)
          CR          1.2   MG/DL (H)   LYMPH        12       % (L)
          GLU          92   MG/DL       MONOS         5       %    
          PHOS        2.6   MG/DL (L)   ATYP LY       1       %    
          BUN          16   MG/DL       CELLS C     100    
          WBC       14.08   K/MM3 (H)   ABS NEU   11.55   K/MM3    
          RBC        3.52   M/MM3 (L)   ABS LYM    1.69   K/MM3    
          HGB        11.8    G/DL (L)   ABS EOS     .00   K/MM3    
          HCT.       32.6       % (L)   ANISO        1+    
          MCV        92.5      FL       MICRO        1+    
          MCH        33.5      PG       HYPO         1+    
          MCHC       36.2    G/DL (H)   

     The chemical profile taken at the time of this reviewed continued clearing to baseline, serum creatinine, and excellent response to her recent surgery. 

Review of chemical profile and symptoms in four weeks will be undertaken to be sure that she has returned to baseline immunosuppression without change in renal function

     Thank you for the opportunity to participate in Anne's care.  We would like to review her in 1 month.  In the interim, we would be happy to discuss or review Anne should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr. Gorby:

     We had the pleasure of seeing Anne in the Renal Program on 5/16/96 for follow up of her renal transplant.
     Anne returns for an interval review after her recent reimplantation  surgery.  She has had clearing of her abdominal pain and has now  recommenced on oral birth control pills for cycling of her menses and control of her endometriosis.  She has been asymptomatic completely since that time.  Past medical history  well known for focal glomerulosclerosis and intercurrent transplant.

Her current medications include:
     IMURAN 75 mg q.o.d.
     PREDNISONE 5 mg q.d.
     BCP

Anne's physical exam was notable for:
     BP 110/68   P 93   R 16   T    HT 151.5cm   WT 75kg
     A moderately overweight, happy teenager.  Head, eyes, ears, nose and throat within normal limits.  
     Neck: supple.  
     Lymph nodes:  not palpable.  
     Chest:  clinically clear.  
     Heart:  rate and rhythm regular without bruit.  
     Abdomen:  no mass or viscous palpable, although there is a fullness in the area of the allografted kidney as expected.   No bruit is audible over this kidney.  Genitourinary system:  deferred.   
     Extremities: no edema
     Skin intact.  
     Neurological, no focalizing signs.
A urinalysis revealed:


Laboratory studies at this time include:
          K           4.0  MMOL/L       MPV         8.7      FL    
          CR          1.1   MG/DL (H)   PLT UNC     363   K/MM3    
          BUN          12   MG/DL       NEUT AB    6.57   K/MM3    
          WBC        9.75   K/MM3       LYMPH A    1.85   K/MM3    
          RBC        3.44   M/MM3 (L)   EOS ABS     .58   K/MM3 (H)
          HGB        10.7    G/DL (L)   NEUT-A     67.3       %    
          HCT.       32.1       % (L)   LYMPH-A    18.9       % (L)
          MCV        93.3      FL       MONO-A      5.9       %    
          MCH        31.1      PG       EOS-A       6.0       %    
          MCHC       33.3    G/DL       BASO-A       .9       %    
          RDW        13.8       %       ATYP LY      .9       %    
          HDW        2.85    G/DL       LEFT SH  ABSENT    

     Anne's renal transplant, now shows good stable function with  clearing of her symptoms after reimplant surgery.   

We would plan no changes in her medication regime.  We will arrange for  nutritional review and support since Anne is anxious to stabilize her  weight.  We will review her in three months or should there be earlier  problems.

     Thank you for the opportunity to participate in Anne's care.  We would like to review her in 3 months.  In the interim, we would be happy to discuss or review Anne should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr. Gorby:

We had the pleasure of evaluating Anne in the Renal Program on 8/14/96 for FSGS.
as a follow-up following her history of a transplanted kidney secondary to focal glomerulosclerosis.  She required a recent ureteral  reimplantation following VUR found after treatment of endometriosis.  Anne has done well in the interim period.  She was last seen here last in May of 1996.  She has no complaints except for mild abdominal pain at the site of her transplanted kidney on the right since the last 3 days which is transient and mild in nature.

Her current medications include:
     PREDNISONE 5 mg po q.d.
     IMURAN 75/50 alt. days
     ORTHO-CYCLER 1 po q.d.

Past medical history:
     Her past medical history is well-known for focal  glomerulosclerosis, a functioning living related kidney transplant from her father as donor.  She has a history of  endometriosis and VUR and a ureteral reimplantation in March of 1996.

Anne's physical exam was notable for:
     BP 125/70   P 81   R    T    HT 152cm   WT 76kg
     General appearance:  She is moderately overweight, happy.
     HEENT: normal.  
     Neck: revealed no lymphadenopathy.  
     Chest: clear to  auscultation.  
     Cardiovascular: Normal on auscultation.  
     Abdominal: scar on right kidney, felt palpable anteriorly and was not tender.  
     GU: deferred.  
     Skin: normal  

A urinalysis revealed:
     SPEC GR UA  1.020           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       6               WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC  N          

Anne's renal transplant seems to show good stable function with clearing of her symptoms from the past after reimplantation surgery.  We do not plan any change in her medication regimen at this stage.  Anne is planning to work on decreasing her weight.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stanwood Gorby, M.D.          RE: Anne Abelard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/80

Dear Dr. Gorby:

We had the pleasure of seeing Anne in the Renal Transplant Program on Tuesday, November 12, 1996.  She has chronic renal failure secondary to focal glomerulosclerosis.  She had a renal transplant on .
Anne is status post motor vehicle accident on October 31st for which she sustained multiple bruises but was otherwise well.  She does complain of abdominal soreness from her bruises caused by the seat belt.  She does not have any hematuria or any change in her urine output.  She came to see us on November 1st after her accident and at that time had a BUN of 13 and creatinine of 1.1 which is stable.

Her current medications include:
     PREDNISONE 5 mg po q.d.
     IMURAN 75/50 alt. days
     ORTHOTRICYCLINE 1 po q.d.

Anne's physical exam was notable for:
     BP 139/74   P 109   R    T    HT 152.2cm   WT 76.2kg   HC cm
     General: cushingoid female in no apparent distress
     Skin: intact. 
     HEENT: eyes, nose and throat clear
     Neck: supple, no lymphadenopathy 
     Chest: clear to auscultation bilaterally
     Heart: regular rate and rhythm no murmur
     Abdomen: soft, multiple ecchymoses over abdomen, non tender graft site, well healed surgical scars, positive bowel sounds.
     Extremities: no edema.
     Neurological: non focal.
A urinalysis revealed:
     SPEC GR UA  1.013           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  0-tra           RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   occ.  
     MICROSCOPC             
HYALINE CAST  few

Laboratory studies at this time include:
          K           4.3  MMOL/L       RDW        13.4       %    
          CA          9.1   MG/DL       HDW        2.69    G/DL    
          CR          1.2   MG/DL (H)   MPV         8.3      FL    
          PHOS        2.4   MG/DL (L)   PLT UNC     432   K/MM3 (H)
          BUN          20   MG/DL (H)   NEUT AB   11.03   K/MM3    
          NA          137  MMOL/L       LYMPH A    1.62   K/MM3    
          CL          102  MMOL/L       EOS ABS     .25   K/MM3    
          CO 2         24   MEQ/L       NEUT-A     79.6       % (H)
          WBC       13.87   K/MM3 (H)   LYMPH-A    11.7       % (L)
          RBC        3.74   M/MM3 (L)   MONO-A      4.9       %    
          HGB        12.0    G/DL       EOS-A       1.8       %    
          HCT.       35.3       % (L)   BASO-A       .8       %    
          MCV        94.3      FL       ATYP LY     1.3       %    
          MCH        32.1      PG       LEFT SH  ABSENT    
          MCHC       34.0    G/DL       

Anne is doing well after her motor vehicle accident on October 31st and her renal function has been stable since that time.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Shabsi Ibsen, M.D.          RE: Johnathan Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/13/74

Dear Dr. Ibsen:

We had the pleasure of seeing Johnathan in the Endocrine Program on 3/1/93 for for follow-up.

History: Johnathan is now an 18 and 10/12 year old young man who is status-post resection of a posterior fossa tumor. The tumor was first diagnosed in 1980. This was treated with two resections on presentation. Johnathan also received 5400 rads to posterior fossa rads and 3800 rads to the whole;e brain.  Johnathan' parents report that he did not receive spinal radiation as treatment for his tumor.  He presents today for neuro-endocrine follow-up. Johnathan and his parents report that he has remained at the same height for two years. They report that he went through puberty at the normal time. Johnathan currently has a normal amount of body, pubic, and axillary hair and shaves frequently each week. Johnathan' genitals have also reportedly matured normally. Johnathan has no history of hypo- or hyperthyroidism. He currently reports no heat or cold intolerance, a normal exercise tolerance, and he denies tremulousness. In terms of adrenal cortical function, Johnathan has not experienced hypotension, severe intercurrent illnesses or syncope. In terms of posterior pituitary function, Johnathan does not report polyuria or polydipsia, but he does awaken twice each night to void. 

Johnathan problems related to his CNS tumor and treatment include a cognitive disability, a cortical visual disability, lower cranial nerve palsies and discoordination. Johnathan does not have a history of seizures and is not currently nor has ever been treated with anticonvulsant medications.  Johnathan' past medical and surgical history are remarkable only for events which relate to his tumor. He has undergone two craniotomies for tumor resection and VP shunt placement. At present neither Johnathan nor his family have serious health concerns. He does not have headaches or complain of vomiting or gagging. His strength and coordination have gradually improved and he now can ambulate quite well independently.

Family history:  There is no family history of hyper- or hypothyroidism, Addison's disease, premature puberty or early gonadal dysfunction or growth failure. Mother's height is 5'3". Father's height is 5'7". Besides Johnathan' brain tumor, there is no other family history of CNS disorders.

Physical exam:  
Height: 149.3 cm        Weight: 62 kg           BP: 170/                
Pulse: 90               Pubic hair: Tanner VI   R. testis: 4.4 x 2.6 cm 
L. testis: 4.3 x 2.6 cm Phallus length: 5 cm    Mid-shaft diam.: 2.6 cm 
HEENT: Remarkable for a left exotropia, alternating visual dominance, and a right nasal hemianopsia.   Neck: Supple without palpable thyroid tissue.   Chest: Normal.   Heart: Normal.   Abdomen: Significant for obesity. No organomegaly.   Neurological: Left exatropia, weak gag and bilateral limb and truncal discoordination. Deep tendon reflexes were 2+ in upper extremities and 3+ in lower extremities with some increase in right overleft.

Laboratory studies:  Prolactin-5.9 ng/mL, T4-5.9 mcg/dL, TBGI-0.98, TSH-1.2 U/L, IGF1-76 ng/mL, cortisol-4.4 mcg/dL, DHEAS-215 mcg/dL, testosterone-234 ng/dL, E OSM 268 mOs/L,  urine specific gravity-1.017.

Impression: The above clinical and laboratory studies indicate that Johnathan has mild neuroendocrine dysfunction involving testicular function (low serum testosterone) and growth hormone production (low IGF1).  Other functions seem to be intact.

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

Sincerely,


Xiajo Grange, MD             Mitsuko Simpson, MD             
                             Chief, Emeritus              


Addendum: Resident in Pediatrics


CONTENT:
Tuba Benise, M.D.          RE: Mae Amado
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/03/85

Dear Dr. Benise:

We had the pleasure of seeing Mae in the Endocrine Program on 10/6/94 for .

History: Mae is a 9 and 1/12 year old girl with hypothyroidism seen on 10/6/94 for routine follow-up.  Mae has been well since her last visit.  She has no symptoms of hypo- or hyperthyroidism.  There was a question of some vaginal discharge suggestive of puberty and the development of body odor.

Current medications: Synthroid 75 mcg daily.  Compliance is excellent.

Physical exam:  
Height: 129.8 cm        Weight: 28.0 kg         BP: 116/62              
Pulse: 84               Breast: Tanner I        
General: Well developed, well nourished. Skin: Normal temperature and texture.  Slightly dry skin on upper arms.  Neck: No goiter.   Extremities: No tremor.  Neurological:  Normal DTRs.

Laboratory studies:  Thyroid function tests.

Impression: Mae is showing no signs of puberty and is clinically euthyroid.  She continues to grow along her accustomed curves.

Disposition: No change in her regimen.  Return to Clinic in six months.
Thank you for letting us share in the care of Mae.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology   


Problem list to date:
CONGENITAL-HYPOTHYROIDISM                    03/04/93  
Transcribed by Sullivan_ma


CONTENT:
Tinisha Brezny, M.D.          RE: Mae Amado
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/03/85

Dear Dr. Brezny:

We had the pleasure of seeing Mae in the Endocrine Program on 4/13/95 for .

History: Mae is a 9 1/12 year old with congenital hypothyroidism seen on 4/13/95 for routine follow up.  She has been well since her last visit although her right front upper incisor has not growing in.  Mae's headaches have largely improved.  She has no signs or symptoms of hypo- or hyperthyroidism.  Review of systems is negative in detail.

Current medications: Synthroid 75 mcg daily.  Compliance is good.

Physical exam:  
Height: 132.4 cm        Weight: 29.5 kg         BP: 102/58              
Pulse: 96               
General:  Well developed, well nourished.
Skin:  Normal temperature and texture.
Neck:  No goiter.
Extremities:  No tremor.
Neurological:  Normal DTR's.

Laboratory studies:  T4  11.8 ug/dL, TT3  154  ng/dL, TSH  2.10 uU/mL, TBGI 0.92

Impression: Mae is clinically euthyroid.

Disposition: Continue Synthroid 75 mcg daily.  Return to clinic in six months.
Thank you for letting us share in the care of Mae.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Tuba Benise, M.D.          RE: Mae Amado
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/03/85

Dear Dr. Benise:

The patient is a 10 year 4 month female who returns for follow up of congenital hypothyroidism secondary to agenesis of thyroid.  Patient continues to do well and be very healthy.  She has received all A's in school again.

Review of systems:  Review of systems is negative in detail.  She recently began wearing glasses.

Physical exam:
HT: 136.1 cm    WT: 30.9 cm
BP: 95/70               Pulse: 90               
Well-developed and well-nourished.  No goiter.  Skin:  normal temperature and texture.  She does have several areas of dry skin.  No tremor.  Brisk deep tendon reflexes.

Laboratory studies:  Thyroid function tests from 12/6/95 show TSH 1.5, T4 10.9, TBI 0.97, and T3 132.

Impression: Patient continues to do very well on Synthroid replacement for congenital agenesis of the thyroid.

Disposition: Continue Synthroid 75 mcg PO q.d.  Follow up in one year.



Sincerely,





Marc J. Laufgraben, MD        Rahul Ibsen, MD                
Fellow in Endocrinology       Attending in Endocrinology


CONTENT:
Tuba Benise, M.D.          RE: Mae Amado
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/03/85

Dear Dr. Benise:

We had the pleasure of seeing Mae in the Endocrine Program on 6/1/92 for evaluation of congenital hypothyroidism.

History: Mae is a 6 and 9/12 year old female who carries the diagnosis of congenital hypothyroidism. This is her first visit to the Children's Hospital Endocrine Clinic. She was previously followed at the Harvard Community Health Plan.

Current medications: 75 mcg/day of Synthroid which she takes at dinner time each day.

Past medical history:  Mae was born in Rochester, NY at Highland Hospital. The pregnancy was significant for post maturity of 42 weeks. Mae was born following a normal, spontaneous vaginal delivery with birth weight being 8 lbs. 5 oz. and  length 20.25 inches. Apgar score 9 and 9. She had noneo natal jaundice and was active and nursing well and gaining rapidly at the time of discharge at 3 days of age. At 1 week of age the mother was called about an abnormal thyroid screen. She returned for a work-up with Dr. McCormick, Endocrinologist at the University of Rochester. A thyroid scan showed no thyroid tissue. She was started on oral therapy by 9-10 days of age. Mae suffered some constipation, but otherwise was normal and healthy when started on treatment. During the first year, she did very well. Her growth by history was normal. Her development was also normal. She sat by 6 months of age, walked at 13 months. By age 2 she had extensive speech. Mother has noted that her teeth came in late and they are just now falling out. She has been on thyroid replacement consistently since diagnosis. We don't have all the records but we know that she was taking 50 mcg/day over the years until about two years ago when her dose went up to 75 mcg/day. She has been growing normally and doing well clinically  on this medication. She has had no hospitalizations and no major acute illnesses. She had a rash and history consistent with Lyme disease and was treated for acute exposure to that disease and did well.

Review of systems:  She has no symptoms of hypothyroidism. She is active, playful, and does well in school. She sleeps an average of 10 hours per night. She has no constipation, problems with hair or skin, or heat or cold intolerance.  In 1/91, she was in a car accident in which she hit her head. Since that time, she has had complaints of headaches, some associated with vomiting and tingling in her hands. She was recently seen by Neurology at Children's Hospital and had a CT scan which  was normal. The neurological evaluation at this time suggests that she is suffering from migraine headaches, however, they plan to do a MRI Scan.

Family history:  Mother is 31 and has uterine fibroids for which she has been operated on. There is a maternal great aunt who has aquired hypothyroidism. Mother's height is 5'0" and father's height is 6'2". Otherwise, family history is negative.

Physical exam:  
Height: 117.5 cm        Weight: 22.9 kg         BP: 96/60               
Pulse: 74               U/L ratio:  1.03        Arm span: 115           
Breast: Tanner I        Pubic hair: Tanner I    
HEENT: Normal.
Chest: Clear. 
Heart: Without murmur.
Abdomen: Benign.
Genitourinary: Normal female.
Extremities: No tremor.
Neurological: DTR's return briskly.

Impression: Mae is a young girl with congenital hypothyroidism who has been doing well over the years. Her previous growth data are unavailable today but presently she is on the normal growth chart for her age. She is clinically euthyroid and we will review present thyroid function tests on Synthroid .075 mg/day and adjust her medications as needed.

Disposition: We plan to see Mae again in six months time and we will also review her MRI done here at Children's Hospital. In the meantime, she can be followed by her pediatrician Dr. Benise.

Laboratory studies pending at this time include: Total T3, T4, TSH, TBG, cholesterol levels and bone age.
Thank you for letting us share in the care of Mae.

Sincerely,


Tinisha Khan, MD       Rahul Ibsen, MD                
                             Attending in Endocrinology   


Addendum: The TFT's were entirely normal.


CONTENT:
Tuba Benise, M.D.          RE: Mae Amado
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/03/85

Dear Dr. Benise:

We had the pleasure of seeing Mae in the Endocrine Program on 3/4/93 for follow-up of congenital hypothyroidism.

History: Mae is a 7 and 6/12 year old female with congenital hypothyroidism secondary to agenesis of the thyroid.  She has been maintained on 62.5 mcg/d of Synthroid.  She has had no recent illnesses and has had no complaints of side effects.  She is doing well in the second grade in a private school.

Current medications: Synthroid 62.5 mcg/d.

Review of systems:  No heat or cold intolerance, some sweating and axillary odor that she had noticed on previous appointments .  No agitation, no sleep abnormalities, occasional mild constipation, no diarrhea and has an average amount of energy.  She continues to have migraines with posterior neck pain and vomiting if she does not stop them by taking Phenergan.  These happen about once a month.  She has grown 1.1 cm. and has gained 0.6 kg. in three months.

Physical exam:  
Height: 120.8 cm        Weight: 24.8 kg         BP: 95/62               
Pulse: 80               Breast: Tanner I        
General: Well appearing, active, talkative child.  
HEENT: PERRL, sharp optic discs bilaterally, ears with tympanic membranes clear, throat clear.
Neck: No nodes or masses.
Chest: Clear.  No axillary hair., no breast buds.
Heart: Regular rate and rhythm, no murmurs, rubs or gallops.
Abdomen: Benign.
Genitourinary: Normal Tanner I female, no pubic hair.
Neurological:Nonfocal, DTR's 2+ throughout.

Laboratory studies:  December 1992:  Bone age 6 years 4 months at 7 years 3 months, SD of 8 months.  T4 9.6, TSH 5.5, TT3 117 (slightly elevated TSH).

Impression: Mae, a 7 and 6/12 year old with a history of congenital hypothyroidism secondary to aplasia of the thyroid, has been growing well on 62.5 mcg/d of Synthroid on the curve 1SD below the mean.  This is consistent with her bone age.  Clinically, there are no real symptoms of hypo- or hyperthyroidism except for mild constipation but labs do show a slightly increased TSH.  We will increase Synthroid dose to 75 mcg/day with follow-up labs in four weeks.  Mae is scheduled to return to clinic in six months but will call if symptoms of hyper- or hypothyroidism develop before this time.

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

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology   


Addendum: Sharon Haussman-Cohen, MD
Harvard Medical Student


CONTENT:
Tuba Benise, M.D.          RE: Mae Amado
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/03/85

Dear Dr. Benise:

We had the pleasure of seeing Mae in the Endocrine Program on 10/21/93 for follow up of hypothyroidism.

History: Mae is an 8 1/2 year old girl with congenital hypothyroidism seen for routine follow-up.  She has been entirely well since her last visit except for some constipation.

Current medications: Synthroid .75 mg/day

Physical exam:  
Height: 124.9 cm        Weight: 24.7 kg         BP: 84/66               
Pulse: 84               
Mae appeared well nourished and well developed.  Skin:  Normal temperature and texture.  Neck:  Without goiter.

Laboratory studies:  TSH 1.20 mcU/mL, TT3119 ng/dL, T4 10.8 mcg/dL, TBGI 1.04.

Impression: Mae is clinically euthroid.

Disposition: She will continue the same dose of Synthroid and return to clinic in six months.
Thank you for letting us share in the care of Mae.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology   


Problem list to date:
CONGENITAL-HYPOTHYROIDISM    Start: 03/04/93  End:          Invalid: 

Transcribed by Nortonsh


CONTENT:
Swartzenegger, M.D.          RE: Gloria Ailey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/21/82

Dear Dr. Swartzenegger:

We saw Gloria, a very nice 13-3/12 year old black adolescent girl, in the Diabetes Clinic on 08/29/95 for a follow-up of type II Diabetes Mellitus.

Gloria is on glyburide 2.5 mg daily with breakfast.  She reports frequent symptomatic hypoglycemic episodes occurring late morning (11:00 to 11:30 am).  She usually does not have a good appetite at breakfast, and often skips mid-morning snacks.  She denies hyperglycemic symptoms; the nocturia and excessive thirst have resolved.  Gloria is overweight and is attempting to lose weight.  She has been exercising this summer (biking and swimming).  
  
Blood glucose monitoring is done once a day, fasting, with values in the normal range (68 to 117 mg/dl).
  
She denies any asthmatic exacerbation over the past two months.  She is currently on Proventil and Intal.   Vanceril was discontinued three months ago.

Physical exam:  
Height: 157.4 cm        Weight: 81.2 kg
Pleasant adolescent girl, generalised obesity. Skin: mild acanthosis at the back of the neck. Neck: no thyromegaly.  Lungs: clear.  The exam was otherwise unremarkable.          

Laboratory studies:   On 06/06/95, fasting blood sugar, 175 mg/dl, insulin 37.1  u/ml, anti-islet cell antibodies negative, anti-insulin antibodies 6  nU/ml (normal 0 to 39 nU/ml), HbA1 12.3%.

Impression: Type II diabetes mellitus in the context of obesity.  There is no evidence of an auto-immune pancreatic disease.  

Disposition:
1. We encouraged mid-morning snacking to avoid the late morning hypoglycemia  and will maintain the current dose of Glyburide.   
2. Weight control by dieting and exercise was emphasized.  Gloria will meet with our dietitian to review/modify her current diet. 
3. We also recommend checking the blood sugar before dinner at least three times a week in addition to the fasting  daily blood sugar checks.

We would like to  see Gloria back in three months.

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


Sincerely,




Zulma Montague, MD             Gleide Crane, MD, PhD           
Fellow in Endocrinology          Attending in Endocrinology   


cc:   Dorette Ailey  32 Park St Apt B3  Brookline , MA  02146


Problem list to date:
OBESITY
Diabetes                                      03/16/92  
Transcribed by Sullivan_ma


CONTENT:
Ashley Pavarotti, M.D.          RE: Gloria Ailey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/21/82

Dear Dr. Pavarotti:

We had the pleasure of seeing Ashley in the Endocrine Program on 03/16/92 for  to rule out early puberty.

History: Ashley is a 9 and 10/12 year old female who moved to the US from Jamaica in August 1991.  She is generally healthy except for a history of asthma.  She now presents with pubic hair since July 1991 (at 9 and 2/12 year old).  She also has breast bud enlargement.  She has not had menstrual flow.  She does not have any axillary hair, but does use a deodorant.  Ashley has been gaining a significant amount of weight over the last two years, with an 11 lb. weight gain in the last six months alone.  She does not have acne.

Current medications: Ventolin inhaler PRN and Benadryl PRN.

Past medical history:  Unremarkable birth history.  She has been generally healthy. She has had approximately 1 admission per year in Jamaica for her asthma.  She has a history of allergy to peanuts and chocolate, as well as eczema.  She was admitted once for viral gastroenteritis in the past.  She has had mumps, and has not had significant injuries or operations.

Review of systems:  Patient denied fatigue, weakness, dizziness, headaches, palpitations, chest pains, abdominal pain, vomiting, diarrhea or cough.

Family history:  Ashley has 2 older brothers who had noticeable puberty with pubic hair at age 9 1/2 and 10 1/2.  Ashley's mother recalls onset of her puberty at 11 year old, with menarche at age 12. Mother's height is 5'4"; father is 5'4".

Physical exam:  
Height: 136.3 cm        Weight: 48.9 kg         BP: 95/65               
Pulse: 96               Breast Tanner: 2        Pubic hair Tanner: 2    
General: Pleasant, cooperative, moderately obese school age female in no acute distress.  
Skin: Mild eczema on her face and on her antecubital fossae.  No skin tags or acanthosis nigricans. 
HEENT: Normocephalic, atraumatic with no acne.  Pupils were round, equal and reactive to light.   Oropharynx was without lesions or exudation.  Normal dentition.  
Neck: Supple, without lymphadenopathy or thyromegaly. 
Chest: Clear to auscultation.  
Heart: Regular rate and rhythm without murmur.  
Abdomen: Obese, soft, non-tender and nondistended. 
Genitourinary: Normal female external genitalia.  
Extremities: No joint swelling, effusion, or edema.
Neurological: Normal muscle tone.  Deep tendon reflexes were 2+ bilaterally.  Toes were downgoing.
Bone Age: Between 8 years 10 months and 10 years.

Impression: Ashley has 1) onset of puberty at 9 and 3/12 year old, which is "early" but within 2 Standard Deviations of the mean age of onset of puberty, so not abnormally early and 2) Obesity.  Patient is 50% overweight for her height/age.  Obesity can contribute earlier onset of puberty.  Predicted adult height is 5'4"-5'5", based on height and current bone age.

Disposition: We reassured Ashley that her pubertal development was within normal limits.  Patient was given counseling regarding the importance of weight loss for her general health maintenance.  Both diet and exercise issues were discussed.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Problem list to date:
OBESITY                      Start: 03/16/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Octavia Hammer, M.D.          RE: Cesar Everett
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/11/91

Dear Dr. Hammer:

We had the pleasure of seeing Cesar in the Endocrine Program on 12/2/93 for evaluation of growth failure associated with a poorly defined syndrome.

History: As you know, Cesar is a 2 2/12 year old boy who was born at term who currently has multiple congenital anomalies of an unclear etiology.  His mother reports that there were no problems during the pregnancy but that the delivery was complicated by asphyxia necessitating intubation because of persistent apnea.  He remained intubated for two or three days with continued episodes of apnea subsequently he had many episodes after extubation and  required hospitalization in Rhode Island for four months for this problem.  During that time, he was noted to be a slowing feeding baby.  He was taught how to feed and,  currently, is doing very well.  He has had an extensive work up in the Genetic Dept. and Birth Defects Services.   Thus far this has consisted of normal chromosomes 46XY, and MRI that showed initially pachygyria but has since been unremarkable except for delayed myelination, a muscle biopsy has been negative.  Muscle biopsy was done in response to myopathic EMG and nerve conduction studies.  He has had an endoscopy which confirmed the presence of reflux but was negative for all else.  His problems currently includes continued intermittent apnea with bradycardia episodes, hypotonia, developmental delay, GE reflux, low immunoglobulins, densities in the liver which now have resolved and history of idiopathic pulmonary edema.

Reglan, Bactrim with some prn over the counter medicines.

Past medical history:  Significant for numerous hospitalizations for aspiration pneumonia and a couple of hospitalizations for diagnostic procedures.  Developmental history shows he is grossly motor delayed as he does not roll over yet  or sit and does not bear weight on his legs.  He smiled at 18 months and is currently somewhat interactive though he has corxical blindness. He intermittently fixes and follows.  He has a grasp but does not transfer from hand to hand.  He babbles but says no recognizable words.

Review of systems:  He has very sensitive skin.  His HEENT exam is significant for optic nerve atrophy.  His hearing is intact though there may be some decrease in high frequency hearing.  His cardiovascular shows he has a bicuspid aortic valve.  GI shows he has GE reflux.  His GU system is unremarkable.  Neurologically he has never had any seizures.

Family history:  Mother is 29 years old and has five brothers and one sister, all of whom have children who are alive and well.  His father is 32 years old, and has a history of one sister who died at birth of unclear reasons.  Cesar also has a 9 year old sister who is healthy and well.  Mother's and father's heights are 5'7".

