# BIGPATS_DOC_STORE

CONTENT:
Carerras, M.D.          RE: Ivan Wrigley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/07/85

Dear Dr. Carerras:

We had the pleasure of seeing Ivan in the Endocrine Program on 5/28/92 for evaluation of astrocytoma.

History: Ivan is now 7 and 2/12 years old. He had resection of his tumor on 3/16/92 with pathology revealing pilocytic astrocytoma. His post-operative course was complicated by development of diabetes insipidus followed by SIADH and  followed by persistent diabetes insipidus; a staphylococcus wound infection; bowel obstruction; and a drug rash of unknown etiology. Since his discharge, he has been doing well. He receives DDAVP 0.1 ml intranasally which has a duration of 12-24 hours.

Current medications: DDAVP 0.1 ml PRN urinary breakthrough, Depot Lupron 7.5 mg IM q month, and Alupent MDI.

Past medical history:  He has environmental allergies.

Review of systems:  skin: dry and itchy. HEENT: no headaches. His vision remains decreased on the right and there is some photophobia. Cardio/respiratory: no shortness of breath or palpitations. GI: occasional emesis after feeds. No constipation. Normal stooling now that he is off laxatives which were causing diarrhea. GU: no dysuria. Neuro: no cold or heat intolerance.  He has increased fatigue and is much more irritable than prior to surgery.

Physical exam:  
Height: 118.8 cm        Weight: 29 kg           BP: 114/68              
Pulse: 96               Pubic hair: Tanner I    R. testis: 3.0 x 1.4 cm 
L. testis: 2.9 x 1.4 cm Phallus length: 7 cm    Mid-shaft diam.: 2.5 cm 
Skin: Warm.
HEENT: Pupils equal, round and reactive to light, decreased upward gaze on right.
Neck: No thyromegaly.
Chest: Clear. 
Heart: Regular rate and rhythm without murmur.
Abdomen: Soft, no hepatosplenomegaly.
Extremities: Well-perfused.
Neurological: 2+ symmetrical deep tendon reflexes with a normal relaxation phase.

Laboratory studies:  Sodium 142 mEq/L3.9 mEq/L, chloride 106 mEq/L, bicarbonate 25 mEq/L, BUN 4 mg/dL, creatinine 0.7 mg/dL.

Impression: Ivan already has a history of precocious puberty treated with Depot Lupron and growth hormone deficiency. He is at risk for development of other hypopituitary states. His increased weight gain could be due to hypothyroidism and his mood swings could be secondary to cortisol deficiency.

Disposition: Ivan will be started on maintenance hydrocortisone 5 mg at 7:30 am and 2.5 mg at 3 pm, for approximately 7.5 mg/m2/day. During times of illness or stress, his mother has been instructed to give him hydrocortisone 10 mg TID. He will have a follow-up appointment in Endocrine Clinic in three months.

Laboratory studies pending at this time include: thyroid function tests, FSH, LH.
Thank you for letting us share in the care of Ivan.

Sincerely,


Leif Pavarotti, MD             Elmo Domingo, MD                 
Fellow in Endocrinology      Attending in Endocrinology   


Addendum: T4 preliminarily 2.2 mcg/dL with TSH 2.2 uU/mL consistent with teritary hypothyroidism.  He has been started on Synthroid 25 mcg po QD for 7 days then 50 mcg po QD.  He needs TFTs and TSH drawn in one month.


CONTENT:
Carerras, M.D.          RE: Ivan Wrigley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/07/85

Dear Dr. Carerras:

We had the pleasure of seeing Ivan in the Endocrine Program on 11/12/92 for evaluation of panhypopituitarism and diabetes insipidus.

History: Ivan is now 7 and 8/12 years old. He is status-post 5400 cGy of radiation and status-post resection of his astrocytoma in 3/92.  He has precocious puberty treated with Depot Lupron 7.5 mg IM q month, hypothyroidism treated with Synthroid 50 mcg q day, diabetes insipidus  treated with DDAVP 0.2 ml PRN urinary breakthrough which has been every six to 24 hours. He has growth hormone deficiency but his growth hormone treatment was discontinued with the regrowth of his tumor. He was started on hydrocortisone 5 mg in the morning and 2.5 mg in the afternoon for mood swings but these have not changed. They seem to be worse with his urinary breakthrough.

Current medications: As above. He is to start Beclovent multidose inhaler.

Review of systems:  He has environmental allergies which are now getting better. He has been gaining weight, but he is not eating tremendous amounts.  He continues to be fatigued but this is improving; he is only taking occasional afternoon naps. He has no cold or heat intolerance, constipation, or diarrhea, change in hair or skin texture, axillary odor, acne, oily skin, or development of pubic hair.

Physical exam:  
Height: 122.8 cm        Weight: 32.8 kg         BP: 100/60              
Pulse: 110              Pubic hair: Tanner I    R. testis: 3.0 x 1.6 cm 
L. testis: 2.9 x 1.5 cm Phallus length: 8 cm    Mid-shaft diam.: 2.3 cm 
Skin: Normal texture.   HEENT: Extraocular movements intact. Right optic disc without papilledema. Left optic disc not visualized.   Neck: No thyromegaly.  Chest: Clear.  Heart: Regular rate and rhythm without murmur.  Abdomen: Soft without hepatosplenomegaly.  Extremities: Well perfused.  Neurological: Normal deep tendon reflexes and relaxation phase.

Laboratory studies:  Sodium 137 mEg/L, Potassium 4.2 mEq/L, Chloride 101 mEq/L bicarbonate 23 mEq/L. T4 8.0 mcg/dL, TSH < 0.05 mcU/mL, bone age 8 years.  LH 0.11 IU/L, FSH pending.

Impression: Ivan has grown 4 cm in the past 5 1/2 months which is good growth velocity off growth hormone treatment. This could be due to unsuppressed puberty but there has been no progression of puberty on physical exam.

Disposition: Continue current doses of medications. Return to clinic in four months.
Thank you for letting us share in the care of Ivan.

Sincerely,


Leif Pavarotti, MD             Elmo Domingo, MD                 
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Carerras, M.D.          RE: Ivan Wrigley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/07/85

Dear Dr. Carerras:

We had the pleasure of seeing Ivan in the Endocrine Program on 7/8/93 for follow-up of hypopituitarism.

History: Ivan is an 8 and 4/12 year old status-post resection of a pilocytic astrocytoma on 3/16/92. He has diabetes insipidus treated with DDAVP  2 puffs PRN urinary breakthrough (approximately daily), hypothyroidism treated with Synthroid 50 mcg q day, precocious puberty treated with Depot Lupron 7.5 mg q month, and possible cortisol deficiency currently receiving hydrocortisone 5 mg q a.m.  He was admitted 4/28/93 with altered mental status most probably secondary to a stroke. He has had a significant increase in weight since his last visit. He has had no advancement in pubertal signs or development of axillary odor, no signs or symptoms of hypothyroidism. He has intermittent squeezing mid-frontal headaches of variable duration which seem to increase in frequency when he does not want to be in school.

Physical exam:  
Height: 127.0 cm        Weight: 38 kg           BP: 94/62               
Pulse: 110              Pubic hair: Tanner I    R. testis: 3.2 x 1.4 cm 
L. testis: 2.8 x 1.4 cm Phallus length: 8.5 cm  Mid-shaft diam.: 2.4 cm 
General: Alert and conversant.  Skin: Normal texture.  HEENT: PERRL. EOMI. Sharp optic discs. There is an area of increased pigmentation vs. hemorrhage at 4:00 on the right fundis.  Neck: No thyromegaly. Chest: Clear. Axillary hair stage I.  Heart: Regular rate and rhythm without murmur.  Abdomen: Soft without hepatosplenomegaly.  Extremities: Well perfused.  Neurological: Normal deep tendon reflex, relaxation phase.

Laboratory studies:  6/16/93 Sodium 140 ME/L, potassium 3.8 mEq/L, chloride 100 mEq/L, bicarbonate 23 mEq/L, BUN 10 mg/dL, creatinine 0.7 mg/dL, T4 9.4 mcg/dL, IGF-1 67 ng/mL, LH < 0.12 IU/L, FSH 0.3 IU/L, testosterone level <10 ng/dL.

Impression: Ivan continues to grow along the delayed curve by one standard deviation on the Bayer Bailey growth chart. In spite a history of growth hormone deficiency and a low IGF-1 level. This may be due to either an acceleration in growht rate with advancing puberty, or to increased insulin levels with obesity. To rule out advancing puberty, a GNRH stimulation test will be performed just prior to a dose of Depot Lupron. In addition, his mother was instructed to administer the Depot Lupron every 28 days, not monthly. Ivan is clinically and biochemically euthyroid. Ivan's diabetes insipidus appears to be under good control. Ivan is empirically on cortisol replacement because of behavioral changes. Since cortisol is not a necessary hormone in prepubertal children except at times of stress, we will continue to wean his dose. He will continue 5 mg daily for a month and then receive 2.5 mg daily for two months and then discontinue treatment. In times of significant stress or illness, he should receive hydrocortisone 10 mg tid.

Disposition: Return to clinic in three months.

Laboratory studies pending at this time include: GNRH stimulation test.  Thank you for letting us share in the care of Ivan.

Sincerely,


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


CONTENT:
Tuba Matlock, M.D.          RE: Ivan Wrigley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/07/85

Dear Dr. Matlock:

We had the pleasure of seeing Ivan in the Endocrine Program on 9/30/93 for follow-up of hypopituitarism.

History: Ivan is an 8 and 6/12 year old s/p resection of pilocytic  astrocytoma on March 16, 1992.  Prior to September 11, 1993 he was receiving DDAVP 2 puffs or of DDAVP every 18 to 24 hours for diabetes insipidus.  Since then however, he has not had large amounts of urinary breakthrough or incontinence.  He drinks 8 oz. approximately every hour and a half during the day but can wait longer and wakes two to three times per night and he also drinks 8 oz of fluids.  Over the past five weeks he has had no appetite and has lost approximately 1 lbs. per week.  He eats no breakfast or lunch.  He begs for food but then says he is full approximately 3 French fries and two tsp of soup.  He vomits if he eats larger quantities such as 3/4 of a bowl of soup.  He has been off hydrocortisone since the middle to end of August.  He complains of headaches at school and has had dizziness tow to threes times over the past month.  He has diarrhea one time per day over the past month.  He has no cold or heat intolerance or diaphoresis.  Over the past three weeks he has had an upper respiratory infection and asthma.

Current medications: Depot Lupron 7.5 mg IM Q 28 days, Synthroid 50 mcg QD, Intal and Alupent multidose inhalers.

Physical exam:  
Height: 128.1 cm        Weight: 35.2 kg         BP: 98/70               
Pulse: 108              Pubic hair: Tanner I    R. testis: 3.0 x 1.4 cm 
L. testis: 3.0 x 1.4 cm Phallus length: 8.5 cm  Mid-shaft diam.: 2.4 cm 
BP:98/70  standing, 78/palp supine   Pulse:  108 standing, 100 supine
General: Alert.
Skin: No jaundice, normal texture.
HEENT: PERRL, EOMI, normal optic discs.  Scleral icterus present.
Neck: No thyromegaly.
Chest: Good air movement with soft wheezes at the bilateral basis.
Heart: Regular rate and rhythm without murmur.
Abdomen: Soft, without hepatosplenomegaly.
Genitourinary: 
Extremities: Well perfused.
Neurological: 2+ patellar deep tendon reflexes bilaterally.

Laboratory studies:  GnRH stimulation test August 11, 1993 showed full suppression  of the hypothalamic-pituitary gonadal axis, electrolytes from his local hospital revealed a sodium of 146 mEq/L, and a urine sp.gr. 1.010 on September 21, 1993 and a odium of 148 mEq/L, and urine sp. gr. of 1.005 on September 24, 1994.

Impression: Ivan has a partial diabetes insipidus at this point .  It is possible that he has decreased free water exertion secondary to adrenal insufficiency.  This would also explain his anorexia.  We wills tart low dose maintenance hydrocortisone of 5 mg at 8:00AM and 2.5 mg at 3:00PM for a dose of 7 mg/m2/day.

Disposition: His mother will phone us in two weeks to see if there is improvement in both  his appetite and whether his diabetes insipidus returns in entirety .  If questions remain we will schedule a Cortrosyn stimulation test off steroid for 24 hours to assess the adrenal axis.  He will return to the Endocrine Program in two to three months.

Laboratory studies pending at this time include: T4, TT3, TBGI< TSH, electrolytes, BUN, creatinine, serum osm and bilirubin.
Thank you for letting us share in the care of Ivan.

Sincerely,


Leif Pavarotti, MD             Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Tuba Matlock, M.D.          RE: Ivan Wrigley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/07/85

Dear Dr. Matlock:

We had the pleasure of seeing Ivan in the Endocrine Program on 9/30/93 for follow-up of hypopituitarism.

History: Ivan is an 8 and 6/12 year old s/p resection of a pilocytic astrocytoma on March 16, 1992.  Prior to September 11, 1993 he was receiving DDAVP 2 puffs (20 mcg)  every 18 to 24 hours for diabetes insipidus.  Since then however, he has not had large amounts of urinary breakthrough or incontinence.  He drinks 8 oz. approximately every hour and a half during the day although he can wait longer.  He wakes two to three times per night and drinks 8 oz of fluids at that time.  Over the past five weeks, he has had no appetite and has lost approximately 1 lb. per week.  He eats no breakfast or lunch.  He begs for food but then says he is full (e.g., after 3 French fries and two tsp of soup).  He vomits if he eats larger quantities.  He has been off hydrocortisone since the middle to end of August.  He complains of headaches at school and has had dizziness two to three times over the past month.  He has had diarrhea one time per day over the past month.  He has no cold or heat intolerance or diaphoresis.  Over the past three weeks, he has had an upper respiratory infection and asthma.

Current medications: Depot Lupron 7.5 mg IM Q 28 days, Synthroid 50 mcg QD, Intal and Alupent multidose inhalers.

Physical exam:  
Height: 128.1 cm        Weight: 35.2 kg         BP: 98/70               
Pulse: 108              Pubic hair: Tanner I    R. testis: 3.0 x 1.4 cm 
L. testis: 3.0 x 1.4 cm Phallus length: 8.5 cm  Mid-shaft diam.: 2.4 cm 
BP:98/70  standing, 78/palp supine   Pulse:  108 standing, 100 supine
General: Alert. Skin: No jaundice, normal texture. HEENT: PERRL, EOMI, normal optic discs.  Scleral icterus present. Neck: No thyromegaly. Chest: Good air movement with soft wheezes at the bilateral basis. Heart: Regular rate and rhythm without murmur. Abdomen: Soft, without hepatosplenomegaly. Extremities: Well perfused. Neurological: 2+ patellar deep tendon reflexes bilaterally.

Laboratory studies:  GnRH stimulation test August 11, 1993 showed full suppression  of the hypothalamic-pituitary gonadal axis, electrolytes from his local hospital revealed a sodium of 146 mEq/L, and a urine sp.gr. 1.010 on September 21, 1993 and a sodium of 148 mEq/L and urine sp. gr. of 1.005 on September 24, 1994.

Date of visit: Sodium 143 mEq/L, potassium 4.0 mEq/L, chloride 105 mEq/L, bicarbonage 27 mEq/L, BUN 3 mg/dL, creatinine 0.7 mg/dL, osm 286, T4 9.1 mcg/dL, TT3 153 ng/dL, TSH 0.92 uU/mL, TBGI 0.92, total bilirubin 1.2.

Impression: Ivan has a partial diabetes insipidus at this point .  It is possible that he has decreased free water exertion secondary to adrenal insufficiency.  This would also explain his anorexia.  We will start low dose maintenance hydrocortisone of 5 mg at 8:00AM and 2.5 mg at 3:00PM for a dose of 7 mg/m2/day.

Disposition: His mother will phone us in two weeks to see if there is improvement in   his appetite and complete his diabetes insipidus.  If questions remain we will schedule a Cortrosyn stimulation test off hydrocortisone for 24 hours to assess his adrenal axis.  He will return to the Endocrine Program in two to three months.
Thank you for letting us share in the care of Ivan.

Sincerely,


Leif Pavarotti, MD             Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Jussara Rolf, M.D.          RE: Bessie Selincourt
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/30/84

Dear Dr. Rolf:

We had the pleasure of seeing Bessie in the Endocrine Program on 3/5/92 for  .

History: Bessie is now 7 and 5/12 old.  She is almost 5 1/2 years out of her CNS irradiation from meulloblastoma which was complicated by e. coli meningitis.  She has been off antiseizure medications for about one year.  She had a feeding tube in place which was removed approximately in August of 1991.  She has been eating well since that time.  Her mother states that she has good verbal communication.  She is still in diapers although this is more of a precaution than a necessity.  She continues to have an unsteady gait.  Her last neurological appointment was approximately in the Spring of 1991 and her mother thinks that she probably had a brain imaging at that time.  Bessie is now at pre-school and appears to be doing well.  She is currently on no medications.

Physical exam:  
Height: 107.6 cm        Weight: 39.8 kg         Breast Tanner: 1        
Pubic hair Tanner: 4    
Neck: Thyroid normal.
Chest: Clear.  Areolae measured 1.2 x 1.3 cm bilaterally.  There was no glandular breast tissue present. 
Heart: Normal without murmur.
Abdomen: At the previous G-tube site, there was superficial wound opening that appeared clean.
Genitourinary: Vaginal mucosa showed no evidence of estrogenation.

Impression: Significant drop off in growth consistent with growth hormone deficiency.  Her pubic hair has increased however, there is a decrease in her breast development and no other evidence of precocious puberty.  It is likely that this problem has now arrested as she is farther out from her cranial irradiation.

Disposition: A repeat ITT, glucagon, LHRH, TRH test was scheduled.   We have also asked that she have follow-up with neurosurgery and a follow-up MRI prior to the initiation of growth hormone which will likely be initiated once the above testing has been obtained and she is cleared from a neurosurgery point of view. To evaluate and follow her abdominal wound, we have scheduled an appointment for her in Surgery Clinic.

Laboratory studies pending at this time include: Insulin glucagon, LH, RH, and TH testing.  Bone age to be done 3/25/92.

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

Sincerely,


M Joan Hammer, MD         
Associate in Endocrinology   


Problem list to date:
HYPOPITUITARISM              Start: 03/05/92  End:          Invalid: 
GH-DEFICIENCY                Start: 03/05/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Jonnie Kramer, M.D.          RE: Bessie Selincourt
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/30/84

Dear Dr. Kramer:

We had the pleasure of seeing Bessie in the Endocrine Program on 9/3/92 for evaluation of cranial irradiation.

History: Bessie is a 7 and 10/12 year old girl who is status-post CNS tumor treated with radiation complicated later by meningitis. She was growing slowly until recently, but her appetite is now increased. Her mother feels that she is growing faster with increasing body hair and breast size and white vaginal secretion. She has had no menarche as yet. She is in a special ed program and says some words.

Current medications: None.

Physical exam:  
Height: 111.1 cm        Weight: 19.6 kg         Breast: Tanner III      
Pubic hair: Tanner III  

General: She has a height velocity of 7 cm/year.  She had some difficulty with the exam. Fundi appeared normal. Thyroid was not enlarged. 5 cm of glandular tissue was present in her breasts. Her abdominal exam was benign. The g-tube site was well healed. Vaginal introitis showed some estrogen effect and her gait was somewhat awkward.

Laboratory studies:  Bone age 7 10/12 years.

Impression: Bessie has now entered a neurogenic precocious puberty with growth acceleration secondary to that. I sent a LH and FSH, T4 and a bone age.

Disposition: I plan to see Bessie back in three months. She may need Depot-Lupron to  hold back her puberty if her growth will be significantly compromised.
Thank you for letting us share in the care of Bessie.

Sincerely,


M Joan Hammer, MD         
Associate in Endocrinology


CONTENT:
Clotilde Pulanski, M.D.          RE: Guy Mikoyan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/29/84

Dear Dr. Pulanski:

We had the pleasure of seeing Guy in the Endocrine Program on 5/15/95 for gynecomastia.

History: Guy is a 10 year old Hispanic boy who comes to the Endocrine Clinic for evaluation of gynecomastia.  He also was seen in August of 1994 for  gynecomastia.  They checked prolactin was 3.0 ng/mL, testosterone was less than 10 ng/dL, an estrodial was 5 ng/dl.  Mom thinks the  gynecomastia started 3-4 years ago and she feels that in the last year it has been getting worse.  There is no galactorrhea, headaches, and no problem with vision.  He has no complains of breast pain.  Mom notes that he has gained a significant amount of weight and does little physical activity.

Current medications: Tylenol.

Past medical history:  Pregnancy was normal.  Full term normal delivery.  Hospitalizations; he was in a motor vehicle accident in 1994.

Review of systems:  He says he is always tired.  No problem with his skin.  No shortness of breath, chest pain, nausea, vomiting or diarrhea.  No polyuria, polydipsia or nocturia.  Occasionally, he  has headaches.

Family history:  As per mother, the father also has some gynecomastia.  The mother's height is 5'4", father's height is 5'7".

Physical exam:  
Height: 140.2 cm        Weight: 46.6 kg         
BP: 90/60               Pulse: 84               
U/L ratio:  0.95        Arm span: 41.5 cm.         
Breast: Tanner I        Pubic hair: Tanner I    Right testis: 2 x 1.6 cm   
General: Looks depressed.  He is overweight for his height.  
Skin: No problems with his skin.  
HEENT: Fundoscopy was normal, sharp discs.  Extraocular muscles were intact.  
Neck: No goiter.  Supple.  
Chest: Lungs clear to auscultation.  There is no breast tissue, just fat tissue 
Heart: S1, S2, no S3.  
Abdomen: Soft.  No hepatosplenomegaly.  
Extremities: Normal.  
Neurological: Nonfocal.

Impression: No real breast tissue was palpable, although this may be different due to the fatty tissue.  We recommend getting a TSH, prolactin, bone age and a nutritionist consult.  The patient will be seen by Dr. Adler in six months and she will call in case any labs come back abnormal.

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


Sincerely,




Kenneth Sheppard, M.D.            Ariel Adler, M.D.           
Fellow in Endocrinology           Attending in Endocrinology   


Addendum:   Guy's lab results included prolactin 4.2, TSH 0.6 IU/ml, and bone age 11 years at CA 10 years 8 months.

Since mom has arranged a nutrition visit, I would like to see Guy in six months after some weight loss.  At that time, a further work up may be needed if the breast enlargement has not decreased with weight loss.


CONTENT:
Nilto McPherson, M.D.          RE: Audrey Isaacs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/84

Dear Dr. McPherson:

We had the pleasure of seeing Audrey in the Endocrine Program on 1/4/94 for follow up of diabetes mellitus.

History: Audrey was diagnosed with diabetes mellitus in December 1992.  Interval history has been uneventful.  Current insulin dosage is 1.5 units  Regular and 7.5 units NPH in the morning, and 0.5-2.0 units Regular and 1.5 units NPH in the evening, for a total of 0.4 u/kg/day.  Diet consists of three meals and three snacks per day, and she feels that this provides an appropriate amount of food for her.  Audrey denies symptoms of hyper- or hypoglycemia.  

Blood sugars are checked three times a day and range as follows: before breakfast 80-140 mg/dL, before dinner 120-240 mg/dL, before bedtime 100-260 mg/dL.

Physical exam:  
Height: 136.2 cm        Weight: 26.8 kg         BP: 96/60               
Breast: Tanner I        Pubic hair: Tanner I    
General: Well appearing, thin.
Neck: Thyroid normal.

Laboratory studies:  Urinalysis3% glucose, no ketones, no protein.  Glycosylated hemoglboin 10.1%, random blood sugar 383 mg/dL.

Impression: Audrey is a 9 and 1/2 year old girl with Type I diabetes mellitus under reasonably good control.  She appears to be coming out of the honeymoon period, with currently increasing insulin requirements.  Although linear growth is normal, she is significantly underweight for height. We would like to increase morning NPH to 8 units.  In addition, she may need extra Regular at breakfast and we have asked the Isaacss to check occasional pre-lunch blood sugars.  For dinner, a sliding scale of 0.5-2.0 units Regular may be employed.  Finally, we have discussed the advantage of TID insulin dosing, and anticipate a change to this routine within one year.   Follow up is recommended for three to four months.

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

Sincerely,


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


CONTENT:
Mitsuko Steinbeck, M.D.          RE: Audrey Isaacs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/84

Dear Dr. Steinbeck:

I saw Audrey in the Endocrine Program on 6/13/96 for insulin-dependent diabetes mellitus.

History: Audrey was diagnosed with diabetes mellitus in December 1992, and was last seen in our clinic on 2/13/96.  Interval health has been good, though mother is concerned about recent variability in blood glucose.  For the summer, Audrey will be attending ice skating camp and an overnight camp.

Mild insulin reactions, often in the evenings, are experienced approximately every other week.  Typical blood sugar ranges as follow:  80-200 mg/dl pre-breakfast, 80-220 mg/dl pre-dinner, 80-300 mg/dl before bed.

Current medications: Current Novolin insulin dosage is: 3 units regular and 15 units NPH morning, 3-4 units regular before dinner and 3 to 3.5 units NPH before bed, for a total of 0.7 u/kg/day.  Audrey follows a meal plan, and obtains moderate amounts of daily exercise.  She anticipates being very active at the overnight summer camp.

Physical exam:
HT: 154.3 cm            WT: 36.5 kg
BP: 116/63              Pulse: 103                   
Breast: Tanner II Pubic hair: Tanner II   
Well appearing, thin, and healthy.  HEENT:  Pupils equal, round, and reactive to light, extraocular movements are intact, lenses clear.  Neck without thyromegaly.  Lungs clear.  Cardiac regular rate and rhythm without murmur.  Abdomen without hepatosplenomegaly.  Extremities with significant hypertrophy at insulin injection sites on the arms.  Skin calluses are present on the fingertips.

Laboratory studies: 141 mg/dl, urinalysis negative for protein, ketones, and glucose, glycosylated hemoglobin at 7.3% (4-6%).  TSH 2.5 mu/ml.  Urinary microalbumin 42 mg/gCr (1-15).

Impression: Audrey is a 11-11/12 year old girl with type I diabetes mellitus under very good control.  Some variability in blood sugars is probably attributable to changes in exercise level and starchy food consumption.  Growth and development are excellent, and she has now entered the early stages of puberty.  When at summer camp, she will require a significant reduction in insulin dosage.  A repeat screening urinary microalbumin is mildly elevated.

Disposition: Dosage of NPH insulin should be adjusted based on activity level as follows:  mornings, 12-15 units and bedtime 2.5 to 3.5 units, (with the smaller amounts given on very active days).  Audrey should avoid insulin injection into the hypertrophied tissue on the arm, using instead the belly at dinner time.  Dosage for summer camp should be decreased to 2 units regular 10 units NPH morning, 2 units dinner and 2.5 units NPH at bedtime with a sliding scale of regular as needed (1 unit regular for blood sugar greater than 240, 2 units regular for blood sugar greater than 400).  Also, of importance, Audrey should take extra snacks throughout the day during the strenuous exercise at summer  camp.  An overnight urine collection for microalbumin should be will be performed at the next visit.  Follow-up is recommended for 3 months with me in diabetes clinic and a nutritionist at Children's Hospital to reassess the meal plan. 

Thank you for referring the Isaacss' to our diabetes clinic.  Please do not hesitate to call us if you have any questions.

Sincerely,






Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Andrew Adler, M.D.          RE: Audrey Isaacs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/84

Dear Dr. Adler:

I saw Audrey in the Diabetes Program on 10/29/96 for insulin-dependent diabetes mellitus.

History: Audrey was diagnosed with diabetes mellitus in 12-92, and was last seen in our clinic on 6-13-96.  Interval history has been good, with no intercurrent illnesses.  She attended YMCA camp over the summer, and is currently doing very well in school.   

She experiences mild insulin reactions less than once a week, typically during or after vigorous exercise.  She follows a 2000 kcal/ADA diet, last updated 7-96.  Exercise is obtained on a daily basis, specifically involving very active participation in gym in the afternoon.   

Blood sugars by report (diabetes log book left at home) are as follows:  92-150 mg/dl before breakfast, lunch rarely checked, dinner 100-150 mg/dl, with occasional readings as low as 50 mg/dl, before bed 120-190 mg/dl.

Current medications: Current insulin dose is 7-8 units Regular and 15-16 units NPH mornings, 2 to 3 units Regular before dinner, 6.5 to 7.0 units NPH before bed for a total of 31 units or 0.75 units/kg/day (NPH dose varied based on activity level).

Physical exam:
HT: 156.8 cm    WT: 41.4 kg
BP: 139/62              Breast: Tanner III      Pubic hair: Tanner III  
General: well appearing adolescent girl. HEENT:  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.  Extremities:  mild to moderate soft tissue hypertrophy on the arms, fingertips show evidence of self monitoring of blood glucose.


Laboratory studies:  Blood sugar 155 mg/dl, hemoglobin A1C 8.2% (4-6%).

Impression: Audrey is a 14-4/12 year old girl with type I diabetes mellitus of the long duration, doing excellently on a t.i.d. insulin regimen.  Growth and development are normal, and she is now entering mid puberty.  I have encouraged her to take extra snacks when especially active, and decrease night time NPH on evenings of intense activity to avoid nocturnal hypoglycemia.  Follow-up is recommended for 3-4 months.

Thank you for referring the Isaacs's to our diabetes clinic.  Please don't hesitate to call should you have any questions.



Sincerely,




Gleide Crane, MD, PhD
Attending in Endocrinology


CONTENT:
Nilto McPherson, M.D.          RE: Audrey Isaacs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/84

Dear Dr. McPherson:

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

History: As you know, Audrey was diagnosed with Type I diabetes approximately 3 months ago. Interval history is notable for one upper respiratory infection, but she remained nonketotic. She is in third grade, likes school, and is generally a happy child.

Current Humulin insulin doses are 1.5 Regular, 3 NPH in the morning, and 1 NPH in the evening which equals 0.2 units/kg/day. There are no symptoms of polyuria, nocturia or polydipsia. She has occasionally had symptoms of mild hypoglycemia, occurring after forgetting a snack. Usual diet is three meals and three snacks a day. Audrey is very active and participates in gym at least five days a week.  Blood sugars are monitored on a One Touch II and have consistently ranged between 80 and 160 mg/dL.

Physical exam:  
Height: 131.1 cm        Weight: 25 kg           BP: 120/70              
Breast: Tanner I        Pubic hair: Tanner I    
General: Alert, pale and nontoxic.  HEENT: Optic fundi without evidence of retinopathy.  Neck: Thyroid palpable, smooth, without enlargement. Chest: Lungs clear. Heart: 2/6 systolic ejection. Abdomen: Without hepatosplenomegaly.

Impression: Audrey is an 8 and 8/12 year old girl with new onset Type I diabetes currently in a honeymoon period. Her weight is up 3 kg from discharge, now to the 25th percentile for her age. We would like Audrey to continue on her current dosage of insulin, and return to clinic in three months. Given her excellent glycemic control, we will defer glycosylated hemoglobin testing at this time.

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

Sincerely,



Gleide Crane, MD             Lancelot Blue, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Nilto McPherson, M.D.          RE: Audrey Isaacs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/84

Dear Dr. McPherson:

We had the pleasure of seeing Audrey in the Endocrine Program on 6/8/93 for follow-up of diabetes mellitus.

History: As you well know, Audrey was diagnosed with Type I diabetes mellitus in December of 1992. Interval history is notable only for a viral syndrome, although she remained nonketotic. Audrey is finishing the third grade, and plans to attend summer day camp starting in July. 

Current Novolin insulin dosage is 1.5 Regular and 3 NPH in the morning and 1 NPH in the evening for a total of 0.2 units/kg/day.  She denies symptoms of hyperglycemia, and has experienced only two mild insulin reactions after missing meals. Diet consists of three meals and three snacks a day, and she participates in daily aerobic-type exercises.  Blood sugars are monitored three times a day and range between 70 and 120 mg/dL before breakfast, 80 and 140 mg/dL before dinner, and 80-200 mg/dL before bedtime.