Physical exam:  
Height: 76.5 cm         Weight: 11.5 kg         U/L ratio:  1.39        
Arm span: 72            R. testis: 2.2 x 1.1 cm L. testis: 2.1 x 1.1 cm 
Phallus length: 3.8 cm  
Ht: which is slightly below the 2SD for height    Wt: which is just at the 2SD below the mean for age

General: Awake, not interactive but occasionally seemed to gaze at mother. Skin: Extra fat folds with doughy feel throughout his body.  Cafe-au-lait spot on the medial aspect of his left foot which measured 3x1.5 cm. HEENT: Head circumference: 48 cm.  Significantly enlarged anterior fontanelle that measured 11 cm x 8 cm.  His ears were normally placed and shaped.  TM's were healthy and gray.  His eyes showed that he had epicanthial folds, they were anicteric with roving pupils that were conjugate.  PERRL and the discs were not seen but the vessels appeared normal.  His nose was upturned and his mouth showed a high-arched palate with teeth throughout.   Neck: Positive fat fold over the nape of his neck.  Thyroid was not palpable. thyroid. Chest: Clear no wheezes, rales or rhonchi.  Some upper airway congestion. Heart: Regular rate, S1, S2 no murmur. Abdomen: Soft, with positive bowel sounds, nontender, nondistended.  No hepatosplenomegaly or masses. Genitourinary: Circumcised male, Tanner I, with downgoing testes bilaterally though his left one was high riding. Extremities:  Neurological: Diffuse hypotonia with with poor head control and hyporeflexia and upgoing toes.

Laboratory studies:  IGG 294 with previous IGG 255.

Impression: Cesar is a 2 and 2/12 year old male with multiple congenital anomalies that are probably part of some syndrome but with no diagnosis currently who presents for an endocrine evaluation regarding possible etiology for his anomalies.  There is potential endocrinology causes include hypothyroidism, hypopituitarism and we plan today to obtain thyroid function tests, DHEA-S and insulin-like growth factor to check his growth hormone.  We don't feel that this is a probable cause of his multiple anomalies but feel compelled to rule these out given some of his physical findings.  Dr. Blue will do phone follow up.

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

Sincerely,


Mireille Green, MD               Lancelot Blue, MD             
                             Attending in Endocrinology   


Addendum: Sr. Resident


CONTENT:
Borgna Plutarch, M.D.          RE: Diana Pitman
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/24/79

Dear Dr. Plutarch:

We had the pleasure of seeing Diana in the Endocrine Program on 5/28/92 for evlauation of short stature.

History: Diana is a 12 and 9/12 year old who has always been short for her age, but she has continued to grow slowly. She has been wearing the same size clothing for the past two years but they appear to now be small. Her shoe size has increased by half a size in one year. She had breast development in January of 1992.

Current medications: none. She has a possible penicillin allergy with a rash.

Past medical history:  She was an 8 1/2  pound product of a 41 week gestation with pregnancy complicated by staining. She was delivered vaginally without complications. Postnatal course was complicated by jaundice and weight loss over the first six weeks during breast feeding. This resolved after a change to formula, although she appeared to have an intolerance to milk products and was switched to a soy formula. Infectious disease: varicella at three years old. Hospitalizations: none.  Injuries: none. Operations: none.

Review of systems:  Skin: no excessive dryness or moistness. HEENT: no headaches, blurry vision, or dyplopia. Cardio/respiratory: no shortness of breath, or palpitations, occasional chest pain with deep inspiration. GI: no constipation or diarrhea. She has regular stools one to two times a day. She does have increased gassiness with cramping. GU: no dysuria. Metabolic: no cold or heat intolerance, polydipsia, polyuria or nocturia. Neuro: no tremors.

Family history:  Maternal height 5'6" with menarche in the late 14th year of age. Paternal height 5'11.5". Maternal grandmother's height approximately 5'2". Maternal grandfather's height approximately 5'8". Paternal grandmother's height approximately 5'6". Paternal grandfather's height approximately 5'7". 22 year old brother is 5'11.75" with facial hair development at 14 years of age.

Physical exam:  
Height: 144.4 cm        Weight: 34 kg           BP: 140/60              
Pulse: 92               U/L ratio:  0.85        Arm span: 145           
Breast: Tanner III      Pubic hair: Tanner II   
Skin: Warm.
HEENT: Pupils equal, round and reactive to light. Extraocular movements in tact, oropharynx clear.
Neck: No thyromegaly.
Chest: Clear.
Heart: Regular, rate and rhythm without murmur.
Abdomen: Soft, with no hepatosplenomegaly.
Extremities: Warm and well-perfused.
Neurological: 2+ symmetrical, deep tendon reflexes with normal relaxation phase.
Bone age: (May 20, 1992) 11 1/2 years.

Laboratory studies:  May 20, 1992:   T4 7.0 mcg/dL, TBGI 0.96, Total T3 195, TSH 1.00 mcU/mL, iron 102 mcg/dL, albumin 4.5 g/dL, total protein 4.9 g/dL, AST 27 mu/mL, ALT 27 mu/mL, alkaline phosphatase 227 mu/mL, LDH 102 mu/mL, calcium 9.3 mg/dL, phosphate 4.9 mg/dL, bilirubin 0.3 mg/dL, creatinine kinase 105 mu/mL, sodium 141 mEq/L, potassium 4.0 mEq/L, chloride 104 mEq/L, bicarbonate 27 mEq/L, BUN 9, creatinine 0.7 mg/dL, glucose 89 mg/dL, white blood count 6.21, hematocrit 36.3, platelets 285,000, normal differential.

Impression: Diana appears to have a mild constitutional delay.  The growth pattern observed on the cross sectional NCHS growth chart probably reflects her mild pubertal delay.  Presently she seems to be having her pubertal growth spurt.  Incidentally when her numbers are plotted on the Bayer-Bayley developmental growth chart, she plots parallel to the "delayed case".  Her estimated final height is 156 to 158 cm.

Disposition: Return to Endocrine Clinic in six months.

Laboratory studies pending at this time include: Anti-endomysial antibodies.
Thank you for letting us share in the care of Diana.

Sincerely,


Leif Pavarotti, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director            


Problem list to date:
CONSTITUTIONAL-DELAY         Start: 05/28/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Leticia DeNiro, M.D.          RE: Jake Reynolds
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/22/78

Dear Dr. DeNiro:

We had the pleasure of seeing Jake in the Endocrine Program on 6/18/92 for rule out diabetes insipidus.

History: Jake was referred to us by The Children's Hospital emergency room to rule out diabetes insipidus. As you know, Jake is now a 13 and 11/12 year old Greek male with a long history of soiling as well as frequent urination.  His encopresis is believed to be secondary to chronic constipation and his symptomology has improved with Docolox tablets and mineral oil. In addition, he has complained of polydipsia and frequent voiding. It is difficult to characterize how much he drinks in a day but it is somewhere between 1/2 to 2 gallons a day. Jake does not wake up at night to drink, he does not crave cold liquids and at the time of his visit was not currently thirsty. Jake voids several times a day. According to him, he voids upon waking in the morning, three times at school, immediately upon returning home, and two to three  times before going to sleep. He also wakes one to two times a week to void in the middle of the night. In addition, Jake has numerous daytime accidents described as a "round spot" on his underwear. Jake believes this happens most often when he is holding his urine for a long period of time. Jake cannot say how often he has these accidents. Jake denies any dysuria, hematuria or penile discharge. He feels that he empties his bladder completely with each void. He is not polyphagia and his weights have remained relatively stable over the course of his clinic visits. On May 21, he weighed 52.6 kilos and today he weighs 52.5 kilos.

Current medications: Mineral oil 1.5 tbs./day. He has no known drug allergies.

Past medical history:  Is significant for a learning disability. He underwent a tonsillectomy and adenoidectomy in June of 1988. Approximately two years ago he was placed on Xantac for symptoms consistent with gastritis or peptic ulcer disease. He also wears reading glasses.

Family history:  His social history is significant for the fact that he moved from Greece to the US three years ago. He lives with his step-mother, father and 17 year old sister. His biological mother lives in Athens. Family history is noted for diabetes mellitus on the maternal side. Jake and his step-mother did not know the onset of diabetes in any of these relatives or whether they take insulin.

Physical exam:  
Height: 167.4 cm        Weight: 52.5 kg         BP: 116/58              
Pulse: 60               Pubic hair Tanner: 4    R. testis: 4 x 2.5 cm   
L. testis: 4 x 2.5 cm   Phallus length: 11 cm   Mid-shaft diam.: 4.5 cm 

General: Jake is a quiet well developed young man in no acute distress. He is in the 50th percentile for his height and weight at his age.  Skin: Acne on his chest.  HEENT: Normal. Neck: Supple without any lymphadenopathy. Chest: Normal. Heart: Normal.  Abdomen: Soft, non tender. Bowel sounds were present in all four quadrants and there was no hepatosplenomegaly. There was an abundance of axillary.  Genitourinary: Had a dimple on the tip of his gland. His urethra meadis was approximately 5 mm inferior to the dimple giving Jake a mild hypospadias.  Extremities: Without clubbing, cyanosis, or edema.  Neurological: Normal.

Laboratory studies:  5/4/92 Urinalysis, CH emergency room: specific gravity 1.006, PH 6.0. There was no evidence of glucosuria or ketonuria. sodium 141, potassium 4.5, chloride 102, TCO2 28, BUN 10, creatinine 0.8, serum glucose 88, serum calcium 10, magnesium 2.1, AST 24, ALT 22, alkaline phosphatase 193, total bilirubin 0.5.

5/21/92 PIP Clinic: Urinalysis, urine specific gravity 1.020, PH 6.0, no ketonuria or glucosuria.

Impression: At this time, we find no evidence for an endocrine etiology for Jake's polydipsia or frequent voiding. Though Jake has a positive family history for diabetes, we don't have any evidence for diabetes at this time, as on two occasions Jake has had no glucosuria and a random blood sugar performed on May 4 showed a serum glucose within normal limits. It is unlikely as well, that Jake has diabetes insipidus given the fact that he is able to concentrate his urine to a specific gravity of 1.020 at least on one occasion. Jake does have a mild hypospadius, however, it does not appear to interfere with complete emptying of his bladder as Jake has no symptoms of urinary retention after voiding. We feel most likely that Jake drinks in excess, secondary to behavioral problems and that his frequent voiding is a result of his excessive drinking. In order to definitively rule out diabetes insipidus we asked Jake to obtain a first morning urine for which we will send for urinalysis. We have asked Jake not to have anything to drink following dinner the day before he produces the sample, to not use water with brushing his teeth, and to not to have anything to drink in the morning prior to emptying his bladder. After an overnight fluid restriction he should be able to concentrate his urine to a specific gravity >1.015. If Jake's urine specific gravity shows a dilute urine  the diagnosis of diabetes insipidous must be more seriously entertained.

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

Sincerely,




Antonio Kramer, MD          Bernardo Red, MD           
Senior Resident              Chief, Division of Endocrinology                                                      


Addendum: Jake's urine specific gravity on 06/22/92 was 1.019 effectively ruling out diabetes insipidus as a cause of his polyuria.


CONTENT:
Anthoula Bonaparte, M.D.          RE: Anita Jagatai
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/21/82

Dear Dr. Bonaparte:

We had the pleasure of seeing Anita in the Endocrine Program on 6/15/92 for evaluation of precocious puberty.

History: Anita is a 9 and 10/12 year old who had breast development at 5 years old, pubic hair and axillary hair development at 6 years old, and axillary odor at 4 years old. She has noted acne on her back for 1-2 years. Her menarche was on 10/25/91 with a regular interval monthly, and duration 5 days.

Current medications: None

Past medical history:  Pregnancy was uncomplicated. She was an 8 lb. product delivered by repeat caesarean section. Growth and development: She walked at 1 year old. She has had no hospitalizations, injuries or operations.

Review of systems:  She has dry skin but no headaches, blurry vision, double vision, shortness of breath, palpitations, vomiting, diarrhea, dysuria, tremors, cold or heat intolerance, polydipsia, polyuria, or nocturia.

Family history:  Her 11 year old brother has no evidence of puberty and is of average height. Maternal height 5'2" with average age of menarche. Paternal height 5'4". Maternal grandmother 5'2". Maternal grandfather 5'6". Paternal grandmother 5'7".  Paternal grandfather was tall. There is adult onset diabetes mellitus in the maternal grandfather, but no other endocrine disorders. There is no family history of precocious puberty.

Physical exam:  
Height: 151.2 cm        Weight: 69.5 kg         BP: 102/68              
Pulse: 68               Breast: Tanner V        Pubic hair: Tanner V    
General: Alert.
Skin: Purplish striae around the breasts and hips. Acne on back.
HEENT: Normal optic discs, pupils equal round and reactive to light, extraocular movements intact. Oropharynx clear.
Neck: No thyromegaly.
Chest: Clear.
Heart: Regular rate and rhythm without murmur.
Abdomen: Soft, no hepatosplenomegaly, nontender.
Genitourinary: no clitoromegaly.
Extremities: Warm and well-perfused.
Neurological: 2+ symmetrical deep tendon reflexes with a normal relaxation phase.

Laboratory studies:  From Greater Lawrence Family Health Center: November 3, 1991 Abdominal ultrasound revealed a normal pancreas, gall bladder, kidney, aorta and spleen. Pelvic ultrasound revealed a small cyst on the left ovary with a maximum diameter of 1.4 cm. Normal right ovary and no adnexal masses. 
November 11, 1991 LH 4 U/mL, FSH 4 U/mL (normal for a female).
April 10, 1992 Bone age 12 years old  with a chronologic age of 9 and 9/12 years old.
April 22, 1992 Normal electrolytes.

Impression: Anita's precocious puberty followed a normal pattern of puberty with no other symptoms. The most likely etiology is idiopathic. Since menarche was six months ago, she  will only grow 1-2 inches. No treatment is indicated at this time.

Disposition: She is to return to clinic if she develops irregular menses.

Laboratory studies pending at this time include: None.
Thank you for letting us share in the care of Anita.

Sincerely,


Leif Pavarotti, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology   


Problem list to date:
IDIOPATHIC-SEXUAL-PRECOCITY  Start: 06/15/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Saurabh Montague, M.D.          RE: Esther Krupp
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/08/83

Dear Dr. Montague:

We had the pleasure of seeing Esther in the Endocrine Program on 8/18/94 for follow-up of acquired hypothyroidism.

History: Esther is a nearly 11 year old girl with acquired hypothyroidism seen on August 18, 1994.  She has been essentially well this past year but has gained considerable weight.  Her medication compliance is reportedly good.  Review of systems is negative in detail.

Current medications: Synthroid 125 mcg daily.

Physical exam:  
Height: 152.1 cm        Weight: 78.4 kg         BP: 126/66              
Pulse: 96               
General: Obese.
Skin: Normal temperature and texture but some acanthosis noted on her neck and backs of her hands.
Neck: No goiter.
Heart: Regular rate.
Extremities:  No tremor.
Neurological:  Normal DTRs.

Laboratory studies:  Thyroid function tests and hemoglobin A1.

Impression: Esther is clinically euthyroid.  I suspect the obesity has a large genetic component.  Presence of acanthosis requires further investigation.

Disposition: I gave father a prescription for Synthroid 150 mcg;  will check thyroid  function tests before starting.  I plan to see Esther again in six months.
Thank you for letting us share in the care of Esther.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Benise, M.D.          RE: Esther Krupp
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/08/83

Dear Dr. Benise:

I saw Esther in the Endocrine Program on 10/26/95 for acquired hypothyroidism.

History: As you know, Esther is a 12 year old girl who is currently maintained on Synthroid 150 mcg daily.  Compliance with her medical regimen has been good.  Esther has been essentially well since her last visit and there are no signs or symptoms of hypo or hyperthyroidism.  Esther has not been seen for nutritional guidance.

Current medications: None.

Physical exam:  
HT: 157.9 cm    WT: 87.4 kg      BP: 116/78      Pulse: 90               
General appearance: overweight. Skin: moderate acanthosis on neck and knuckles.  Neck: no goiter.

Laboratory studies:  Thyroid function tests were obtained and showed a T4 of 6.2 mcg/dl, a TBGI of 0.95, a total T3 of 139 nn/dl and a TSH of 13.2 microunits/ml.  A hemoglobin A1 was 7.3%.

Impression: Esther is clinically euthyroid, however, her thyroid function tests clearly suggest undertreatment.  The glycosalated hemoglobin is in the normal range and thus improved from her last visit.

Disposition: Thyroid hormone will be increased to 175 mcg daily and thyroid function tests will be repeated in late December.  We will see Esther back at yearly intervals assuming that her thyroid levels are in the normal range.



Sincerely,




Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Saurabh Montague, M.D.          RE: Esther Krupp
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/08/83

Dear Dr. Montague:

We had the pleasure of seeing Esther in the Endocrine Program on 6/18/92 for evaluation of hypothyroid and precocious puberty.

History: Magaret is a 8 and 9/12 year old girl with a one and a half year history of hypothyroidism on Synthroid, who presents with the question of precocious puberty. Mom is concerned about the early puberty leading to decreased height and also that she is still hypothyroid. She was dxd 2/91 following three months of recurrent sinusitis with and increase in weight gain, puffiness, and decreased activity and hoarse voice noted by mom who has been hypothyroid herself since age 11. Peggy was started on Synthroid for restoration of her sx and normalization of her thyroid function tests. Mom has become concerned as over the last year Peggy has had breast enlargement and body odor requiring regular deodorant use. She was noted to have a small amount of pubic hair six months ago which has increased. Mom states that Peggy still has excessive weight gain and her energy level is not the same as other kids her age. She has also been diagnosed recently as learning disabled and will be starting special classes this fall.  Peggy's growth is consistent following an accelerated course ( 1 SD above normal). Her weight gain also follows the accelerated curve.

Current medications: Synthroid 0.1 mg po QD. She has no known allergies and her immunizations are up to date.

Past medical history:  Remarkable only for recurrent sinusitis 10/90-2/91. Decreased immune system as an infant. She received IVIG periodically until one year of age. At four months of age she had pneumonia.

Review of systems:  Negative.

Family history:  Mother's height is 5'7" and father's height is 6'.

Physical exam:  
Height: 140.3 cm        Weight: 55 kg           BP: 110/64              
Pulse: 84               Breast: Tanner III      Pubic hair: Tanner II   

General: Alert, pleasant obese child. 
Skin: Normal skin, warm dry, and without rashes. 
HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx benign. 
Neck: Supple, without adenopathy or thyromegaly. 
Chest: Clear. 
Heart:Regular rate and rhythm. Normal S1 and S2, distal pulses at 1sym.  
Abdomen: Soft, non tender, non distended, without masses. 
Genitourinary: Without estrogenization. 
Extremities: Normal. 
Neurological: Deep tendon reflexes 2+ and symmetrical. Cranial nerves grossly intact.

Laboratory studies:  1/25/91 TSH 663.2.
6/14/91 TSH 8.02, T3U 45.4, T4 7.6, FT41 3.5.
2/3/92 TSH 2.71, T3U 42.4, T4 8.0, FT41 3.4.

Impression: Peggy is an 8 and 6/12 year old girl with hypothyroidism and early puberty but within the normal range for pubertal development. She is on therapy for hypothyroidism and had normal thyroid function tests four months ago. Today we will check thyroid function tests and bone age to double check her thyroid control and to be sure her bone age is appropriate.

Disposition: Check results of thyroid function tests and bone age. Follow-up by phone with Dr. Ibsen. Return to clinic as needed.
Thank you for letting us share in the care of Esther.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology   


Addendum: Alice Reich

Problem list to date:
HASHIMOTO'S-THYROIDITIS      Start: 06/18/92  End:          Invalid: 

Transcribed by Cassells


CONTENT:
Saurabh Montague, M.D.          RE: Esther Krupp
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/08/83

Dear Dr. Montague:

We had the pleasure of seeing Esther in the Endocrine Program on 6/18/92 for evaluation of hypothyroidism and precocious puberty.

History: Peggy is a 8 and 9/12 year old girl with a one and a half year history of hypothyroidism on Synthroid, who presents with the question of precocious puberty. Mom is concerned about the early puberty leading to decreased height and also that she is still hypothyroid. She was diagnosed in February of 1991 following three months of recurrent sinusitis with an increase in weight gain, puffiness, and decreased activity and hoarse voice noted by mom who has been hypothyroid herself since age 11. Peggy was started on Synthroid for restoration of her symptoms and normalization of her thyroid function tests. Mom has become concerned as over the last year Peggy has had breast enlargement and body odor requiring regular deodorant use. She was noted to have a small amount of pubic hair six months ago which has increased. Mom states that Peggy still has excessive weight gain and her energy level is not the same as other kids her age. She has also been diagnosed recently as learning disabled and will be starting special classes this fall.  Peggy's growth is consistent following an accelerated course ( 1 SD above normal). Her weight gain also follows an accelerated curve.

Current medications: Synthroid 0.1 mg po QD. She has no known allergies and her immunizations are up to date.

Past medical history:  Remarkable only for recurrent sinusitis October 1990-February 1991. Decreased immune system as an infant. She received IVIg periodically until one year of age. At four months of age she had pneumonia.

Review of systems:  Negative.

Family history:  Mother's height is 5'7" and father's height is 6'.

Physical exam:  
Height: 140.3 cm        Weight: 55 kg           BP: 110/64              
Pulse: 84               Breast Tanner: 3        Pubic hair Tanner: 2    
General: Alert, pleasant obese child.   Skin: Normal skin, warm dry, and without rashes.   HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx benign.   Neck: Supple, without adenopathy or thyromegaly.   Chest: Clear.   Heart:Regular rate and rhythm. Normal S1 and S2, distal pulses at 1sym.    Abdomen: Soft, non tender, non distended, without masses.   Genitourinary: Without estrogenization.   Extremities: Normal.   Neurological: Deep tendon reflexes 2+ and symmetrical. Cranial nerves grossly intact.

Laboratory studies:  January 25, 1991: TSH 663.2.
June 14, 1991: TSH 8.02, T3U 45.4, T4 7.6, FT41 3.5.
February 3, 1992: TSH 2.71, T3U 42.4, T4 8.0, FT41 3.4.

Impression: Peggy is an 8 and 6/12 year old girl with hypothyroidism and early puberty but within the normal range for pubertal development. She is on therapy for hypothyroidism and had normal thyroid function tests four months ago. Today we will check thyroid function tests and bone age to assess her thyroid control and to be sure her bone age is appropriate.

Disposition: Check results of thyroid function tests and bone age. Follow-up by phone with Dr. Ibsen. Return to clinic as needed.
Thank you for letting us share in the care of Esther.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology   


Addendum: Alice Reich, MD
Resident
Boston City Hospital

Peggy's T4 was 8.8 mcg/dL but the TSH was 18.3 mcU/mL.  I will recommend an increase in Synthroid to 125 mcg daily and repeat her blood work one month after starting this new dose.  The bone age was 11 years which is indeed somewhat advanced but gives Peggy a predicted adult height of 62-63".

enclosures:  prescription and lab req


CONTENT:
Saurabh Montague, M.D.          RE: Esther Krupp
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/08/83

Dear Dr. Montague:

We had the pleasure of seeing Esther in the Endocrine Program on 7/29/93 for follow-up of hypothyroidism.

History: Peggy is a 9 and 11/12 year old girl with acquired hypothyroidism seen on July 29,1993 for follow-up.  She has been essentially well since last year.  Compliance is generally good but Peggy has not had Synthroid now in five days.  She did well in school last year and will be mainstreamed this year.  Both Peggy and mom have joined a weight loss program together.

Current medications: Synthroid 125 mcg/day.

Physical exam:  
Height: 147 cm          Weight: 64.6 kg         BP: 120/78              
Pulse: 84               Breast: Tanner IV       Pubic hair: Tanner III  
General:  Well developed, overweight girl. Skin: Normal temperature and texture.  Slightly dry over the elbows. Neck: No goiter.  No adenopathy. Extremities: No tremor. Neurological: Normal DTRs.

Impression: Peggy is clinically euthyroid.  She should have thyroid function tests checked in three weeks and return to the Endocrine Program in six months for follow-up.

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

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Clotilde Seinfeld, M.D.          RE: Ingrid Siegbahn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/16/86

Dear Dr. Seinfeld:

     We had the pleasure of seeing Ingrid in the Renal Program on 7/5/95 for hematuria.
     The patient is an 8 year old white female referred by Dr.  Clotilde Seinfeld with a history of microscopic hematuria since 1993.  A  past urine culture was negative.  She had two previous urinalyses that showed 15 to 25 red blood cells with s hematocrit of 41.5 and a hemoglobin of 13.6.  There is  no history of bone or joint pain, no rash, no enuresis, no urinary  symptoms, no vomiting or diarrhea.  There is no history of rash.  The  immunizations are up to date.  There is no history of medication allergy.    The patient  is on no medications and has never been admitted to the hospital and has had no surgeries.  The father has a history of UTI in the past and  also one of the uncles on the mother's side has a history of hematuria.

Her current medications include:


Ingrid's physical exam was notable for:
     BP 115/59   P 68   R 20   T    HT 133.8cm   WT 29.9kg
     General:  The patient appears  well nourished no acute distress.  
     HEENT: The pupils were equal and  reactive to light.  The tympanic membranes were normal.  The throat  examination was within normal limits. 
     Skin: No rashes 
     Neck: Supple
     Lymphs Nodes:  Not palpable. 
     Lungs:  Clear to auscultation. 
     Abdomen: Soft.  Bowel sounds were present.  There was no mass palpable.
     Extremities: Free range of motion without any evidence of edema.  
     Neurological: Within normal limits.  The patient was oriented with normal deep tendon reflexes,  normal muscle tone.
A urinalysis revealed:
     SPEC GR UA  1.034           RBC/HPF     2-5        
     PH UA       5.0             WBC/HPF     0          
     BLOOD UA    +3              SQUAM EPI   0          
     PROTEIN UA  Trc.  mg/dl     BACTERIA    Neg.  
     GLUCOSE UA  Neg.       

Laboratory studies at this time include:
          C3           85   MG/DL       CR          0.5   MG/DL    
          CAU        13.5   MG/DL       ESR           3   MM/HR    
          CRU       124.2   MG/DL       

     Ingrid has had persistent microscopic hematuria.  The differential diagnosis for this condition is quite broad but with normal renal function, normal blood pressure, normal complement levels, no evidence of hypercalciuria, and a quiet urine sediment, it is unlikely that there is a significant glomerular lesion present.

Of note, several family members including Ingrid's parents and siblings also have microscopic menaturia.  It could well be that there is a familial hematuria ongoing.  Since there is no family history of significant renal diseas, we would surmise that the prognosis would be good for such a condition.

We would like to check a renal ultrasound on Ingrid, however, before we complete our evaluation, we would like to rule out any structural abnormalities or evidence of other anotomic problems.  We have scheduled this to take place in the next few weeks.

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

               Sincerely,


               Antonio Khan, MD
               Instructor in Pediatrics


CONTENT:
Clotilde Seinfeld, M.D.          RE: Ingrid Siegbahn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/16/86

Dear Dr. Seinfeld:

     We had the pleasure of seeing Ingrid in the Renal Program on 7/12/95 for hematuria.
     The patient is a 9 year old here in clinic to follow-up results for  hematuria.  Initially results, the creatinine 0.5, calcium creatinine  ratio of 0.1, C3 85 within normal limits.  The patient currently has no  complaints, no fever, vomiting or diarrhea, urinary symptoms or cough.   The weigh today if 29.8 kg.  The blood pressure is 90/62.  The pulse is  90.

Her current medications include:


Ingrid's physical exam was notable for:
     BP 90/62   P 90   R 20   T    HT cm   WT 29.9kg
     General:   Basically unchanged from first visit.  No  distress, well nourished.  Normal cranial nerves.  Pupils equal and  reactive to light. 
     HEENT:   No adenopathy palpated.
     Neck: Supple. 
     Chest:   Clear to auscultation.  
     Heart: No murmur was heard.
     Abdomen:  No bowel sounds present.  No masses were palpated.  
     Genitourinary:  Examination was deferred.   
     Extremities: Had full range of  motion x4.  No edema. 
     Neurological: Examination was intact.
A urinalysis revealed:
     SPEC GR UA  1.003           GLUCOSE UA  N          
     PH UA       2.0             RBC/HPF     2-5        
     BLOOD UA    +++             WBC/HPF     0     
     PROTEIN UA  trace mg/dl
     Urinalysis showed specific gravity of 1003, no leukocytes, pH of 7,  protein traces, red blood cells were found 2 to 5.  Ultrasound done on  day of visit show hydronephrosis on the right.

Laboratory studies at this time include:


     This is a 9 year old with a history of hematuria.   Apparently normal renal function with normal creatinine, normal  pressure, fond to have mild hydronephrosis on the right side during  work-up.  At this point, we need to rule out vesicoureteral reflux.  The  patient will be started on prophylaxis with Bactrim 2 mg/kg/day q. hour  sleep until VCUG has been done.  The VCUG will be done during the first  week in August and after we have the results, we will contact the  patient for follow-up visit.

     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,


               Stefano Animal, MD         Mitsuko Khan, MD
                                            Director, Clinical Services


CONTENT:
Eldre DeNiro, M.D.          RE: Stella Edson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/03/80

Dear Dr. DeNiro:

We had the pleasure of seeing Stella in the Endocrine Program on 8/11/94 for delayed puberty.

History: We had the pIeasure of seeing this 14 0/12 year old girl for constitutional delay of puberty  on 8/11/94.   

She is growing quite well, having gained 5.6 cm in the past year to her present 151 cm, 45.1 kg.   She has not yet had menarche.  She does have some increased breast development, pubic hair development and noted some vaginal mucous.  She is continually cold.

Physical exam:  
BP: 124/51              Pulse: 72               U/L ratio:  -1          
Arm span: 154.5         Breast: Tanner III      Pubic hair: Tanner III  
She looks approximately 13 and has very mild facial acne.   No abdominal masses were noted.  Her bone age is approximately one year delayed.

Laboratory studies:  T4          8.5   ug/dL       TBGI        .86 (C)
TSH        1.00   uU/mL
Bone age: 13 years


Impression: Based on her growth acceleration I think she will undergo menarche within the next 12 to 18 months.

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

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology


CONTENT:
Eldre DeNiro, M.D.          RE: Stella Edson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/03/80

Dear Dr. DeNiro:

Stella was back at 15-0/12 on 08/17/95 for reassessment of her pubertal development, which was indeed delayed.  She is now entering the 10th  grade and has had further progression in breast development, pubic  hair, and axillary hair development, but she has never really showed a  remarkable growth spurt, nor has she yet had menarche.  She is not very  physically active, and there is no caloric drain or underweight status  to account for the delay in menarche, but I believe it is most likely  consistent with the lateness of initial pubertal progression.  She is on  no medication.