Physical exam:  
Height: 133.6 cm        Weight: 25.4 kg         BP: 100/60              
Breast: Tanner I        Pubic hair: Tanner I    
General: alert, well developed and healthy appearing. Eyes without retinopathy.  Thyroid palpable but not enlarged. The remainder of the physical exam was unremarkable.

Laboratory studies:  Glycosylated hemoglobin 8.1%.

Impression: Audrey is an 8 and 11/12 year old girl with Type I diabetes, remaining in the "honeymoon period".  She demonstrates excellent glycemic control on very low insulin dosage.  Rapid linear growth over the past three months may indicate impending onset of puberty. We would like Audrey to continue her current insulin dosage and return to clinic in three to four months time. In addition, she should get a baseline ophthalmologic exam by her eye doctor.

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

Sincerely,


Gleide Crane, MD             Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Nilto McPherson, M.D.          RE: Audrey Isaacs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/04/84

Dear Dr. McPherson:

We had the pleasure of seeing Audrey in the Endocrine Program on 9/21/93 for follow-up of diabetes mellitus.

History: Audrey was diagnosed with diabetes mellitus in December 1992.  Interval health has been good.  She is starting fourth grade this month, and knowledgeable adults are available at school to assist with diabetes management.  

Current Novolin insulin dosage is 1.5 units Regular/4 units NPH mornings, and 1 unit NPH evenings, for a total of 0.25 units/kg/day.  She denies symptoms of hyperglycemia; occasional mild insulin reactions are associated with forgetting to take snacks.  Diet consists of three meals and three snacks a day, and Audrey is satisfied with this diet plan. 

Blood sugars are monitored on a One Touch II and range 70-110 mg/dL before breakfast, 80-140 mg/dl before dinner and 80-180 mg/dL before bedtime.

Physical exam:  
Height: 134.5 cm        Weight: 26.3 kg         BP: 124/61              
Breast: Tanner I        Pubic hair: Tanner I    
General:  Alert, healthy, pleasant. Skin: Injection sites without atrophy or hypertrophy. HEENT: PERRL, EOMI, lens clear. Neck: Thyroid palpable, smooth, symmetrical. Chest: Lungs clear. Heart: Without murmurs. Abdomen: Without hepatosplenomegaly.

Impression: Audrey is a 9 and 1/12 year old girl with Type I diabetes mellitus under excellent control, and is still in the honeymoon period.  She is of slim build with weight relatively low for height.  We recommend continuing the current insulin dose regimen, and would like to encourage increased caloric intake.  In view of the excellent glycemic control, we  deferred glycosylated hemoglobin testing today.  Audrey is to return to Clinic in three months.

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

Sincerely,


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


CONTENT:
Sanders, M.D.          RE: Rosalie Kirby
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/27/85

Dear Dr. Sanders:

We had the pleasure of seeing Rosalie in the Endocrine Program on 12/15/94 for early puberty.

History: Rosalie is a 9 and 6/12 year old black female referred for evaluation of early puberty.   The patient was diagnosed with ALL at 2 years of age in 1987.   She received about 1,800 rads for three weeks in 1987 and then received chemotherapy.  She has been in remission for the past 5 years.   She is not on any medications at present.   She was noted to have breast development by her mother about a year ago with concomitant body odor.   Nine months ago, her mother noticed pubic hair growth.   Over the past two months, there has been some vaginal discharge.   There has been no nipple discharge.

Past medical history:  She was the 37 week product of an uncomplicated pregnancy by normal spontaneous vaginal delivery.   Normal growth and development.   Nutrition: mom reports that Rosalie has had increased appetite during and since the Prednisone therapy for the ALL.   No hospitalizations other than those for the ALL treatment.

Review of systems:  Positive for cataracts followed by ophthalmology.

Family history:  Sickle cell anemia and carcinomas in teh family members,  breast and bone cancer in the maternal grandparents.   Her mother is healthy, and she doesn't remember when her menarche occurred.   The patient also has a 17 year old sister who had menarche at 15 years of age.   Mother's height is 5'3", father's height is 5'9", by report.

Physical exam:  
Height: 145.2 cm        Weight: 58 kg           BP: 98/62               
Pulse: 80               U/L ratio:  0.96        Arm span: 152           
Breast: Tanner IV       Pubic hair: Tanner III  
Pubic hair: Tanner III-IV

General: Alert, overweight, hyperactive black female in no acute distress.   
Skin: Warm and dry with no rashes. 
HEENT: Pupils equal and reactive to light.   Extraocular movement intact.   Oropharynx clear.   Tympanic membranes clear.  
Neck: Supple, with no adenopathy or thyroid enlargement.  
Chest: Clear to auscultation bilaterally.    
Heart: Regular rate and rhythm without murmur.  
Abdomen: Soft, nontender, not distended, with no hepatosplenomegaly or masses. 
Genitourinary: Normal female.   Tanner III-IV.   Estrogenized vaginal mucosa present.   
Extremities: Warm and well perfused with no cyanosis, clubbing or edema.   
Neurological: Alert and oriented x3.   Deep tendon reflexes 2+/4.   Cranial nerves 2-12 were intact.
Bone age: 13 years


Impression: Aishea is going through puberty at an early age relative to her family members probably secondary to cranial irradiation.  As she is not undergoing a precocious puberty, should reach a "normal" adult height (albeit probably less than her target height), and has moved to Maryland, we chose to do nothing but observe her.

Disposition: The patient will move to Maryland as of January 1, 1995.   The patient is to follow up with pediatrician there in about 4 months, and it was suggested that they seen an endocrinologist at Hopkins.
Thank you for letting us share in the care of Rosalie.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology   


Addendum: Stephania Natalone, M.D.
Resident in Pediatrics
Boston City Hospital


CONTENT:
Valdeci Meisner, M.D.          RE: Jerome Borden
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/09/80

Dear Dr. Meisner:

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

History: I saw Jerome, age 14 years 10 1/2 months, for follow-up of insulin- dependent diabetes mellitus diagnosed approximately ten years ago.

He is becoming more involved in diabetes self-management and now draws up, mixes, and gives his insulin under parental supervision.

He reports no significant hypoglycemia, has a good appetite, and is physically active.  Blood glucose monitoring is usually done twice daily but he does not always record the data.

Current medications: Insulin dose:  10 Regular and 26 NPH before breakfast; 10 Regular before supper; and 14 NPH at bedtime (60 units or 1.22 u/kg/day).

Physical exam:  
Height: 158.2 cm        Weight: 49.2 kg         BP: 106/66              
Pulse: 80               
Physical exam was entirely unremarkable.  Injection sites were healthy.  Thyroid gland was not palpable.

Impression: Jerome is growing and gaining weight normally.  His diabetes appears to be under satisfactory control.  Based on the blood glucose data available, I recommended increasing the insulin dose to 11 Regular and 26 NPH before breakfast; 10 Regular before lunch, and 15 NPH at bedtime (62 units or 1.26 u/kg/day).  We discussed the desirability of more frequent monitoring and meticulous record keeping and Jerome promised he would try to comply.  He is due for an annual dilated retinal examination to screen for retinopathy.  Thank you for the opportunity to share in the care of this delightful youngster.  He will follow-up with Dr. Ludwig in 3 months.


Laboratory studies pending at this time include: Urine had 1% glucose, negative ketones and protein.  Plasma glucose 274 mg/dl, hemoglobin A1 9.3 (nl.5.2-7.8)%.
Thank you for letting us share in the care of Jerome.

Sincerely,


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


Problem list to date:
INSULIN-DEPENDENT-DM                         05/12/89  
Transcribed by Sullivan_ma


CONTENT:
Valdeci Meisner, M.D.          RE: Jerome Borden
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/09/80

Dear Dr. Meisner:

I saw Jerome in the Endocrine Program on 7/9/96 for insulin-dependent diabetes mellitus.

History: Jerome was diagnosed with diabetes in early childhood.  His overall management has been complicated by conflicts with his parents regarding control of diabetes issues.  Of note, his father has recently undergone cardiac bypass surgery, from which he is now recovering.  Jerome is in town for the summer, and has decided not to attend diabetes camp this summer. 

Jerome describes frequently experiencing symptoms of hypoglycemia in the afternoon, especially associated with exercise or missed afternoon snacks.  He generally eats 3 meals and 2 snacks a day, but does not follow any specific meal plan.

Current insulin dose is 11 units regular, 30 units NPH mornings; 13 units regular dinner; and 18 units NPH at bedtime.  

Blood sugars are monitored very infrequently; however, the majority of afternoon values in the past few weeks have been in the 40-100 mg/dl range.

Physical exam:
HT: 166.3 cm    WT: 57.6 kg

Physical examination deferred.

Laboratory studies: Blood sugar 308 mg/dl, glycosylated hemoglobin 8.7%, total cholesterol 210.  Urinalysis with 5% glucose, no ketones, no protein.

Impression: Jerome is a 16 year old boy with poorly controlled  insulin-dependent diabetes mellitus, related to noncompliance with fingerstick blood glucose monitoring and diet.  Of concern, he is shows frequent signs and symptoms of hypoglycemia in the afternoon, and probable hyperglycemia at other times.  Underlying issues include a control struggle with the parents over how to manage diabetes issues.  Jerome, in an extensive private conversation with me, described feeling that his parents treat him without respect, and do not allow him adequate freedom.

Disposition: I counseled Jerome that a good way to demonstrate responsibility to his parents, was to take better care of his diabetes.  He agreed to check blood glucose at least twice a day, and call in with questions.  In addition, I would like to decrease morning NPH to 25 units, in an attempt to decrease the incidence of afternoon hypoglycemia.  Follow-up is recommended for three months.


Sincerely,






Gleide Crane, MD, PhD             
Attending in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Jerome Borden
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/09/80

Dear Dr. Meisner:

I saw Jerome in the Diabetes Program on 10/29/96 for insulin-dependent diabetes mellitus.

History: Jerome was diagnosed with diabetes mellitus in 1995, and was last seen in our clinic on 7/9/96.  Interval history is notable for high blood sugars in the past month, though he is otherwise doing well.  Jerome describes no problems in school, though experiences continued struggle with his parents over the diabetes management.  He has attempted to show more responsibility vis-a-vis diabetes care, and the parents have noted a somewhat improved attitude on his part recently.  

Jerome occasionally experiences symptoms of hypoglycemia, characteristically when skipping a snack.  Blood sugars are available only for the past week in his diabetes log book (the last book was not brought to clinic):  120-180 mg/dl before breakfast, 100-300 mg/dl before lunch, 50-300 mg/dl before dinner, and 100-300 mg/dl before bedtime.

Physical exam: HT: 166.9 cm    WT: 59.2 kg         BP: 136/63              
On physical examination today, general: well-appearing.  HEENT: unremarkable.  Thyroid:  palpable though non-goiterous.  Remainder of exam within normal limits.

Laboratory studies:  hemoglobin A1c 8.9%, blood glucose 354 mg/dl, urinalysis specific gravity 1.035, 3+ glucose, no protein, no ketones.

Impression: Jerome is a 16-2/12 year old boy with diabetes mellitus under reasonable glycemic control.  Growth and development are normal.  Continued family conflict exists over diabetes management; specifically, the question of taking adequate responsibility vs. having appropriate independence.  I have held an extensive discussion with Jerome alone and together with his parents regarding these issues.

Disposition: Continue at the current insulin dose, calling in as-needed for  adjustments.  Avoid skipping afternoon snacks, especially when active.  In addition, the Borden's may benefit from a short course of family counseling, a decision which I will leave to you and the Borden's.  Finally, when Jerome and his parents prefer, care can be switched from our Diabetes Clinic to the Joslin Diabetes Center for a more adult environment. 

Thank you for referring the Borden's to our Diabetes Clinic.  Please do not hesitate to call should you have any questions.



Sincerely,




Gleide Crane, MD, PhD
Attending in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Jerome Borden
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/09/80

Dear Dr. Meisner:

We had the pleasure of seeing Jerome in the Endocrine Program on 10/11/91 for evaluation of diabetes mellitus.

History: Jerome is an 11 and 2/12 year old youngster with diabetes for 5 years.  He has been largely well since his last visit.  His parents note that he has become more independent over the last several months and this has made his care somewhat more difficult.  He has not had any reactions and remains on a 3 meal/3 snack dietary regimen.

Current medications: Insulin 0-4 units of regular and 20 units of lente in the morning and 0-2 units of regular and 6 units of lente in the evening for a total daily dose of approximately 0.8 units/kg/day.

Review of systems: Occasional stomach aches which resolve spontaneously.

Physical exam:  
Height: 135.2 cm        Weight: 33.1 kg         BP: 96/68               
Pulse: 78               Pubic hair Tanner: 2    
Testes and penis were prepubertal in size.
General: Jerome was well-developed and well-nourished. 
Skin: No stiffness, atrophy, or hypertraphy.
HEENT: Pupils equal, round, reactive to light and accomodation.
Neck: Thyroid non-palpable.
Neurological: Intact.

Laboratory studies:
Glycolsylated hemoglobin 9.2% -- outstanding!

In summary: Jerome appears to be doing well on his current regimen.

Disposition: Jerome is to return to clinic in 4 months.

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

Sincerely,


Rahul Ibsen, MD                Bernardo Bird, MD


CONTENT:
Valdeci Meisner, M.D.          RE: Jerome Borden
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/09/80

Dear Dr. Meisner:

We had the pleasure of seeing Jerome in the Endocrine Program on 10/27/92 for follow-up of diabetes mellitus.

History: As you know, he was diagnosed with diabetes mellitus in 1985. Since then he has generally done well, without major complications. Interval history has been good. He currently takes Pork insulin twice a day at the following dose: a.m. 3-5 units regular, 20 units Lente; p.m. 1-3 units regular, 7 units Lente for a total of 33 units a day or 0.95 units/kg/day. He denies recent polydipsia, polyuria, nocturia, or symptoms of hypoglycemia. Diet and exercise regimen are somewhat erratic and there is some struggle with the parents regarding exactly what and when to eat. Blood glucoses are checked by One Touch I Meter and tend to be between 60 and 240 before breakfast and in the 200s before dinner.

Physical exam:  
Height: 139.8 cm        Weight: 34.9 kg         BP: 116/70              
Pulse: 90               
General: Alert and nontoxic. Thyroid normal. Lungs clear. Cardiac exam benign. Abdomen was without masses. GU: Tanner Stage I. Neuro exam nonfocal. The remainder of the general physical exam was normal.

Laboratory studies:  Hemoglobin-A1 9.3.

Impression: In summary, Jerome is now 12 and 2/12 years old with juvenile onset diabetes mellitus in fair control. There is considerable variability in diet and exercise, and blood sugars before dinner are somewhat higher than ideal. Jared appears to have  control struggles with his parents over management of the diabetes, and currently will check blood sugar only twice a day.

Disposition: Our plan is as follows: 1. increase a.m. lente to 22 units, 2. use extra regular PRN hyperglycemia, 3. ophthalmology exam needed in the next three months, 4. we will send TSH, cholesterol, and hemoglobin-A1 at this visit, 5. try to obtain occasional lunch and bedtime glucose values for better adjustment of regular insulin, 6. the family is to consider diabetes winter camp for Jerome.
Thank you for letting us share in the care of Jerome.

Sincerely,


Gleide Crane, MD             M Joan Hammer, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Jerome Borden
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/09/80

Dear Dr. Meisner:

We had the pleasure of seeing Jerome in the Endocrine Program on 1/12/93 for follow-up of diabetes mellitus.

History: Jerome was diagnosed with diabetes mellitus approximately 6 years ago. Intercurrent history is unremarkable. He is currently in the 7th grade, and doing well. Diabetes management has been complicated, however, by struggles between Jerome and his parents over diet, number of finger stick blood sugars to be performed each day, etc. 

He currently receives in the morning 0-5 units Regular and 22 units Lente; in the evening 0-3 units Regular and 7 units Lente, which equals 1.0  units/kg/day. He has had no symptoms of hypoglycemia in the past few months. Review of systems is positive for polyuria,  polydipsia and blurry vision over the past several weeks. 