Physical exam:  
Height: 156 cm          Weight: 49.1 kg         
BP: 100/60              
U/L ratio:  0.93        Arm span: 159 cm.           
Breast: Tanner IV       Pubic hair: Tanner IV   
On physical exam, she has Tanner stage II axillary hair.  She looks  about a year and a half younger than her chronologic age.  She has no  thyromegaly, and the exam is otherwise unremarkable.  I have drawn and  estradiol level and have done a bone age today.

If she does not have menses in a year, then I would be quite surprised  and would put her through a more completely examination, checking to be  absolutely certain that there is no blockage of vaginal secretions.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Eldre DeNiro, M.D.          RE: Stella Edson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/03/80

Dear Dr. DeNiro:

We had the pleasure of seeing Stella in the Endocrine Program on 8/5/92 for delayed growth.

History: Stella is a 12 year old white female who is referred to us for evaluation  of her delayed growth.  Her mother noticed that Stella has not been developing for the past two years.  Her brother was diagnosed at the age of 3 with growth hormone deficiency and was followed at Mass. General Hospital.  He was put on growth hormone injections and has been doing well, almost reaching normal growth pattern.  According to her mother, Stella's father was also slow to develop but the family is mostly worried because of the history of her brother with growth hormone deficiency.

Review of systems:  Only significant for dry skin on her legs and cold intolerance.  She has not had menses.

Family history:  Mother's height is 5'4 and 3/4", father's height is 5'9".  Father had delayed development during puberty.

Physical exam:  
Height: 140.8 cm        Weight: 35.7 kg         BP: 106/65              
Pulse: 76               Breast Tanner: 2        Pubic hair Tanner: 2    
General: Stella is a pleasant white female in no distress.
Skin: She has no facial hair.
HEENT: PERRLA, EOM intact, no visual field defects.  
Neck: NO thyromegaly.
Chest: Clear to auscultation and percussion..
Heart: S1, S2 regular rate and rhythm.
Abdomen: Soft, nontender, bowel sounds +X4, no organomegaly.
Genitourinary: No pubic or axillary hair.
Extremities: No clubbing, cyanosis, or edema, reflexes are within normal limits.
Neurological: Oriented X3, nonfocal.

Impression: We believe that most likely Stella has constitutional delay of growth but we are going to check her TFTs to rule out hypothyroidism, a Somatomedin-C level to rule out growth hormone deficiency, FSH to rule out Turner syndrome, and ESR to rule out inflammatory bowel disease, antiendomysial antibodies to rule Celiac disease and a bone age.  Stella will return to clinic in two weeks to receive the results of the status.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Addendum: Ioanna Gouni, MD
Fellow in Endocrinology
Joslin Diabetes Center

Thyroid function tests were normal (T4 8.9, TT3 153, TSH 1.1), IGF1 was normal (193 ng/mL), FSH was normal (0.7 IU/L) and ESR was normal (10).

Bone age:  10 1/2 years, predicted adult height 62".


CONTENT:
Eldre DeNiro, M.D.          RE: Stella Edson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/03/80

Dear Dr. DeNiro:

We had the pleasure of seeing Stella in the Endocrine Program on 8/4/93 for follow-up of her pubertal development.

History: Since last seen on August 5, 1992, Stella has been well. She had no significant intercurrent illness.  She thinks she has grown and had further development of her breast, but did not have menarche.  She uses a deodorant on occasions.  She did not have acne.  She has a good appetite and does not exercise excessively.  The review of systems was negative.  She however has cold intolerance.

Physical exam:  
Height: 145.4 cm        Weight: 39.7 kg         BP: 119/64              
Pulse: 75               Breast: Tanner III      Pubic hair: Tanner II   
Stella was healthy looking, and cooperative. Skin: Normal texture, no acne.  Skin was warm not cold nor mottled.  No axillary hair. HEENT: Negative Neck: Thyroid not enlarged.  No lymphadenopathy. Chest: Clear lungs. Heart: Normal S1 and S2, no murmurs. Abdomen: Soft, no tenderness, no hepatosplenomegaly. Extremities: Normal. Neurological:  Nonfocal.

Impression: Stella grew 4.6 cm. and gained 4 kg. and had further evidence of pubertal changes.  These findings are consistent with Constitutional Delay.

Disposition: Stella was reassured that she is a normal but slow grower like her father.  I would like to see her again in one year for re-evaluation.
Thank you for letting us share in the care of Stella.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Zylpha Leary, M.D.          RE: Charles Anderson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/80

Dear Dr. Leary:

I saw Charles in the Endocrine Program on 7/8/96 for insulin-dependent diabetes mellitus.

History: Charles was diagnosed with type I diabetes mellitus in 1992.  He has done very well, overall, and was last seen in diabetes clinic on 3/12/96.  Interval history has been excellent.  He follows a 3000 kilocalorie per day diet, and denies symptoms of hypoglycemia.   

Current insulin dosage is as follows:  14 units regular 35 units NPH mornings, 10-12 units regular before dinner, and 15-19 units NPH before bed for a total of 77 units or 1.0 u/kg/day. 

Blood sugar range between 80-220 mg/dl before breakfast, 100-200 mg/dl before lunch, 160-260 mg/dl before dinner, and 160-240 mg/dl before bedtime.

Physical exam:
HT: 179 cm              WT: 80.1 kg
BP: 129/57              Pulse: 80               
General, well appearing, active, healthy.  HEENT pupils equal, round, and reactive to light, extraocular movements are intact, lens are clear, fundi normal.  Thyroid without enlargement.  Lungs are clear.  Cardiac regular rate and rhythm.  Abdomen without hepatosplenomegaly.

Laboratory studies: HGB A1C 9.5 %, blood glucose 123 mg/dl.

Impression: Charles is a 16-4/12 year old male with type I diabetes mellitus, doing quite well overall.  Growth and development are on track.  He is a bit underinsulinized, as evidenced by afternoon and evening hyperglycemia and a moderately high HgA1c.  He is very active through much of the day, and is planning to attend summer camp.

Disposition: Insulin dose has been increased as follows:  14 units regular, 38 units NPH mornings, 10-14 units regular before dinner, and 16-20 units before bedtime.  In addition, he should check occasional overnight blood sugars to rule out nocturnal hypoglycemia.  A recommended insulin dosage was given for basketball camp, involving an overall 10% reduction.  In addition, when very active, he should take additional snacks.  Next appointment is recommended for 3 months.

Thank you for referring the O'Donnell's to our clinic.

Sincerely,





Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Zylpha Leary, M.D.          RE: Charles Anderson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/80

Dear Dr. Leary:

I saw Charles in the Diabetes Program on 11/26/96 for insulin-dependent diabetes mellitus.

History: Charles was last seen in clinic on 7-8-96.  Interval history has been excellent.  He enjoyed basketball camp this summer.  He is currently in the 11th grade and doing well.  Charles denies signs or symptoms of hypo-or hyperglycemia.

Current insulin dosage is: 14 units Regular, 38 units NPH mornings, 10-14 units Regular before dinner, 16-20 units NPH before bedtime, for a total of 82 units or 1.0 units/kg/day.

Blood sugars range as follows:  120-220 mg/dl before breakfast, 80-160 mg/dl before lunch, 60-240 mg/dl before dinner, and 100-200 mg/dl before bed.

Physical exam:
HT: 179.1 cm    WT: 82.2 kg     BP: 126/66          Pulse: 82               
General: well appearing and well-developed.  HEENT:  pupils equal, round and reactive to light, extraocular movements intact, retina without evidence of diabetic changes.  Thyroid: palpable smooth and symmetrical, lungs clear. Cardiac: regular rate and rhythm no murmurs. Abdomen without hepatosplenomegaly.  Injection sites without evidence of hypertrophy.  Fingertips with evidence of self blood glucose monitoring.

Laboratory studies: Blood glucose 180 mg/dl, hemoglobin A1C 8.5%, urinalysis negative.

Impression: Charles is 16-8/12 year old boy with diabetes mellitus under very good control.  Morning blood sugars are slightly high.  However, because of anticipated increased evening physical activity, I do not recommend an increase in evening NPH.

Disposition: I would like to continue insulin at the present dose, adjusting NPH per a sliding scale dependent upon activity level.  In addition, I have counseled Charles regarding the responsible use of ethanol: namely, to limit consumption to one drink with food.  Follow-up is recommended for three months. 

Thank you for referring the O'Donnells to our diabetes clinic.



Sincerely,




Gleide Crane, MD, PhD
Attending in Endocrinology


CONTENT:
Mitsuko Bird, M.D.          RE: Charles Anderson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/80

Dear Dr. Bird:

We had the pleasure of seeing Charles in the Endocrine Program on 12/8/92 for evaluation of diabetes mellitus.

History: As you know, Charles was diagnosed with diabetes mellitus in July 1992. Since then he has been in good health with no interval problems. He is currently in the 7th grade, and enjoys literature and geography. There has been no difficulty adjusting diabetes management to fit his school schedule. 

Charles describes occasional symptoms of hypoglycemia, occurring approximately once a week, precipitated by exercise usually before lunch. There is no significant nocturia, polyuria, or polydipsia. 

Current Humulin insulin dosage is 5 regular and15 NPH a.m., 3 regular and 6 NPH p.m.  which is 0.56 units/kg/day. Diet is approximately 3000 kcals a day, divided between three meals and three snacks. 

Blood sugars are checked generally four times a day with a One Touch II meter. Pre-breakfast values are about 160-240, pre-lunch are 40-200, pre-dinner 80-240, and pre-bed 80-200 mg/dL.

Physical exam:  
Height: 49.8 cm         Weight: 159.1 kg        BP: 118/64              
General: Alert, well developed, and well nourished.  There is no thyromegaly. The remainder of the exam is unremarkable.

Laboratory studies:  Hemoglobin-A1 9.5 (5.2-7.8%). Also of note, anti-islet cell antibodies on Scott and Steven (siblings of Charles) are negative.

Impression: Charles has recent onset type I diabetes mellitus under good control, but with consistently elevated a.m. blood glucoses. He has occasional low sugars before lunch precipitated by exercise. Growth and development have been excellent. Screening studies on the siblings do not indicate evidence for risk of diabetes mellitus. 

Our plan is as follows: 1. we will adjust a.m. insulin dosage to 4 regular and 7 NPH, 2. Charles is to check occasional 2 a.m. blood sugars especially during the next two weeks, 3. snacks are to be taken before vigorous exercise, 4. we would like Charles to be seen by an ophthalmologist sometime in the next three months, 5. we have sent thyroid function tests to screen for subclinical disease 6. we would like to see Charles  back in three to four months.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Mitsuko Bird, M.D.          RE: Charles Anderson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/80

Dear Dr. Bird:

We had the pleasure of seeing Charles in the Diabetes Program on 3/9/93 for follow-up of diabetes mellitus.

History: Charles was diagnosed with diabetes mellitus in July 1992. Interval history has generally been good, however sugars have been running moderately high for the past 1-2 weeks. Current Humulin dose is 5 units Regular, 15 units NPH a.m., 3 units Regular, 7 units NPH p.m. for a total of 30 units a day or 0.6 units/kilo/day. He describes occasional symptoms of polyuria, nocturia, and polydipsia but no recent insulin reactions. Diet consists of three meals and three snacks a day. Blood sugars are checked on a One Touch II monitor and range as follows: before breakfast 200-300, before lunch 100-300,  before dinner 200-400, and before bed 150-400 mg/dL.

Physical exam:  
Height: 161.2 cm        Weight: 50 kg           BP: 98/60               
Pulse: 80               Breast: Tanner IV       Pubic hair: Tanner IV   
General: Alert, well developed and pleasant.  HEENT:  Fundi without evidence of retinopathy.  Neck:  Thyroid smooth, symmetrical and of normal size.  Chest: Lungs clear.  Heart: Benign.  Abdomen: Without hepatosplenomegaly.

Laboratory studies:  Hemoglobin-A1 12.8%.

Impression: Charles is a 13 year old boy with insulin dependent diabetes diagnosed about 8 months ago. Blood sugars have been consistently high and may reflect the end of his honeymoon period.  We would like to increase overall insulin dose at this time by 10% to 6 units Regular, 16 units NPH mornings, 4 units Regular and 8 units NPH in the evening. We have asked the parents to call us in one week to discuss glycemic control. We plan to see Charles back in clinic in four months.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology   


Problem list to date:
INSULIN-DEPENDENT-DM         Start: 07/01/92  End:          Invalid: 

Transcribed by Nortonsh


CONTENT:
Mitsuko Bird, M.D.          RE: Charles Anderson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/80

Dear Dr. Bird:

We had the pleasure of seeing Charles in the Endocrine Program on 7/20/93 for follow-up of diabtes.

History: Charles was diagnosed with Type I diabetes in July 1992.  Interval health has been entirely unremarkable.  He plans to participate in the basketball summer camp in August, and will be starting the eighth grade in the fall.  He denies drug or alcohol misuse.  

Current Novolin insulin dose is 8 units of Regular and 22 units of NPH in the mornings, 6 units of Regular 12 units of NPH in the evening which equal 48 units/day or 0.86 units/kg/day.  He denies signs or symptoms of hyper- or hypoglycemia.  Diet consists of three meals  and three snacks a day, approximating 3200kcals.  He receives daily exercise, mostly in the afternoon, and adjusts food accordingly.  

Blood sugars are monitored done a One Touch II, and range between 120-240 mg/dL in the morning, 80-200 mg/dL before lunch, 120-300 mg/dL before dinner, and 60-200 mg/dL before bed.

Physical exam:  
Height: 164.8 cm        Weight: 55.4 kg         BP: 126/70              
Pubic hair: Tanner IV   
General: alert, nontoxic, well developed boy. Skin: Injection site hypertrophy over the triceps. Neck: Thyroid normal.

Impression: Charles is a 13 and 4/12 year old boy with diabetes mellitus under reasonable control.  He is progressing through normal puberty, and experiencing the adolescent growth spurt.  Charles is probably somewhat underinsulinized overall at 0.86 units/kg/day of insulin.  Furthermore, the NPH insulin given at dinnertime is probably peaking at 2:00AM, and weaning by breakfast.  

Our plan is to raise the overall dose of insulin at this time, and begin tid insulin dosing as follows: before breakfast 9 units of Regular and 24 units NPH, before dinner 8 units of Regular, and before bedtime 9 units NPH.  This regimen should provide a more physiologic distribution of insulin through the night.  Charles is to check blood sugars carefully next week with a few measurements at 2:00AM.   Further, he is encouraged to take extra snacks in anticipation of vigorous exercise.  Lastly, injection sites should be rotated to avoid hypertrophy.  We would like to see Charles back in the Diabetes Program in approximately three months.

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

Sincerely,


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


CONTENT:
Mitsuko Bird, M.D.          RE: Charles Anderson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/05/80

Dear Dr. Bird:

We had the pleasure of seeing Charles in the Endocrine Program on 10/5/93 for .

History: Charles was diagnosed with diabetes mellitus in July 1992.  Interval health has been good, and he is  doing well in the eighth grade.  

Current Novolin insulin dosage is 10 units of Regular and 25 units of NPH mornings, 6 to 8 units of Regular before dinner,  and 9 to 10 units NPH before bed for a total of 0.9 units/kg/day.  He denies symptoms of hyperglycemia; however, occasional mild insulin reactions are experienced especially during the afternoon while working on his paper route.  Diet consists of three meals and three snacks a day, with extra snacks taken as needed.   Blood sugars are checked on a One Tough II monitor four times  a day.  Typical readings are 100-220 mg/dL before breakfast, 100-200 mg/dL before lunch, 60-180 mg/dL before dinner, and 80-180 mg/dL before bedtime.

Physical exam:  
Height: 166.8 cm        Weight: 56.6 kg         BP: 116/76              
Pubic hair: Tanner IV   
General: Alert, well appearing, well developed.
HEENT: EOMI, PERRL, fundi without retinopathy.
Neck: Thyroid smooth and symmetrical
Genitourinary: Genitalia Tanner IV.

Laboratory studies:  Glycosylated hemoglobin 10.1%.

Impression: Charles is a 13 and 7/12 year old boy with Type I diabetes mellitus under improved glycemic control on TID insulin dosing (glycosylated hemoglobin on BID insulin was 12.8%).  Pre-breakfast blood sugars are somewhat on the high side, except following evenings when vigorous exercise was obtained.  Occasional afternoon insulin reactions  are again associated with vigorous exercise.

Disposition: We would like Charles to anticipate vigorous exercise during the day with larger meals and/or extra snacks.  Usual bedtime NPH insulin dose should be 10 units; however, 8 or 9 units may be given following an especially vigorous evening exercise.  We are awaiting the results of screening thyroid function tests, and would like to see Charles back in clinic in three months.
Thank you for letting us share in the care of Charles.

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

     We had the pleasure of seeing Kari in the Renal Program on 4/28/94.
     Katie comes in for an interim checkup for her membranoproliferative glomerulonephritis, type 2.  Since her last renal evaluation four months ago, she has been doing well.  She states that her urine appears to be normal in color.  She has had no episodes of dysuria.  She denies any edema.  She continues on her alternate day steroid regimen.  She is somewhat concerned over her increased weight gain. She tells me that she has been participating in sports and has been trying to be quite active.  She also has been trying to avoid high calorie foods.  Otherwise, she has been doing well.  The family reports that Katie's headaches have decreased significantly in frequency since her Inderal dose was recently increased.

Current medications include:
     PREDNISONE 60 mg q.o.d.
     PROPRANOLOL HCL 120 mg q.d.

Physical exam:
     BP 121/67     P 68     HT 148.5cm     WT 47.2kg
     General: Alert, active, in no distress
     HEENT:  TMs clear bilaterally, fundi unremarkable, 
     oropharynx benign
     Neck: Supple, without adenopathy
     Chest: Clear throughout
     Heart: Without murmur
     Abdomen: Soft, there is no organomegaly or mass
     Extremities: Well formed, no edema

Urinalysis:
          SPEC GR UA  1.020                PH UA       5          
          PROTEIN UA  3+    mg/dl          GLUCOSE UA  N     mg/dl
          BLOOD UA    3+                   RBC/HPF     2-5   /HPF 
          WBC/HPF     rare                 GRAN CAST   rare  
          SQUAMOUS EPITHELIAL  N

     Katie continues to do well on her alternate day steroid therapy.  Clinically, she has had some increased weight gain since initiating steroids 15 months ago.  She has gained approximately 25 pounds during this time period.  She has, however, grown more than two inches.  I spent some time reiterating with the family the  need for Katie to be as active as possible as well as to avoid high calorie foods.  The family understands that Katie will have a tendency to gain weight while on her steroids.  Otherwise, Katie has shown no significant steroid sequelae. Her rate of growth has been well within normal limits and her blood pressure has remained quite normal.  

Katie's proteinuria and hematuria were somewhat greater today than on her most recent visits.  Her urine sediment remained benign.  I have sent urine off to quantitate the degree of proteinuria.  At this point I would continue to recommend that we maintain Katie on her alternate day steroids until she completes two years of therapy.  At that point I would recommend rebiopsying her and reassessing the renal lesion.
     We have asked Katie to return in four months.  Thank you for allowing us to share in the care of Kari.

     Sincerely,


     Antonio Khan, MD           
     Instructor in Pediatrics


CONTENT:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

     We had the pleasure of seeing Kari in the Renal Program on 8/11/94 for MPGN, type 2.

     Katy comes in for an interim check-up with her mother.  It has been 4 months since her last evaluation.  During this time, she has been doing well.  She states that her urine has generally appeared yellow in color.  She continues to take her prednisone on an every-other-day basis.  She has been trying to avoid high-calorie foods, but her weight continues to go up somewhat

Katy had a follow-up visit with the neurologist for her migraine headaches.  She has been maintained on her current dose of propranolol and has been doing well.  She is having fewer than 1 headache per month at this point.  The neurologist had recommended continuing the propranolol until the prednisone is weaned.  At that point, we could then try Katy off her propranolol and see what happens with the frequency of her headaches.

Current medications include:
     PREDNISONE 60 mg q.o.d.
     PROPRANOLOL HCL 120 mg q.d.

Physical exam:
     BP 126/84   P 72   HT 149.5cm   WT 50.9kg
     General:  Katy was alert and active in no distress.  She was mildly cushingoid in appearance
     Skin:  Free of rash
     HEENT:  Benign
     Neck:  Supple without thryomegaly or adenopathy
     Chest:  Clear throughout with normal configuration and excursion
     Heart:  Without murmur, with a normal S1 and S2, pulses were full
     Extremities:  Well-formed, there was no edema or cyanosis

Urinalysis:
     SPEC GR UA  1.028           PH UA       6          
     PROTEIN UA  2+              BLOOD UA    N          
     GLUCOSE UA  N               WBC/HPF     N          
     RBC/HPF     rare            SQUAM EPI   rare  
     CASTS       N

     Clinically, Katy continues to manifest some mild to moderate side effects of her steroid therapy.  She has had a substantial weight gain during the 20 months she has been on steroids.  She has continued to grow, however, and since I would anticipate her alternate day steroid therapy will be weaned or discontinued in the near future, I believe that we should not alter her therapy at this point.  

I spent some time discussing with Mrs. Malan our desire to re-biopsy Katy in approximately 4 months time.  We could then evaluate the effects of 2 years of alternate-day steroid therapy and come to a decision regarding KatyUs steroids.  The family seemed agreeable to this approach and we had made tentative plans to perform KatyUs biopsy during her school vacation at Christmas time.

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

               Sincerely,


               Antonio Khan, MD
               Instructor in Pediatrics


CONTENT:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

     We had the pleasure of seeing Kari in the Renal Program on 01/26/95 for MPGN, type 2.

     Katie comes in today with her mother.  It has been approximately one month since she underwent her repeat renal biopsy.  She tolerated the procedure well and has had no dysuria or discomfort over the biopsy site.  Her mother states that Katie has been tolerating the wean from Prednisone without difficulty.  She is currently on 30 mg q.o.d. and is due to go to 20 mg q.o.d. later this week.

Current medications include:
     PREDNISONE 30 mg po q.o.d.
     INDERAL 120 mg po q.d.


Physical exam:
     BP 125/75   P 84   HT 151.6cm   WT 54.3kg
     General:  Katie was alert and active in no distress. 
     Skin:  Free of rash
     HEENT:  Benign
     Neck:  Supple without thyromegaly or adenopathy
     Chest:  Clear throughout with normal configuration and excursion.  Clear to auscultation
     Heart:  Without murmur
     Abdomen:  Soft.  There is no organomegaly or mass.
     Extremities:  Well-formed, there was no edema.

Urinalysis:
     SPEC GR UA  1.015           WBC ENZ UA  1+         
     PH UA       7               PROTEIN UA  3+         
     BLOOD UA    1+              GLUCOSE UA  N     mg/dl
     WBC/HPF     2-3             RBC/HPF     1-3        
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   rare            WAXY CAST   N          
     SQUAM EPI   many            BACTERIA    N     


Laboratory studies at this time include:
          ALB         3.4    G/DL       C3           84   MG/DL    
          CRU        68.5   MG/DL       CR          0.5   MG/DL    
          U PROT      188   MG/DL (H)   


     Katie's repeat renal biopsy was remarkable for a fair amount of sclerosis in her glomeruli.  In addition, there continue to be a large amount of messangial proliferation. In reviewing the biopsy results with the pathologist and members of the nephrology division, it was felt that Katie continues to have active MPGN however it is difficult to discern just what efficacious effect the alternate day steroid administration has been having.  Certainly, Katie has had some significant sequela from her steroids, most notably her marked weight gain and a mild diminution in her growth velocity.  

I believe it would be most reasonable for us to wean Katie from her alternate day Prednisone.  During the wean, we will continue to closely monitor her for exacerbation of her renal disease.  If Katie tolerates the wean, I would then consider possible therapy with an ACE inhibitor such as Enalapril to both decrease her proteinuria and to render some degree of hemodynamic protection to her remnant glomeruli.

I spent some time discussing these plans with Katie and her mother.  They are anxious for Katie to come off her steroid medication because of her side effects.  

For the time being, I would continue Katie on her current dose of Inderal for her migraine prophylaxis.  The neurologist have felt that these steroids may have exacerbated her headaches and until she is off her steroids for a fair amount of time I do not believe we should try weaning this medication.

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

               Sincerely,


               Antonio J.G. Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

     We had the pleasure of seeing Kari in the Renal Program on 3/9/95 for MPGN, type 2.

     Katie comes in today with her mother.  It has been approximately 6 weeks since her last visit to the Renal Program.  During that time, she has tapered her steroids to 5 mg of prednisone every other day.  She has been tolerating the wean fine.  The family has not noticed any change in the appearance of Katie's urine.  She has also had no changes in the frequency of her migraine headaches.

Current medications include:
     INDERAL 120 mg po q.d.
     PREDNISONE 5 mg q.o.d.

Physical exam:
     BP 117/73   P 85    HT 151.8cm   WT 56kg
     General: Alert, active, less cushingoid than in prior visits
     Skin: Free of rash.  There are several pigmented nevi which are present on the back bilaterally and the suprascapular area
     HEENT: Benign
     Neck: Supple, there is no adenopathy
     Chest: Clear throughout
     Heart: Without murmur.  Pulses were full
     Abdomen: Soft.  No organomegaly or mass
     Extremities: Well formed, without edema or cyanosis

Urinalysis:
     SPEC GR UA  1.008           PH UA       5          
     PROTEIN UA  2+              BLOOD UA    2+         
     GLUCOSE UA  N               WBC/HPF     5-8        
     RBC/HPF     3-5             SQUAM EPI   many  
     CASTS       N

Laboratory studies at this time include:
          ALB         3.3    G/DL       C3           72   MG/DL (L)
          CRU        32.9   MG/DL       CR          0.5   MG/DL    
          U PROT       82   MG/DL (H)   

     Clinically, Katie is doing quite well.  She has tolerated her prednisone wean and will be discontinuing her steroids in 10 days.  Since her steroids had exacerbated her headaches and caused our use of Inderal for prophylaxis, I discussed with Mrs. Malan discontinuing the Inderal after the prednisone has stopped.  They should keep a careful record of Katie's headaches and if they do increase in frequency or intensity then I told the family that I would reinstitute the Inderal prophylaxis.  I do not believe that the Inderal has been having any significant cardiovascular effect on Katie.  Her pulses have been routinely running in the 80s to 90s and her blood pressures have not significantly changed while on this medication.

I did discuss once more with the Malan's my desire to initiate Katie on Enalapril therapy.  I would like to use this medication to decrease her proteinuria as well as to maintain her blood pressure in the low normal range.  As we have discussed previously, there is some theoretic rational for wanting to decrease proteinuria and change renal hemodynamics in kidneys in which there is ongoing scarring.

     We have asked Kari to return in three months.  Thank you for allowing us to share in Kari'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:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

     We had the pleasure of seeing Kari in the Renal Program on 6/22/95 for .
     Katie comes in today with her mother.  It has been three  months since her last renal program evaluation.  During that time, Katie  has been doing well.  She has been weaned completely off her steroids.   There has been no change in the gross appearance of her urine and the  family denies any episodes of edema.  

After Katie was weaned from her steroids, her Inderal which had  been given for migraine headache prophylaxis was also discontinued.   Subsequently, Katie has had only one headache over the  last month during which she has been off of her Inderal. 

Otherwise, Katie has had no illnesses.  Incidently, on the way to this  appointment, the family was involved in an automobile accident and Katie  states that her neck now hurts.  She was the belted front seat passenger  in a car which was the second car in line when it was struck from the  rear.  Katie denies losing consciousness or striking her head on any  portion of the car interior.  She denies any headache, sensory changes  or muscular weakness.  She states that she has some discomfort if she  bends her head in certain ways.

Her current medications include:
     Vasotec 5 mg. q.d.

Kari's physical exam was notable for:
     BP 131/84   P 97   R    T    HT 154.4cm   WT 54.5kg
     General: Alert, active, healthy appearing child in no  distress.  
     HEENT:  examination is unremarkable.  Of note, the pupils are  equal and reactive and the fundi are benign.  
     Neck:  Some tense musculature.  There is free range of motion actively and passively.  There is no point tenderness.  The discomfort appears to be localized to the trapezius muscles especially with flexion  or extension of the neck.  There is no adenopathy. 
     Lungs: Clear to auscultation.
     Heart: Without murmur.  S1 and S2 are normal.  The  pulses are full. 
     Abdomen:  Soft without organomegaly or mass.   
     Extremities:  Well formed without edema or cyanosis. 
     Neurological: Including cranial nerves II-XII  including deep tendon reflexes, tone, strength, coordination and gait  are all within normal limits.
A urinalysis revealed:
     SPEC GR UA  1.022           RBC/HPF     Rare       
     PH UA       5               WBC/HPF     Neg.       
     BLOOD UA    2+              SQUAM EPI   Many       
     PROTEIN UA  3+    mg/dl     BACTERIA    Neg.  
     GLUCOSE UA  Neg.       

Laboratory studies at this time include:
          ALB         3.2    G/DL       CR          0.5   MG/DL    
          C3           81   MG/DL (L)   U PROT      365   MG/DL (H)
          CRU       117.3   MG/DL       

     Clinically, Katie continues to do well.  She has tolerated  her wean from her steroids without a flair in her underlying MPGN.  Her  serum albumen remains within a normal range.  She continues to have a  significant proteinuria, but this is not surprising given her degree of  underlying renal damage.   

I was a little concerned regarding Katie's blood pressure today.  Her  systolic pressures were somewhat higher than normal.  This may be  related to the car accident the family was involved with on the way into  the appointment.  I have asked the family to monitor the blood pressure  over the next several weeks and to let me know if these higher readings  are sustained. 

I believe it would be worthwhile to attempt to increase Katie's enalapril.  Given her underlying disease and her persistent significant  proteinuria, it may prove beneficial to attempt to alter her glomerular  hemodynamics.  I have asked the family to increase her to 7.5 mg daily.   In three months time I would like her to have a urine protein to  creatinine ratio checked locally.  At that point, if the ratio not changed significantly and her blood pressure will  tolerate it, I would again increase her enalapril to 10 mg daily.

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

               Sincerely,


               Antonio Khan, MD
               Instructor in Pediatrics


CONTENT:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

     We had the pleasure of seeing Kari in the Renal Program on 12/14/95 for membranoproliferative glomerulonephritis.
      Katie comes in with her mother for an interim visit.  It  has been approximately 6 months since her last follow-up.  During that  time, Katie has generally been well.  She was hospitalized approximately  2 months ago for a viral illness which triggered significant  bronchospasm.  Katie was treated acutely with steroids and with  bronchodilators but is now off all these medications and has no  pulmonary symptoms whatsoever.  Currently, Katie is being treated for  sinusitis with amoxicillin. 

Katie denies any episodes of swelling or any change in the gross  appearance of her urine.  She continues to have excellent energy and  good appetite.  The family has no specific concerns.

Her current medications include:
     AMOXICILLIN 500 mg t.i.d. 10days
     ENALAPRIL 10 mg q day

Kari's physical exam was notable for:
     BP 104/64   P 84   R    T    HT 156.9cm   WT 50.5kg
     General, alert, active, healthy-appearing child.  HEENT exam  is benign.  Neck is supple without thyromegaly or adenopathy.  The  configuration excursion of the chest is normal.  Lungs are clear to  auscultation.  Cardiac exam is without murmur.  S1 and S2 are normal.   Pulses are full.  The abdomen is soft without organomegaly or mass.   Extremities:  Well formed without edema.
A urinalysis revealed:
     SPEC GR UA  1.035           WBC/HPF     freq       
     PH UA       5               SQUAM EPI   freq       
     WBC ENZ UA  -               RBC CAST    0          
     BLOOD UA    1+              WBC CAST    0          
     PROTEIN UA  3+              GRAN CAST   0          
     GLUCOSE UA  -               WAXY CAST   0          
     RBC/HPF     rare            BACTERIA    -     

Laboratory studies at this time include:
          CRU       265.9   MG/DL       U PROT      656   MG/DL (H)

     Clinically, Katie continues to do well.  She continues to have  significant proteinuria but this is not unexpected given the extent of  her glomerular lesion.  She does appear to be tolerating her enalapril  well.  Her current dose is relatively adequate for the glomerular  protection which we are theoretically achieving with this agent. 

The Baribeau's understand that Katie's MPGN is a chronic renal disease  and that we have nothing which can repair any damage which has already  occurred to Katie's kidney.  Although Katie's ultimate renal prognosis  is relatively guarded, she continues to do well with stable renal  function and normal blood pressure.  At this point, I would advise that  we continue her enalapril therapy and maintain close follow-up.

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

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

     We had the pleasure of seeing Kari in the Renal Program on 5/23/96 for MPGN, type 2.
     Katie comes in today with her mother.  It has been approximately six  months since her last Renal Program evaluation.  During that time, Katie  has been doing well.  She has had no significant interim illnesses.  She  was evaluated at the end of December at the Lahey Clinic for an episode  of syncope which accompanied vigorous exercise and playing soccer.  Her  evaluation at that time was negative.  She has had no recurrent episodes.   

Her blood pressure at home has remained in the normal range on 10 mg of  Vasotec daily.  She reports no difficulty taking that medication.  She  denies any changes in the appearance of her urine nor any episodes of  edema.

Her current medications include:
     VASOTEC 10  mg q.d.


Kari's physical exam was notable for:
     BP 116/68   P 81   R    T    HT 159.4cm   WT 54.1kg
     Objective:  general:  alert, active, healthy appearing adolescent.   
     HEENT examination is benign.  
     The neck is supple.  There is no adenopathy.  
     The chest is clear throughout.  
     Cardiac examination is regular rate and rhythm with no murmur.  S1 and S2 are normal.  
     The  abdomen is soft without organomegaly or mass.  
     Extremities are without edema.
A urinalysis revealed:
     PH UA       5.0             WBC/HPF     -          
     BLOOD UA    1+              SQUAM EPI   freq.      
     PROTEIN UA  2+              GRAN CAST   rare  
     GLUCOSE UA  -               BACTERIA    -     
     RBC/HPF     2-5        

Laboratory studies at this time include:
          CRU       100.0   MG/DL       BUN          14   MG/DL    
          ALB         3.5    G/DL       U PROT       89   MG/DL (H)
          CR          0.5   MG/DL       

     Clinically, Katie continues to do well.  She is now approximately 18  months post-cessation of her alternate day steroid therapy.  During that time, her urine sediment has not changed and the level of proteinuria  has been relatively stable.  Her renal function has also remained in a  normal range. 

The Malan's understand the MPGN may be progressive disease and that  Katie needs routine follow-up.  They also understand that we are giving  the Vasotec to attempt to reduce the scarring which can occur due to a  chronic renal process. 

At this point, I have advised the Malan's to maintain Katie on her current dose of enalapril.  They should contact my office if there are  any significant changes in the appearance of Katie's urine or if she  develops significant swelling.

     Thank you for the opportunity to participate in Kari's care.  We would like to review her in 6 to 8 months.  In the interim, we would be happy to discuss or review Kari should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Kishwar Montague, M.D.          RE: Kari Malan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/14/81

Dear Dr. Montague:

We had the pleasure of seeing Kari in the Renal Program on 12/12/96 for MPGN.
Katie comes in today with her mother.  It has been approximately 6  months since her last Renal Program evaluation.  During that time, she  has been doing well.  She continues to take her Vasotec without  problems.  She is quite active in school and has made the honor roll.   The family has no specific health concerns.

Her current medications include:
    VASOTEC 10 mg q.d.

Kari's physical exam was notable for:
     BP 119/57   P 80   R    T    HT 161.6cm   WT 54.8kg
     On physical examination, Katie is an alert and active adolescent in no  distress.  
     HEENT exam is benign.  
     Neck is supple without thyromegaly or  adenopathy.  Configuration excursion of the chest is normal.  
     Lungs are  clear to auscultation.  
     Cardiac exam is without murmur.  S1 and S2 are  normal.  Pulses are full.  
     Abdomen is soft without organomegaly or mass.   
     GU is Tanner 2.  
     Extremities are normal without clubbing, edema, or  cyanosis.  
     Skin is free of rash.
A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     0          
     WBC ENZ UA  -               RBC/HPF     rare       
     PH UA       6               WBC CAST    0          
     PROTEIN UA  1+              RBC CAST    0          
     BLOOD UA    1+              GRAN CAST   0          
     GLUCOSE UA  -               WAXY CAST   0     
     BACTERIA    -               SQUAM EPI   many  

Clinically, Katie continues to do well.  She has persistent hematuria  and proteinuria, but both of these are somewhat lower in grade than in  the past.  Her urine sediment is also quite quiescent.  

I spent some time discussing the need for us to continue Vasotec therapy  with Katie.  This medication is used in individuals with chronic  proteinuric renal disease in an attempt to decrease the progression of  glomerular scarring.  Katie has been tolerating this medication well and the benefits of continuing would outweigh discontinuing it at this  point.

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

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


cc:


CONTENT:
Tinisha Khan, M.D.          RE: Henry Yeats
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/91

Dear Dr. Khan:

We had the pleasure of seeing Shaquile in the Endocrine Program on 4/4/94 for evaluation of premature adrenarche.

History: Shaquile is a 2 and 8/12 year-old boy who has had axillary odor for more than one year.  His statural growth has been steady along the 90th percentile.  He is generally healthy and has no history of headaches, visual problems, dry skin, constipation, frequent infections, excess thirst or urination, or loss of energy.

He is on no medications.

Past medical history:  He was born at term weighing 7 lbs 3 oz by vaginal delivery.  He had bilateral inguinal herniorrhaphies at 8 months.  Shaquile does not have sickle trait.

Family history:  The mother is 27 years old, 67 inches tall, and in good health.  She has sickle trait.  She had menarche at 15 years and began to have axillary odor at 14.  Her sister had menarche at 11 years of age.  The father is 32 years old, 69 inches tall, and  healthy.  Shaquile's 3-month-old half-sister with the same mother is healthy.

Physical exam:  
Height: 99 cm           Weight: 16 kg           BP: 92/58               
Pulse: 108              Breast: Tanner I        Pubic hair: Tanner I    
R. testis: 2.0 x 1.0 cm L. testis: 2.0 x 1.0 cm Phallus length: 5.2 cm  
Mid-shaft diam.: 1.8 cm 
Healthy-looking boy.  Skin with normal texture and a 1x2cm cafe-au-lait spot with smooth borders on the upper back.   Thyroid not enlarged.  Abdomen without hepatosplenomegaly.  Axillary hair Tanner I.  Axillary odor present.  Neuro extraocular movements intact.

Laboratory studies:  April 4, 1994: Bone age: 2 8/12 years (SD 4.5 months).

January 3, 1994 (12:40pm) - DHEAS 45 mcg/dl, androstenedione 19 ng/dl.

April 1, 1994: (2:38pm) - testosterone <10 ng/dL, DHEAS 42 mcg/dL, FSH 0.2 IU/L, LH <0.10 IU/L.  Pending progestereone, 17-hydroxyprogesterone.

Impression: Shaquile has premature adrenarche evidenced only by apocrine odor.  He has had no growth spurt or bone age advancement, and the testes are prepubertal.  No intervention is needed at this time.   However, if he shows further signs of puberty (an acceleration of statural growth or advancing bone age), he would need reevaluation.


Laboratory studies pending at this time include: April 1, 1994 - DHEAS, testosterone, LH, FSH.
Disposition: We would like to see Shaquile again if he shows any further progression of pubertal signs.
Thank you for letting us share in the care of Shaquile.

Sincerely,


Rene Daley, MD         Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief Emeritus


CONTENT:
Brezny, M.D.          RE: Luther Lesage
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/03/87

Dear Dr. Khalil-Brezny:

I saw Luther in the Diabetes Program on 9/30/96 for insulin-dependent diabetes mellitus.

History: Luther was last seen in clinic on May 7, 1996.  Interval history has been good:  no intercurrent illnesses, and he has had a busy and active lifestyle.  Occasional mild insulin reactions are experienced in the early evening associated with exercise.  He follows a regular meal plan and has no particular concerns about his diabetes management. 

Typical blood sugars run as follows:  100 to 280 mg/dl in the mornings, lunch readings not available, 100 to 300 mg/dl at dinner and 80 to 200 mg/dl before bed.

Current medications: Insulin dose:  3 units Regular and 14 units NPH in the morning, 1.5 to 2.5 units Regular at dinner, and 5 to 5.5 units NPH at bedtime.

Physical exam:
HT: 133.8 cm            WT: 33.7 kg
BP: 114/61              Pulse: 81               
On physical examination he was well appearing, skin with mild soft tissue hypertrophy on the arms.  The HEENT exam shows pupils were equal, round, and reactive to light, extraocular movements are intact.  Neck was without thyromegaly.  Lungs were clear.  Cardiac was regular rate and rhythm without murmur.  Abdomen was without hepatosplenomegaly.  Neurologic exam was normal.

Laboratory studies: HGB A1C 9.8 %, glucose 421 mg/dl
Urinalysis  3+ glucose, no ketones

Impression: Luther is a 9-3/12 year old boy with type I diabetes mellitus, doing reasonably well overall.  Growth and development are on target.  I am somewhat concerned about the manner in which the sliding scale has been utilized.  Instead of adjusting insulin dose for exercise level, dosage has been varied based on unclear criteria.  In addition, documentation appears to be somewhat haphazard.

Disposition: Sliding scale Regular insulin at dinner should range between 1.5 and 2.5 units as determined by evening activity level.  In addition, bedtime NPH should be varied between 5 and 5.5 units, again as determined by activity level in the evening.  Occasional blood sugar checks at lunch will prove useful for maximizing glycemic control.  Finally, Luther has been encouraged to write his blood sugars in a log book accurately, as supervised by parents.  Follow-up is recommended for 3 months.

Thanks for referring the Lesages to our Diabetes clinic.  Please don't hesitate to call with questions.


Sincerely,






Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Lear, M.D.          RE: Luther Lesage
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/03/87

Dear Dr. Khalil-Lear:

We saw Luther in the Diabetes Program on 1/21/97 for type I diabetes mellitus.

History: Luther was diagnosed with diabetes mellitus in June 1992 and was last seen in clinic on September 30, 1996.  Interval history has been good, without intercurrent illnesses.   Luther's weight is believed to be down a bit in recent months.  He currently attends the fourth grade, receiving A's and B's, and is very active in hockey. 

He denies symptoms of hyperglycemia, and experiences occasional mild insulin reactions approximately once per week.  Blood sugars, as noted in the diabetes logbook, run between 95 and 190 mg/dl throughout the day.

Current Novolin insulin dosage is 3 units Regular and 14 units NPH in the morning, 1.5-2.0 units Regular before dinner, and 5 units NPH before bedtime for a total of 0.72 units/kg/day.

Physical exam:
HT: 134.2 cm            WT: 33.4 kg
BP: 102/72              Pulse: 89               Pubic hair: Tanner I    
General:  Well-appearing well-proportioned and healthy.  HEENT:  Pupils equal, round and reactive to light, extraocular muscles intact, lenses clear.  Neck:  Thyroid palpable, smooth, symmetrical.  Lungs:  Clear.  Cardiac:  Regular rate and rhythm, no murmurs.  Abdomen:  Without hepatosplenomegaly.  Skin:  Without atrophy or hypertrophy at the injection sites, fingertips clean, with evidence of self blood glucose monitoring.

Laboratory studies: Blood sugar 113 mg/dl, hemoglobin A1C 11.7% (4-6).

Impression: Luther is a 9-7/12 year-old boy with type I diabetes mellitus under fair control.  There is a marked discrepancy between the blood sugars noted in the logbook, and his current glycosylated hemoglobin value.  Also of some concern is decreased weight velocity at the current visit.  However, he has no other signs or symptoms of uncontrolled diabetes mellitus such as polyuria or polydipsia.

Disposition: We would like to continue the current insulin dose for the next few weeks, and will have the Lesages call us to discuss these values.  Should blood sugars indicate, an increase in insulin dosage will be suggested.  Otherwise, we will await the results of the next glycosylated hemoglobin and consider other possible causes for this high value:  including, errors in technique of blood glucose monitoring or accuracy of glucometer. 

Thank you for referring the Lesages to our Diabetes Clinic, please don't hesitate to call should you have any questions.


Sincerely,





Valija Plutarch, MD                 Gleide Crane, MD, PhD             
Resident in Pediatrics       Attending in Endocrinology


CONTENT:
Lear, M.D.          RE: Luther Lesage
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/03/87

Dear Dr. Khalil-Lear:

We had the pleasure of seeing Luther in the Endocrine Program on 9/15/92 for evaluation of diabetes mellitus.

History: Luther was diagnosed with diabetes mellitus in July 1992. Since discharge from the hospital he has done well without intercurrent illnesses. Since starting kindergarten two weeks ago his blood sugars have been somewhat higher. The parents report some frustration in negotiating meals with Luther. Otherwise, things are going well at home. Current insulin dose is a.m. 10 units NPH, p.m. 2 units NPH for a total of 12 units/day or 0.55 units/kilo/day of Humulin insulin. Blood sugars have been between 80-120 in the morning, 120-240 at lunch, 180-300 at dinner and 180-300 mg/dLat bedtime.

Physical exam:  
Height: 110.5 cm        Weight: 22.3 kg         
On exam, Luther was alert, playful and non-toxic. There was no thyromegaly. The exam was otherwise unremarkable.

Impression: Luther is now a 5 and 2/12 year old with new onset diabetes mellitus generally doing quite well. Blood sugars have been high before dinner and at bedtime. He is a fussy eater but appears to be taking adequate calories. 

Plan: 1. increase a.m. insulin to 11 units NPH and p.m. insulin to 1/2 unit regular and 2 units NPH, 2. will arrange meeting with a nutritionist, 3. will obtain glycosylated hemoglobin, 4. return to clinic in three months.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Lear, M.D.          RE: Luther Lesage
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/03/87

Dear Dr. Khalil-Lear:

We had the pleasure of seeing Luther in the Endocrine Program on 8/3/93 for follow-up of diabetes mellitus.

History: Luther was diagnosed with diabetes mellitus in July 1992. He has not suffered any significant complications of the disease, though interval history is notable for one insulin reaction in April. He is very active with karate and basketball this summer, and plans to start the first grade in the fall. Current Novolin insulin dose is 16 units NPH mornings,  4 units NPH evenings (with 0.5-1 unit regular for blood sugars >240 mg/dL).  This equals approximately 0.8 units/kg/day. No symptoms of hyper- or hypoglycemia have been noted in the past two months. Diet consists of three meals and three snacks a day. Exercise is obtained on a daily basis with adjustment in food as needed. Blood sugars are checked on a One Touch II and range between 60-200 mg/dL before breakfast, 40-300 mg/dL before lunch, 80-240 mg/dL before dinner, and 60-100 mg/dL before bed.

Physical exam:  
Height: 117.7 cm        Weight: 25.3 kg         BP: 100/60              
Pubic hair: Tanner I    
General: Alert and well appearing boy.  Neck: Thyroid palpable, smooth, not enlarged. Chest: Clear. Heart: Normal. The remainder of the exam was within  normal limits.

Laboratory studies:  Glycosylated hemoglobin 9.4%.

Impression: Luther is a 6 and 2/12 year old boy with Type I diabetes under reasonably good glycemic control. Some fluctuation in blood sugars, especially around lunch and dinner, are likely attributable to variation in diet and exercise. Luther is demonstrating good growth and development at this time. 

We would like Luther to continue his current insulin dose and take supplemental snacks especially when exercising vigorously in the evenings.   Luther is to return to clinic in three  months.

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

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Niall Shields, M.D.          RE: Marilyn Rawlings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/19/86

Dear Dr. Shields:

We had the pleasure of seeing Marilyn in the Endocrine Program on 9/17/92 for precocious puberty.

History: About one year ago Marilyn developed progressive bilateral breast enlargement without galactorrhea.  Her growth, which has always been rapid, has accelerated during the past year.  Body odor has been noted recently; however, there has been no pubic or axillary hair development, acne, or menstruation.  She has also apparently acted forgetful and distractible in school and at home over the past several months.  There are no visual changes, headache, syncopy, heat or cold intolerance, polydipsia, polyuria, skin changes or mucosal lesions.  Appetite and energy level are good.  There is no history of head trauma.

Current medications: None.

Past medical history:  Pregnancy normal, term.  Delivery vaginal without complications.  growth and development: walked at 9 months, talked at one year.  Nutrition is good.  There have been no significant infections, immunological diseases, hospitalizations, injuries or operations.

Review of systems:  Negative except at noted above.

Family history:  Marilyn lives with both parents, two sisters and a brother.  Mother is 30 years old and works as a nurse.  Father is 33 years old and is a mechanic.  Sisters are 2 and 4 years old, her brother is 7 years old.  All family members are healthy.  There is no family history of early puberty, thyroid disease or other endocrinologic problems.  Mother's estimated height is 5'5", father's estimated height is 5'11".

Physical exam:  
Height: 123.9 cm        Weight: 26.8 kg         BP: 110/70              
Pulse: 80               Breast: Tanner IV       Pubic hair: Tanner I    
General: Alert, active appearing older than stated age but behaving distractible and somewhat immature.    Skin: Without lesions, rashes, axillary or pubic hair.  HEENT: Normocephalic atraumatic, pupils equal round reactive to light and accommodation.  Peripheral fields grossly intact, discs sharp.  Extraocular muscles intact.  Oropharynx with small dark macules on the soft palate.
Neck: Supple without thyromegaly.  Chest: Clear to auscultation.    Breasts: 4 cm enlargement bilaterally without galactorrhea.
Heart: Benign.  Abdomen: Soft, nontender without hepatosplenomegaly or masses.  Genitourinary: Normal female without clitoromegaly, vaginal mucosa red.  Extremities: Full range of motion.  No clubbing, cyanosis or edema.  Neurological: Nonfocal.

Previous bone age determined three months ago was 8 years and 3 months.

Laboratory studies:  TSH 2.4, T3 uptake 28%, estradiol <20, LH <0.5, FSH 2.0, prolactin 10.6, DHEA-S 24.8 mcg/dL.

Impression: Marilyn is a 5 and 11/12 year old girl with a one year history of bilateral progressive breast enlargement, body odor, accelerated growth crossing percentiles, and question of recent distractibility and forgetfulness in school.  Bone age is significantly advanced with a predicted adult height currently at 65" (165 cm).   Favoring central causes over ovarian tumors is her unsuppressed FSH level of 2.0.  Our work-up at this point will seek to distinguish idiopathic precocious puberty from the unlikely possibility of a pituitary/hypothalamic tumor.

Disposition: 1. Return to clinic on October 12, 1992 following the MRI.  2.  We will schedule a GnRH stim. test when the results of the MRI are available, and at that time consider further work-up.

Laboratory studies pending at this time include: An MRI of the head is scheduled for October 12, 1992 at 7:00AM.
Thank you for letting us share in the care of Marilyn.

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director            


Problem list to date:
SEXUAL-PRECOCITY             Start: 09/17/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Niall Shields, M.D.          RE: Marilyn Rawlings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/19/86

Dear Dr. Shields:

We had the pleasure of seeing Marilyn in the Endocrine Program on 1/8/93 for evaluation of early puberty.

History: Marilyn was last seen three months ago; she had a one year history of bilateral progressive breast enlargement, body odor, accelerated growth crossing percentiles, advanced bone age (chronologic age 5 8/12 years, bone age 8 and 3/12 years), and recent onset of distractablility and forgetfulness in school. Because of concern for a hypothalamic lesion, an MRI was recommended.

Interval history is significant for continued breast development, persistent body odor, and accelerating growth. She has no acne, nor menstrual periods. Marilyn continues to be forgetful and is doing poorly in school, by report of her teachers. There is no headache, visual changes, or other signs of neurologic disease.

Current medications: None.

Physical exam:  
Height: 127.4 cm        Weight: 27.8 kg         BP: 110/70              
Breast: Tanner III      Pubic hair: Tanner III  
General: Alert, active, nontoxic girl, appearing older than her stated age, but acting somewhat distractible and immature.  Skin: Without lesions,  slight axillary hair. HEENT: Pupils equal, round and reactive to light. Extraocular muscles intact. Optic discs sharp. Peripheral fields grossly intact. Neck: Without thyromegaly. Chest: Clear to auscultation.Abdomen: Without masses. Genitourinary: Vaginal mucosa red, without evidence of significant estrogenization.  Neurological: Nonfocal.

Laboratory studies:  TSH 2.4, Estrodial <20, LH <0.5, FSH 2.0, prolactin 10.6, DHEAS 24.8 mcg/dL.

MRI obtained at HCHP on 10/6/92  was reported as negative.

Impression: Marilyn is a 6 and 2/12 year old girl with precocious puberty, dramatically advancing height, and accelerated bone age.  As hypothalamic or pituitary tumor have been ruled out, the differential diagnosis is central idiopathic vs. peripheral precocity. To distinguish between these two possibilities and in preparation for possible suppression of puberty, we have arranged a GNRH stimulation test for January 22, 1993 at 8:30 a.m. We will see Marilyn back in clinic in 2-3 months to discuss the results of this test, and to discuss initiation of Lupron therapy. We would appreciate a copy of the cranial MRI performed last October for our records.

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

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Niall Shields, M.D.          RE: Marilyn Rawlings
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/19/86

Dear Dr. Shields:

We had the pleasure of seeing Marilyn in the Endocrine Program on 4/15/93 for evaluation of precocious puberty.

History: Marilyn has had progressive breast development, accelerated growth, and advancement of the bone age for 18 months duration. Previous MRI of the head was normal, however, GnRH stimulation test is consistent with central precocity. Interval history is notable for progressive breast development, difficulty with concentration and poor grades at school.

Physical exam:  
Height: 129.4 cm        Weight: 28.4 kg         BP: 120/80              
Breast: Tanner IV       
General: Alert, non-toxic, behaviorally immature. Remainder of the exam as previously described.

Laboratory studies:  GnRH stimulation test 1/22/93 LH pre 0.19 IU/L, LH maximum 6.1 IU/L, FSH pre 1.6 IU/L, FSH maximum 6.0 IU/L, estrogen <20 pg/mL, TSH 1.7 mcU/mL, T4 10.0 mcg/dL, TBGI 1.02, Prolactin 5.9 ng/mL, bone age 8-8 6/12 years (at a chronologic age of 6 years).

Impression: Marilyn is a 6 and 6/12 year old girl with central precocious puberty. There are no structural abnormalities of the pituitary or hypothalamus. Predicted adult height at this time is 5'5". We have discussed with Mrs. Rawlings the benefits of Lupron treatment, including in particular psycho-social issues.

Disposition: We plan to meet with both parents on May 20 to decide whether or not to begin Lupron therapy to suppress puberty. In addition, we are referring Marilyn to our developmental clinic for evaluation of her concentration difficulties.
Thank you for letting us share in the care of Marilyn.

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Cavinder Brezny, M.D.          RE: Bart Baugh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/19/84

Dear Dr. Brezny:

We had the pleasure of seeing Bart in the Endocrine Program on 7/20/95 for short stature.

History: He is a 10 and 7/12 year old with a history of attention deficit hyperactivity disorder who has been on Ritalin for three years, and now presents with decreased rate of growth and weight gain for approximately 1 year duration. The patient is currently on the sustained release Ritalin 20 mg by mouth each morning with PRN afternoon doses of the short acting Ritalin 10 mg (given approximately twice a week).  His mother reports, overall, Bart has been well with a high energy level.  No recent illnesses.  No history of fever, constipation, diarrhea, vomiting, change in skin or hair, however, she does report that since being placed on Ritalin, he has significantly decreased appetite while the Ritalin is in effect (especially at lunch time).  Despite reportedly having a large afternoon snack, dinner, and night time snack, Bart has had minimal increase in height and weight during the past two years.

Current medications: Ritalin sustained release 20 mg by mouth each morning, PRN short acting Ritalin 10 mg.  No known drug allergies and immunizations are up to date.

Family history:  Unremarkable.  Mother's height is 5 ft 5 in and father's is 5 ft 4 in, giving the patient a mid-parental height of 5 ft 7 in.

Physical exam:  
Height: 123.2 cm            Weight: 21.2 kg         
U/L ratio:  0.94            Arm span: 122.5 cm.    
BP: 100/60                  Pulse: 90                    
Pubic hair: Tanner I    
Right testis: 1.75 x 1 cm   Left testis: 2 x 1.5 cm   
General: Well-developed, small boy.
HEENT: PERRL, EOMI, fundi were flat, discs were sharp.  Tympanic membrane were pearly with a normal light reflex.  Oropharynx was without erythema or exudate.
Neck: Supple with a 1/2 cm diameter nontender, mobile left anterior cervical node.  No thyromegaly.
Chest: Clear.
Heart: Regular rate and rhythm with no murmurs.
Abdomen: Normal active bowel sounds.
Genitourinary: Circumcised male and testes were descended bilaterally.  Normal prepubertal phallus.
Neurological: +2 DTR throughout.  Nonfocal.

Laboratory studies:  GH 0.4 ng/mL (no stimulation), IGF-I 40 ng/mL (low), T4 10.6 ug/dL, TBGI 0.89, TSH 3.10 uU/mL, IGF BP3 1.0 mg/L

Impression: Bart is a 10 and 7/12 year old on Ritalin for ADHD, who presents with short stature and delayed growth.  His bone age was preliminarily read as 9 years of age at the time of this visit.  The most likely etiology for this patient's presentation was his Ritalin, however, he had his IGF-1, IGFBP3, post exercise growth hormone, TFTs, and anti-endomysial antibodies checked at the time of this visit to rule out any other possible etiologies.

Disposition: The patient will follow up with Dr. Carter by telephone when the results of these laboratory investigations are available.  The patient will subsequently follow up with their primary pediatrician.

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


Sincerely,




Victor Romanov, MD                Nilto Carter, MD             
Resident in Endocrinology           Associate in Endocrinology   


Addendum:  The thyroid functions tests are normal.  Low growth hormone production could be secondary to Ritalin use and decelerated weight.  Thought meds to be given to significant increase in caloric intake and/or alternative A.D.D. therapy.


CONTENT:
Anthoula Carter, M.D.          RE: Hazel Goodhue
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/06/89

Dear Dr. Carter:

We had the pleasure of seeing Hazel in the Endocrine Program on 3/27/94 for follow up of precocious puberty.

History: Hazel is a 4 9/12 year old white female presenting for evaluation of precocious puberty.  Mother first noted breast development at the age of 3 1/2 years and a diagnosis of precocious puberty was made due to advancing height, bone age and breast development.  An MRI revealed a hamartoma.  At the age of 4 years Depot Lupon therapy was initiated.

On Depot Lupron her breast development has decreased.  She has no acne, body odor, or pubic hair.  She rarely complains of headache.  Behavior problems are not noted.  

Accoridng to mom, Hazel was seen by Dr Scott who recommend surgery for the hamartoma but as a second opinion she saw Dr. Cohen who recommended against surgery.

Her Depot Lupron dose has changed twice over  the last year;  she began on 5 mg/month for 3 doses, increased to 7.5 mg for three doses, and she is presently on 11.25 mg for 3 doses.   She has been followed by random LH, FSH; and values have decreased while on Lupron.

Current medications: Depot Lupron 11.25 mg every month.

Past medical history:  Pregnancy: amniocentesis was normal.  Increased AFP.  Delivery: Normal spontaneous vaginal delivery.

Review of systems:  Skin: linear nevis syndrome.  HEENT: ear infections.

Family history:  Both parents are 5'7".  On the paternal side there is some history of short stature, father first shaved at age 13.  Mother had menarche at age 12, maternal siblings are between 5'6" and 5'11".  Elizabeth has an 8 year old brother who is 4'8",  a 12 year old sister who is pre-pubertal and is 5'2", and a 14 year old sister who had menarche at age 13 years and is 5'4"

Physical exam:  
Height: 114.8 cm        Weight: 24.3 kg         BP: 76/48               
Breast: Tanner II       
General: Hazel was an alert, cooperative child.  Skin: Linear nevis on left shoulder and arm, extending to forearm.  No cafe-au-lait spots noted.  Hair normal texture, not oily.  HEENT: Head normal cephalic, atraumatic.  PERRL. Fundi normal. Neck: Thyroid normal size and consistency.   No lymphadenopathy. Chest:  Lungs clear.  Heart: Regular rate and rhythm, no murmur. Abdomen: Soft, nontender.  No hepatosplenomegaly, no masses. Neurological:  DTR 2+/4+ and equal bilaterally.