Blood sugars checked by a One Touch I Monitor, approximately twice a day. Typical readings before breakfast range between 60 and 300, and before dinner between 80 and 300.

Physical exam:  
Height: 139.9 cm        Weight: 35.5 kg         BP: 100/70              
Alert, well developed. Thyroid gland palpable, homogeneous, nongoiterous. Lungs clear. Heart benign. Belly without hepatosplenomegaly. Remainder of the exam unremarkable.

Laboratory studies:  1/12/93 hemoglobin-A1 10.3, total cholesterol 223, HDLC 55, triglyceride 93.

Impression: In summary, Jerome is a 12 and 5/12 year old boy with insulin dependent diabetes mellitus of long duration, in fair to good control. There is considerable variability in blood glucose readings, especially in the morning, raising concern for nocturnal hypoglycemia. Recent onset of visual changes and polyuria, however, suggest a need for increased total insulin dosage. In addition, Jerome appears to be experiencing adolescent control struggles regarding diabetes management with his parents. 

Our plan is as follows; 1) check lunch and occasional 2 a.m. blood glucoses over the next couple of weeks. Parents are to call  in three weeks, at which time alterations in insulin dose will be discussed. 2) Jerome is to receive a thorough ophthalmologic evaluation in the next 2-3 weeks. 3) Elevated cholesterol is of some concern. However, HDLC of 55 may be somewhat protective. Jerome is to be advised to consume a low saturated fat and cholesterol diet. 4) Cooperation and understanding between Jerome and his parents is to be fostered as relating to diabetes management. In this respect, diabetes summer camp may prove helpful.

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

Sincerely,


Gleide Crane, MD             M Joan Hammer, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Valdeci Meisner, M.D.          RE: Jerome Borden
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/09/80

Dear Dr. Meisner:

We had the pleasure of seeing Jerome in the Endocrine Program on 10/5/93 for follow-up of diabetes mellitus.

History: Jerome was diagnosed with diabetes in 1985.  Interval history has been without significant complications.  He is currently in the eighth grade, and has no problems managing diabetes at school.

Current Porcine insulin dose is 3 to 5 units Regular/25 units Lente mornings, and 1 to 3 units Regular/8 units Lente evenings for a total of 1.05 U/kg/day.  He denies symptoms of hyper- or hypoglycemia.  Diet consists of three meals and two snacks per day (morning snack is omitted).  Blood sugar is checked on a One Touch II monitor approximately twice a day.  Typical pre-breakfast blood sugar reading are are 80 to 300 mg/dL, and 80 to 360 mg/dL pre-dinner.

Physical exam:  
Height: 143.5 cm        Weight: 37.3 kg         BP: 110/80              
Pubic hair: Tanner II   


Laboratory studies:  Glycosylated hemoglobin 10.8%.

Impression: Jerome is a 13 and 2/12 year old boy with insulin-dependent diabetes mellitus.  Management is complicated by variability of diet and schedule, and infrequent blood glucose monitoring.  Please note that he has a history of high cholesterol and currently shows trace proteinuria.  The growth deceleration noted recently is characteristic of the pre-adolescent period. Finally, although Jerome denies problems at home or at school, his affect is suggestive of mild depression.

Disposition: We have discussed with Jerome and his parents the importance of improved glycemic control especially now that he is entering adolescence.  We recommend close attention to dietary regimen (a meeting has been arranged with our nutritionist, Laurie Higgins, RD) and more frequent blood sugar testing.  In addition, three times a day insulin dosing should be considered.  Our social worker, Ellen Goodman, LICSW, will give the family a call and discuss possible emotional or psychological problems.  We will await the results of urine for microalbuminuria, and would like to speak with the Bordens in two weeks.  Follow up appointment is recommended for three months.
Thank you for letting us share in the care of Jerome.

Sincerely,


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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 4/11/94 for .

History: I saw Miguel, age 9 years and 6 months in follow up for percocious puberty.   He was last seen November 1993.   

He is currently on Lupron 7.5 mg monthly.  He is on no other medications.

He has had three ear infections over the winter and he is currently not taking antibiotics.  Mother stated that she has recently observed more self-stimulatory behavior especially when he is sitting,  for example in teh bath.   There is a question of possibly more black heads and more increased pubic hair.  He has a large appetite.  Bowel movements occur every other day.  He sleeps well without disturbance.

Physical exam:  
Height: 132.6 cm        Weight: 38.6 kg         Pulse: 80               
Breast: Tanner I        Pubic hair: Tanner II   R. testis: 2 x 1 cm     
L. testis: 2 x 1 cm     Phallus length: 5.5 cm  Mid-shaft diam.: 2.2 cm 
The examination was difficult


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

Sincerely,


Bernardo Bird, MD         
Clinical Director            


Addendum: Associate Professor of Pediatrics, HMS

Problem list to date:

Transcribed by Fahey


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 4/11/94 for .

History: I saw Miguel, age 9 years and 6 months, in follow up for precocious puberty.   He was last seen November 1993.   

He is currently on Lupron 7.5 mg monthly.  He is on no other medications.

He has had three ear infections over the winter.    Mother stated that she has recently observed more self-stimulatory behavior especially when he is sitting,  for example in the bath.   There is a question of possibly more blackheads and more increased pubic hair.  He has a large appetite.  Bowel movements occur every other day.  He sleeps well without disturbance.

Physical exam:  
Height: 132.6 cm        Weight: 38.6 kg         Pulse: 80               
Breast: Tanner I        Pubic hair: Tanner II   R. testis: 2 x 1 cm     
L. testis: 2 x 1 cm     Phallus length: 5.5 cm  Mid-shaft diam.: 2.2 cm 
The examination was difficult because he was "tactiley defensive".  
General:  Looks well.  Color and hydration were good.  Well nourished.
Skin: No comedones.
HEENT: Unremarkable.
Neck: No thyromegaly.
Lymph Nodes: Not palpable.
Chest: Clear to percussion and auscultation.
Heart: No murmur.
Abdomen: Mildly obese; liver, spleen and kidneys were not enlarged and there were no masses.

Laboratory studies:  Serum LH and FSH were less than 0.1 and 1.1 IU/L, respectively; serum testosterone less than 10 ng/dL, and bone age was 12 years, 0/6 months (standard deviation 10 months).

Impression: Miguel has grown 1.9 cm in five months (an annualized growth velocity of 4.6 cm per year); weight has increased 4.2 kg in this period.   

His growth rate has slowed significantly and the lab studies indicate that puberty is suppressed.   

I recommended continuation of Lupron 7.5 mg monthly.   I would appreciate the opportunity to see him again in follow up in three months.

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

Sincerely,


Bernardo Bird, MD         
Clinical Director            


Addendum: Associate Professor of Pediatrics, HMS


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 7/11/94 for .

History: I saw Miguel, age 9 years 8 1/2 months, in follow-up for precocious puberty.

He is currently on Lupron Depot 7.5 mg (0.19 mg/kg) monthly.  He is on no other medications.

There has been no evidence of acne and no change in behavior.  He has an excellent appetite and has three meals and 1-2 snacks daily.  He sleeps from ~ 7:30 p.m. until 6:00 a.m.   Sleep is undisturbed.  

His mother is anxious for him not to enter puberty at this time.

Physical exam:  
Height: 135.9 cm        Weight: 39.2 kg         Breast: Tanner I        
Pubic hair: Tanner III  R. testis: 2.2 x 1.1 cm L. testis: 2.2 x 1.2 cm 
Phallus length: 7.0 cm  Mid-shaft diam.: 2.1 cm 
General: Well-developed, well-nourished, tanned; color and hydration were normal.
Skin: No acne or comedones.
HEENT, neck and lymph nodes were all unremarkable.
Abdomen: Liver, spleen and kidneys are not enlarged; no masses; mild abdominal obesity.  Axillary hair not present.

Laboratory studies:  Prior bone age was 12 years 6 months at chronologic age 9 years 6 months.  His predicted adult height based on this measurement was ~ 63".  

His growth velocity over the past year was 8.4 cm. and weight gain 7.0 kg.  He is growing too rapidly.  I am concerned that puberty is not satisfactorily suppressed.  Accordingly, I have recommended switching to more frequent administration of Lupron, 7.5 mg at three week intervals rather than 4 week intervals.  I have scheduled a repeat GnRH test in three months just prior to his next dose of Lupron.


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

Sincerely,


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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 9/19/94 for .

History: I saw Miguel, age 9 years 11 months, in follow-up for precocious puberty.

Medications: Lupron 7.5 mg q 3 weeks; Ritalin 5 mg bid for the past month.

During the past month, he has had ear infections treated with Amoxicillin.  He is currently taking Ceftin.  

Since starting Ritalin, appetite has decreased, especially at lunch.  His diet consists of breakfast and then very little until a 4:00 p.m. snack and dinner at 6:00 p.m.  

There have been no changes in general behavior and, in particular no self-stimulatory behavior.  Except for " a couple of blemishes on his face", there have been no additional signs of secondary sexual development.  He does have an apocrine odor and mother applies a deodorant.

Physical exam:  
Height: 137.1 cm        Weight: 39. kg          Pubic hair: Tanner III  
R. testis: 2.0 x 1.0 cm L. testis: 2.0 x 1.0 cm Phallus length: 6.0 cm  
Mid-shaft diam.: 1.8 cm 
General: He was uncooperative and it was difficult to measure his height acurrately. Skin: Tanned and smooth.   No axillary hair present. HEENT, neck and lymph nodes:  Unremarkable.  Abdomen: No abdominal masses or organ enlargement.

Laboratory studies:  Baseline LH and FSH values were <0.1 and 1.3 U/L, respectively.  The values 45 minutes after GnRH were <0.1 and 1.5 U/L, respectively.

Impression: There has been a minor decrease in weight and a slowing of linear growth.  These findings, together with his response to GnRH, indicate that sex steroid production has decreased since we increased the dose of Lupron.  I plan to continue treating him on the current dose until I see him again in four months.

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

Sincerely,


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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 1/9/95 for .

History: I saw Miguel, age 10 years .25 months, for follow-up of precocious puberty.

Medications:  Lupron. Depot 7.5 mg q 3 weeks; Tegretol 100 mg bid; Zoloft 25 mg daily.

He has a large appetite.  There have been difficulties in school relating to his behavior.  School personnel have had difficulty handling Miguel.  He had a BEAM test at Children's Hospital and this was apparently markedly abnormal.

Physical exam:  
Height: 137.4 cm        Weight: 42.5 kg         BP: 110/80              
Pulse: 80               Pubic hair: Tanner III  R. testis: 2 x 1 cm     
L. testis: 2 x 1 cm     Phallus length: 6.0 cm  Mid-shaft diam.: 2.4 cm 
Height was difficult to measure accurately and was 137.4 cm. 138.1 cm., 138.8 cm.; weight 42.5 kg.  Tanner pubic hair stage III.
Left testis 2x1, right testis 2.x1.  Penile stretch length 6.0 cm. mid-shaft diameter 2.4 cm.
Physical exam was difficult.  He looked well; had smooth warm skin and no acne.  There was no axillary hair.  Thyroid gland was not palpable.  Chest was clear.  I heard a grade II/IV systolic ejection murmur.  The remainder of the exam was unchanged.

Laboratory studies:  Serum LH 0.15, FSH 1.0 IU/L, testosterone <10 ng/dL, indicating suppression of the pituitary-gonadal axis.

Impression: Miguel's weight has increased 3.5 kg and height has increased between 1 and 1.7 cm. in a little less than four months.  There appears to have been a modest increase in the size of his phallus.  Accordingly, I have increased his dose of Lupron  to 11.25 mg q 4 weeks (0.27 mg/kg).  I plan to see him again in four months.

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

Sincerely,


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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 4/24/95 for .

History: I saw Miguel, age 10 years 6 months, for follow up of precocious puberty.

General health has been good.  

He is currently on Tegretol 300 mg bid; Zoloft 25 mg qd; Lupron 11.5 mg q4 weeks (0.25 mg/kg).

There have been no significant changes in his signs or symptoms of secondary sexual development.

Physical exam:  
Weight: 45.6 kg         Pulse: 70               Pubic hair: Tanner II   
R. testis: 2.0 x 1.1 cm L. testis: 2.0 x 1.0 cm Phallus length: 7.0 cm  
Mid-shaft diam.: 2.2 cm 
Height: 140.1, 140.5 cm (difficult to measure accurately).
He looked well and had good color and hydration.  Skin was smooth and warm.  There was no facial acne or comedones.  There was no axillary hair.  There was mild obesity.  The remainder of the exam was unchanged.

Impression: His growth rate is normal; weight continues to increase at a rate greater than his increase in height.  The serum LH, FSH, and testosterone vaIues indicate suppression of the pituitary-gonadal axis.  I have recommended continuing the current dose of Lupron and will see him again in four months.


Laboratory studies pending at this time include: Serum LH .12, FSH 1.1 IU/L, testosterone <10 ng/dL, DS 21 5g/dL.  Bone age was 11 years 6 months (standard deviation 10.5 months).
Thank you for letting us share in the care of Miguel.

Sincerely,


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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

I saw Miguel, age 10 years 10 months, for follow-up of precocious puberty on 8/21/95. 

He has enjoyed good health.  Mother has observed no changes in signs of  secondary sexual development and there has been no increase in  self-stimulatory behavior. 

He has a voracious appetite and his mother has to restrict food.  He has  bowel movements every other day.  He sleeps from 8:00 p.m. until  approximately 7:30 a.m. without disturbance.  He continues to have  enuresis four nights per week.  He is dry during the day.

Current medications: Tegretol 300 mg bid; Zoloft 5 mg qAM; Lupron 11.5 mg q 4 weeks (0.24 mg/kg).

Physical exam:  
Height: 140.1 cm        Weight: 48.0 kg                      
Pulse: 80      
Breast: Tanner I        Pubic hair: Tanner III  
Phallus length: 6.0 cm  Mid-shaft diam.: 2.2 cm 
He was uncooperative and difficult to examine.  He has  evidence of a summer tan.  Chest was clear.  Heart normal.  Abdomen was  obese without striae.  There was no organ enlargement or masses.

Laboratory studies: LH <0.10, FSH 0.87 IU/L, testosterone <10 ng/dL; T4 5.9 5g/dL, TBGI .90, TSH 2.7 5U/mL, all normal.

Impression: His height is unchanged; weight has increased 2.4 kg.  There appears to  be a little more pubic hair but no other obvious change in the signs of secondary sexual development.  The LH, FSH and testosterone levels are consistent with suppression of puberty.

Disposition: I have recommended continuing the current dose of Lupron for an additional 2 months; thereafter, increase the dose to 15 mg q 4 weeks to approximate the recommended dose of 0.3 mg/kg.

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

Sincerely,



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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

I saw Miguel, age 11 years 1.5 months, for follow-up of precocious puberty. 

Medications:  Lupron 15 mg. (0.31 mg/kg) q4wk IM; Tegretol 300 mg b.i.d.; Zoloft 25 mg qa.m. 

He has enjoyed good health.  Mother stated that he has a large appetite.  He is doing well in school.  There has been no increase in aggressive behavior; in fact, his mother stated that he is happier than ever before. 

She has not observed any change in his genital development and there has been no self-stimulatory behavior.  He uses a deodorant in the summer.

Current medications: None.

Physical exam:
Height: 141.7 cm         Weight: 48.6 kg
Pulse: 70                Pubic hair: Tanner IV   
Phallus length: 6.0 cm   Mid-shaft diam.: 2.3 cm 
He looked well, had no facial acne or axillary hair.  He has moderate abdominal obesity.  The remainder of the examination was unchanged. 

His growth rate is within the normal range.  His rate of weight gain has decreased.  According to my measurements, there has been no change in the appearance of his external genitalia.