Laboratory studies:  February 1993:  Bone age was 5 years 9 months at chronological age 3 years 8 months.  LH 2.2, FSH 3.5, T4 6.9 mcg/dL, T3 176, TSH 2.2 mcU/mL.  June 1993:  LH 29.8, FSH 11.6, E2 < 5.  Pelvic ultrasound was normal.

Impression: Hazel is a 4 9/12 years old with precocious puberty associated with a peduculated hypothalamic hamartoma.  Clinically she has had regression of pubertal signs on Lupron.

Disposition: I would appreciate receiving a copy of the MRI to review.  I recommend a GnRH stimulation test before the next dose of Lupron and adjust the frequency of the injections to every three weeks if her pubertal response is not adequately suppressed. A repeat bone age and MRI should be performed yearly.
Thank you for letting us share in the care of Hazel.

Sincerely,


Ariel Adler, MD           
Attending in Endocrinology


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

We had the pleasure of seeing Liz in the Endocrine Program on 2/28/94 for hashimoto's thyroiditis.

History: Liz was diagnosed with hypothyroidism in 1992, and has since been maintained on thyroid replacement.  

Interval history:  Good energy and appetite, sleeps 9 hours per night, no constipation or diarrhea, no skin or hair changes, no temperature intolerance, normal menstrual cycles lasting approximately 7 days.  She denies forgetting to take her medications.

Current medications: Synthroid 75 mcg per day.

Physical exam:  
Height: 160.3 cm        Weight: 56.1 kg         Pulse: 82               
General: Healthy.
Skin: Warm and dry.
HEENT: PERRL.   No lid lag or stare.  
Neck: Without thyromegaly.
Chest: Clear.
Heart: Regular rate and rhythm without murmur.
Neurological: No tremor, reflexes normal.

Laboratory studies:  T4 9.2 mcg/dL,  TBGI 1.00, TSH 1.2 mcU/mL.

Impression: Liz is a 14 year old girl with Hashimoto's thyroiditis, stable on treatment.  She is clinically and biochemically euthyroid.  Recent weight loss of approximately 6 pounds has been apparently intentional.

Disposition: Return to clinic in 9 months.
Thank you for letting us share in the care of Liz.

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director            


Problem list to date:
HASHIMOTO'S-THYROIDITIS                      08/26/93  
PRIMARY-HYPOTHYROIDISM                       09/10/92  
Transcribed by Nortonsh


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

I saw Liz in the Endocrine Program on 11/13/95 for Hashimoto's thyroiditis.

History: Liz was last seen in Endocrine clinic in February of 1994.  Interval history has generally been good:  she has normal energy level and appetite, no temperature intolerance, no constipation or diarrhea.   SHe mensturates regular, every 3-4 weeks.  Liz occasionally forgets to take her thyroxin replacement.  Of particular concern, she ran out of medication last week and has taken no replacement in the past 7 days.

Current medications: Synthroid 75 mcg/day.

Physical exam:
HT: 160.4 cm    WT: 64.5 kg       Pulse: 80               
Generally well-appearing.  Skin: warm and dry.  HEENT: normal neck, thyroid firm homogeneous approximately 35 gm. in mass (twice normal).  Lungs: clear.  Cardiac: benign.  Extremities:  without edema.  Neurologic: normal deep tendon responses.

Laboratory studies:  TSH 1.1 uU/ml, T4 7.6  mcg/dl.

Impression: Liz is a 15-10/12 year old girl with Hashimoto's thyroiditis, whose management has been complicated by poor medical compliance.  Also of note, she has gained about 10 lbs. since the last visit, but is not overtly hypothyroid to examination.

Disposition: The importance of regular thyroxine administration has been emphasized to the Moodys.  In addition, we discussed weight management, and the difficulty of maintaining normal body weight without regular thyroxine treatment.  We would like to see Liz back in clinic in 6-8 months, or sooner for symptoms of hypo- or hyperthyroidism.



Sincerely,




Gleide Crane, MD             
Attending in Endocrinology


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

I saw Liz in the Endocrine Program on 9/16/96 for follow-up of Hashimoto's thyroiditis.

History: Liz was last seen in Endocrine Clinic in November, 1995.  Interval health is described as good: normal energy and strength, good appetite, normal sleep pattern, no temperature intolerance, no constipation or diarrhea, and normal menstrual cycles (7 days' duration, normal flow).  Liz now takes her medication on a regular basis.

Current medications: Synthroid 75 mcg per day.

Physical exam:
HT: 161.4 cm            WT: 61.3 kg
BP: 116/65              Pulse: 71               
General: well appearing.  Skin: warm and dry.  HEENT: pupils are equal, round and reactive to light, extraocular muscles intact.  Neck: thyroid normal size and consistency (approximately 15-20 grams).  Lungs: clear.  Cardiac: regular rate and rhythm, no murmurs.  Neurologic: nonfocal.

Laboratory studies: T4 7.7 ug/dL, TSH 1.00 uU/mL, TBGI 1.04.

Impression: Liz is a 16-9/12 year old girl with Hashimoto thyroiditis, clinically and biochemically euthyroid on replacement therapy.  Normalization of gland size raises the possibility of a clinical remission.  Liz wants to have a trial off thyroxine.

Disposition: Begin a trial off Synthroid replacement.  Recheck thyroid function tests in four to six weeks (lab slip given).  Liz was counseled in the symptoms of hypothroidism; she should call us if these symptoms develop.  Follow-up is recommended for six to nine months.


Sincerely,





Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

We had the pleasure of seeing Liz in the Endocrine Program on 9/10/92 for to rule out hypothyroidism.

History: Liz was previously well with normal menstrual periods occurring approximately every month since menarche about one year ago. In August, menstrual flow was noted to be twenty days in length, from the 6th until the 26th, and she used four pads per day. Abdominal cramps were noted this time.  Laboratory evaluation at this time were suggestive of hypothyroidism. She denies other symptoms and complaints. On questioning, she describes being tired and sleeping excessively (13 hours a night) over the past two months. She denies cold intolerance, weight gain, skin or hair changes, bowel changes, or swelling. There is no history of radiation exposure to the head or neck. Interestingly, Liz was diagnosed about one year ago with a moderately severe learning disability including difficulty with short term memory, reading, and word processing. Both Liz and her mother believe that this problem dates back several years.

Current medications: None.

Past medical history:  Normal pregnancy, labor and delivery. Normal growth and development. Nutrition; adequate. No serious illnesses, hospitalizations, or operations.

Review of systems:  As above.

Family history:  Mother is 41 years old and experienced a prior episode of hyperthyroidism requiring treatment with PTU.  She is now well, although obese, and off all medications. Father is 43 years old. There are two siblings ages 17 and 9,  both are well.  A maternal grandmother has type II diabetes mellitus and several cousins of the mother have type I diabetes mellitus.  Liz herself is in 7th grade and is a B/C student.

Physical exam:  
Height: 158.2 cm        Weight: 58.8 kg         BP: 124/64              
Pulse: 80               Breast: Tanner V        Pubic hair: Tanner V    
General: Well developed, well nourished adolescent girl in no apparent distress, with a moderately dull affect.   Skin: Greasy with facial acne.  HEENT: Pupils equal, round, and reactive to light, extraocular movements intact. Discs sharp, tongue normal, no facial edema.   Neck: Supple, thyroid moderately enlarged, left lobe 4 x 3 cm., right lobe 3.5 x 2.5 cm. pyramidal lobe palpable, gland of a homogeneous and firm consistency.   No delphian node.  Chest: Clear.   Heart: Benign.   Abdomen: Soft and nontender, no hepatosplenomegaly.   Genitourinary: Normal female.   Extremities: No clubbing, cyanosis, or edema.   Neurological: Normal deep tendon reflexes, with a normal relaxation time.

Laboratory studies:  T4 2.8, TSH 85, hematocrit 39.

Impression: Liz is a 12 and 8/12 year old girl with menorrhagia, tiredness, and increased sleeping of 1-2 months duration. Physical exam was notable for an enlarged homogeneous thyroid, and prior laboratory work-up is consistent with primary hypothyroidism, most probably caused by Hashimoto thyroiditis. We feel that hypothyroidism probably is not contributory to her previously diagnosed learning disability given the long standing nature of Liz's problems in school. However, it will be interesting to follow her progress in school on replacement hormone therapy.

Disposition: Liz is to begin Synthroid at 50 mcg PO qd for two weeks, then increase to 75 mcg po qd. She is to return to clinic in six weeks for repeat thyroid function tests and further evaluation.

Laboratory studies pending at this time include: T4, TSH, TBGI, antithyroglobulin, and antimicrosomal antibodies.
Thank you for letting us share in the care of Liz.

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director            


Addendum: T4 4.1 (normal 5.5-11.0), TSH 26.6 (normal <6).


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

We had the pleasure of seeing Liz in the Endocrine Program on 10/19/92 for evaluation of therapy for hypothyroidism.

History: Liz was diagnosed with hypothyroidism in September after presenting with fatigue and menstrual abnormalities. She was placed on Synthroid which she has been taking daily. Interval history has been good; she has good energy level and decreased hypersomnlence. There is no constipation or cardiac palpitation. Her last menstrual period began 10/14/92 and flow has been relatively light.

Current medications: Synthroid 50 mcg/day for 2 weeks, currently 75 mcg/day, (past two weeks).

Physical exam:  
Height: 157.7 cm        Weight: 60 kg           
BP: 120/60              Pulse: 80               
General: Alert, nontoxic in no apparent discomfort.  Skin: Warm and dry. HEENT: Pupils equal, round, and reactive to light. Extraocular movements intact.  Neck: Thyroid gland enlargement significantly improved, gland weight now approximately 25-30 grams. Consistency homogeneous and firm.  Chest: Clear.  Heart: Benign. Abdomen: Without masses.  Genitourinary: Normal female.  Neurological: Non-focal.

Laboratory studies:  TSH 5.10, T4 6.9, Thyroid growth stimulating immunoglobulin pending. Antimicrosomal and Anti-thyroglobulin antibodies pending.

Impression: Liz is a 12 and 10/12 year old girl with hypothyroidism, now clinically euthyroid on replacement hormone. The previously identified goiter shows dramatic improvement, and the gland is now almost normal in size. Laboratories reveal a slightly elevated TSH; however, Liz has been on 75 mcg Synthroid for only two weeks, and may not yet have reached steady state serum T4 levels.

Disposition: Continue 75 mcg Synthroid per day.  We would like to re-check Liz's thyroid function tests again in one month. If TSH remains elevated, we would increase her daily dose of Synthroid. Thank you for letting us share in the care of Liz.

Sincerely,



Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

We had the pleasure of seeing Liz in the Endocrine Program on 11/30/92 for evaluation of hypothyroidism.

History: Liz was diagnosed with Hashimoto's thyroiditis after presenting with metrorrhagia and fatigue. She has been maintained on Synthroid 75 mcg a day which she takes consistently. Her last thyroid function tests were mildly elevated, but the full dose of Synthroid had only been taken for two weeks when the test was done. Her interval health has been good, with the exception of one URI. Her  menstrual periods occur every 4-6 weeks and the duration of menstrual flow is 7-8 days. Her energy level is good, she sleeps 8-9 hours a night,  and has no heat or cold intolerance. There is no constipation or diarrhea, and no cardiac palpitations.

Current medications: Synthroid 75 mcg q day.

Physical exam:  
Height: 158.1 cm        Weight: 59.3 kg         BP: 112/70              
Pulse: 72               
General: Alert and nontoxic.  Skin: Normal.  HEENT: No proptosis, lid lag, or stare. Pupils equal, round, and reactive to light, extraocular muscles intact.  Neck: Thyroid 25-30 grams, swelling much decreased from presentation. Consistency is firm and homogeneous.  Chest: Clear.  Heart: Benign.  Abdomen: Without hepatosplenomegaly.  Neurological: No tremor.

Laboratory studies:  10/19/92 T4 6.9, TSH 5.1, Antithyroid and Antimicrosomal antibodies negative at Children's, but positive from endocrine science laboratory.

Impression: Liz is a 12 and 11/12 year old girl with Hashimoto's thyroiditis, clinically euthyroid on replacement therapy. However, she continues to have mild menstrual abnormalities which may reflect borderline low thyroid function tests.

Disposition: We would like Liz to continue Synthroid at 75 mcg a day for now. If thyroid function tests prove to be low, we will increase the dose to 100 mcg a day.

Laboratory studies pending at this time include: T4, TSH, TBGI.
Thank you for letting us share in the care of Liz.

Sincerely,


Gleide Crane, MD             Lancelot Blue, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

We had the pleasure of seeing Liz in the Endocrine Program on 3/4/93 for follow-up of hashimoto's thyroditis.

History: Liz was diagnosed with Hashimoto' s thyroiditisafter presenting with menorrhagia and hypothyroidism in September of 1992. She has been maintained on Synthroid with good clinical response.  Interval history is notable for four viral infections this winter. Her energy level has been good, she sleeps eight hours a night, has a good appetite and describes mild heat intolerance. Her menstrual periods are now normal, every 28 days, lasting 7 days.

Current medications: Synthroid 75 mcg/day.

Physical exam:  
Height: 157.9 cm        Weight: 57.8 kg         BP: 112/70              
Pulse: 80               Breast: Tanner V        Pubic hair: Tanner V    
General:  Alert, active, and nontoxic.   Skin: Warm and dry.   HEENT: Pupils equal, round and reactive. Extraocular muscles intact, no lid lag, stare, or proptosis.   Neck: Thyroid approximately 20 grams, normal consistency.   Chest: Clear.   Heart: Regular rate and rhythm with no murmurs, pulses 2+ and symmetrical.   Abdomen: Normal.   Extremities: Benign.  Neurological: Deep tendon reflexes, 2+ and symmetrical, relaxation time brisk.

Laboratory studies:  TSH 0.8 mcU/mL,  T4 10.3 mcg/dL.

Impression: Liz is a 13 and 2/12 year old girl with Hashimoto's thyroiditis, clinically euthyroid on Synthroid replacement.

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

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Niall Matlock, M.D.          RE: Liz Moody
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/03/80

Dear Dr. Matlock:

We had the pleasure of seeing Liz in the Endocrine Program on 8/26/93 for follow-up of hypothyroidism.

History: Liz was diagnosed with hypothyroidism in the summer of 1992, after presenting with menorrhagia.  Interval history notable for regular periods every 28 days, normal energy, normal bowel habits, and mildly decreased appetite. Medication is forgotten occasionally, but an extra pill is taken the next day.

Current medications: Synthroid 75 mcg po qd.

Physical exam:  
Height: 160 cm          Weight: 58.9 kg         BP: 118/64              
Pulse: 88               Breast: Tanner V        Pubic hair: Tanner V    
General: Alert, well appearing.  Skin: Warm and moist.  HEENT: PERRL, EOMI, no exophthalmus, lid lag or stare.  Neck: Thyroid normal. Gland approximately 20 grams in size.  Chest: Clear.  Heart: Regular rate and rhythm with no murmur.  Abdomen: Without hepatosplenomegaly.  Genitourinary: Normal female. Extremities: Without clubbing, cyanosis or edema.  Neurological:  Nonfocal. Reflexes brisk.

Laboratory studies:  TSH 1.4 mcU/mL, T4 10.9 mcg/dL.

Impression: Liz is a 13 and 7/12 year old girl with Hashimoto's thyroiditis,  euthyroid on replacement therapy. Liz has obtained her final adult height of approximately 5'3".  We would like to see Liz back in clinic in six months.

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

Sincerely,



Gleide Crane, MD             Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Yvette Seinfeld, M.D.          RE: Dana Walsh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/09/90

Dear Dr. Seinfeld:

     We had the pleasure of seeing Dana in the Renal Program on 3/10/95 for Hematuria.
     Dana is a usually well four year old who has a four day history of fever and malaise and new onset of hematuria.  Dana initially had a temperature to 101.5 on March 7.  On March 8th her fever increased to 103.8, although she was feeling fairly well.  Two days prior to her visit, she had an increasing malaise with complaints of left sided back and flank pain.  She also had an occasional cough and complained of headaches.  She had a markedly decreased oral intake and an occasional episode of emesis.  She has had no complaints of dysuria, urgency, frequency or incontinence.  She has also had no gross hematuria or edema.  Evaluation on March 9th included a urinalysis with 0-2 WBC/HPF, 15-20 RBC/HPF and no protein.  A throat culture and urine culture were both no growth.  

There is no known family history of hematuria or renal disease.  Dana has never been hospitalized.

Her current medications include:


Dana's physical exam was notable for:
     BP 80/56   P 96   R 16   T    HT 117.3cm   WT 22.5kg
     General: Dana was pale, mildly ill appearing and in no acute distress.  
     Skin: No rashes or other lesions.
     HEENT: Pharynx was mildly injected.
     Neck: Supple.
     Chest: Clear with good aeration. 
     Heart: Regular rate and rhythm without murmur.
     Abdomen: Soft, non-tender with mild tenderness to deep palpation in the left upper quadrant and particularly along the 11th and 12th ribs in the mid axillary line.  There was no CVA tenderness.  There were no palpable masses or organomegaly.
A urinalysis revealed:

     Dana was unable to void in a 2-hour period in the clinic.

Laboratory studies at this time include:


     The connection between Dana's current illness and her hematuria is unclear.  Unfortunately, I was unable to examine her urine during her visit.  The combination of her flank pain, hematuria and fever would be consistent with pylonephritis or a pylonephritis setting of a ureteral pelvic junction obstruction.  Her negative culture, however, makes this highly unlikely.  I think it is most likely that Dana has a viral gastroenteritis with concomitant hematuria.  Her hematuria may have been preexisting this illness or it may reflect an exacerbation of an underlying problem with afebrile illness.  The likely etiology for hematuria would include benign hematuria either sporadic or familial, hypocalciuria, IgA nephropathy, or less likely glomerulonephritis.  Her GI symptoms don't seem to be consistent.

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

               Sincerely,


               Kinze Brando, MD
               Attending, Pediatric Nephrology


CONTENT:
Nannette Stone, M.D.          RE: Sybil Falla
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/12/91

Dear Dr. Stone:

We had the pleasure of seeing Sybil in the Endocrine Program on 5/20/93 for evaluation of premature thelarche.

History: Sybil is a 20 month old infant who was referred to us for evaluation of premature breast development that was first noted when she was approximately 1 year old. Since that time her breasts have increased in size in proportion to her body. She has had normal growth and normal development. There has been no associated pubic or axillary hair, no associated apocrine odor, no vaginal bleeding or discharge. Sybil's evaluation to date included a bone age done in February 1993, when she was 17 months old which when reviewed by us today revealed a bone age that was equal to her chronologic age. She also had a pelvic ultrasound  performed on March 8, 1993 which was essentially normal, revealing no evidence of ovarian cysts.

Current medications: None.

Past medical history:  She was born at 36 weeks by caesarean section for breech and preterm labor. She was the second of twins. Her growth and development has been normal. At the age of 7 months she was evaluated for a question of spasticity in her lower extremity, however, this resolved spontaneously with no evidence of any motor or developmental delays. She has had no previous hospitalizations, no serious injuries or surgery, no serious infections.

Review of systems:  Negative.

Family history:  Noncontributory. Mother's height 5'10". Father's height 5'10".

Physical exam:  
Height: 83.5 cm         Weight: 98.9 kg         BP: 65/                 
U/L ratio:  1.39        Arm span: 79            Pubic hair: Tanner I    
General: Well appearing young female who was comfortable.  Skin: Normal.  HEENT: Normal.  Neck: Supple.  Chest: Lungs clear.  Heart: Normal.  Breasts: Bilateral palpable breast tissue with a diameter of 4 cm on the right and 3.5 cm on the left. There was no tenderness.  Abdomen: Normal.  Genitourinary: Normal prepubertal vaginal mucosa.  Extremities: Normal.  Neurological: Grossly intact.

Impression: Sybil has premature thelarche. There is no clinical evidence of estrogen excess in terms of her normal growth and normal bone age. There is no evidence of a tumor of her ovary as evidenced by the normal ultrasound. There is also no evidence of gonadotropic stimulation of her ovaries given the absence of any ovarian cysts. The etiology of this premature thelarche is not known. The presumption of this is due to increased sensitivity of breast tissue to existing levels of estrogen.

Disposition: The parents were reassured that this would resolve spontaneously. There will no further need for follow-up in this clinic, if her clinical remain stable.
Thank you for letting us share in the care of Sybil.

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Addendum: Evan Dale Able, MD
Fellow in Endocrinology


CONTENT:
Fai Stalin, M.D.          RE: Agatha Carlyle
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/24/86

Dear Dr. Stalin:

We had the pleasure of seeing Agatha in the Endocrine Program on 11/16/92 for evaluation of short stature.

History: Agatha is a 6 year old white girl who is here for evaluation of her short stature. Agatha has a history of being an x-premie with a birth weight of 3 lbs. and 12 oz. She had very few complications at the time of birth and was discharged five days later. However, Agatha was noted to have multiple congenital anomalies including left facial nerved palsy and an abnormal left pinna with probable hearing loss of the left ear. She also had bilateral congenital hip dislocations. During the first few years of life, Agatha was thought to have developmental delay. However, she attended special education  preschool and daycare and now is attending regular kindergarten without any difficulties. The parents deny any past medical problems or past surgical history. They report that they have always thought that Agatha was smaller than other children and they felt that this was due to her being premature.

Current medications: None.

Past medical history:  Agatha is the product of a normal spontaneous vaginal delivery at 34 weeks gestation . Birth weight 3 lbs. 12 oz. Her congenital anomalies include a left facial nerve palsy, abnormality of the left pinna with probable hearing deficit of the left ear.  She also has bilateral hip dislocation.

Review of systems:  No skin lesions or headaches reported. No polyuria, polydipsia, diarrhea, or constipation.

Family history:  No history of short stature or pubertal delay. Mother's height is 5'7". Father's height is 6'1".

Physical exam:  
Height: 91.4 cm         Weight: 12.6 kg         BP: 82/60               
Pulse: 80               U/L ratio:  0.9         Arm span: 93            
Breast: Tanner I        Pubic hair: Tanner I    
General: Agatha was a petite, pleasant girl.   Skin: No lesions. No cafe-au-lait spots noted.   HEENT: Left facial nerve palsy. A small remnant was noted on the left side of her face from a previous skin tag that was removed. Her left pinna was abnormally small with a small auditory meatus and a short auditory canal, unable to visualize the left tympanic membrane. Moderately high arched palate. The right tympanic membrane was not visible due to mild cerumen.   Neck: Supple. No thyromegaly.   Chest: Clear to auscultation.   Heart: Regular rate and rhythm. No murmurs, gallops, rubs.   Abdomen: Soft, no tenderness, no hepatosplenomegaly. 
Genitourinary: Normal female. No clitoromegaly.   Extremities: Decreased external rotation both passive and active of both lower extremities.   Neurological: Alert and active. Palsy of the left seventh cranial nerve. 
Bone age done on November 13, 1992 at a chronologic age of 6 years read at 4 and 2/12 years.

Laboratory studies:  from September of 1988: karyotype showed a normal female, bone age 11/13/92 4 and 2/12 years at a chronologic age of 6 years. Plotting Agatha's height over the past six years including todays height on the Bayer Bailey curve it is concerning that Agatha's height has fallen dramatically over the last few years with a decrease in the growth velocity.

Impression: Agatha's short stature needs further investigation. In particular, we need to rule out a deficiency of growth hormone especially in light of her multiple congenital anomalies. We also need to rule out thyroid disease, and an enteropathy which may be contributing to her lack of growth.

Disposition: Follow-up in four weeks.

Laboratory studies pending at this time include: GH stimulation test with insulin and glucagon, sedimentation rate, CBC differential, BUN, and creatinine. Electrolytes, endomyseal antibodies, thyroid function tests. Urinalysis.
Thank you for letting us share in the care of Agatha.

Sincerely,


Mitsuko Leary, MD           Ariel Adler, MD           
Fellow in Endocrinology


CONTENT:
Crane, M.D.          RE: Agatha Carlyle
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/24/86

Dear Dr. Crane:

We had the pleasure of seeing Agatha in the Endocrine Program on 12/21/92 for evaluation of short stature .

History: This is a return visit for a 6 and 1/12 year old white female who was seen about one month ago for evaluation of short stature. Agatha is an ex-premie, 34 weeker. Her birth weight was 3 lbs. 12 oz.,  with multiple congenital anomalies including left facial nerve palsey, abnormal left pina with probable left sided hearing loss and bilateral congenital hip dislocation. She was seen approximately one month ago and growth hormone deficiency was considered given her growth curve. Agatha was sent for a growth hormone stimulation test which was done on December 7th. Other lab studies, including thyroid function tests, electrolytes, sedimentation rate, and endomyseal antibodies were all within normal limits. During her stimulation tests she received both insulin and glucogon and had appropriate growth hormone cortisol responses to both. It is our impression at this time that Agatha's short stature is due to her multiple congenital anomalies most importantly her bilateral congenital hip dislocation. It is important at this time to evaluate the possibility of surgical correction of her hip dislocation. This was discussed with Agatha's father and he will seek orthopedic advice within the next month. It is our intention to follow Agatha at six month intervals however, Agatha's father reports that they are moving to Arizona and has requested a copy of Agatha's chart so that her care can be followed in Arizona .

Physical exam:  




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

Sincerely,


Mitsuko Leary, MD           Ariel Adler, MD           
Fellow in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Blue:

I saw Richard in the Endocrine Program on 8/6/96 for insulin-dependent diabetes mellitus.

History: Tim was last seen in the Diabetes Clinic on 5/7/96.  Since then, he has done well, without interval illnesses. He plans to begin vigorous football practice between 4:30 and 6:30 in the afternoons for the rest of the Summer.   

Tim denies symptoms of hyperglycemia (polyuria, nocturia, enuresis, or  polydipsia); but experiences 1-2 mild insulin reactions usually before lunch and associated with increased activity.  He wears a MedicAlert tag, and has glucagon available at home. 

Tim takes the following insulin dosage:  4 units Regular, 11 units NPH mornings, 3.5-4.5 Regular before dinner, 12 units NPH before bedtime, for a total of 31 units or 1.0 units/kg per day.   

Blood sugars, according to the log book, run as follows:  80-100 mg/dl before breakfast, 50-160 mg/dl before lunch, 70-240 mg/dl before dinner, and 90-200 mg/dl before bed.  Occasional 3 a.m. blood sugars run in the mid 100's.

Physical exam:
HT: 131.6 cm            WT: 31.3 kg
BP: 113/61              Pulse: 90               Pubic hair: Tanner I    
R. testis: 2.0 x 1.0 cm L. testis: 2.2 x 1.1 cm 
Tim is well-appearing and comfortable.  HEENT:  pupils are equal, round and reactive to light.  Extraocular muscles intact.  Neck is without thyromegaly.  Lungs were clear.  Cardiac is regular rate and rhythm, no murmurs.  Abdomen without hepatosplenomegaly.   Injection sites with mild (improving) subcutaneous tissue hypertrophy in the triceps area, fingertips with evidence of self-blood glucose monitoring.

Laboratory studies: Laboratories:  Random blood sugar 227 mg/dl, hemoglobin A1C 8.6%, urinalysis negative proteins, negative ketone, 2+ glucose.

Impression: Tim is a 9-3/12 year old boy with type I insulin dependent diabetes mellitus of 3-1/2 years duration, doing very well on 3 times a day insulin therapy.  Growth and development are on target.  However, blood sugars tend to run a bit low before lunch, and overall insulin requirements may decrease during football practice.

Disposition: I would like to decrease morning Regular to 3 units and bedtime NPH to 11-12 units, based on activity level.  When football practice begins, overall insulin dose should be decreased by about 10%, as discussed with the parents.  Follow-up is recommended for 3 months. 

Thank you for referring the Grange's to our Diabetes Clinic.  Please do not hesitate to call if we can be of any assistance.


Sincerely,






Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Blue:

I saw Richard in the Diabetes Program on 10/29/96 for insulin-dependent diabetes mellitus.

History: Richard was diagnosed with diabetes mellitus in 1992, and was last seen in our clinic in 8-96.  He has done well until approximately four weeks ago, when he developed intermittent poor glycemic control (with or without ketones), bouts of vomiting, diarrhea, headaches, abdominal pain, and malaise.  These episodes have lasted up to three days, are characteristically worse at night, and then resolve almost completely.  He was recently treated for an otitis media with amoxicillin.  Of note, streptococcal pharyngitis was diagnosed in another family member.   

Tim experiences occasional mild insulin reactions, generally before lunch and when not getting sufficient snacks in the morning.  There are otherwise no diabetes-related concerns.  Typical blood sugars run as follows: before breakfast 100-240 mg/dl, before lunch 80-240 mg/dl, before dinner 60-240 mg/dl, and before bedtime 60-280 mg/dl.  When checked overnight (3 a.m.) blood sugar is generally around 200 mg/dl.

Current medications: Current insulin dose is 4 to 5 units Regular and 10.5-11 units NPH in the morning, 4 units Regular before dinner, and 12 to 12.5 units NPH before bed for a total of 31 units per day or 0.95 units/kg/day.

Physical exam:
HT: 132.8 cm    WT: 32.6 kg      BP: 109/63       Pulse: 64               
General: well appearing boy in no specific discomfort.  HEENT:  pupils equal, round and reactive to light, extraocular movements  intact, tympanic membranes entirely normal without effusion, oropharynx without exudate.  Thyroid: without enlargement.  Lungs: clear. Cardiac:  regular rate and rhythm, no murmurs.  Abdomen: nontender without hepatosplenomegaly.  Extremities: without hypertrophy at insulinin jection sites.

Laboratory studies:  Positive rapid strep, hemoglobin A1C 9.7%, TSH 0.9 mcu/ml, sed rate 1 (0-20), negative monospot, normal CBC, normal electrolytes, and normal liver function tests.

Impression: Tim is a 9-6/12 year old boy with type I diabetes mellitus under moderately good control, complicated by a four week period of intermittent illness of unclear etiology.  Richard denies, at the present time, symptoms of pharyngitis.  However, in view of the absence of any other contributing entity, and the positive rapid strep, it may be prudent to try another course of a penicillin agent, a decision that I will leave up to you and the Grange's.

Disposition: I also recommended changing to fresh bottles of insulin, and following blood sugars carefully over the next few weeks, calling in as needed for insulin dosage adjustments.  Finally, Tim shows none of the classic signs of Addison's disease, though if symptoms persist, an ACTH stimulation test to rule out this condition may be considered.  Follow-up is recommended for 3-4 months. 

Thank you for allowing us to follow the Grange's in our diabetes clinic.  Please don't hesitate to call should you have any questions.



Sincerely,




Gleide Crane, MD, PhD
Attending in Endocrinology


CONTENT:
Colston Welby, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Welby:

I saw Richard in the Diabetes Program on 1/7/97 for follow-up of insulin-dependent diabetes mellitus.

History: Tim was diagnosed with Type I diabetes mellitus in November, 1992 and was last seen in Clinic two months ago.  He has generally had good diabetes control, although in the past four months blood sugars have fluctuated without clear explanation.  He was diagnosed with a Strep throat and treated with penicillin three months ago.  Otherwise, health is good.   

Exercise is obtained on a daily basis, but varies in timing from morning to late afternoon, depending on weather conditions and personal preference.  Diet consists of three meals and three snacks a day.  He tends to be especially hungry in the evening.  Insulin reactions are experienced about once or twice a week, generally before lunch or with increased exercise.

Current insulin dosage is 6.5 units regular and 11.5 units NPH mornings; 4 units regular before dinner; 11 units NPH before bed time for a total of 33 units a day or 1.0 units/kg/day.  Blood sugars typically run in the 200 mg/dl range before breakfast; 40-300 mg/dl before lunch; 60-280 mg/dl before dinner; 80-240 mg/dl before bedtime; and 200-400 mg/dl at 3 a.m. when occasionally checked.

Physical exam:   Deferred.
HT: 133.6 cm    WT: 33.5 kg   BP: 102/57      Pulse: 86               

 
Laboratory studies:  Hemoglobin A1c 10.2%; blood glucose 489 mg/dl.

Impression: Tim is a 9 and 8/12 year old boy with Type I diabetes mellitus under fair control in recent months.  Variability in blood sugar is attributable to changes in exercise level, meal timing, and meal composition, most likely.

Disposition: I have recommended the following changes: First, Tim should have only one snack in the morning at around 10:30-11:00, rather than multiple snacks during the weekdays as is the current practice.  Second, lunch should be increased in size.  Third, the composition of meals, in terms of macronutrient balance and amount of starch, should be controlled as closely as possible.  In particularly, Tim should strive to have more fruit and less starchy food before bed time.  Fourth, insulin should be adjusted in anticipation of  increased activity as follows:  4-5 units regular before breakfast, based on morning activity level,  9-11 units NPH before breakfast, based on afternoon activity level.  3-4 units regular before dinner based on dinner based on evening activity level, and 9-11 units NPH at bedtime based on late afternoon and evening activities.  Fifth, snack size should also be adjusted for high activity level.  Sixth, blood sugar should be checked around 2-3 a.m. for several nights, to rule out nocturnal hypoglycemia.  Seventh, I have encouraged the Granges to call us in two weeks to discuss blood sugar results and possible fine tuning of the insulin dosage.   

Thank you for referring the Granges to our Diabetes Clinic.  Please do not hesitate to call should you have any questions.


Sincerely,



Gleide Crane, MD, PhD
Attending in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Blue:

We had the pleasure of seeing Richard in the Endocrine Program on 1/12/93 for follow-up of diabetes mellitus.

History: Richard was diagnosed with diabetes two months ago. He has done extremely well, with the exception of one mild upper respiratory illness over the Christmas holiday. He is currently in kindergarten. 

He currently takes Humulin insulin at a dose of 3 units NPH a.m., 2 units NPH p.m., which equals 0.25 units/kg/day. He has had approximately two episodes of hypoglycemia, characterized by weakness, pallor, and finger stick blood glucose concentrations are around 60 mg/dL.  Review of systems is  negative for polyuria, nocturia, enuresis, or polydipsia. 

He eats three meals and three snacks a day; gets exercise approximately 4 times a week. Blood sugars are monitored 4 times a day on a One Touch II Meter. Typical readings are breakfast 100-200, lunch 80-240 and dinner 100-300 mg/dL.

Physical exam:  
Height: 111 cm          Weight: 20.6 kg         BP: 90/60               
General: Alert, active, and healthy. Thyroid gland is palpable, homogeneous, and of normal size. The remainder of the physical exam is unremarkable.

Laboratory studies:  Hemoglobin-A1 is 8.8%, TSH 1.3 mu/mL.

Impression: Richard is a 5 and 6/12 year old boy with newly diagnosed diabetes and doing very well. He has been in a  "honeymoon period", with low daily insulin requirements. However, recent blood sugars appear to be rising. We would like to restart Regular insulin, 0.5 units morning and evening, as indicated by preprandial finger stick blood glucose concentrations >150 mg/dL. The Grange's are to call me in a couple of weeks to discuss adequacy of blood glucose control.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Blue:

We had the pleasure of seeing Richard in the Endocrine Program on 4/13/93 for follow-up of diabetes mellitus.

History: who was diagnosed approximately six months ago with insulin dependent diabetes mellitus. Interval history is notable for one upper respiratory infection with wheezing. He is currently in kindergarten and doing well. However, episodes of irritable behavior have been noted in the past two months. 

Richard takes Humulin insulin twice a day according to the following schedule: 3 units NPH in the morning, 1 1/2 units NPH in the evening which equals 0.2 units/kilo/day. There have been no symptoms of hyperglycemia, and only occasional mild insulin reactions with blood glucose measurements in the 50-60 mg/dL range. His diet consists of three meals and three snacks a day, and exercise is obtained daily.  Blood sugars are checked on a One Touch II meter and range between 80 and 140 mg/dL in the morning, 50-180 mg/dL before lunch, and 80-200 mg/dL before dinner.

Physical exam:  
Height: 113.1 cm        Weight: 21.2 kg         BP: 90/50               
General: Alert and playful. The remainder of the exam was unremarkable.

Laboratory studies:  Hemoglobin A1 9.1%.

Impression: Richard is a 5 and 11/12 year old boy with diabetes mellitus,  currently still in the "honeymoon period". He appears to be adjusting well to the disease, though he has occasional episodes of irritability. Blood sugars tend to be at their lowest, down to 50 mg/dL, before lunch. 

We recommend that Richard receive a larger snack in the morning, especially with vigorous exercise, to prevent hypoglycemia. We would like to see him back in clinic in three months time.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Blue:

We had the pleasure of seeing Richard in the Endocrine Program on 7/20/93 for follow-up of diabetes mellitus.

History: Richard was diagnosed with diabetes mellitus in November 1992.  Interval history is notable for pharyngitis with blood sugars up to 400 mg/dL, though he remained nonketotic.  Tim will be participating in summer swimming lessons,a and plans to begin first grade in the fall.  HE is able do his own blood sugar checking and insulin injections, under the supervision of his mother.

Current insulin dosage is 4.5 units of NPH before breakfast and 4.0 units NPH before dinner, for a total 0.4 units/kg/day.  He experiences no symptoms of hyperglycemia, but has occasional insulin reactions before lunch, characterized by dizziness, headache and fatigue.  He is able to recognize these symptoms and knows to ask for a snack.  Diet consists of three meals and three snacks a day.  He is an active boy, participating in daily running and swimming, usually in the afternoon.  

Blood sugars are determined on a One Touch II monitor, typically range between 80 and 200 mg/dL before breakfast, 50 and 300 mg/dL before lunch, 80 and 240 mg/dL before dinner and 100 and 240 mg/dL before bedtime.

Physical exam:  
Height: 114.6 cm        Weight: 21.3 kg         BP: 90/60               
Pubic hair: Tanner I    
General: Alert and nontoxic, thin and playful.
Skin: 
HEENT: 
Neck: Thyroid without enlargement.  the remainder of the exam was unremarkable.

Laboratory studies:  Hemoglobin A1 11.7%.

Impression: Richard is a 6 and 1212 year old boy with Type I diabetes mellitus of recent onset.  He is still on a relatively low insulin dose, but is probably somewhat underinsulinized at this time.  Variability in blood glucose readings in attributable to changes in his diet and daily routine.  

We have encouraged the Grange's to strive for regularity in meals and insulin injections.  We would like to add a little bit of Regular insulin at this time: 0.5 units of Regular and 4.5 units NPH before breakfast, 0.5 units of Regular and 3.5 units of NPH before dinner.  Occasional 2:00AM blood sugars are to be checked for the next few weeks.  We would like to speak with the Granges by phone in about one week, and see Richard back in the Diabetes Program three months time.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology   


Problem list to date:
INSULIN-DEPENDENT-DM         Start: 04/13/93  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Nekia Blue, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Blue:

We had the pleasure of seeing Richard in the Endocrine Program on 7/20/93 for follow-up of diabetes mellitus.

History: Richard was diagnosed with diabetes mellitus in November 1992.  Interval history is notable for pharyngitis with blood sugars up to 400 mg/dL, though he remained nonketotic.  Tim will be participating in summer swimming lessons, and plans to begin first grade in the fall.  He is able do his own blood sugar checking and insulin injections, under the supervision of his mother.

Current insulin dosage is 4.5 units of NPH before breakfast and 4.0 units NPH before dinner, for a total 0.4 units/kg/day.  He experiences no symptoms of hyperglycemia, but has occasional insulin reactions before lunch, characterized by dizziness, headache and fatigue.  He is able to recognize these symptoms and knows to ask for a snack.  Diet consists of three meals and three snacks a day.  He is an active boy, participating in daily running and swimming, usually in the afternoon.  

Blood sugars are determined on a One Touch II monitor and typically range between 80 and 200 mg/dL before breakfast, 50 and 300 mg/dL before lunch, 80 and 240 mg/dL before dinner and 100 and 240 mg/dL before bedtime.

Physical exam:  
Height: 114.6 cm        Weight: 21.3 kg         BP: 90/60               
Pubic hair: Tanner I    
General: Healthy, thin and playful. Neck: Thyroid without enlargement.  

The remainder of the exam was unremarkable.

Laboratory studies:  Hemoglobin A1 11.7%.

Impression: Richard is a 6 and 2/12 year old boy with Type I diabetes mellitus of recent onset.  He is still on a relatively low insulin dose, but is probably somewhat underinsulinized at this time.  Variability in blood glucose readings in attributable to changes in his diet and daily routine.  

We have encouraged the Grange's to strive for regularity in meals and insulin injections.  We recommended that he begin a  small dose of Regular insulin: 0.5 units of Regular and 4.5 units NPH before breakfast, 0.5 units of Regular and 3.5 units of NPH before dinner.  Occasional 2:00AM blood sugars are to be checked for the next few weeks.  We would like to speak with the Granges by phone in about one week, and see Richard back in the Diabetes Program in three months.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Richard Grange
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/06/87

Dear Dr. Blue:

We had the pleasure of seeing Richard in the Diabetes Program on 10/5/93 for follow-up of insulin-dependent diabetes mellitus.

History: Diabetes mellitus was diagnosed in November 1992.  Interval history is notable for numerous episodes of symptomatic hypoglycemia.  He is currently in the first grade and is doing well.  

Current Novolin insulin dose is 4.5 units NPH mornings and 3.5 units NPH evenings for a total of 0.35 units/kg/day.  Mild insulin reactions were experienced on a daily basis around 3:00PM; however, after instituting a second afternoon snack, this problem is substantially improved.  Blood sugars are checked on a One Touch II monitor and range 60-180 mg/dL before breakfast, 80-240 mg/dL before lunch, 70-160 mg/dL before dinner and 150-200 mg/dL when sporadically checked overnight.

Physical exam:  
Height: 116.4 cm        Weight: 22.2 kg         BP: 110/70              
Pubic hair: Tanner I    
General: Alert, active, slightly pale. Skin:  Mild injection site hypertrophy on the arms. HEENT: PERRL, EOMI, lens clear. Neck: Thyroid smooth and symmetric. Chest: Lungs clear. Abdomen: Benign.  Without hepatosplenomegaly. Genitourinary: Genitalia Tanner I.

Laboratory studies:  Glycosylated hemoglobin 9.3%.

Impression: Richard is a 6 and 5/12 year old boy with Type I diabetes mellitus in good glycemic control.  Low overall insulin dosage suggests substantial endogenous insulin production.  Growth and development have been good.  Frequent afternoon insulin reactions are adequately prevented by adding a second afternoon snack.

Disposition: We suggested an adjustment of the insulin dose and will use diluted U10 Regular insulin as follows: AM 0-0.5 Regular and 4.0 NPH, PM 0-0.5 Regular and 3.0 NPH.  We will reconsider the necessity of the second afternoon snack on this reduced AM dosage of NPH.  Finally, we will await screening thyroid function tests and would like to see Richard back in clinic in three months.
Thank you for letting us share in the care of Richard.

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Mary Leakey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/28/92

Dear Dr. Meisner:

We had the pleasure of seeing Mary in the Endocrine Program on 12/17/92 for evaluation of congenital hypothyroidism.

History: Mary is a 19 day old girl with a history of abnormal newborn thyroid function tests on state screen. On day one of life she had a T4 level of 9.26 mcg/dL and a TSH of 20-30 units. The T4 was normal and the TSH was elevated. A sample sent on 12/7/92 had a T4 of 8.06 mcg/dL and a TSH of 60-70 mcU/dL. A third sample drawn on 12/14/92 showed a T4 of 6.5 mcg/dL, TSH of 49 mcU/dL and a TSH duplicate of 56. All tests consistently show an elevated TSH with the sample on 12/14/92 showing a low T4.

Past medical history:  Mary's birthweight was 3 lbs. 15 oz. Length 17 3/4 inches. Head circumference 11.5  inches. She was transferred to Children's Hospital on day one of life where she received a partial exchange transfusion. She was transferred back to Malden Hospital on day two of life  after the transfusion when she was on full feeds of Enfamil 20 or breast milk every three hours. Family has lived in Malden since early November 1992 when the Father's job transferred them here from Saudi Arabia.  Mother has a history of being a Hepatitis B carrier, although she was Hepatitis B surface antigen negative at Malden. Mary did receive heptarax and at HBIg. Mom is a 27 year old G5P4-5 who delivered a 37 week gestational age female by precipitous delivery. Mary was menconium stained and had apgars of 8 and 9;  she was transferred to CHMA for respiratory distress and intrauterine growth retardation.

Family history:  There is no thyroid disease in Mary's siblings. Parents have no history  of thyroid disease.  Mother's reported height is 165 cm. Father's reported height is 165 cm.

Physical exam:  
Height: 19 cm           Weight: 2.55 kg         BP: 92/49               
Pulse: 102              
General: Active baby girl.  Skin: Pink, well perfused. No cyanosis or pedal edema.   HEENT: No cleft pallet. Pupils equal, round, and reactive to light. Anterior fontanelle open and flat. Neck: No palpable thyroid gland.  Chest: Regular rate and rhythm without murmur.  Heart: Lungs clear.  Abdomen: Soft, no umbilical hernia.  Genitourinary: Normal.  Extremities: No anomalies.  Neurological: DTRs +2/4  bilaterally.

Impression: Mary had biochemical evidence of hypothyroidism detected on her initial as well as repeat thyroid screening tests.  We repeated her TFT's and again found an elevated TSH  The TSH was 25.3 mcU/mL  (normal < 5.0) T4 was 5.0 mcg/dL (normal 7-15) and TBGI 1.07 (normal). We started her on Synthroid 25 mcg q d after a thyroid scan performed on 12/18/92. We asked her to return on 01/05/93 to have repeat labs drawn. We will see her in clinic in four weeks.

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

Sincerely,


Rahul Hagen, MD           Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Valdeci Meisner, M.D.          RE: Mary Leakey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/28/92

Dear Dr. Meisner:

We had the pleasure of seeing Mary in the Endocrine Program on 1/14/93 for congenital hypothyroidism.

History: Mary is a former 37 week gestational age infant who is now 6 weeks old and was diagnosed with congenital hypothyroidism on day of life 19 by repeat state lab screen and by laboratory values at  Children's Hospital. An iodine 123 scan had slightly below normal uptake 4 hours and 24 hours after the isotope was given. She is currently on 25 mcg of Synthroid q day which she started on December 18, 1992. She has missed no doses of Synthroid. She had a repeat set of TFTs sent on January 7, 1993. At that time her TSH was 0.7. The T4 was not done because the sample was too small. Her father describes her as an active smiling baby girl who sleeps 3 hours then awakens to eat. She is drinking breast milk q 3 hours. Most often, she breast feeds 15 minutes on each side and she eats eagerly. She has bowel movements 1-5 times q d. She has wet diapers approximately 7 times a day.

Physical exam:  
BP: 124/71              Pulse: 177              
General: She was a consolable infant in dad's arms.   Skin: Not jaundiced or dry.   HEENT: Anterior fontenelle measured 3 cm x 4 cm. Posterior fontenelle slightly open. She has a strong suck, positive red reflex  bilaterally.   Neck: No thyromegaly.   Chest: Lungs clear.   Heart: Regular rate and rhythm without murmur.   Abdomen: Soft, no umbilical hernia.   Genitourinary: Normal female.   Neurological: Deep tendon reflexes +2/4 bilaterally in the upper and lower extremities.

Impression: Congenital hypothyroidism with unclear etiology. Baby is experiencing good weight gain which suggests she is on an appropriate dose of Synthroid. Laboratory values we obtained that day include a T4 that was 15.5 mcg/dL, with the normal range being between 17.2 and 14.4, Total T3 116 ng/dL, TBGI 1.03, TSH 0.8.  

The family will be moving to Saudi Arabia and we are asking her to continue her current dose of Synthroid which is 25 mcg q d. We asked them to repeat the thyroid function tests in two weeks.  We are referring the baby to a Dr. Al Jurayan at King Fahdat Hospital.

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

Sincerely,


Rahul Hagen, MD           Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Mary Leakey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/28/92

Dear Dr. Meisner:

We had the pleasure of seeing Mary in the Endocrine Program on 5/17/93 for evaluation of congenital hypothyroidism.

History: Mary is a 6 month old female diagnosed with either congenital hypothyroidism on day of life 19 or iodine exposure in the form of betadine during a sepsis work-up in infancy. She was polycythemic at birth and transferred to Children's Hospital where she was partially transfused to get her hematocrit from 70-60. She also underwent a sepsis work-up during that hospitalization. Her day of life 1 thyroid screening test revealed a T4 of 9.26 and a TSH of 20-30. Repeat thyroid function tests drawn December 7, 1992 revealed a T4 of 8.06 and a TSH of 60-70. Repeat drawn December 14, 1992 revealed a T4 of 6.5 and TSH of 49 and on repeat 56. On day of life 19 she was started on 25 mcg of Synthroid per day. Follow-up thyroid function tests in January 1993, T4 15.5, T3 116, TBGI 1.03, TSH 0.8. Since then she went back to Saudi Arabia initially on 25 mcg a day. While in Saudi she was noted to be somewhat anxious and nervous and was seen by a physician there who decreased her dose of Synthroid to 25 mcg every other day. Thyroid function tests obtained there are currently not available. Since returning from Saudi two weeks ago she was seen by her pediatrician in Medford, Dr. Meisner who reportedly obtained thyroid function tests which according to the father revealed a TSH of 6.7. Dr. Quinn was contacted by phone and instructed the patient to resume 25 mcg a day of Synthroid. Mary has been on this dose for the past two weeks and ten days ago had repeat thyroid function tests done at Children's Hospital which revealed a TSH of 0.70, T4 10.7, and a Total T3 of 172, TBGI 1.02. Mary has been growing well in the interim. She eats one formula feeding a day as well as baby food, cereal, and bananas and three to five breast feedings a day. She sleeps twelve hours though not continuously. She has loose bowel movements of >1 a day. Occasionally she has semi-formed or formed stools particularly after having solid foods. She has had one URI in the interim but otherwise has been healthy. She is beginning to sit up on her own and crawl. She makes good eye contact and  coos frequently.

Current medications: 25 mcg a day.

Physical exam:  
Height: 64.3 cm         Weight: 6.0 kg          BP: 100/60              
Pulse: 110              
Head Circumference: 42 cm. 
General: Smiling, cheerful, interactive infant.  Skin: Normal,  no rashes.  HEENT: Normal. Anterior fontenelle still open. Posterior fontenelle unable to detect any opening. No periorbital edema. Lid reflex bilaterally. No lid lag.  Neck: Supple, no thyromegaly. No adenopathy.  Chest: Lungs clear.  Heart: Regular rate and rhythm with no murmur. Normal S1, S2.  Abdomen: Soft, nontender. No masses, no umbilical hernia.  Extremities: No clubbing, cyanosis or edema.  Neurological: Reflexes are brisk and symmetric.

Impression: Mary is a 6 month female with either congenital hypothyroidism vs. iodine exposure as a neonate who currently appears clinically euthyroid on 25 mcg a day. She is currently growing and developing well. Her thyroid function tests are a little bit difficult to interpret given the recent dosage change. We will continue Synthroid 25 mcg a day and repeat her thyroid function tests in three weeks. If she is truly hypothyroid she is likely soon to outgrow this dose of Synthroid and will need life long Synthroid. For the present,  we plan on supplementing her thyroid for at least the first year when  CNS development is critical.  After the age of one year, if it appears that she may in fact have had only transient hypothyroidism related to iodine exposure as a neonate, we will consider stopping the dose and following her thyroid function tests off Synthroid after one year of life. She will return to clinic in one month.

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

Sincerely,


Ariel Adler, MD           
Attending in Endocrinology   


Addendum: Cecilia Larson, MD
Fellow in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Mary Leakey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/28/92

Dear Dr. Meisner:

We had the pleasure of seeing Mary in the Endocrine Program on 7/1/93 for congenital hypothyrodism vs. iodine exposure.

History: Mary is a 7 month old girl with congenital hypothyroidism vs. iodine exposure here for follow-up.  She is doing well in the interim feeding every 3 to 4 hours of breast milk or formula.  She sleeps through the night and is very active.  She has several soft stools daily but no diarrhea, fever or vomiting.  The only complaint is diaphoresis during the day which is not associated with feeds.  Developmentally she is doing well, she is babbling, pulls to stand, sits on her own and has some stranger anxiety.

Current medications: Synthroid 0.025 mg/day.

Physical exam:  
Height: 68 cm           Weight: 6.63 kg         
General: Well nourished, smiling baby.
Skin: Warm and dry with diffuse erythematous papules at the base of the neck.
HEENT: Head circumference 42.5 cm.  EOMI, PERRLA.  Oropharynx is clear.  Positive red reflex bilaterally.  
Neck: Supple, no thyromegaly.  No adenopathy.
Chest: Clear to auscultation, no rhonchi rales or rubs.  
Heart: Regular rate and rhythm, no murmurs.
Abdomen: Soft, nontender, nondistended.  No masses were palpated.
Genitourinary: Normal female genitalia.
Extremities: No cyanosis, clubbing or edema.
Neurological: Grossly intact. with patella reflexes +2 downgoing toes bilaterally and no clonus.

Laboratory studies:  TBGI=0.99, TSH=1.6, T4=14.2.

Impression: Mary is a 7 month old with congenial hypothyroidism vs. iodine exposure managed on Synthroid 0.025 gm qd.  She is doing well with good growth and development.  She is euthyroid at this time and is to continue Synthroid until at least 2 years of age.  We will see her again in three months.

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

Sincerely,


Pericles Beaker, MD                Rahul Ibsen, MD                
                             Attending in Endocrinology   


Addendum: Junior Resident


CONTENT:
Valdeci Meisner, M.D.          RE: Mary Leakey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/28/92

Dear Dr. Meisner:

We had the pleasure of seeing Mary in the Endocrine Program on 9/16/93 for ngential hypothyroidism vs. iodine excess in the perinatal period.

History: Mary is a 9 1/2 month old girl who has been treated with Synthroid 25 mcg QD since birth when she presented with an elevated TSH and low T4 level.  Since then she has maintained normal thyroid function tests and is developmentally appropriate.  At present, her father describes her as an active girl who is learning to walk; she has four teeth; her current sleep schedule is 11:30PM until 9:00AM , and she then naps between 2:00PM and 4:00PM.  Her food intake is 16 oz of milk per day plus baby food.

Current medications: Synthroid 25 mcg QD.

Physical exam:  
Height: 73.2 cm         Weight: 7.99 kg         Pulse: 120              
Breast: Tanner I        Pubic hair: Tanner I    
General: Active, crying infant in no apparent distress.
Skin: No dryness.
HEENT: Head circumference: 44 cm.  Mucous membranes moist, 4 teeth present.
Neck: No thyromegaly
Chest: Normal.
Heart: Normal.
Abdomen: Normal.
Genitourinary: 
Extremities: On right medial knee she has a scar from a healing burn.
Neurological:

Laboratory studies:  obtained on September 7, 1993 include T4 10.2 mcg/dL, TSH 3.5 mcU/mL, TT3 159 ng/dL, TBGI 1.06.


Disposition: We recommend that Mary have follow-up in Endocrine Clinic in three months at which time she should have repeat thyroid function tests done.  We recommend that she should continue the Synthroid until the age of 3 years although the dose she is on suggests that her hypothyroid status was probably transient.
Thank you for letting us share in the care of Mary.

Sincerely,


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


CONTENT:
Yan Plato, M.D.          RE: Harriet Caruso
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/26/86

Dear Dr. Plato:

We had the pleasure of seeing Harriet in the Endocrine Program on 3/17/94 for follow up of idiopathic premature adrenarche.

History: Harriet is a 7 and 6/12 year old first grader who is being followed for premature adrenarche.  Her mother has noticed no new pubic hair growth and no axillary hair growth although she has noticed the occasional adult body odor.  Her mother also wonders if she is beginning to develop breast buds.   Her mother characterisizes Harriet's  behavior as "emotionally unstable" which she describes as having "feelings comparable to those a teen-ager has", that is, her feelings are hurt easily and she is very concerned about her appearance.  The child says that she occasionally has a slight headache but it resolves without Tylenol and she has never mentioned the headaches to her mother.

Physical exam:  
Height: 131.8 cm        Weight: 30.6 kg         BP: 84/62               
Pulse: 88               U/L ratio:  0.94        Arm span: 129           
Breast: Tanner I        Pubic hair: Tanner II   
General: Active girl in no apparent distress.
Skin: No acne; no hyperpigmentation.
HEENT: Sharp disc margins bilaterally.
Neck: No thyromegaly.
Chest: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Benign.
Genitourinary: No labial pubic hair.  Distribution of pubic hair is over the mons pubis.
Neurological: Nonfocal.

Laboratory studies:  Sepetember 22, 1993:  Bone age 8 and 10/12 at chronologic age 7 10/12.

Impression: We reassured Mrs. Caruso that Harriet's growth is following a slightly accelerated pattern; however, she has a normal weight for height ratio.  We reviewed again the results of the ACTH stimulation test that had been done in 1993, and told her mother that she had absolultely no sign of an adrenal overproduction of steroids and that she required no treatment.  We ordered no studies today.  We requested from Anna Jacques Hospital a copy of both bone films.  We have asked Harriet to return to clinic in twelve months.

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

Sincerely,


Rahul Hagen, MD           Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Yan Plato, M.D.          RE: Harriet Caruso
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/26/86

Dear Dr. Plato:

We had the pleasure of seeing Harriet in the Endocrine Program on 3/30/95 for idiopathic premature adrenarche.

History: Harriet is an 8 and 6/12 year old with idiopathic premature adrenarche seen in follow up.   Her mother reports no new pubic hair but notes occasional axillary odor.   Harriet is still the tallest child in her class.   She recently missed five days of school with a stomach flu.   Her mother denies headaches.

Current medications: None.

Physical exam:  
Height: 139.4 cm        Weight: 34.2 kg         BP: 100/56              
Pulse: 90               U/L ratio:  0.98        Arm span: 136.5         
Breast: Tanner I        Pubic hair: Tanner II   
General: Active girl in no apparent distress.   
Skin: No acne.    
Neck: No thyromegaly.   Lymph nodes not palpable.   
Chest: Clear to auscultation.   
Heart: Regular rate and rhythm without murmur.   
Abdomen: No hepatosplenomegaly.  
Genitourinary: As above.   Tanner pubic hair stage II.   She has fine hair on her labia and mons pubis.   
Extremities: No anomalies.   
Neurological: Normal.

She had a bone age of 7 and 10/12 years at chronologic age of 7 and 0/12 years (this was done in September 1993).

Impression: We reassured Harriet's mother that her growth is following a slightly accelerated pattern and emphasized that she is now within the normal age range for onset of puberty.   We looked at the growth curve with her mother and showed her that her weight and height were equivalently progressing along the accelerated curve.   We asked Harriet's mother to obtain a bone age film at Anna Jacques's Hospital and to send us a copy of the film when it is obtained.   We asked Harriet to return to clinic in 12 months.

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

Sincerely,


Rahul Hagen, MD           Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Yan Plato, M.D.          RE: Harriet Caruso
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/26/86

Dear Dr. Plato:

I saw Harriet in the Endocrine Program on 6/18/96 for follow-up of idiopathic premature adrenarche and accelerated growth velocity.

History: Harriet is a 9 and 9/12 year old girl with a history of idiopathic premature adrenarche who has been following a slightly accelerated growth curve since we have followed her in the Endocrine Program at Children's Hospital in December 1992.  Over the  past 3 and 1/2 months her mother has noticed an increase in pubic hair and breast development.  Her mother notes that Harriet occasionally has axillary odor and that axillary hair appears to be starting to growth.  Harriet has just completed the third grade.  She does not have any headaches and has a good activity level.

Current medications: None.

Physical exam:
HT: 148.7 cm    WT: 43.5 kg       BP: 109/57         Pulse: 71               
Breast: Tanner II       Pubic hair: Tanner II   
She is a well-hydrated happy child in no  apparent distress.  She has no acne.  Her skin is tanned.  Neck shows no  thyromegaly.  Lungs are clear to auscultation.  Heart regular rate and  rhythm without murmur.  Abdomen no hepatosplenomegaly, soft.  GU, she  has Tanner II pubic hair.  Extremities no deformities.

Laboratory studies:  Bone age which was  equal to 10 and 0/12 at her current chronologic age of 9 and 9/12.

Impression: Harriet continues to grow along the accelerated growth curve which could be likened to the 90th to 95th percentiles on the cross sectional growth curves used in the pediatric office.  We have  reassured her mother that her growth and onset of pubarche and breast development are within normal.  We reassured her mother that menarche would probably not occur for approximately 18 months although this cannot be accurately estimated.