Laboratory studies: 
AST          34     U/L       LYMPH A    1.33   K/MM3    
NA          141  MMOL/L       EOS ABS     .10   K/MM3    
TEG         9.9  MCG/ML       NEUT-A     59.3       %    
WBC        5.01   K/MM3       LYMPH-A    26.5       %    
RBC        4.53   M/MM3       MONO-A      8.6       % (H)
HGB        13.4    G/DL       EOS-A       2.0       %    
HCT.       40.1       %       BASO-A       .7       %    
MCV        88.5      FL       ATYP LY     2.9       %    
MCH        29.6      PG       NF-2002  ABSENT    
MCHC       33.4    G/DL       DS           29   ug/dL (C)
RDW        13.0       %       LH        <0.10    IU/L    
HDW        2.67    G/DL       FSH        0.87    IU/L    
PLT UNC     217   K/MM3       TESTOS      <10   ng/dL (*)
NEUT AB    2.97   K/MM3

Impression: He is growing at a normal rate; rate of weight gain has decreased.  Puberty continues to be suppressed.  Continue Lupron Depo 15 mg q4wk.



Sincerely,




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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

I saw Miguel, age 11 years 6 months, for follow up of precocious puberty. 

Medications:  Lupron 15 mg q4 weeks (0.3 mg/kg); Tegretol 300 mg b.i.d.; Zoloft 25 mg q.a.m.  

He has enjoyed good health.  Parents stated that he seems more hungry, possibly related to boredom. They have to stop him from overeating.  He has three meals daily and two snacks at school.  Bedtime is approximately 7:30-8 p.m. and he sleeps well without disturbance.  He continues to have enuresis at night but rarely during the day.

Current medications: None.

Physical exam:
HT: 142.6 cm            WT: 50.5 kg
Pulse: 80               Pubic hair: Tanner IV   
Phallus length: 6.0 cm  Mid-shaft diam.: 2.5 cm 
He looked well, had good color and hydration.  He is moderately overweight.  There was no facial acne or hair on the upper lip.  There was no thyromegaly or lymphadenopathy.  Chest was clear and heart was normal.  He had no axillary hair.  He had abdominal obesity but no masses or organ enlargement.  Testes were retractile and measured approximately 3 ml on the right and 2 ml on the left (difficult to measure accurately).
Bone age: 14 years

Laboratory studies: Serum LH <0.10, FSH 0.80 IU/L; DS 31 5g/dL; testosterone pending.

Impression: He continues to have a pre-pubertal growth rate.  Weight gain has continued at an accelerated pace.  There has been no progression of secondary sexual development.

Disposition: In view of Miguel's significant development delay, I think it is appropriate,  for psychosocial reasons, to continue to use Lupron to suppress puberty.  Accordingly, I have renewed his prescription for Lupron 15 mg I.M. q4 weeks.

Sincerely,



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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

I saw Miguel, age 11 years 10 months, for follow-up of precocious puberty. 

Medications:  Lupron 15 mg q4 weeks; Tegretol 300 mg. b.i.d.; Zoloft 25 mg. qam. 

He has been healthy except for a recent otitis media.  Mother stated that he has been "happy and focused".   

There has been no increase in sexual hair or facial acne.  There has been no unusual masturbation or self-stimulatory behavior.  He does use an axillary deodorant.

Physical exam:
HT: 144.5 cm            WT: 52.1 kg
Pulse: 92               Breast: Tanner I        Pubic hair: Tanner III  
Phallus length: 5.5 cm  Mid-shaft diam.: 2.4 cm 
He looked well, he is moderately overweight, skin was tan.  There was no facial acne.  His tympanic membranes were clear.  Testes were difficult to measure; both were approximately 2 ml. in volume.

Laboratory studies: Serum LH <0.2, FSH 1.10 IU/L, testosterone <10 ng/dL. Plasma tegretol level 10.2 mcg/mL; sodium 141, potassium 3.7, chloride 107, TCO2 24 mmol/L; HGB 11.4 g/dL, HCT 31.2 %, MCV 83.0 FL, WBC 5.41, platelets 295 K/MM3.

Impression: Height and weight have increased 1.9 cm. and 1.6 kg., respectively since his last visit.  His growth velocity over the past year is 4.4 cm. per year.  His growth is following that of a boy with pubertal delay, which is to be anticipated in a boy who's puberty is being arrested pharmacologically.

Disposition: He will continue to take Lupron 15 mg. q.4 weeks.

Sincerely,





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


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 2/8/93 for precocious puberty.

History: Miguel is an 8 and 4/12 year old male has a history of motor and verbal delay after having been born one month premature; birth weight at 3 lbs. 3 oz; delivered by Cesarean section for breech presentation. His mother noticed sparse pubic hair approximately two months ago, which has steadily increased since that time.  In addition, over the last few months she has noticed Miguel engaging in self stimulation and having erections.  She has not noticed any axillary hair or increased hair growth on legs or arms.  He seems to be physically stronger and has an increased appetite.  Hehas gained weight and grown taller.  Since the summer he has been growing out of his clothing.  He has not complained of nausea, vomiting, headaches, or visual problems.  Mother does believe that she also notices his eye brows darkening and thickening.

Past medical history:  He was born one month premature and was delivered by Cesarean section secondary to breech presentation.  He was hospitalized for five weeks after birth.  He was diagnosed to have IVH of the left ventricle after three days of life.  His birth weight was 3 lbs. 3 oz.  Since birth he was slow to gain weight.  He had feeding problems characterized by gagging.  He did breast feed.  His growth and development was always delayed since birth and it is only since this past summer that he seems to be catching up.  He has had multiple bouts of otitis media for which he had myringotomy and tympanostomy on three separate occasions.  He had bilaterally orchidopexies in 1989 for undescended testes.

Review of systems:  At the present time, he has good hearing and does not have tympanostomy tubes in place.  Still being toilet trained.  Neurological delay in speech and motor functions.  There is asymmetric quadriplegia which was previously diagnosed by a neurologist.  CT of brain was done a few years ago to look for any anomalies, this was reported as negative.

Family history:  Unremarkable.  Parents have no genetic abnormalities or congenital anomalies in their families.  Miguel has a brother also born one month prematurely but he is healthy.  Mother's height is 5'4", father is 5'5".

Physical exam:  
Height: 123.7 cm        Weight: 30.0 kg         U/L ratio:  0.69        
Arm span: 126           Pubic hair: Tanner II   R. testis: 2.0 x 1.0 cm 
L. testis: 1.8 x 1.1 cm Phallus length: 6.0 cm  Mid-shaft diam.: 2.0 cm 
His height has shifted from 10th to 25th centile; weight has increased from 50th to 75th centile.  
General: Very difficult to exam and difficult to communicate with.  Therefore a reliable blood pressure reading was impossible to obtain despite several attempts.  A flush blood pressure was obtained of approximately 80 mm Hg.    Skin: Small scratches on his face from falling off gym at the playground, otherwise was within normal limits.  HEENT: Head circumference:  50.5 cm.  Normocephalic, atraumatic.  Eyes with good red reflex.  Fundi were slightly visualized and no ocular pathology was seen.  EOMI.  PERRLA.  Tympanic membranes were intact without tympanostomy tubes at this time.  The tympanic membranes were not red or bulging.  Throat was poorly visualized due to lack of compliance and cooperation by the patient.  Neck: Supple, full range of movement and without lymphadenopathy.  Chest: Clear to auscultation with equal breath sounds bilaterally.  Heart: Regular rate and rhythm,  S1, S2 were appreciated and there was no S3, S4 noted.  Abdomen: Soft, nontender, nondistended.  Bowel sounds were present.  No organomegaly noted.    Genitourinary: Testes were descended bilaterally s/p orchidopexy,  however they were quite small and soft.    Extremities: Full range of movement without excessive hair growth noted on the legs, arms or chest.  No axillary hair.  Neurological: Consistent with the previous neurological history and neurological history found in the record.  Poor motor control with Miguel requiring help to climb onto the exam table.  However, he did have good and equal strength bilaterally.

Laboratory studies:  LH 12.8, FSH 51.4 IU/L, testosterone 138 ng/dL and prolactin 6.0 ng/mL, DHEA 161 ng/dL and DHEAS 86 mcg/dL, 17-hydroxyprogesterone 25 ng/dL,  androstenedione 39 ng/dL and thyroid function tests were normal.  Bone age was 9 6/12 years. 

These findings are consistent with central precocious puberty.  A cranial MRI has been ordered and if this is normal, we would recommend suppression of puberty with long-acting GnRH analogue injections.

Impression: Miguel is an 8 and 4/12 year old white boy with a history significant for  motor and verbal delay, delayed growth and weight gain since birth.  He now presents with pubic hair growth (Tanner stage II) which began approximately two months ago with increased weight gain, linear growth and apparent increase in strength.  There is clear evidence of an androgen affect seen on his scrotum  and sexual hair development.  However the testes are still quite small.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology   


Addendum: Adrienne Ferracci, MD
Harvard Medical Student


CONTENT:
Pulanski, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Ms. Pulanski:

PERSONAL AND CONFIDENTIAL:

Miguel William Bankhead, DOB 10/22/84, has been evaluated in the Endocrinology Clinic at the Children's Hospital for precocious puberty.  He has already reached Tanner stage III pubertal development at age 8 1/2 years.  He has a past history of developmental delay probably related to premature birth.  

I have discussed the advantages and disadvantages of attempting to arrest puberty using the gonadotropin release hormone agonist Lupron.  I have prescribed Lupron 7.5 mg to be given intramuscularly monthly in an attempt to arrest puberty and expect that this will be necessary for at least 2 to 3 years provided that it is effective in achieving the stated goal namely arrest of premature puberty.  Thereafter, Lupron would be discontinued and puberty allowed to progress.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 4/26/93 for follow-up of precocious puberty.

History: Miguel is age 8 and 1/12 years old.  In the interval since his last visit, his mother reports increased hair growth especially on the lower extremities, black heads in the ears, more pubic hair and possibly thicker eyebrows. She has noticed that his scalp hair is slightly more curly.

Appetite is good and bowel movements have been unchanged. His sleep is undisturbed from 7:30 p.m. to 6:30 a.m. He occasionally wets the bed.

There has been no significant change in behavior since his last visit. He is in first grade. Mother has not observed more agressive behavior.

Physical exam:  
Height: 125.7 cm        Weight: 30.7 kg         Pulse: 80               
Pubic hair: Tanner II   R. testis: 2.5 x 1.3 cm L. testis: 2.2 x 1.2 cm 
General: He appeared well developed and well nourished. He was difficult to examine at times.   Skin: Smooth and warm and he has a fair complexion.   Chest: Normal.   Heart: Normal.   Abdomen: No organ enlargement or masses.   Genitourinary: Genitalia Tanner III. Scrotum is rugated and pigmented. Neurological: He had 3+ deep tendon reflexes at the knees and ankles bilateally.

Laboratory studies:  Serum LH 17.7, FSH 53.8 mIU/L, testosterone 198 ng/dL.

Impression: Height has increased 2.0 cm and weight 0.7 kg in two months. The recent MRI of the head showed no specific abnormality. 

Miguel shows evidence of central precocious puberty with extraordinarily high levels of LH and FSH suggestive of a primary gonadal defect. I discussed the results of his laboratory tests and imaging studies with both parents and suggested the use of GnRH agonist therapy to arrest puberty. I prescribed  Lupron 7.5 mg to be given intramuscularly monthly for three months.  At the end of this time, he should have a GNRH stimulation test to confirm that gonadotropin secretion has been suppressed. 

Miguel shows clear evidence of central precocity but is extraordinarily unusual in having markedly elevated gonadotropins, which leads me to think that he may have a primary gonadal disorder as well. This could be related his dysgenetic testes (testes were undescended and required surgery to bring them into the scrotum). Elevated LH and FSH in this range is also seen in Klinefelter's syndrome and a karyotype should be done to rule out a chromosomal disorder.

I plan to see him back in approximately three months.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 8/16/93 for .

History: I saw Miguel, age 8 years 10 months, in follow-up for precocious puberty.

We began treatment with Lupron (a potent GnRH agonist) to suppress gonadotropin production.  His first dose was administer June 14th and his third dose was given today.

He has enjoyed good health and had one ear infection in the early summer.  He has a large appetite and parents report that he was physically more active during the summer.  Sleep is undisturbed.  

Parents have noted reduced self-stimulatory behavior.

Physical exam:  
Height: 130.4 cm        Weight: 32.4 kg         Pulse: 64               
Pubic hair: Tanner III  R. testis: 2.3 x 1.1 cm L. testis: 2.2 x 1.1 cm 
Mid-shaft diam.: 2.3 cm 
He was tanned and looked well.  Color and hydration were good.  He has "adult" body odor.  He has Tanner stage II pubic hair, no gynecomastia.

Laboratory studies:  A repeat GnRH test was performed today.  I am pleased to report that his baseline serum LH was <0.1 and FSH 1.0 mIU/mL, testosterone <10 mg/dL, a prepubertal level.  In response to GnRH the LH and FSH values did not increase and testostereone was <10 mg/dL after 2 hours.

Impression: Because Miguel has unusually small testes for a boy with precocious puberty and inordinately high levels of LH and FSH (prior to Lupron treatment), we suspect that he has a co-existing primary defect of the testes.  His karyotype was, however, 46XY and no abnormality in the chromosomes was detected.  

We have suggested continuation of Lupron therapy in the same dose 7.5 mg at four weekly intervals.  We plan to see him again in clinic in three months.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Uta Chef, M.D.          RE: Miguel Bankhead
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/22/84

Dear Dr. Chef:

We had the pleasure of seeing Miguel in the Endocrine Program on 11/15/93 for .

History: I saw Miguel, age 9 years 1 month, in follow up for precocious puberty.

He has continued to receive Lupron 7.5 mg monthly.  He has tolerated the injections well.  His parents reports that the "adult" body odor has diminished, pubic hair has regressed and he has less frequent erections.

Physical exam:  
Height: 130.7 cm        Weight: 34.4 kg         BP: 140/                
Pulse: 80               U/L ratio:  4.03        R. testis: 2.1 x 1.1 cm 
L. testis: 2.0 x 1.1 cm Phallus length: 5.0 cm  Mid-shaft diam.: 2.5 cm 
He appeared well-developed, and well nourished but was not cooperative.  Skin was normal.  There was no thyromegaly.  The remainder of the exam was unremarkable.

Impression: His rate of linear growth has decreased and the history and physical examination suggests that puberty has been arrested.  Serum LH <0.12, FSH 0.8 IU/L, and testosterone 11 ng/dL confirm the clinical impression.  Meanwhile, we have continued Lupron Depot in a dose of 7.5 mg monthly.  

Thank you for the opportunity to share in the care of this youngster.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Daren Animal, M.D.          RE: Sandra Osler
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/15/78

Dear Dr. Animal:

We had the pleasure of seeing Sandra in the Endocrine Program on 8/20/92 for evaluation of weight gain and fatigue.

History: Sandra is a 14 year old white female with a history of recurrent viral illnesses diagnosed with IgG3 deficiency in January 1991. Over the past 5-6 months she reports a history of weight gain, increase in fatigue, increased thirst and cold intolerance. She also reports that she has been sleeping approximately 12 hours a day with an occasional afternoon nap. She denies symptoms of polyuria, polyphagia, skin dryness, or changes in bowel habits. Over the past three months, she has been trying to lose weight. Her diet consists of mainly salads with low cal dressing. Over an eight month period she has gained approximately 10 lbs. She exercises approximately 30 mins. a day either walking or riding her bike. She is a 9th grade honor student and has been playing piano for 9 years. Most of her 7th and 8th grades were spent at home where she was tutored.

Current medications: Florinol, Tagmet 300 mg TID, IgG3 every 2 weeks and Vanceril.

Past medical history:  Sandra was the product of a full term pregnancy with a normal vaginal delivery. Growth and development have been normal. She has had recurrent infectious diseases including upper respiratory infections, sinusitis, and multiple ear infections. She has documented IgG3 deficiency since January 1992. She has had three hospitalizations for migraine headaches and has been on several medications. She has had no injuries or operations.

Review of systems:  Positive sinusitis, asthma. GI: Reflux and occasional abdominal pain. GU: She denies polyuria. She began menarche at the age of 11. Neuro: Recurrent migraines.

Family history:  Mom has rheumatoid arthritis. Dad has an attention deficit disorder. Her aunt has hypothyroidism and a grandmother age 77, has diabetes and hypothyroidism. Her paternal grandparents have a history of hypertension.

Physical exam:  
Height: 162.1 cm        Weight: 62.2 kg         BP: 87/60               
Pulse: 68               U/L ratio:  0.93        Arm span: 164           
Breast Tanner: 5        Pubic hair Tanner: 5    

General: Well developed, well nourished, slightly overweight white female. 
Skin: Clear without lesions. 
HEENT: Normocephalic and atraumatic. Pupils are equally reactive to light and accommodation. Her extraocular movements are intact. Fundi exam was normal. 
Neck: Soft and supple with no thyromegaly. 
Chest: Clear to auscultation bilaterally. 
Heart: Regular rate and rhythm without murmur. Normal S1 and S2.
Abdomen: Soft, nontender, normal bowel sounds. No evidence of hepatosplenomegaly or masses. 
Extremities: Palpable upper and lower pulses. 
Neurological: Nonfocal. Reflexes +2 bilaterally. Cranial nerves 2-12 are intact. Normal deep tendon reflexes.

Laboratory studies:  T4 8.0, (normal 5.5-11), TBGI 1.13, (normal .88-1.13). 1991 2 MRIs both reported negative.

Impression: Sandra's clinical history is suggestive of hypothyroidism. However, on physical exam there are no positive physical findings that are noted. To rule out hypothyroidism, the following tests were ordered TSH, TBGI,TS and T4.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Addendum: Melanie Armstrong, MD
Medical Student - IV

The thyroid function tests were normal (T4 7.3, TBGI 1.06, TT3 120, TSH 1.60) and rule out hypothyroidism.


CONTENT:
Yvette Seinfeld, M.D.          RE: Gretel Brooks
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/11/81

Dear Dr. Seinfeld:

We had the pleasure of seeing Gretel in the Endocrine Program on 6/1/92 for follow up of her short stature.

History: Gretel has been well since last seen on 04/02/91.  She has had no intercurrent illness.  She has been very active, doing well in school and is into soccer as her favorite sport.  She claims not to be concerned about her height although she has tall friends.  The review of systems was negative.

Physical exam:  
Height: 130.5 cm        Weight: 28.4 kg         BP: 100/64              
Pulse: 82               Breast: Tanner II       Pubic hair: Tanner I    
Gretel was healthy looking; she was short but proportionate.
Skin: Normal texture.  HEENT: Fundi normal.  PERRLA.  EOM intact.  Normal oropharynx.  Neck:  Supple.  Thyroid not enlarged.  Chest:  Lungs are clear.  There is a small but definite breast tissue on the right within the confines of the areola with few strands on the left.  Cor:  Normal S1 and S2.  No murmurs.  Abdomen.  Soft, no masses, No hepatosplenomegaly.  GU:  Vaginal mucosa was not estrogenized.  Extremities:  Normal.  Neurological:  Cranial nerves II - XII intact.  DTR 2+, symmetrical.

Impression: Gretel grew 5.5 cm in 14 months, her bone age did not mature unduly (BA 8 6/12 years) and her predicted adult height is 5'2".  She will be reassessed in six months.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Problem list to date:
CONSTITUTIONAL-DELAY         Start: 06/01/92  End:          Invalid: 

Transcribed by Nortonsh


CONTENT:
Yvette Seinfeld, M.D.          RE: Gretel Brooks
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/11/81

Dear Dr. Seinfeld:

We had the pleasure of seeing Gretel in the Endocrine Program on 06/23/93 for follow up of her growth and pubertal devleopment.

History: Since last seen on 06/01/92 Gretel has been well.  Mrs. Brooks did note that she has outgrown the size of her clothes and shoes.  She did well in school, was active, and was on the soccer team.  She did also note  some breast development but no vaginal discharge.  Review of systems was negative.  She uses a deodorant.

Current medications: None.

Physical exam:  
Height: 139.2 cm        Weight: 31.4 kg         BP: 108/67              
Pulse: 80               Breast: Tanner II       Pubic hair: Tanner III  
Gretel was healthy looking, pleasant and cooperative. Skin:  Normal texture. No acne. HEENT:  Normal fundi. EOM intact. Benign oropharynx.  Neck:  Thyroid not enlarged.  Lymph Nodes:  No lymphadenopathy.  Chest:  Clear lungs.  Cor:  Normal S1 and S2, no murmurs.  Abdomen:  Soft, no hepatosplenomegaly.  GU:  Has axillary hair in addition to Tanner II pubic hair.  Vaginal mucosa minimally estrogenized.  Extremities:  Normal.  Neurological:  DTR 3+ symmetrical.  Cranial nerves II-XII intact.

Laboratory studies:  Be age 10 1/2 to 11 years; predicted adult height 5'1".

Impression: Gretel unexpectedly started her pubertal development given that her bone age of only 8 1/2 last year.  With her pubertal development she also has a growth spurt (8.7 cm in 12 months) but there was a concomitant significant increase in her bone maturation (bone age 10 1/2 to 11 years).  her predicted adult height however was not significantly compromised, she will probably reach the 5'1" height

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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Jayne Pulanski, M.D.          RE: Cesar Zola
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/10/79

Dear Dr. Pulanski:

We had the pleasure of seeing Cesar in the Endocrine Program on 8/4/94 for short stature.

History: Cesar is a 15 year 6 month old white male who is quite concerned that he has reached his final height of 5'1".   He reports that he is very active and healthy.   He currently plays several sports and is entering the 10th grade.  His medical history is significant for very sensitive skin and acne.    He has had some minor surgery including having his tonsils removed.   He reports that through 5th, 6th and 7th grade, he seemed of more average height and perhaps greater build than most of his classmates.   He reports that he was shaving at approximately 13 years of age.  He denies any pertinent symptoms such as headaches, vision problems, chronic diarrhea, lung or heart problems.

Family history:  Significant for congenital heart disease in one grandfather and ALS in his paternal grandmother.   Significant for a mother whose height is 4'11"  whose history is relevant for very early puberty and menarche at 11 years of age.   His father is 5'11.5" and remembers being at average height compared to his peers.

Physical exam:  
Height: 157 cm          Weight: 59.1 kg         BP: 118/58              
R. testis: 4.5 x 2.3 cm L. testis: 4.5 x 2 cm   
General:  Short.  Skin: He had mild facial acne and appeared sunburned.   HEENT: Benign.   Neck: Normal thyroid.  Chest: Lungs were clear to auscultation.    Heart: No heart murmur.    Abdomen: Soft without hepatopslenomegaly. Genitourinary: Revealed a Tanner V male.   There is no evidence of scoliosis in his back.    Extremities: Normal.  Neurological: Normal.

Laboratory studies:  IGF-1 level of 245 ng/mL which is normal for his age.   He also brought in bone films which revealed a bone age of 16-17 years.

Impression: He is a 15 and a half year old male with familial short stature that was complicated by early puberty like his mother.   His bone films reveal near complete fusion of all epiphyses.   This would suggest there is no role for growth hormone.   I had an extended discussion with the patient and his family.

Disposition: At this time we will just recommend yearly follow up with you.
Thank you for letting us share in the care of Cesar.

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology   


Addendum: Robert S. Kahn, M.D. 
Resident in Pediatrics


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on
3/29/94.  Francesca is generally doing well since her last visit.  Francesca's main concern at the time of this visit was that her last menstrual period was
six weeks ago.  Francesca states that she is careful and she uses condom and foam on a regular basis.

Current medications include: IMURAN 150 mg po q.d., PREDNISONE 15 mg po q.o.d.
and FOLIC ACID 1 mg po q.d.

Physical exam:
     BP 124/88     P 60       HT 164.1 cm     WT 65.5 kg
     HEENT: mouth clear
     Neck: supple with no adenopathy
     Chest: clear
     Heart: regular rate and rhythm
     Abdomen: soft nontender
     Extremities: no edema

Urinalysis:
          SPEC GR UA  1.020                PH UA       5          
          PROTEIN UA  1+    mg/dl          GLUCOSE UA  N     mg/dl
          BLOOD UA    N                    WBC ENZ UA  0          
          RBC/HPF     2-4   /HPF           WBC/HPF     1-2   /HPF 
          SQUAMOUS EPITHELIAL occas.

Laboratory studies at this time include:
          BUN 10         CR 0.7         NA 141    K 3.9        CL105
          GLU 75         CA 9.2         PHOS 3.3  WBC 5.37     HCT 35.9
          HGB 11.6       MCV 102.0      PLT 323   N- 69.4      L- 22.0
          B- .3          ABN 3.72       CO2  27
          urinary pregnancy test negative

Francesca continues to have good graft function following living related donor transplant in November of 1988.  We have continued to encourage Francesca to have protected sex both for concerns about pregnancy and sexually transmitted diseases.  We made no changes in her regimen and have asked Francesca to return in one month.

Thank you again for allowing us to share with you in the care of Francesca.

Sincerely,


Kathy Jabs, MD            
Assistant in Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on April 26, 1994.  She has chronic renal failure secondary to MPGN.  She had a renal transplant on November 4, 1988.

Francesca has no complaints since her last visit.

Current medications include: IMURAN 150 mg po q.d., PREDNISONE 15 mg po q.o.d. and FOLIC ACID 1 mg po q.d.

Physical exam:
     BP 110/80     HT 164.7cm     WT 66.8kg
     General: Francesca appears well
     HEENT: within normal limits 
     Chest: clear 
     Heart: regular rate and rhythm without murmur
     Abdomen: soft, non-tender graft
     Extremities: without edema

Urinalysis:
          SPEC GR UA  0                    PH UA       5          
          PROTEIN UA  trace                GLUCOSE UA  N     mg/dl
          BLOOD UA    N                    WBC ENZ UA  0          
          RBC/HPF     0     /HPF           WBC/HPF     0     /HPF 
          WBC CAST    0     /LPF           RBC CAST    0     /LPF 
          GRAN CAST   0     /LPF           WAXY CAST   0     /LPF 


Laboratory studies at this time include:
          BUN 9         CREAT 0.7      NA 143      K 4.4        Cl 108    
          GLUCOSE 85    CA 9.0         Po4 3.7     CO2  24
          AST 26        ALT 28  
          WBC 4.62      HCT 34.4       HGB 11.3    MCV 100.0    PLT 256 
          NEUT 65.6     LYMPH 21.4     BASO 1.0    ABS N 3.04

Francesca is doing well and no changes are necessary at this point.

She will return in one month.

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

Sincerely,


Clotilde Goldwater, MD           
Director, Dialysis Unit
Director, Renal Transplant Program


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on May 24, 1994.  She has chronic renal failure secondary to MPGN.  She had a renal transplant on November 4, 1988.

Francesca has no complaints since her last visit here to the renal transplant program.  She has not had any dysuria or fever.

Current medications include: IMURAN 150 mg q.d., PREDNISONE 15 mg q.o.d. and FOLIC ACID 1 mg qd.

Physical exam:
     BP 123/73     P 79     R 18    HT 164.8cm     WT 65.3kg
     HEENT: oropharynx is clear and moist
     Neck: supple without masses
     Chest: clear to auscultation
     Heart: regular rate and rhythm
     Abdomen: soft, there is no tenderness or bruit over the graft
     Extremities: no peripheral edema.

Urinalysis:
          SPEC GR UA  1.020                PH UA       7          
          PROTEIN UA  trace                GLUCOSE UA  N     mg/dl
          BLOOD UA    N                    WBC ENZ UA  0          
          RBC/HPF     0-2   /HPF           WBC/HPF     0-5   /HPF 
          WBC CAST    0     /LPF           RBC CAST    0     /LPF 
          GRAN CAST   0-5   /LPF           WAXY CAST   0     /LPF 
          Squamous Epithelial 0-5

Laboratory studies at this time include:
          BUN 12      Cr 0.8      Ca 9.2     PO4 3.4       CO2 26
          Na 139      Cl 106      K 3.9      GLUC 82
          WBC 4.32    HGB 11.8    HCT 35.0   MCV 99.7      PLT 249
          N 69.4      L 19.6      B .5       ABS N 3.00
        

Francesca has no complaints since her visit here.  She continues to have good allograft function.

She will return in one month.

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

Sincerely,


Kinze Brando, MD               
Assistant in Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

     We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, August 30, 1994.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis II.  She had a renal transplant on November 4, 1988.
     Francesca has been well since her last visit.  She has noticed a decrease in her appetite and loss of weight since her last visit.  She has been a resident at college for the summer and has been doing a lot of physical activities.

Current medications include:
     IMURAN 150 mg q.d.
     PREDNISONE 15 mg q.o.d.
     FOLIC ACID 1 mg q.d.

Physical exam:
     BP 110/75   P 70   R 16   HT 165.2 cm   WT 61.9 kg
     General: appeared well
     Skin:  
     HEENT: normal 
     Neck: supple with no masses, lymph nodes not palpable
     Chest: clear
     Heart: two heart sounds with no murmurs
     Abdomen: soft non-tender with right sided graft 
     Genitourinary: Tanner 5
     Extremities: lump on left side of chin from an accident.  Scar on the 
     left hand.

Urinalysis:
     SPEC GR UA  1.010           WBC ENZ UA  N          
     PH UA       6               PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N          
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   1+              BACTERIA    N     


Laboratory studies at this time include:
          CO2 29      MEQ/L (H)         CA         10.1   MG/DL
          CR          1.0   MG/DL       GLU          85   MG/DL    
          PHOS        2.8   MG/DL       BUN          11   MG/DL    
          NA          141  MMOL/L       K           4.3  MMOL/L    
          CL          107  MMOL/L       PLT         310   K/MM3    
          WBC        6.76   K/MM3       RBC        3.54   M/MM3 (L)
          HGB        10.9    G/DL (L)   HCT.       35.9       % (L)
          MCV       101.5      FL (H)   MCH        30.8      PG    
          MCHC       30.3    G/DL       RDW        16.0       % (H)
          HDW        2.36    G/DL       PLT UNC     310   K/MM3    
          NEUT AB    4.64   K/MM3       LYMPH A    1.36   K/MM3    
          EOS ABS     .02   K/MM3       NEUT-A     68.7       %    
          LYMPH-A    20.1       % (L)   MONO-A      9.1       % (H)
          EOS-A        .4       %       BASO-A       .4       %    
          ATYP LY     1.2       %       MACRO-A      ++ (*)

     Francesca is doing well since her last visit.  Her weight loss is likely due to activity changes, but we will monitor it.

     We have asked Francesca to return in two months.

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

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

     We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, October 25, 1994.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on November 4, 1988.
     Francesca is well since her last visit.  She has had no new problems.  She continues to have occasional sharp pains over her transplanted kidney.  At least several times she has required analgesic medications.

Current medications include:
     PREDNISONE 15 mg q.o.d.
     IMURAN 150 mg q.d.
     FOLIC ACID 1 mg q.d.

Physical exam:
     BP 122/80   P 92   HT 165cm   WT 61.1kg   
     General: appeared well.
     Skin: normal. 
     HEENT: normal. 
     Neck: supple with no masses, lymph nodes not palpable.
     Chest: clear
     Heart: two heart sounds.
     Abdomen: soft with right sided transplant.
     Genitourinary: Tanner 5
     Extremities: scar on left hand following calcium infusion.
     Neurological: normal.
Urinalysis:
     SPEC GR UA  1.019           WBC ENZ UA  0          
     PH UA       6               PROTEIN UA  trace      
     BLOOD UA    2+              GLUCOSE UA  N     mg/dl
     WBC/HPF     0               RBC/HPF     100-1      
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    0     


Laboratory studies at this time include:
          CO 2         30   MEQ/L (H)   CA          9.0   MG/DL    
          CR          1.0   MG/DL       GLU          79   MG/DL    
          PHOS        3.0   MG/DL       BUN          14   MG/DL    
          NA          143  MMOL/L       K           4.1  MMOL/L    
          CL          107  MMOL/L       WBC        5.75   K/MM3    
          RBC        3.47   M/MM3 (L)   HGB        10.8    G/DL (L)
          HCT.       35.5       % (L)   MCV       102.4      FL (H)
          MCH        31.1      PG       MCHC       30.4    G/DL    
          RDW        15.6       % (H)   HDW        2.44    G/DL    
          PLT UNC     322   K/MM3       


     Francesca is doing well.