Disposition: We would like Harriet to return to clinic in twelve months,  however, her mother is requesting that she be started on Lupron.  I do  not think that this is necessary because this growth represents  normal growth and pubertal development.  Please call if you have any questions.

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



Sincerely,




Rahul Hagen, MD           
Attending in Endocrinology


CONTENT:
Yan Plato, M.D.          RE: Harriet Caruso
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/26/86

Dear Dr. Plato:

We had the pleasure of seeing Harriet in the Endocrine Program on 12/3/92 for evaluation of pubic hair.

History: Harriet is a 6 and 2/12 year old white female who had her yearly physical exam by her primary pediatrician in 11/92 and was noted to have pubic hair on physical exam. Mom reports that she had not noticed that she had pubic hair at an earlier date. A bone age was done by the primary provider on 11/6/92 at which time Harriet's chronologic age was 6 and 2/12 years and her bone age was read as 7 and 10/12 years which is 2 standard deviations from the mean. Harriet's mother denies a family history of precocious puberty, however she notes that Harriet's half sister (daughter of Harriet's father) irregular menses and hirsutism. Harriet complains of rare headaches. She complains of sporadic blurry vision 5-6 times over the past two years. This vision has not been evaluated by an ophthalmologist or optometrist. She also experiences very intermittent abdominal pain. Mother says she has not had any vaginal spotting. She has no axillary hair or breast enlargement. 

Harriet is living with her mother and her two year old sister. Father no longer lives in the house with them. He had a stroke in November of 1990 and her mother started college in January of 1991. Mother is in an RN nursing degree program.

Current medications: cough syrup.

Past medical history:  Harriet was born as a full term product by vaginal delivery to a 31 year old G4 P01 83 therapeutic ???. Growth and development have been appropriate. She has well balanced nutrition and her only injury has been a laceration in her right eyebrow. Mother denies hospitalizations and surgeries.

Review of systems:  Mother denies any cafe-au-lait spots or changes in birth marks. She does acknowledge that she has several skin tags or warts on the back of her knee and thigh removed with liquid nitrogen at age 5 years old. Mother denies any heart murmur or asthma. She claims that she has occasional constipation. She denies polyuria and seizures.

Family history:  Mother's measured height is 168.4 cm. Father's reported height is 5'6.5". Mother had menarche at age 12. Mother has four sisters whose heights are between 61 and 69 inches. Mother has three brothers whose heights are between 65 and 69 inches. None of mothers sisters underwent early puberty or unusual growth accelerations. Harriet's younger sister is  2 years old and is growing at the 90th percentile.

Physical exam:  
Height: 122.7 cm        Weight: 25.4 kg         BP: 96/58               
Pulse: 90               U/L ratio:  1           Arm span: 118           
Breast: Tanner I        Pubic hair: Tanner II   
General: She is an active girl in no apparent distress. 
Skin: She has a few birth marks that are one mm non-raised and dark pigmentation. Three of these are on her upper lip and the other is on her labia majora. 
HEENT:  Fundi benign. Mucous membranes moist. No tonsillar erythema exudate or enlargement. 
Neck:  No thyromegaly bilateral interior cervical adenopathy. 
Chest: Clear. 
Heart: Regular rate and rhythm without a murmur. 
Abdomen: Soft, no palpable masses or hepatosplenomegaly. 
Genitourinary: Very fine downy quality pubic hair growing over the mons pubis. Her vaginal mucosa appears to be non-estrogenized. 
Neurological: Normal.

Laboratory studies:  7 10/12 years at a chronologic age of 6 and 2/12 years. Vaginal smear that shows a cellularity of 35%.
Bone age: 7.10 years


Impression: Harriet appears to have premature adrenarche. The most likely etiology of the premature appearance of pubic hair is late onset non-classical congenital adrenal hyperplasia. Other possible causes include an adrenal steroid producing tumor. To evaluate the CAH we have scheduled ACTH stimulation test to be done at Children's Hospital to be done at January 11, 1993 at 8:30 a.m. to evaluate her pituitary-adrenal axis and her steroidogenic pathway. We will discuss the results with Harriet and her mother three months from now at a follow-up visit.

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

Sincerely,


Rahul Hagen, MD           Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology   


Problem list to date:
                             

Transcribed by Cassells


CONTENT:
Yan Plato, M.D.          RE: Harriet Caruso
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/26/86

Dear Dr. Plato:

We had the pleasure of seeing Harriet in the Endocrine Program on 12/3/92 for evaluation of  pubic hair.

History: Harriet is a 6 and 2/12 year old white female who had her yearly physical exam by her primary physician in November 1992 and was noted to have pubic hair. Mom reports that she had not noticed that Harriet had pubic hair at an earlier date. A bone age was done by the primary care provider on November 6, 1992 at which time Harriet's chronologic age was 6 and 2/12 years and her bone age was read as 7  and 10/12 years which is 2 SD from the mean. Harriet's mother denies a family history of precocious puberty, however, she notes that Harriet's half sister (daughter of Harriet's father) has irregular menses and hirsutism. Harriet complains of rare headaches.  She complains of sporadic blurry vision, 5-6 times over the past two years. This vision has not been evaluated by an ophthalmologist or optometrist.  She also complains of occasional abdominal pain.  Mother says Harriet has not had any vaginal spotting.  She has no axillary hair nor breast enlargement.

Harriet is living with her mother and her two year old sister.  Father no longer lives with them.  He had a stroke in November of 1990.  Mother started nursing school in January 1991.

Current medications: Cough syrup.

Past medical history:  Harriet was a full term infant born by vaginal delivery to a 31 year old G4P01A3.  Growth and development have been appropriate.  She has well balanced nutrition and her only injury has been a laceration in her right eyebrow.  Mother denies hospitalizations and surgeries.

Review of systems:  Mother denies any cafe-au-lait spots or changes in birth marks. She acknowledges that Harriet does have several skin tags or warts on the back of her knee removed with liquid nitrogen at age 5. years.  Mother denies any heart murmur, asthma.  She claims that Harriet has occasional constipation.  She denies polyuria and seizures.

Family history:  Mother's measured height is 168.4 cm. Father's reported height is 5'6.5". Mother had menarche at age 12. Mother has four sisters whose heights are between 61 and 69 inches. Mother has three brothers whose heights are between 65 and 69 inches.  Mother has three brothers whose heights are between 65 and 69 inches.  None of mother's sisters underwent early puberty or unusual growth acceleration.  Harriet's younger sister is 2 years old and is growing at the 90th percentile.  Harriet's parental half-sister has hirsutism and irregular menses.

Physical exam:  
Height: 122.7 cm        Weight: 25.4 kg         BP: 96/58               
Pulse: 90               U/L ratio:  1           Arm span: 118           
Breast: Tanner I        Pubic hair: Tanner II   
General: She is an active girl in no apparent distress.   Skin: She has a few 1 mm. diameter, non-raised,   dark pigmentation.  Three of these are above her upper lip and the otehr is on her labia majora.   HEENT: Fundi benign. Mucous membranes moist.   Neck: No thyromegaly; bilateral anterior cervical adenopathy.   Chest: Lungs clear.   Heart: Regular rate and rhythm without murmur.   Abdomen: Soft, no palpable masses. No hepatosplenomegaly.   Genitourinary:  Very fine downy pubic hair growing over the mons pubis. Her vaginal mucosa appears to be non-estrogenized; i.e., red.   Neurological: Normal.

Laboratory studies:  Bone age 7 and 10/12 years at a chronologic age of 6 and 2/12 years. Vaginal smear shows a cellularity of 35%.

Impression: Harriet appears to have premature adrenarche. The most likely etiology of the premature appearance of pubic hair is late onset nonclassical congenital adrenal hyperplasia. Other possible causes include an adrenal steroid producing tumor. To evaluate for CAH, we have scheduled an ACTH stimulation test to be done at Children's Hospital on January 11, 1993 at 8:30 a.m.  We will discuss the results with Harriet and her mother three months from now at a follow-up visit.

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

Sincerely,


Rahul Hagen, MD           Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Yan Plato, M.D.          RE: Harriet Caruso
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/26/86

Dear Dr. Plato:

We had the pleasure of seeing Harriet in the Endocrine Program on 9/16/93 for follow-up of idiopathic premature adrenarche.

History: Harriet is a 6 and 11/12 year old girl initially in December 1992 for evaluation of premature adrenarche.  Her mother has not noticed evidence of pubic hair growth nor onset of apocrine odor since then.  She has had no intercurrent illnesses.  She denies headaches,and has lost 6 deciduous teeth in nine months.  She occasionally complains of abdominal pain.  She is on no medications.

Physical exam:  
Height: 128.1 cm        Weight: 28.4 kg         BP: 104/62              
Pulse: 72               U/L ratio:  1           Arm span: 128.0         
Breast: Tanner I        Pubic hair: Tanner II   
General: Well developed, well nourished. Skin: No axillary hair. HEENT: Fundi with bilaterally sharp disc margins. Neck: No thyromegaly. Abdomen: No abdominal masses.

Laboratory studies:  Bone age=7 10/12 years on November 1992.

Impression: The results of Harriet's ACTH stimulation test in January 1993 suggest that she has idiopathic premature adrenarche.  Her growth velocity over the past 9 months represents an annual height velocity of 8.1 cm.  This is slightly above average and is consistent with an accelerated bone age.

Disposition: We would like Harriet to return to Clinic in 9 months.

Laboratory studies pending at this time include: We have asked Mrs. Caruso to repeat Harriet's bone age and send the initial and current bone age films to us for comparison.
Thank you for letting us share in the care of Harriet.

Sincerely,


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


Addendum: The bone age obtained on February 22, 1993 was less than 8 10/12 thus did not advance inappropriately over a period of 10 months.

Problem list to date:
                             

Transcribed by Sullivan


CONTENT:
Tatyana Sanders, M.D.          RE: Joanne Korngold
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Sanders:

I saw Joanne in the Endocrine Program on 6/11/96 for insulin-dependent diabetes mellitus.

History: Joanne was diagnosed with Type I diabetes mellitus in 1992, and was last seen in diabetes clinic on 3/18/96.  Her interval health has been good:  She has had no illnesses, and no specific complications with diabetes management.  Joanne does describe feeling "different" from other children at school, especially because of her dietary regimen.  She is currently involved in psychotherapy for issues related to diabetes and the parental divorce.  Over the summer, Joanne plans to attend a day care camp, and will begin 3rd grade next fall. 

Mild episodes of hypoglycemia are experienced approximately once per week, usually in the afternoon, and attributable to activity or delayed meals.  Blood sugars run as follows:  Morning 120-300 mg/dl, pre-lunch 80-300 mg/dl, pre-dinner 80-300 mg/dl, and pre-bed 80-280 mg/dl.

Current medications: Current Novolin insulin dose is 4 units regular and 7 units NPH  mornings, 3 units regular at dinner and 4 units NPH at 10 PM, for a total of 18 units or 0.7 u/kg/day.  She obtains vigorous exercise on a daily basis, especially in the afternoon.

Physical exam:
HT: 123.3 cm        WT: 27.1 kg
BP: 102/43              
General: Well appearing, active, and appropriate.  HEENT:  pupils equal, round, and reactive to light, extraocular movements are intact, lenses clear.  Thyroid smooth, symmetrical and nongoiterous.  Lungs are clear.  Cardiac: regular rate and rhythm, no murmurs.  Abdomen is without hepatosplenomegaly.  Extremities: arms with mild to moderate hypertrophy at insulin injection sites.  Skin notable for calluses on the finger tips.

Laboratory studies: Blood sugar 220 mg/dl, glycosylated hemoglobin is 9.6% (4-6%), urinalysis 5% glucose, no protein.

Impression: Joanne is an 8-3/12 year old girl with diabetes mellitus under reasonably good control.  She is slightly under insulinized, with intermittently high blood sugar throughout the day.  Variability in glycemic control is probably attributable to changes in diet and exercise level.  Occasional control struggles with mother over diet have been noted.  Growth and development are on track.

Disposition: Improved blood sugar control would probably be obtained by adjusting NPH insulin dose for level of activity as follows: 4 units regular and 6-8 NPH mornings, 3 units regular, and 4 or 5 units NPH at bedtime (smaller amounts of NPH on active days).  In addition, total consumption of starchy and sweet foods should remain consistent from day to day.  Follow-up is recommended for 3 months. 

Thank you for referring the Korngolds to our diabetes clinic.

Sincerely,






Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Tatyana Sanders, M.D.          RE: Joanne Korngold
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Sanders:

I saw Joanne in the Diabetes Program on 9/24/96 for insulin-dependent diabetes mellitus.

History: Joanne was diagnosed with diabetes mellitus in 1992, and was last seen in our clinic on 6/11/96.  Interval history has been unremarkable, without intercurrent illnesses.  Of note, the parents were recently divorced, but cooperate with regard to Joanne's care.   She is now entering 3rd grade, and is doing well.  She attended the Clara Barton Diabetes Camp over the summer, reportedly enjoying the experience. 

Insulin reactions are experienced on a very rare basis; symptoms of hyperglycemia such as polyuria and polydipsia occur on occasion. 

Blood sugars typically run as follows:  100 to 300 mg/dL before breakfast, 120 to 240 mg/dL before lunch, and 100 to 300 mg/dL before dinner, and 60 to 240 mg/dL before bedtime.

Current medications: Insulin: 4 units Regular, 7 units NPH before breakfast, 3 to 4 units Regular before dinner, and 4 to 5 units NPH before bed, for a total of 19 units, or 0.65 u/kg/day.

Physical exam:
HT: 125.8 cm            WT: 29.3 kg
BP: 110/53              Pulse: 84               
General:  Well appearing and pleasant.  HEENT:  Pupils equal, round and reactive to light.  Neck:  No cardiomegaly.  Lungs:  Clear.  Cardiac:  Regular rate and rhythm, no murmurs.  Abdomen:   Without hepatosplenomegaly.  Fingertips with evidence of self blood glucose monitoring.

Laboratory studies: Glycosylated hemoglobin 9.1%, blood glucose 255 mg/dl.

Impression: Joanne is an 8-6/12-year-old girl with diabetes mellitus under reasonable control.  She shows good overall growth and development, though weight has consistently been somewhat greater than height.  I am also concerned about underinsulinization during the day and excessive insulin action around dinner.

Disposition: New insulin regimen as follows:  4 units Regular, 8 units NPH in the morning, 2.5 to 3.5 units Regular at dinner, and 4.5 to 5 units NPH before bed.  She has been counseled to rotate injection sites appropriately, and avoid excessive starchy and sweet foods beyond her meal plan.  Follow-up is recommended for 3 months.


Sincerely,





Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Tatyana Sanders, M.D.          RE: Joanne Korngold
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Sanders:

I saw Joanne in the Diabetes Program on 12/24/96 for follow-up of insulin-dependent diabetes mellitus.

History: Joanne was diagnosed with diabetes mellitus in 1992 and was last seen in clinic on 9-24-96.  Interval history is remarkable for a bicycle accident resulting in a fractured mandible, which is now healing well.  She currently attends the third grade and is on the honor roll with straight A grades.   

She rarely experiences symptoms of hypoglycemia.  On several such occasions, she received her insulin dosage in the morning but fell asleep before having breakfast.  She does not typically awake in the morning with a headache or vomiting, and has never described nocturnal hypoglycemia.   

Typical blood sugars range as follows: before breakfast 160-300 mg/dl, before lunch 60-240 mg/dl, before dinner 60-240 mg/dl, before bedtime 80-200 mg/dl.

Current medications: Current insulin dosage is as follows:  4 units Regular, 8 units NPH mornings; 3.5 units Regular before dinner; and 5 units NPH before bedtime for a total of 20.5 units per day or 0.7 units/kg/day.

Physical exam:
HT: 127.5 cm    WT: 28.8 kg         Breast: Tanner I        
General: well appearing.  Pupils equal, round and reactive to light, extraocular movements intact, neck without thyromegaly.  Lungs: clear. Cardiac: regular rate and rhythm, no murmurs.  Abdomen: without hepatosplenomegaly.

Laboratory studies:  Hemoglobin A1C 9.6%, blood glucose 308 mg/dl, urinalysis 3+ glucose, no protein, no ketones.

Impression: Joanne is an 8-9/12 year old girl with type I diabetes mellitus of longstanding duration, doing reasonably well on a t.i.d. insulin replacement regimen.  Growth and development are normal;  however, morning blood sugars run a bit high, without evidence of nocturnal hypoglycemia.

Disposition: We would like to increase bedtime NPH to 5.5 units.  Blood glucose should be checked at 3:00 AM for several nights after initiating this change.  Insulin dosage should be decreased for high levels of activity, especially at night.  The risks of hypoglycemia caused by delaying breakfast more than about 30 min after insulin injection (as for example by falling back asleep) have been emphasized.  Finally, insulin injection sites should be rotated per the following schedule:  leg in the morning, stomach before dinner, and arm before bedtime.  Follow-up is recommended for three months.

Thanks for referring the Korngolds to our clinic, don't hesitate to call if you have any questions.


Sincerely,



Gleide Crane, MD, PhD
Attending in Endocrinology


CONTENT:
Tatyana Sanders, M.D.          RE: Joanne Korngold
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Sanders:

We had the pleasure of seeing Joanne in the Endocrine Program on 3/9/93 for follow-up of diabetes mellitus.

History: Joanne was diagnosed with insulin dependent diabetes mellitus approximately three months ago. Interval history is notable for Varicella, and a tonsillectomy in January. Joanne has returned to preschool and is coping very well with the diabetes. 

Current Humulin insulin dosage is 3.5 units Regular and 5.5 NPH in the morning, and 0.5 Regular and 2.0 NPH in the evening for a total of 11 units a day or 0.5 units/kilo/day. She eats three meals and three snacks a day, and there are no symptoms of either hypo- or hyperglycemia. 

Blood sugars are checked on a One Touch II monitor and typically range between 80 and 240 mg/dL.

Physical exam:  
Height: 107.4 cm        Weight: 21.4 kg         Breast: Tanner I        
Pubic hair: Tanner I    
General: Alert, playful, shy and adorable young girl. Neck:  Thyroid smooth and without enlargement.  Chest: Lungs clear. Heart: Benign. Abdomen: Without hepatosplenomegaly.

Laboratory studies:  Hemoglobin-A1 9.1%.

Impression: Joanne is a 5 year old girl with insulin dependent diabetes under good control on a moderate dosage of insulin.  Some variability in her blood sugars probably reflect changes in her diet. We would  like to increase her insulin to 3.5 Regular, 6 NPH in the morning and 0.5 Regular and 2.5 NPH in the evening. Joanne's parents are to call us in two weeks to discuss her blood sugars on this new insulin dosage.

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

Sincerely,



Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Tatyana Sanders, M.D.          RE: Joanne Korngold
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Sanders:

We had the pleasure of seeing Joanne in the Endocrine Program on 7/8/93 for follow-up of diabetes mellitus.

History: Joanne was diagnosed with insulin dependent diabetes mellitus in December 1992. Since then she has done quite well, without intercurrent illnesses.  She will be starting kindergarten this summer and is coping with the diabetes well. 

Current Humulin dosage is 3.5 units Regular, 6 units NPH mornings, 0.5 Regular, 2.5 NPH evenings, for a total of 0.54 units/kg/day. She has no symptoms of hyperglycemia; however, occasional mild insulin reactions associated with excessive activity are experienced. Her diet consists of three meals and three snacks a day, and she receives daily vigorous exercise. 

Blood sugars are monitored on a One Touch II, and typically range between 80 and 180 mg/dL through the day.

Physical exam:  
Height: 108.5 cm        Weight: 23.1 kg         BP: 100/60              
General: Alert, nontoxic, well developed. The remainder of the exam was within normal limits.

Laboratory studies:  Glycosylated hemoglobin 9.8%.

Impression: Joanne is a 5 and 4/12 year old girl with Type I diabetes mellitus of recent onset. She is in good glycemic control, now apparently coming out of the "honeymoon" period.  Of some concern is her increasing weight, now above the 90th percentile for age. 

We would like Joanne to begin a strict calorie count, and meet with our dietitian today. In addition, we recommend reducing morning NPH dose to 5.0 units (to help avoid afternoon hypoglycemia and reduce further weight gain). We would like to see Joanne back in clinic in three months time.

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

Sincerely,


Gleide Crane, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director            


Problem list to date:
                             

Transcribed by Cassells


CONTENT:
Tatyana Sanders, M.D.          RE: Joanne Korngold
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Sanders:

We had the pleasure of seeing Joanne in the Endocrine Program on 9/21/93 for follow-up of diabetes mellitus.

History: Joanne was diagnosed with diabetes mellitus about nine months ago.  Since then, she has done well, without significant complications.  She is starting kindergarten this month, and is well tolerating the new schedule.  

Current Humulin insulin dose is 3.5 units Regular/5 units NPH mornings, and 0.5 units Regular/2 units NPH evenings, for a total of 0.47 units/kg/day.  There are no symptoms of hyperglycemia; occasional mild insulin reactions are experienced before lunch.  These reactions are characterized by hunger and dizziness, and occurr especially when morning snacks are not finished.  

Blood sugars are checked on a One Touch II monitor and range 120-240 mg/dL mornings, 60-140 mg/dL before lunch, 100-300 mg/dL before dinner,  100-200 mg/dL before bed and around 200 mg/dL when checked overnight.

Physical exam:  
Height: 111.1 cm        Weight: 23.4 kg         Pubic hair: Tanner I    
General: Healthy, somewhat chubby young girl. Skin: Injection sites without atrophy or hypertrophy.   HEENT: PERRL, EOMI, lenses clear. Neck: Thyroid not palpable. Genitourinary: Tanner I. Extremities: Scoliosis not present.

Laboratory studies:  Glycosylated hemoglobin A1 10.4% and random blood glucose 174 mg/dL.

Impression: Joanne is a 5 and 6/12 year old girl with Type I diabetes mellitus under good control.  Growth and development are normal, though she remains somewhat overweight for her height.  Blood sugars are typically low before lunch and somewhat high overnight.

We would like Joanne to continue to follow her diet closely, and avoid excess calories.  We will redistribute her insulin dose (without changing overall amount) to avoid late morning lows as follows: 2.5 units Regular/5.5 units NPH mornings, and 0.5 units Regular/2.5 units NPH evenings.  The Korngolds are to check occasional 2:00AM blood sugars and give us a call in two weeks.  Her next appointment is scheduled for three months.

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

Sincerely,


Gleide Crane, MD             Bernardo Bird, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Ashley Blue, M.D.          RE: Kenneth Thiers
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/21/89

Dear Dr. Blue:

We had the pleasure of seeing Kenneth in the Endocrine Program on 6/6/94 for pineal blastoma.

History: Thank you for referring Kenneth Thiers, who as you know is a 5 year old, status post subtotal resection of a pineal blastoma in February of 1994.   Afterwards he received chemotherapy and he is now currently receiving radiation therapy.   He has been receiving radiation therapy for six weeks.   He is now referred for evaluation of growth.   He is also status post a endoscopic gastroscopy due to poor oral intake in April of 1994 and he is now taking 300 cc of Pediasure q4 hours and still eats very little.

We don't have data from previous growth charts, any additional information in this regard would be appreciated.

Current medications: Dilantin and Cimetidine.

Physical exam:  
Height: 109.8 cm        Weight: 22.4 kg         


Impression: He is at the 50th percentile for height at the 75th percentile for weight.  His growth so far appears to within the normal range.   The concern is that he might have secondary hypocortisolism due to suppression caused by high-dose Corticosteroids received during his surgery.   He also might have hypopituitarism due to radiation therapy.

Disposition: We are ordering an am Cortisol IGF-1, T4, TSH and a bone age as well as urine and serum osmolarity.   We will follow up in six months.
Thank you for letting us share in the care of Kenneth.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Addendum: Angela Palumbo, M.D.
Fellow in Endocrinology

SErum osmolarity 280 mOsm/kg.  Urine osmolarity 768 mosm/kg.  IGF1 174 ng/ml, T4 8.1 mcg/dl, TSH 0.5 mcU/ml, cortisol (at 10:00 a.m.) 4.7 mcg/dl.  

In summary, there is no evidence of hypopituitarism at this time although stress dose glucocorticoids with surgery or significant illness would be prudent.


CONTENT:
Kurt Rolf, M.D.          RE: Kenneth Thiers
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/21/89

Dear Dr. Rolf:

We saw Kenneth in the Endocrine Program on 10/30/95 for growth failure.

History: Patient is a 6-5/12 year old status post a total excision of a pineal blastoma in February of 1994.  He subsequently received chemotherapy included Vincristine, Cytoxan, and Platinum.  He received 5400 RADS to the brain and spine including a boost dose of radiation to the spinal droplets.  His deficits include hearing loss, which was possibly present before therapy as well as left eye blindness.  He is referred to Clinic because of the lack of growth and height since his diagnosis.

Current medications: "Sleep" medicine since he has abnormal sleep cycles.

Past medical history:  Notable for apparently normal growth and development until his tumor was diagnosed.

Review of systems:  Notable for G-tube placement in March of 1994.  He currently has night-time supplementation with 6 cans of Pediasure per night.  He eats during the day, but has a decreased appetite.  Neurologic:  Issues are notable for being nonverbal since the surgery.  He has no seizure disorder, however, he has insomnia and will go 1-2  days without sleep.

Family history:  Notable for having three other siblings that are apparently well.  There is no history of growth problems in the family.  His mother is 5'6" tall.  His father is approximately 5'8" tall.

Physical exam:
Ht: 113.3 cm    Wt: 21.5 kg
Pulse: 75               Pubic hair: Tanner I    Phallus length: 5.5 cm  
Mid-shaft diam.: 1.5 cm 
We were unable to obtain a blood pressure.  In general he was nonverbal, somewhat small boy.  His skin was quite dry without obvious lesions.   HEENT exam:  Pupils were intact equal and reactive.  There was nystagmus at extreme gaze.  I was  unable to visualize the fundi.  There is a significant skull deficit in the occipital area.  His neck was supple without thyromegaly.  His lung and chest and heart exam were within normal limits.  Abdominal exam was normal for a G-tube that was in place without erythema or drainage.  GU exam was Tanner I.  Neurologic exam was notable for left facial weakness.  He had fine tremor of hands and face.  His reflexes were brisk, but symmetric.  His toes were withdrawn.  His gait was slow and unsteady, and he had poor balance.

Laboratory studies:  Prior laboratory studies in July 1995 show a T4 of 11.2, TSH of 1.5.  He had a complete blood count that was normal.  An AST, LDH, and alkaline phosphatase were also normal.  His electrolytes were normal.  His erythrocyte sedimentation rate was 29.

Impression: This is a 6-1/2 year old with growth failure status post excision, chemotherapy, and radiation for a pineal blastoma.  His growth failure is likely secondary to pituitary dysfunction status post radiation with resultant growth hormone insufficiency.

Disposition: Today we will schedule a complete evaluation of his hypothalamic pituitary and adrenal axes to various stimuli.  A bone age will be obtained at that time. 

We would like the patient to return in two months to discuss the findings of these tests as well as to monitor additional growth.



Sincerely,




Valdeci Pavarotti, MD                   Maritza Brezny, MD             
Resident in Pediatrics             Attending in Endocrinology
  

cc:  Gloria Whitehammond, M.D. South End Health Center
     400 Shawmut Avenue Boston, MA 02118


CONTENT:
Simpson, M.D.          RE: Kenneth Thiers
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/21/89

Dear Dr. White-Simpson:

I saw Kenneth in the Endocrine Program on 7/17/96 for poor growth status post pineal blastoma treated with chemo and radiation therapy.

History: Kenneth is now 7 and 2/12 years old and was last seen by me 7 months ago.  Mother states that he has had a cold in the interim and constant clear coryza.  He has only an occasional cough and no wheezing.  He continues to be fed via G-tube overnight, taking 5 cans of Pediasure and Biocare.  As well eats 3 meals a day and snacks throughout the day.  He also drinks constantly (reportedly just like his brother).  He goes through 5-9 diapers a day and there is no change in that over the long term.  He has bowel movements about every other day which appear to be normal and not firm in consistency.  He will have one or two runny stools in the  morning after he takes Clonidine.  He continues to have his sleep disorder, staying awake for long periods of time through the night.  He has dry skin "ever since the surgery" and there is no change in his hair.

Current medications: Clonidine 0.1 mg. about 3x a week for sleep.

Physical exam:
Height: 115.8 cm        Weight: 23.5 kg
Pulse: 100              Pubic hair: Tanner I    
Blood pressure was done at Dana Farber this morning so not repeated 90/58).   This is a small African-American male who is eating or gumming constantly and who has a slow but close to normal walk but some interesting posturing when he is left quiet.  His skin is very smooth and oiled.  His hair is quite sparse and there is an occipital bony defect.  He does have 3 permanent incisors with a 4th one emerging.  The mother says that has been stable for a  year and that in fact he lost another lateral incisor, he has not had eruption of a new tooth.  The neck exam is normal.  The lungs are clear.  The heart shows a slightly rapid sinus rhythm without murmur.  The abdominal exam is difficult; it seems to be benign with a G-tube present.  The genitalia are prepubertal with a normal phallus and rather soft small testes in a well developed scrotum.  The neurologic exam shows 3x and equal deep tendon reflexes with bilaterally upgoing  plantars. 

A bone age was 7 years.

Impression: This child is status post surgery and cranial irradiation for pineal blastoma.  He demonstrates slowing growth.  As well, the history of delayed eruption of teeth is interesting.  He has had good weight gain in the last six months and in fact, has also grown 2.5 cm. in the past 9 months, but is still slowing overall.  I have scheduled him for a complete pituitary evaluation on July 31, at 8 am.  Mother understands the time and will have EMLA cream provided by her nurse at the Dana Farber.  I have asked the mother to fast the child from midnight and to put a urine bag on in the morning to obtain a first morning void for specific gravity before he drinks any water.  I have told her that we should follow him about every six months even if the test is normal and that we will rearrange that if need be according to the tests. 

Thank you for letting us share in Kenneth's care.



Sincerely,




Maritza Brezny, MD             
Attending in Endocrinology
  

cc: Barry Paw, M.D.  Dana Farber Cancer Institute  44 Binney Street  Boston, MA 02215


CONTENT:
Simpson, M.D.          RE: Kenneth Thiers
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/21/89

Dear Dr. White-Simpson:

I saw Kenneth in the Endocrine Program on 12/18/96 for follow up of pituitary evaluation.