     We have asked Francesca to return in two months.

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

               Sincerely,


               Mitsuko Khan, MD
               Director of Clinical Services


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

     We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, January 10, 1995.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on November 4, 1988.
     Francesca has done well since her last visit.

Current medications include:
     PREDNISONE 15 mg q.o.d.
     IMURAN 125 mg q.d.
     FOLIC ACID 1 mg q.d.

Physical exam:
     BP 125/75   P 80    HT 164.9cm   WT 61.8kg  
     General: she appeared well
     Skin: left hand scar from chemical burn
     HEENT: normal
     Neck: supple, no masses, lymph nodes not palpable
     Chest: clear
     Heart: 2 heart sounds, no murmurs
     Abdomen: soft, non-tender
     Genitourinary: Tanner 5
     Extremities: no edema

Urinalysis:
     SPEC GR UA  1.010           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     0               RBC/HPF     0          
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    0     


Laboratory studies at this time include:
          CO 2         26   MEQ/L       CA          9.3   MG/DL    
          CR          1.0   MG/DL       GLU         105   MG/DL    
          PHOS        3.0   MG/DL       BUN          12   MG/DL    
          NA          139  MMOL/L       K           4.2  MMOL/L    
          CL          105  MMOL/L       WBC        6.61   K/MM3    
          RBC        3.67   M/MM3 (L)   HGB        11.5    G/DL (L)
          HCT.       36.5       %       MCV        99.4      FL (H)
          MCH        31.4      PG       MCHC       31.6    G/DL    
          RDW        15.1       %       HDW        2.27    G/DL    
          PLT UNC     289   K/MM3       


     Francesca is doing well.  She has occasional crampy pain in the right iliac fossa unrelated to her menstrual cycles.  We will review her ovaries on her next renal ultrasound.  Her renal function is stable.

     We have asked Francesca to return in two months.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

     We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, March 28, 1995.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on November 4, 1988.
     Francesca has done well since her last visit.  She has just returned from Paris.  She has no new complaints.

Current medications include:
     PREDNISONE 15 mg q.o.d.
     IMURAN 125 mg q.d.
     FOLIC ACID 1 mg q.d.

Physical exam:
     BP 125/90   P 90   R 20     HT 164.7cm   WT 60kg   
     General: she appeared well
     HEENT: normal
     Neck: supple, no masses, lymph nodes not palpable
     Chest: clear
     Heart: 2 heart sounds, no murmurs
     Abdomen: soft, non-tender
     Genitourinary: Tanner 5
     Extremities: Long standing scar, left hand.  No edema.

Urinalysis:
     SPEC GR UA  1.019           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     1               RBC/HPF     1          
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   3+              BACTERIA    0     


Laboratory studies at this time include:
          CO 2         29   MEQ/L       CA          9.6   MG/DL    
          CR          1.0   MG/DL       GLU          73   MG/DL    
          PHOS        2.6   MG/DL (L)   BUN          13   MG/DL    
          NA          141  MMOL/L       K           3.5  MMOL/L    
          CL          104  MMOL/L       WBC        7.01   K/MM3    
          RBC        3.74   M/MM3 (L)   HGB        11.1    G/DL (L)
          HCT.       37.0       %       MCV        99.0      FL (H)
          MCH        29.7      PG       MCHC       30.0    G/DL    
          RDW        15.5       %       HDW        2.40    G/DL    
          PLT UNC     280   K/MM3       


     Francesca is well.

     We have asked Francesca to return in two months.

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

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

     We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, August 1, 1995.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.
     Since her last visit in March 1995, there have been no complaints.  Blood pressure has been well controlled.  She has gained approximately 3 kg since her last visit.

Her current medications include:
     PREDNISONE 15 mg q.o.d.
     IMURAN 125 mg q.d.
     FOLIC ACID 1 mg q.d.

Francesca's physical exam was notable for:
     BP 110/70   P 88   R 18    HT 166cm   WT 63.6kg   
     General: she appeared well in no acute distress.
     Skin: no rash
     HEENT: pupils were equal and reactive to light.
     Neck: supple, lymph nodes not palpable
     Chest: clear to auscultation
     Heart: no murmurs
     Abdomen: soft with bowel sound present.
     Extremities: Free range of motion X 4.
     Neurological: oriented X 3.
A urinalysis revealed:
     SPEC GR UA  1.017           RBC/HPF     0          
     WBC ENZ UA  N               WBC CAST    0          
     PH UA       6               RBC CAST    0          
     PROTEIN UA  trace           GRAN CAST   0          
     BLOOD UA    N               WAXY CAST   0          
     GLUCOSE UA  N     mg/dl     SQUAM EPI   1-5        
     WBC/HPF     0               BACTERIA    0     

Laboratory studies at this time include:
          CO 2         27   MEQ/L       CA          9.0   MG/DL    
          CR          0.9   MG/DL       GLU          76   MG/DL    
          PHOS        3.3   MG/DL       BUN          17   MG/DL    
          NA          141  MMOL/L       K           4.4  MMOL/L    
          CL          106  MMOL/L       WBC        5.51   K/MM3    
          RBC        3.79   M/MM3 (L)   HGB        11.7    G/DL (L)
          HCT.       37.0       %       MCV        97.7      FL    
          MCH        30.9      PG       MCHC       31.6    G/DL    
          RDW        16.0       % (H)   HDW        2.20    G/DL    
          PLT UNC     275   K/MM3       NEUT AB    3.45   K/MM3    
          LYMPH A    1.33   K/MM3       EOS ABS     .12   K/MM3    
          NEUT-A     62.5       %       LYMPH-A    24.2       % (L)
          MONO-A      7.1       %       EOS-A       2.1       %    
          BASO-A      1.4       %       ATYP LY     2.7       %    
          MORPH       YES               ANISO        1+    
          MACRO        2+ (*)           HYPO         1+    


     Francesca has stable graft function.  She will return for follow up during school vacation.

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

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, August 13, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.
Francesca has been doing well since her last visit.  She does say that she has cold symptoms today and that she has been drinking lots of water at home even awakening overnight to drink.  She had a urinary tract infection that required therapy in February and has had no further symptoms since that time.

Her current medications include:
     PREDNISONE 15 mg q.o.d.
     IMURAN 125 mg q.d.
     FOLIC ACID 1 mg q.d.
     TRIPHASIL 1 po q.d.

Francesca's physical exam was notable for:
     BP 130/80   P 106   R    T    HT 165.6cm   WT 67.4kg   HC cm
     General: well appearing, well nourished young female in no distress
     Skin: clear
     HEENT: normal except for nasal congestion.
     Neck: supple, lymph nodes not palpable
     Chest: clear
     Heart: regular rate and rhythm with no murmurs
     Abdomen: soft and graft was non-tender.
     Extremities: no edema
     Neurological: non-focal
A urinalysis revealed:
     SPEC GR UA  1.010           RBC/HPF     1-2        
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       7               RBC CAST    N          
     PROTEIN UA  1+              GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   many       
     WBC/HPF     2-4             BACTERIA    prese 

Laboratory studies at this time include:
          K           3.8  MMOL/L       RDW        14.4       %    
          CA          9.0   MG/DL       HDW        2.63    G/DL    
          MG          2.2   MG/DL       MPV         9.9      FL    
          CR          2.6   MG/DL (H)   PLT UNC     303   K/MM3    
          GLU         120   MG/DL (H)   NEUT AB    4.27   K/MM3    
          NA          141  MMOL/L       LYMPH A    1.01   K/MM3    
          BUN          17   MG/DL       EOS ABS     .27   K/MM3    
          WBC        6.35   K/MM3       NEUT-A     67.2       %    
          RBC        3.63   M/MM3 (L)   LYMPH-A    15.9       % (L)
          HGB        10.0    G/DL (L)   MONO-A      9.9       % (H)
          HCT.       30.7       % (L)   EOS-A       4.3       %    
          MCV        84.7      FL       BASO-A      1.2       %    
          MCH        27.5      PG       ATYP LY     1.5       %    
          MCHC       32.5    G/DL       LEFT SH  ABSENT    

Francesca is doing well.  Given the presence of bacteria on her urinalysis, we will send her urine for culture today.  If there is evidence of pure growth we will consider therapy.  Given increase in creatinine she must have repeat labs performed; if creatinine is still increased, imaging and possible biopsy are indicated.

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

               Sincerely,


               Nazek Carerras, MD            Antonio Khan, MD
               Renal Fellow                 Attending, Pediatric Nephrology


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, August 27, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca comes to us after being recently discharged for a Solumedrol pulse.  She complains of an increase in frequency of bowel movements although most of the time the stools are formed.  She also notes feeling weak with note of fine tremors occasionally.

Her current medications include:
     IMURAN 125 mg q.d.
     PREDNISONE 30 mg b.i.d.
     PROCARDIA XL 30 mg b.i.d.
     FOLIC ACID 1 mg q.d.
     BACTRIM (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-FNEORAL 225 mg   b.i.d.


Francesca's physical exam was notable for:
     BP 136/81   P 95   R 12   HT 165.8cm   WT 70kg   
     General: well nourished in no distress.
     Skin: no lesions.
     HEENT: moist mucus membranes.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm without murmur.
     Abdomen: soft without bruits or tenderness at graft site.
     Extremities: no edema.
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  1.006           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5               RBC CAST    N          
     PROTEIN UA  1+              GRAN CAST   0-1        
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           5.0  MMOL/L (H)   MCHC       31.7    G/DL    
          CA          8.6   MG/DL       RDW        15.7       % (H)
          CR          2.7   MG/DL (H)   HDW        2.33    G/DL    
          CYA         117   MCG/L       MPV         8.7      FL    
          GLU         126   MG/DL (H)   PLT UNC     386   K/MM3    
          PHOS        3.4   MG/DL       NEUT AB   10.79   K/MM3    
          BUN          49   MG/DL (H)   LYMPH A     .61   K/MM3    
          NA          139  MMOL/L       EOS ABS     .05   K/MM3    
          CL          109  MMOL/L       NEUT-A     87.7       % (H)
          CO 2         24   MEQ/L       LYMPH-A     5.0       % (L)
          WBC       12.30   K/MM3 (H)   MONO-A      5.9       %    
          RBC        3.59   M/MM3 (L)   EOS-A        .4       %    
          HGB        10.0    G/DL (L)   BASO-A       .9       %    
          HCT.       31.6       % (L)   ATYP LY      .2       %    
          MCV        88.0      FL       HYPO-A        +    
          MCH        27.9      PG       LEFT SH  ABSENT    

Francesca was recently discharged after completing a Solumedrol pulse.  Her symptoms may be related to her recent pulse and we will recheck her electrolytes today to make sure that this is not metabolic in etiology.  Her cyclosporine level is adequate.  We will recheck her laboratories later this week.

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

               Sincerely,


               Antonio Khan, MD
               Attending, Pediatric Nephrology


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, September 3, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca was recently re-admitted for a rise in creatinine which improved with hydration.  Her creatinine decreased from 2.9 mg/dl to 2.4 mg/dl.  Now she is taking a minimum of 2.5 liters per day.  She was also started on Amoxicillin for shigella gastroenteritis.  At this point her shigella appears to have improved with stools decreased to bid.

Her current medications include:
     IMURAN 125 mg q.d.
     PREDNISONE 30 mg b.i.d.
     PROCARDIA XL 30 mg b.i.d.
     ZANTAC 150 mg b.i.d.
     AMOXICILLIN 250 mg b.i.d.
     BACTRIM (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     NEORAL 225 mg  b.i.d.

Francesca's physical exam was notable for:
     BP 150/80   P 119   R 14   WT 70kg   
     General: well hydrated, well nourished in no distress.
     Skin: no lesions.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm without murmur.
     Abdomen: soft without tenderness nor bruits at graft site.
     Extremities: no edema.
     Neurological: no lateralizing signs.

Laboratory studies at this time include:
          K           4.7  MMOL/L (H)   RDW        17.8       % (H)
          CA          8.4   MG/DL       HDW        2.50    G/DL    
          CR          2.6   MG/DL (H)   MPV         8.4      FL    
          CYA         202   MCG/L       PLT UNC     243   K/MM3    
          GLU         110   MG/DL       NEUT         76       % (H)
          PHOS        3.9   MG/DL       LYMPH         4       % (L)
          BUN          36   MG/DL (H)   MONOS        12       % (H)
          NA          134  MMOL/L (L)   BAND          8       %    
          CL          105  MMOL/L       CELLS C     100    
          CO 2         20   MEQ/L (L)   ABS NEU    5.24   K/MM3    
          WBC        6.24   K/MM3       ABS LYM     .25   K/MM3    
          RBC        3.44   M/MM3 (L)   ABS EOS     .00   K/MM3    
          HGB         9.7    G/DL (L)   ANISO        1+    
          HCT.       29.1       % (L)   MICRO        1+    
          MCV        84.7      FL       POLYCHRINCREASE (*)
          MCH        28.2      PG       BASO ST      1+ (*)
          MCHC       33.3    G/DL       NUC RBC       1    

Francesca is currently stable after her recent solumedrol pulse.  Her blood pressure is borderline and we will continue to observe this.  Her cyclosporine level is a bit high, but we won't change the dose now.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, September 10, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.
Francesca complains of persistent discomfort in her mouth from oral thrush that was noted last week.  She has had some difficultly keeping up with her po intake.  She reports that her stool has more form than it had previously.  Francesca says that her blood pressure has been under relatively good control at home but in the morning she sometimes has diastolics in the 90's but in the evenings will have diastolics in the mid 70's.

Her current medications include:
     IMURAN 125 mg q.d.
     PROCARDIA XL 30 mg b.i.d.
     ZANTAC 150 mg b.i.d.
     AMOXICILLIN 250 mg b.i.d.
     PREDNISONE 60 mg q.d.
     BACTRIM (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     NEORAL 225 mg  b.i.d.
     NYSTATIN SS 10 cc M-W-F

Francesca's physical exam was notable for:
     BP 140/102   P 87   R    T    HT cm   WT 69.6kg   HC cm
     General: alert and attentive with no distress.
     Skin: clear.
     HEENT: significant for oral thrush.
     Neck: supple.  Lymph nodes were negative.
     Chest: clear.
     Heart: regular rate and rhythm.
     Abdomen: soft, graft was not tender.
     Extremities: no edema.
     Neurological: normal.
A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     0-1        
     WBC ENZ UA  N               RBC/HPF     2-4        
     PH UA       5               WBC CAST    0          
     PROTEIN UA  1+              RBC CAST    0          
     BLOOD UA    large           GRAN CAST   0          
     GLUCOSE UA  N               WAXY CAST   0          
     BACTERIA    N               SQUAM EPI   0     
     MICROSCOPC             
1 hyaline cast
many vaginal epithelial

Laboratory studies at this time include:
          K           4.8  MMOL/L (H)   RDW        19.2       % (H)
          CA          8.4   MG/DL       HDW        2.47    G/DL    
          CR          3.3   MG/DL (H)   MPV         8.5      FL    
          CYA         177   MCG/L       PLT UNC     254   K/MM3    
          GLU         119   MG/DL (H)   NEUT AB    3.27   K/MM3    
          PHOS        4.6   MG/DL (H)   LYMPH A     .35   K/MM3    
          BUN          58   MG/DL (C)   EOS ABS     .06   K/MM3    
          NA          134  MMOL/L (L)   NEUT-A     82.1       % (H)
          CL          104  MMOL/L       LYMPH-A     8.8       % (L)
          CO 2         21   MEQ/L (L)   MONO-A      5.9       %    
          WBC        3.98   K/MM3 (L)   EOS-A       1.4       %    
          RBC        3.06   M/MM3 (L)   BASO-A       .4       %    
          HGB         8.8    G/DL (L)   ATYP LY     1.4       %    
          HCT.       26.9       % (L)   ANISO-A      ++ (*)
          MCV        88.0      FL       MACRO-A       +    
          MCH        28.8      PG       LEFT SH  ABSENT    
          MCHC       32.7    G/DL       

As Francesca's blood pressure was consistently elevated she will receive Nifedipine 10 mg.  We will continue to follow Francesca's oral thrush and if this is not improved next week we will consider a change in therapy.  Francesca is currently menstruating.  Her creatinine is increased again.  We will decrease her cyclosporine to 200 mg bid and re-check her creatinine later this week.  We will also encourage po fluids.