History: Kenneth was last seen in July of 1996, and his mother says that he has  been generally in good health since.  He underwent pituitary evaluation  at the end of July.  His only new concern is that his behavioral has  changed in that he is crying for no very obvious reason and pushing on  his right eye as if he might be uncomfortable.  Review of systems  reveals no change in his sleep pattern, no change in his skin, no change  in his gait.  He continues to have bowel movements once or twice a week  as always.  His appetite is unchanged.

Current medications: clonidine 0.1 mg q.h.s. for sleep.

Physical exam:
HT: 116.3 cm    WT: 56.8 kg
BP: 95/60               Pulse: 100              
Kenneth is a mildly overweight, non-verbal youngster  with apparent developmental delay.  His skin is of normal turgor.  His  eyes appear to have full extraocular motions with some right lateral  nystagmus.  The pupils are equal, round and reactive.  The thyroid feels  normal.  The lungs are clear.  The heart shows a normal sinus rhythm  with no murmurs.  The abdomen is mildly obese but without  hepatosplenomegaly or mass.  There is a G-tube button in place.  The  genitalia were not examined today.  The neurologic exam shows an ataxic  gait, varying level of cooperation with commands, rather brisk deep  tendon reflexes throughout.

The pituitary evaluation completed on 07/31 showed several  abnormalities.  The growth hormone response was very limited, the TSH  response to TRH was also quite limited.  However, in the face of that  the thyroid function tests were normal, the IGF-1 was just below the  lower limit of normal.  The cortisol response was excellent.


Laboratory studies:  T4 9.9 ug/dL, TBGI 0.96
IGF-1 and IGF BP 3 are pending.

Impression: Kenneth is status post surgery, chemotherapy and radiation for a  pineal blastoma and continues to show a slowing growth velocity although  he does continue to grow.  His weight gain is also slower than it had  been through his first 5 years.  It is noted that he has an abnormal TSH  response but normal circulating thyroid hormone levels in July.  As  well, he has an abnormal growth hormone response but an almost normal  IGF-1.  So, obviously there has been some impact of all the events of  several years ago but nothing that needs an urgent response.  

I have repeated the thyroid functions today and would recommend  replacement if these are low.  The growth hormone will probably have to  be replaced at some point, but I would like to have him euthyroid prior  to that point.  As well, although Dr. Paw tells me that his last MRI was  entirely disease free, I would like to have that repeated before we put  him on growth hormone, to be certain that that continues to be  situation.   

I have given Kenneth an appointment in 3 months but will be in touch  sooner if the thyroid tests have become abnormal and if we need to  repeat that.  Otherwise, I would like to get another 3 months of growth  data prior to instituting any other therapy.   

Thank you for letting us share in Kenneth's care.



Sincerely,




Maritza Brezny, MD             
                             




cc:
  


Problem list to date:
CRANIAL-IRRADIATION                          07/18/94  
PANHYPOPITUITARISM                           07/18/94  
Transcribed by Sullivan_ma


CONTENT:
Gleide Rolf, M.D.          RE: Claudia Branting
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/14/92

Dear Dr. Rolf:

     We had the pleasure of evaluating Claudia in the Renal Program on 11/16/95 for hematuria.
     This 3-1/2 year old who noted to have hematuria two weeks ago during a  urinalysis performed for dysuria.  At that time she developed fever and  left flank pain for a week.  Her urinalysis showed moderate blood with  10-15 white cells per high powered field and 5-10 granular casts per  high powered field.  A urine culture done was negative however she  received a 10 day course of Amoxicillin with good response.  Otherwise,  she has had no joint pains, no rashes, no throat infections during that  time.  

Since 2/95, she has had multiple upper respiratory tract infections .

Her current medications include:


Past medical history:
     Positive for hospitalization at 11 months of age  for pneumonia, positive history of asthma.

Review of systems:
     Negative

Family history:
     Negative for renal disease, deafness or blindness.

Claudia's physical exam was notable for:
     BP 87/49   P 105   R    T    HT 97.4cm   WT 16.3kg
     General Appearance: Claudia appears very well and active.  
     HEENT:  positive for enlarged tonsils, no exudate noted.  
     Neck: supple, lymph  nodes positive submandibular shotty lymph nodes.  
     Chest: clear. 
     Heart:  without murmur. 
     Abdomen: soft, flat without masses, no tenderness,  without lesions.  
     Extremities: no edema, no deformities.  
     Skin: no rash.  
     Neurologic: no lateralizing signs.
A urinalysis revealed:
     SPEC GR UA                  WBC/HPF     10-15      
     PH UA       5               SQUAM EPI   few        
     WBC ENZ UA  2+              RBC CAST    0          
     BLOOD UA    2+              WBC CAST    0          
     PROTEIN UA  N               GRAN CAST   0          
     GLUCOSE UA  N               WAXY CAST   0          
     RBC/HPF     3-5             BACTERIA    N     

Laboratory studies at this time include:
          CRU        49.2   MG/DL       IGA         111   MG/DL    
          C3           93   MG/DL       IGM         118   MG/DL (H)
          ALB         4.5    G/DL       AAT         133   MG/DL    
          CAU        17.6   MG/DL       HAPT         87   MG/DL    
          CR          0.3   MG/DL       TRF         244   MG/DL    
          TP          7.3   GM/DL       C4           16   MG/DL    
          IGG         882   MG/DL       CRP       <0.30   MG/DL    

     In summary, Claudia's hematuria appears to be non-glomerular in origin and more infection related, however, her urine culture is negative.  Her laboratory studies are remarkable for an elevated urine calcium to creatinine ratio ot 0.37.  We have thus requested a 24 hour urine collection to quantify her calcium excretion.

     Thank you for the opportunity to participate in Claudia's care.  We would like to review her in We will see Claudia again once the results of the above tests come in.  In the interim, we would be happy to discuss or review Claudia should you or the family wish it.

               Sincerely,


               Joakuim Chef, MD           Antonio Khan, MD
               Fellow, Pediatric Nephrology Attending, Pediatric Nephrology


CONTENT:
Gleide Rolf, M.D.          RE: Claudia Branting
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/14/92

Dear Dr. Rolf:

     We had the pleasure of seeing Claudia in the Renal Program on 12/14/95 for hematuria.
      Claudia comes in for a follow-up visit.  Her initial  screening evaluation revealed hypercalciuria on a random urine specimen.   A 24-hour collection was obtained last week, and the results show that  in this period of time Claudia excreted greater than 6 mg/kg/day.  A  normal amount of calcium excretion is less than 4 mg/kg/day.  The  remainder of Claudia's screening laboratories and her renal ultrasound  were completely unremarkable.

Her current medications include:


Claudia's physical exam was notable for:
     BP 104/57   P 111   R    T    HT 99.2cm   WT 15.5kg

A urinalysis revealed:
     SPEC GR UA  1.027           WBC/HPF     0          
     PH UA       5               SQUAM EPI   freq       
     WBC ENZ UA  0               RBC CAST    0          
     BLOOD UA    1+              WBC CAST    0          
     PROTEIN UA  trace           GRAN CAST   0          
     GLUCOSE UA  -               WAXY CAST   0          
     RBC/HPF     3-5        

Laboratory studies at this time include:


     Claudia's hematuria is most likely related, therefore, to  hypercalciuria.  In this phenomenon, red blood cells will frequently be  seen associated with high levels of urinary calcium.  Sometimes these  children may go on to develop urinary stones but, at this point, there  is no evidence of Claudia having nephrolithiasis. 

The mainstay of therapy in children who are relatively asymptomatic with  hypercalciuria is hydration.  I discussed with Claudia's family making  sure that her urine always looks relatively light in color.  I would  advise them to give her between 1 and 2 quarts of fluid a day.  I also  emphasized that they should refrain from giving Claudia a high salt  diet since salt excretion is related to calcium excretion.It is relatively unclear whether high high calcium levels in the urine  are associated with high calcium dietary intake.  To clarify this issue  further with Claudia, I have asked the mother to give her a calcium  load prior to her next visit to the Renal Program in 3 months' time.  I  would like to see what hydration does in the meantime and, if she shows  any increase in urinary calcium excretion following a one-time calcium  load with 3 Tums taken orally followed by a urine specimen 2 hours  later, then we could consider reviewing her dietary history.  Rarely,  children with hypercalciuria are treated with thiazide diuretics.  At  this point I would not recommend such intervention since Claudia is  relatively asymptomatic and hydration in a vigorous fashion has not been  attempted.

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

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Gleide Rolf, M.D.          RE: Claudia Branting
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/14/92

Dear Dr. Rolf:

     We had the pleasure of seeing Claudia in the Renal Program on 4/25/96 for hypercalciuria.
     Claudia comes in with her parents for an interim visit.  It has been  approximately five months since her last visit.  During that time, the  family states that Claudia has been doing well.  They have been attempting to keep her well-hydrated.  They state that she drinks a lot  of apple juice.  Otherwise, Claudia has had no significant interval  illnesses. 

I had asked the family to give Claudia a calcium challenge this  morning in the form of TUMs.  The family forgot these instructions,  however, and this was not performed.

Her current medications include:


Claudia's physical exam was notable for:
     BP 95/58   P 109   R    T    HT 101cm   WT 17.8kg
     Objective:  In general, alert, active, happy appearing child in no  distress.  
     HEENT examination is benign.  
     Neck is supple without  thyromegaly or adenopathy.  Chest is clear throughout.  Cardiac  examination is without murmur.  S1 and S2 are normal.  Pulses are full.   Abdomen is soft.  There is no organomegaly or mass.  GU is Tanner I.   Extremities are well-formed without clubbing or cyanosis.
A urinalysis revealed:
     SPEC GR UA  1.025           WBC/HPF     3-5        
     PH UA       5               SQUAM EPI   many       
     BLOOD UA    2+              RBC CAST    -          
     PROTEIN UA  -               WBC CAST    -          
     GLUCOSE UA  -               GRAN CAST   -          
     RBC/HPF     3-6             WAXY CAST   -     

Laboratory studies at this time include:
          CRU       103.0   MG/DL       CAU        24.2   MG/DL    

     Claudia continues to manifest microscopic hematuria.  This is not  surprising given her  hypercalciuria.  I spent some time  discussing with the family that hypercalciuria tends to be a chronic  condition.  The amount of calcium excretion in Claudia's 24 urine  collection is significant.  Normally, children excrete less than 4  mg/kg/day.  Claudia's level was at the 6 mg/kg level.  Sometimes  thiazide diuretics are used to decrease the amount of calcium excretion.   I had hoped to somewhat assess an absorptive component of her  hypercalciuria with a calcium challenge this morning.  Unfortunately,  the family could not remember the directions that I provided them, and  this was not performed.  Given that the degree of calcium excretion by spot ratio has not exacerbated from that documented several months  ago, I believe it would be reasonable to continue monitoring Claudia  and to push her degree of hydration.  I am somewhat concerned, however,  because her urine specific gravities on all of my visits with her have  been in the high-normal range.  I once more reiterated my desire to have  Claudia to take 1 to 2 liters of fluid per day and to avoid a diet  high in sodium. 

In six months time, I would like to see Claudia back and recheck a  renal ultrasound to rule out any calcifications.  In addition, I  would like to obtain a 24 hour urine collection to quantitate more  precisely her calcium excretion.  We may need to consider thiazide  diuretics at that point.  In the interval, the family should contact  their primary care physician or my office if they have any concerns  regarding Claudia's status.

     Thank you for the opportunity to participate in Claudia's care.  We would like to review her in 6 months.  In the interim, we would be happy to discuss or review Claudia should you or the family wish it.

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


CONTENT:
Cavinder Stalin, M.D.          RE: Alexander Sanger
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/25/79

Dear Dr. Stalin:

We had the pleasure of seeing Alexander in the Endocrine Program on 2/4/93 for short  stature.

History: Alexander is a 13 11/12 year old man who was adopted at age three and a half weeks.   The patient has no significant past medical history.   According to his adoptive mother, he is here for evaluation of short stature.  The patient has always been small framed and has had no abrupt changes in his growth pattern according to the mother.   He met his milestones appropriately.   Has no significant problems in school.  Alexander has no known allergies.

Current medications: None.

Past medical history:  Vaginal delivery that was uncomplicated by report.  The patient is a healthy young male with no axillary hair development, no change in his vision, a few pimples.   He does use deodorant but has no body odor with exercise.   He has had pubic hair for approximately 8 months and has noticed some increase in his testicular size over the year.

Review of systems:  Unremarkable.

Family history:  Uncertain.   The mother was approximately 5'6" tall and had multiple medical and psychiatric problems and of note had no prenatal care.

Physical exam:  
Height: 147.6 cm        Weight: 38.1 kg         Pubic hair: Tanner III  
R. testis: 3.0 x 1.6 cm L. testis: 3.0 x 1.5 cm Phallus length: 8.0 cm  
Mid-shaft diam.: 1.9 cm 
General: Unremarkable.  Skin: Normal.  HEENT: Normal.  Neck: Thyroid, gland is palpable but not enlarged, no nodules.  Chest: Normal.  Heart: No murmurs.  Genitourinary: Foreskin intact.  Extremities: Normal.  Neurological:Normal.

Impression: Alexander has  probable constitution of delay based on stable growth pattern on records sent from pediatrician.   consistent with this is the recent onset of puberty.  We will check a bone age today to confirm this and have Alexander follow up in six months.   If at that time,  there is any change in his pattern of growth, will check thyroid function tests.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Margaret Sowell, MD
Fellow in Endocrinology
Brigham & Women's Hospital


CONTENT:
Larry Piggy, M.D.          RE: Diane Phillips
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/29/78

Dear Dr. Piggy:

We had the pleasure of seeing Diane in the Endocrine Program on 2/8/93 for evaluation of possible hypoglycemia.

History: As you know, Diane is a 14 and 4/12 year old white female who presents with an approximately three month history of shaky episodes occurring at 10:30-11:00AM .  She reports feeling weak, light-headed, dizzy and the symptoms are relieved by food.  She has had no palpitations, or excessive sweating at those times.  These were occurring 1-2 times per week.  A particularly bad episode occurred on Christmas morning at approximately 4:00AM when she awoke feeling short of breath, light-headed and dizzy.  She apparently had eaten at 3:00PM the previous day, though did have a snack of cider and pastry before bed at 10:00PM.  She has had no other episodes in the early morning or before breakfast.  Her other episodes have occurred at school during the weekday.  

Diet history reveals that Diane awakes at 5:30-6:00AM, eats breakfast at 6:30, which usually consists of a bagel with cream cheese, and orange juice.  She is now having a 10:30-11:00AM snack of cheese and crackers and juice.  She usually has a slice of pizza or sandwich for lunch also with juice.  In the afternoon, at 2:30 PM she has a snack of chips with a glass of juice or leftovers from previous night's dinner.  For dinner, at approximately 5-5:30PM, she has meat, potato, vegetable and salad.  She does not usually have dessert.  She sometimes has a snack prior to bed of ice cream or popcorn and a glass of juice as well.  Her breast development started at age 11, menarche at age 12.  She now has regular periods which last 3-4 days, cycles are every 28 days.  She has no complaints of dysmenorrhea and denies sexual activity.

Current medications: Ibuprofen prn for knee pain or migraines.  She has never been on birth control pills.

Past medical history:  Diane was the 7 lbs 8 oz product of a 42 week gestation born via induced vaginal delivery.   There were no complications with the pregnancy or delivery.  Mother states that her nutrition and growth and development were always normal.  She did have frequent episodes of otitis media and pharyngitis as a young child.  Diane has had no hospitalizations.  She did have a tonsillectomy and adenoidectomy and myringotomy tubes placed as a child.

Review of systems:  Skin: Negative.  HEENT:  She has a history of corneal abrasion X2.  Cardio/respiratory:  She does complain of feeling short of breath and does have trouble catching her breath with these episodes.  She has no GI or GU complaints.   She has a normal sense of smell.  She gets headaches  (bilateral frontal) which she has been calling migraines for the past 1 1/2 -2 years, one every other month responsive to Ibuprofen.

Family history:  Significant for insulin dependent diabetes in the maternal aunt.  Adult onset diabetes in the maternal grandfather and the paternal great-grandmother.  Mother has a history of hypothyroidism for the past 5-6 years and has been on Synthroid.  There is no other significant family history of endocrinopathies.  Mother's height was 5'3", father's height 5'8".  Mid-parental height is 5'3".

Physical exam:  
Height: 159.1 cm        Weight: 54.7 kg         BP: 117/65              
Pulse: 68               U/L ratio:  0.87        Arm span: 158           
Breast: Tanner V        Pubic hair: Tanner V    
General: Well developed, well nourished, white female in no apparent distress.  Skin: No birthmarks, lesions or rashes.  HEENT: Normocephalic, atraumatic.  Fundi were normal bilaterally.  Visual fields were intact.    Neck: Supple with no lymphadenopathy and no palpable thyroid.  Chest: Clear to auscultation.   Heart: Regular rate and rhythm, normal S1, S2 no
murmurs.  Back: No scoliosis.  Abdomen: Soft, nontender, nondistended with normal active bowel sounds.  N hepatosplenomegaly or masses.  Genitourinary: Normal genitalia.  Extremities: Full range of motion, no clubbing, cyanosis or edema.  Neurological: Nonfocal.

Laboratory studies:  December 21, 1992:  Sodium 139, potassium 4.2, chloride 103, bicarbonate 21, BUN 15, creatinine 1.1, calcium 9.2, glucose 92, phos 3.3, cholesterol 74, alk phos 103, LDH 125, AST 11, ALT 9, T4 7.9, TSH 1.2, bilirubin 0.6, total protein 6.7, albumin 4.4.   CBC showed a white count of 8.7, hemoglobin of 12.5, hematocrit 37, platelets 312.  Hemoglobin A1C 5.5%, epinephrine 18.0, norepinephrine 372, dopamine <10 pg/mL.  Urine VMA 2.36 mg/24 hour.

Impression: Diane clearly has symptoms consistent with adrenergic activation.  The history is consistent with reactive hypoglycemia but this has not been documented.  The fact that Diane has had no episodes at any other times of the day or first thing in the morning makes dysregulation of insulin secretion unlikely.  Her symptoms are now under excellent control with a mid-morning snack.  Our impression was shared with the parents and a decision was made to perform no further testing at this time but to return to Endocrine clinic if symptoms return or appear at other times of the day.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology   


Addendum: Elizabeth Carlin, MD
Senior Resident
Boston City Hospital


CONTENT:
Bernardo Hugo, M.D.          RE: Aggie Watterson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/23/91

Dear Dr. Hugo:

We had the pleasure of seeing Aggie in the Endocrine Program on 4/21/93 for enlarged breasts.

History: Aggie is a 17 month old girl who was first taken into the care of Mrs. Lepore, her foster mother, at 2 months of age.  She then had some  breast enlargement which soon disappeared to reappear at the age of 9 months, after an initial growth it has stabilized in size.  At about the same time Mrs. Lepore noted that Aggie had a rapid growth spurt.  She however did not notice any vaginal discharge or any vaginal bleeding.  Otherwise she has been healthy in general and has had a normal development (physically and mentally).  

Of interest is that her sister (Jenna Lee Holmes), in another foster home, is being investigated for premature adrenache.

Current medications: None.

Past medical history:  History of pregnancy and delivery are unknown.  Her growth and development  have been normal and she has a good appetite.  She has no previous hospitalizations, injuries or operations.

Review of systems:  Skin:  She has a mild diaper rash.  HEENT:  She had ear tubes put for repeated otitis.  The remainder of the review of systems was negative.

Family history:  Family history is unknown except that the mother is a drug abuser.

Physical exam:  
Height: 83.2 cm         Weight: 11.10 kg        BP: 106/57              
Breast: Tanner III      
Aggie was a healthy looking tall baby (90th centile).   Skin:  She has three cafe-au-lait pigmented lesions, each around 1 cm, two on the lateral aspect of the left mid-thigh, and one on the right lower chest anteriorly.   HEENT:  Ear tubes bilaterally, otherwise negative.  Neck: Thyroid not enlarged.  Chest:  Clear lungs.  Heart: Normal S1 and S2, no murmurs.  Abdomen: Soft, not tender, no masses, no hepatosplenomegaly.  Genitourinary:  Well estrogenized vaginal mucosa.  Extremities: Normal.  Neurological: Non-focal.

Impression: Premature thelarche.  However, in view of the three pigmented lesions, the growth spurt by history, and the well estrogenized vaginal mucosa, the McCune-Albright syndrome has to be ruled out.


Laboratory studies pending at this time include: Pelvic ultrasound and bone age.
Thank you for letting us share in the care of Aggie.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Bernardo Hugo, M.D.          RE: Aggie Watterson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/23/91

Dear Dr. Hugo:

The bone age determined on Aggie was 1 year 9 months which is not significantly different from her chronologic age of 1 year 5 months.  

The pelvic ultrasound did not show any evidence of ovarian tumor or cyst.

Her diagnosis then is Premature Thelarche, a self limited process with excellent prognosis.

Please do not hesitate to call if you have any questions.


Sincerely,



Kendell Simpson, MD
Clinical Director


CONTENT:
Fozzie Steinbeck, M.D.          RE: Leontyne Brisbane
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/11/92

Dear Dr. Steinbeck:

     We had the pleasure of seeing Leontyne in the Renal Program on 5/5/94 for follow-up of reflux.
     Leontyne has an older sister (five years older) who had urinary tract infections and ureteral reflux.  Leontyne was hospitalized here in February, 1993 for fever.  She was found to have a urinary tract infection.  Subsequent evaluation demonstrated bilateral grade II-III ureteral reflux.  A renal ultrasound suggested possible right upper pole renal increased echogenisity.  There was a report of a normal IVP in a letter from Dr. Link.  I could not find a report of an IVP here at Children's but I did not have Leontyne's X-Ray folder today.  Thus I am not sure that she has actually had an IVP.  At any rate, she had a radionuclide VCUG performed on March 24, 1994.  That study was unsatisfactory because of incomplete bladder filling.  There was only 25cc of contrast instilled into the bladder.  There was transient grade I vesicoureteral reflux seen on the left.  She had a conventional voiding cystourethrogram done on April 25, 1994.  That was a more satisfactory study with 150cc instilled into the bladder.  Reflux began at approximately 150cc of filling.  There was grade II reflux on both the right and left sides.  There was no intrarenal reflux seen.

Current medications include:
     Prophylactic Antibiotic at bed time

Physical exam:
     BP /     P 140     R 24     HT 77.5cm     WT 9.95kg
     General: Appears well, actively fighting the exam, crying constantly
     HEENT: Negative
     Neck: Supple, lymph nodes no adenopathy
     Chest: Clear to percussion and auscultation
     Heart: S1 normal, S2 split, no S3 S4 murmur
     Abdomen: Benign, no masses or tenderness
     Genitourinary: Normal
     Extremities: No edema

Urinalysis:
          SPEC GR UA  1.008                PH UA       6          
          PROTEIN UA  trace mg/dl          GLUCOSE UA  N     mg/dl
          BLOOD UA    N                    RBC/HPF     0-1   /HPF 
          WBC/HPF     0-2                  CASTS       N     
          SQUAMOUS EPITHELIAL   several


Laboratory studies at this time include:
          URINE CULTURE:   MIXED CULTURE OF FOUR COLONY TYPES; 
          CONSISTENT WITH CONTAMINATION

     Leontyne has had a serious urinary tract infection and currently has bilateral grade II reflux.  Her reflux is quantitatively better than it was a year ago.  Her renal status is unknown but with her normal growth and development and with relatively normal previous studies, I cannot imagine that there is a serious problem.  I think that she should have a follow-up renal ultrasound before she is five years old to assess whether or not she has any scars.  Unfortunately, the radionuclide VCUG has been unsuccessful and thus, I am afraid that she will need a follow-up VCUG in a few years to determine whether the reflux has completely gone away.  I would suggest continuation of the prophylactic antibiotic and check a urine culture every three months.  We often do radionuclide VCUGs on an annual basis but in her case since it did not work, I think it would be better to do the usual VCUG.  Since we are doing that, due to the amount of radiation associated with it we should not do it as often as we do the radionuclide studies.  As long as she is free of infections and she is tolerating the antibiotics well, I do not see any reason to want to discontinue that treatment in the near future.  Thus, specifically, I would suggest that she continue the antibiotics and get a follow-up VCUG and a renal ultrasound at about five years of age.  Also, it would be best if you could obtain a blood pressure somewhere along the line.  It is rare for us to be unsuccessful in doing so but she put up such a fight that it was absolutely impossible.  I sent off a urine culture today.  I did not do any other tests.  I did not make an appointment for her to be seen by me.  I will be happy to do so but for the time being, I think that you can probably do all the the tests that we would do any way.
     Thank you for allowing us to share in the care of Leontyne.

     Sincerely,


     Clotilde Goldwater, MD           
     Director, Pediatric Nephrology


CONTENT:
Fozzie Steinbeck, M.D.          RE: Leontyne Brisbane
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/11/92

Dear Dr. Steinbeck:

     We had the pleasure of seeing Leontyne in the Renal Program on 4/20/95 for reflux.
     Leontyne has been doing quite well.  She has had no urinary tract infections in the last year.  Because of slight leukopenia the Bactrim was discontinued but she has been taking Furadantin nightly since that time.  Periodic urine cultures have all been negative.  She had a radionuclide VCUG performed earlier this month.  That study demonstrated intermittent Grade 1 reflux on the left side.  However, only 100cc's was instilled into the bladder and she voided 25cc's during the examination.

Her current medications include:
     FURADANTIN 1/4 tsp qhs

Leontyne's physical exam was notable for:
     BP 86/55   P 125   R 20   T    HT 85.2cm   WT 11.7kg
     General: Appears well.  Generally resists exam but no acute distress.
     HEENT: Negative
     Neck: Supple, lymph nodes no adenopathy
     Chest: Clear to percussion and auscultation
     Heart: Core S1 normal, S2 split, no S3 S4 murmur
     Abdomen: Soft and flat, no masses, tenderness or organomegaly 
     Genitourinary: Normal
     Extremities: No edema

A urinalysis revealed:
     SPEC GR UA  1.006           RBC/HPF     0          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       7               RBC CAST    N          
     PROTEIN UA  0               GRAN CAST   N          
     BLOOD UA    0               WAXY CAST   N          
     GLUCOSE UA  0     mg/dl     SQUAM EPI   N          
     WBC/HPF     0-2             BACTERIA    N     

Laboratory studies at this time include:


     Leontyne seems to be doing quite well.  I think the radionuclide study is generally good.  However she still does have intermittent reflux.  Also, on her last VCUG up to 150cc's was instilled into the bladder.  Thus I am not sure that the most recent exam was done at complete bladder capacity.  Thus, I think that the wisest plan is to continue the Furadantin indefinitely.  I should see her back in a year and we should repeat the radionuclide cystogram at that time.  Hopefully she will be less resistant the the exam and it can be done under more normal circumstances.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Fozzie Steinbeck, M.D.          RE: Leontyne Brisbane
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/11/92

Dear Dr. Steinbeck:

     We had the pleasure of seeing Leontyne in the Renal Program on 5/9/96 for ureteral reflux.
     Leontyne has done well since her last visit here.  She has had  no documented urinary tract infections.  She continues on Furadantin at  a dose that her mother describes as "one-quarter teaspoon" at bedtime  each night.  She seems to be growing and developing well.  She had a  VCUG performed at the New England Medical Center last month.  That  showed grade II reflux on the right side with no reflux on the left  side.  The summation of her bladder studies, therefore, is as follows:   

03/93: MGH, VCUG: Grade III, bilateral. 03/94: CH, RNC: Grade I, left.  04/94: CH, VCUG: Grade II, bilateral. 04/95: CH, RNC: Grade I, left. 04/96: NEMC, VCUG: Grade II, right.

Her current medications include:
     FURADANTIN 25 mg q.h.s.


Leontyne's physical exam was notable for:
     BP 103/66   P 109   R 12   T    HT 90.9cm   WT 13.6kg
     Appears well and in no distress.  
     HEENT:  negative; fundi are benign, no significant adenopathy.  
     Chest: clear to  auscultation, no rales or wheezes.  
     COR: S1 normal, S2 split, no S3, S4  or murmur.  
     Abdomen: soft and flat, no masses, nontender or  organomegaly. 
     Extremities: no edema.
A urinalysis revealed:
     SPEC GR UA  1.010           WBC/HPF     0-1        
     PH UA       8               RBC CAST    none       
     WBC ENZ UA  neg             WBC CAST    none       
     BLOOD UA    neg             GRAN CAST   none       
     PROTEIN UA  neg             WAXY CAST   none  
     GLUCOSE UA  neg             BACTERIA    neg   
     RBC/HPF     0          

Laboratory studies at this time include:


     Overall, Leontyne seems to be doing quite well.  She continues to have  grade II reflux on the right, but the left reflux seems to have cleared.   Thus, she is following the usual course with gradual clearing of the  reflux.  I reiterated to her mother that she must continue on the  antibiotics until the reflux is entirely gone.  I could not predict, of  course, when that would happen.  She seems to be tolerating the  Furadantin, but the dose does seem to be somewhat low.  However, even at  that level, if it is working, I don't see any reason to change it.  I  would evaluate her again in one year.  Routinely, we should get a  radionuclide cystogram.  Her cystograms have seemed underestimate the  amount of reflux.  Nonetheless, as she gets older, they may be  technically more easy to do, and I would continue to try to get a  radionuclide study rather than a regular VCUG because of the decreased  amount of radiation exposure.  I think we may also want to get a DMSA  scan at the next visit also, to see if there is any sign of renal  scarring.  Certainly her blood pressure and urinalysis would not suggest  that, but remember that there was a previous ultrasound that suggested a  radiolucent area in the right upper pole.  Alternatively, of course, we  could just repeat the ultrasound, but I think if there is any  abnormality go with the DMSA and probably it is better just to do that  study.  In any case, I would be happy to discuss this prior to the next  visit.

     Thank you for the opportunity to participate in Leontyne's care.  We would like to review her in 1 year with RNC.  In the interim, we would be happy to discuss or review Leontyne should you or the family wish it.

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