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

               Sincerely,


               Nazek Carerras, MD            Clotilde Goldwater, MD
               Renal Fellow                 Director of Nephrology


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, September 17, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca says that her oral thrush has significantly decreased.  She still complains of some abdominal discomfort although her diarrhea has resolved.  She reports that she is able to eat and drink more than she was able to before.

Her current medications include:
     IMURAN 125 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 60 mg q.d.
     NEORAL 100 mg  b.i.d.
     NYSTATIN SS 10 cc q.i.d.
     FLUCONAZOL 100 mg q.d.
     FOLIC ACID 1 mg po q.d.
     PROCARDIA XL  30 mg q.a.m., 60 mg q.p.m.
     BACTRIM (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F

Francesca's physical exam was notable for:
     BP 138/71   P 135    WT 68.4kg   
     General: alert and attentive.
     Skin: normal.
     HEENT: oral thrush still present but significantly reduced from previous examination.
     Neck: supple.  Lymph nodes were negative.
     Chest: clear.
     Heart: regular rate and rhythm without murmurs.
     Abdomen: soft.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     2-4        
     WBC ENZ UA  N               RBC/HPF     2-4        
     PH UA       5               WBC CAST    0          
     PROTEIN UA  1+              RBC CAST    0          
     BLOOD UA    trace           GRAN CAST   +          
     GLUCOSE UA  N               WAXY CAST   0          
     BACTERIA    N               SQUAM EPI   0     
     MICROSCOPC             
many vag. squam
many renal epi.

Laboratory studies at this time include:
          K           4.3  MMOL/L       RDW        20.2       % (H)
          CA          8.1   MG/DL (L)   HDW        2.67    G/DL    
          CR          2.8   MG/DL (H)   MPV         7.8      FL    
          CYA          92   MCG/L       PLT UNC     335   K/MM3    
          GLU         131   MG/DL (H)   NEUT AB    7.60   K/MM3    
          PHOS        2.3   MG/DL (L)   LYMPH A     .96   K/MM3    
          BUN          42   MG/DL (H)   EOS ABS     .10   K/MM3    
          NA          137  MMOL/L       NEUT-A     82.3       % (H)
          CL          109  MMOL/L       LYMPH-A    10.4       % (L)
          CO 2         20   MEQ/L (L)   MONO-A      5.1       %    
          WBC        9.23   K/MM3       EOS-A       1.1       %    
          RBC        2.87   M/MM3 (L)   BASO-A       .1       %    
          HGB         8.4    G/DL (L)   ATYP LY     1.0       %    
          HCT.       25.2       % (L)   ANISO-A      ++ (*)
          MCV        87.9      FL       MICRO-A       +    
          MCH        29.3      PG       MACRO-A       +    
          MCHC       33.3    G/DL       LEFT SH PRESENT    

Francesca's oral thrush is improving.  She looks clinically better than she did last week.  If the oral thrush is not completely resolved at the end of the seven day course of Fluconazole we will continue for another seven days.  Her renal function is stable.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, September 24, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca comes in for follow up of her oral thrush.  She has been on Fluconazole for 1.5 weeks.  She reports that this is markedly improved and offers no new complaints today.

Her current medications include:
     IMURAN 125 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 55 mg q.d.
     NEORAL 100 mg b.i.d.
     NYSTATIN SS 10 cc q.i.d.
     FLUCONAZOL 100 mg q.d.
     FOLIC ACID 1 mg po q.d.
     PROCARDIA XL  30 mg q.a.m., 60 mg q.p.m.
     BACTRIM (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F

Francesca's physical exam was notable for:
     BP 124/70   P 100   WT 65.5kg  
     General: well hydrated and in no distress.
     Skin: no lesions.
     HEENT: within normal limits, positive markedly improved oral thrush with minimal residual lesions noted.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm.
     Abdomen: soft without bruits or tenderness at graft site.
     Extremities: no edema.
     Neurological: no lateralizing signs.

A urinalysis revealed:
     SPEC GR UA  1.018           WBC/HPF     2-3        
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5               WBC CAST    0          
     PROTEIN UA  2+              RBC CAST    0          
     BLOOD UA    N               GRAN CAST   3-5        
     GLUCOSE UA  N               WAXY CAST   0          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             

Laboratory studies at this time include:
          K           5.4  MMOL/L (H)   HDW        2.70    G/DL    
          CA          8.5   MG/DL       MPV         7.6      FL    
          CR          3.0   MG/DL (H)   PLT UNC     321   K/MM3    
          CYA         225   MCG/L       NEUT AB    3.34   K/MM3    
          GLU         131   MG/DL (H)   LYMPH A     .40   K/MM3    
          PHOS        3.8   MG/DL       EOS ABS     .05   K/MM3    
          BUN          39   MG/DL (H)   NEUT-A     82.6       % (H)
          NA          137  MMOL/L       LYMPH-A     9.9       % (L)
          CL          108  MMOL/L       MONO-A      4.2       %    
          CO 2         20   MEQ/L (L)   EOS-A       1.3       %    
          WBC        4.05   K/MM3 (L)   BASO-A       .2       %    
          RBC        2.60   M/MM3 (L)   ATYP LY     1.8       %    
          HGB         7.4    G/DL (C)   ANISO-A      ++ (*)
          HCT.       22.9       % (L)   MICRO-A       +    
          MCV        88.2      FL       MACRO-A       +    
          MCH        28.5      PG       HYPO-A        +    
          MCHC       32.3    G/DL       LEFT SH  ABSENT    
          RDW        19.8       % (H)   

Francesca has improved oral thrush however, we will extend her therapy for another seven days because of persistence of a few lesions.  She is otherwise stable without complaints.  We will change the Neoral dosing to 100 mg qd until she is off the Fluconazole.

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

               Sincerely,


               Joakuim Chef, MD           Clotilde Goldwater, MD
               Renal Fellow                 Director of Nephrology


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, October 1, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca says that she has intermittent stomach cramps and is stooling frequently at home however the stool is not loose, her diarrhea having resolved several weeks ago.  Oral candidiasis has resolved completely and she says that her mouth feels well.

Her current medications include:
     IMURAN 125 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 55 mg q.d.
     NEORAL 100 mg q.d.
     FLUCONAZOL 100 mg q.d.
     FOLIC ACID 1 mg po q.d.
     PROCARDIA XL  30 mg q.a.m., 60 mg q.p.m.
     BACTRIM (Trimethoprim 40 mg, Sulfamethoxazole 200 mg) M-W-F

Francesca's physical exam was notable for:
     BP 127/77   P 112    WT 66kg  
     General: alert and attentive in no distress.
     Skin: normal.
     HEENT: mildly cushingoid facies, no oral lesions noted on todays examination.
     Neck: lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm, no murmurs noted.
     Abdomen: soft with a non tender graft.
     Extremities: left arm exam at baseline, no edema noted.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.018           WBC/HPF     0-2        
     WBC ENZ UA  N               RBC/HPF     2-4        
     PH UA       5.5             WBC CAST    N          
     PROTEIN UA  1+              RBC CAST    N          
     BLOOD UA    N               GRAN CAST   coars      
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   N     
     MICROSCOPC             
many vaginal epithelials

Laboratory studies at this time include:
          K           3.9  MMOL/L       RDW        20.4       % (H)
          CA          8.0   MG/DL (L)   HDW        2.93    G/DL    
          CR          2.5   MG/DL (H)   MPV         7.6      FL    
          CYA         <30   MCG/L (*)   PLT UNC     419   K/MM3 (H)
          GLU         119   MG/DL (H)   NEUT         55       %    
          PHOS        1.7   MG/DL (L)   LYMPH        16       % (L)
          BUN          31   MG/DL (H)   MONOS         8       %    
          NA          140  MMOL/L       BAND         19       % (H)
          CL          111  MMOL/L (H)   METAMYE       2       %    
          CO 2         21   MEQ/L (L)   CELLS C     100    
          WBC        4.08   K/MM3 (L)   ABS NEU    3.02   K/MM3    
          RBC        2.43   M/MM3 (L)   ABS LYM     .65   K/MM3    
          HGB         7.0    G/DL (C)   ABS EOS     .00   K/MM3    
          HCT.       21.5       % (L)   MICRO        1+    
          MCV        88.3      FL       HYPO         1+    
          MCH        28.8      PG       POLYCHRINCREASE (*)
          MCHC       32.6    G/DL       NUC RBC       1    

With resolution of her oral candidiasis we will discontinue Francesca's Fluconazole after today.  She will resume 100 mg bid of cyclosporine tomorrow.  A repeat cyclosporine level will be obtained on Friday morning.  We will repeat CBC in one week.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, October 8, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca says that she is feeling well at home.  Her anal discomfort has resolved completely, she no longer has any GI upset.

Her current medications include:
     IMURAN 125 mg q.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 50 mg q.d.
     NEORAL 100 mg b.i.d.
     FOLIC ACID 1 mg po q.d.
     PROCARDIA XL  30 mg q.a.m., 60 mg q.p.m.
     BACTRIM (Trimethoprim 40 mg, Sulfamethoxazole 200 mg) M-W-F

Francesca's physical exam was notable for:
     BP 146/95   P 86  WT 68.1kg   
     General: alert, in no distress.
     Skin: normal.
     HEENT: normal with oral thrush resolved.
     Neck: lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm, no murmurs noted.
     Abdomen: soft with a non-tender graft.
     Extremities: no edema noted.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     0          
     WBC ENZ UA  N               RBC/HPF     1-2        
     PH UA       6               WBC CAST    N          
     PROTEIN UA  trace           RBC CAST    N          
     BLOOD UA    3+              GRAN CAST   +          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   many  
     MICROSCOPC             

Laboratory studies at this time include:
          K           4.4  MMOL/L       PLT UNC     432   K/MM3 (H)
          CA          8.1   MG/DL (L)   NEUT AB    4.85   K/MM3    
          CR          2.6   MG/DL (H)   LYMPH A    2.30   K/MM3    
          CYA          85   MCG/L       EOS ABS     .03   K/MM3    
          GLU          83   MG/DL       NEUT-A     60.6       %    
          PHOS        3.2   MG/DL       LYMPH-A    28.8       %    
          BUN          28   MG/DL (H)   MONO-A      7.2       %    
          NA          142  MMOL/L       EOS-A        .4       %    
          CL          114  MMOL/L (H)   BASO-A       .4       %    
          CO 2         22   MEQ/L       ATYP LY     2.5       %    
          WBC        8.00   K/MM3       LEFT SH  ABSENT    
          RBC        2.10   M/MM3 (L)   MORPH       YES    
          HGB         6.1    G/DL (C)   ANISO        2+ (*)
          HCT.       19.0       % (C)   MICRO        1+    
          MCV        90.6      FL       MACRO        1+    
          MCH        29.0      PG       HYPO         1+    
          MCHC       32.1    G/DL       POLYCHRINCREASE (*)
          RDW        21.1       % (H)   POIK         1+    
          HDW        3.31    G/DL (H)   OVALO        1+    
          MPV         7.7      FL       TEAR       RARE (*)

Francesca appears to be doing well at this time.  She has stable renal function.  Her hematocrit is low and we will check iron stores during her next visit.  We will discuss initiation of Erythropoietin.  We will increase the Procardia XL to 60 mg bid and the Cyclosporine to 125 mg bid.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
Craig Stirrat, M.D.
Department of Orthopaedics
Harvard Community Health Plan
2 Fenway Plaza
Boston, MA 02115


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, October 29, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca has no complaints today.  She is feeling well.

Her current medications include:
     IMURAN 125 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 60 mg b.i.d.
     PREDNISONE 45 mg q.d.
     NEORAL 125 mg b.i.d.
     FOLIC ACID 1 mg po q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F

Francesca's physical exam was notable for:
     BP 159/93   WT 69.2kg   
     General: alert and attentive in no distress.
     Skin: normal.
     HEENT: normal.
     Neck: lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm.
     Abdomen: soft with a non-tender graft.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     2-4        
     WBC ENZ UA  N               RBC/HPF     1-2        
     PH UA       5.5             WBC CAST    N          
     PROTEIN UA  2+              RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             

Laboratory studies at this time include:
          K           5.5  MMOL/L (H)   NEUT AB    7.33   K/MM3    
          CA          9.2   MG/DL       LYMPH A    2.88   K/MM3    
          CR          2.3   MG/DL (H)   EOS ABS     .05   K/MM3    
          CYA          69   MCG/L       NEUT-A     63.0       %    
          GLU          63   MG/DL (L)   LYMPH-A    24.7       % (L)
          PHOS        4.4   MG/DL       MONO-A      9.2       % (H)
          BUN          30   MG/DL (H)   EOS-A        .4       %    
          NA          136  MMOL/L       BASO-A       .2       %    
          CL          105  MMOL/L       ATYP LY     2.4       %    
          CO 2         22   MEQ/L       ANISO-A      ++ (*)
          WBC       11.64   K/MM3 (H)   MACRO-A       +    
          RBC        2.72   M/MM3 (L)   HYPO-A       ++ (*)
          HGB         7.9    G/DL (C)   LEFT SH  ABSENT    
          HCT.       26.1       % (L)   MORPH       YES    
          MCV        95.8      FL       ANISO        2+ (*)
          MCH        29.0      PG       MICRO        1+    
          MCHC       30.3    G/DL       MACRO        2+ (*)
          RDW        18.4       % (H)   HYPO         1+    
          HDW        2.79    G/DL       POLYCHRINCREASE (*)
          MPV         8.2      FL       POIK         1+    
          PLT UNC     456   K/MM3 (H)   

Francesca is doing well.  We will decrease the frequency of her visits to every four weeks.  We will increase the cyclosporine to 150 mg bid and recheck the level in two weeks.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, November 19, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.
Francesca offers no complaints.  During her blood draw from three days ago her creatinine was elevated at 3.1 mg/dl.

Her current medications include:
     IMURAN 125 mg q.d.
     ZANTAC 150 mg b.i.d.
     PROCARDIA XL 60 mg b.i.d.
     PREDNISONE 35 mg q.d.
     NIFEDIPINE 60 mg b.i.d.
     NEORAL 150 mg b.i.d.
     FOLIC ACID 1 mg po q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F

Francesca's physical exam was notable for:
     BP 133/77   P 86   R 14   WT 70.4kg   
     General: well appearing and in no distress.
     Skin: no lesions.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm without murmur.
     Abdomen: soft without tenderness or bruits at graft site.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.014           WBC/HPF     3-5        
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  2+              RBC CAST    N          
     BLOOD UA    N               GRAN CAST   2-3        
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             
0-1 mixed cell cast

Laboratory studies at this time include:
          CRU        90.9   MG/DL       MCHC       30.9    G/DL    
          K           4.9  MMOL/L (H)   RDW        15.2       %    
          CA          8.9   MG/DL       HDW        2.57    G/DL    
          CR          3.2   MG/DL (H)   MPV         8.9      FL    
          CYA          93   MCG/L       PLT UNC     347   K/MM3    
          GLU         111   MG/DL       NEUT AB    6.28   K/MM3    
          PHOS        4.2   MG/DL       LYMPH A    1.36   K/MM3    
          BUN          55   MG/DL (C)   EOS ABS     .08   K/MM3    
          NA          136  MMOL/L       NEUT-A     77.5       % (H)
          CL          107  MMOL/L       LYMPH-A    16.8       % (L)
          CO 2         21   MEQ/L (L)   MONO-A      3.2       %    
          WBC        8.10   K/MM3       EOS-A       1.0       %    
          RBC        3.32   M/MM3 (L)   BASO-A       .3       %    
          HGB         9.5    G/DL (L)   ATYP LY     1.3       %    
          HCT.       30.8       % (L)   HYPO-A       ++ (*)
          MCV        92.7      FL       LEFT SH  ABSENT    
          MCH        28.6      PG       U PROT      147   MG/DL (H)

Francesca's creatinine remains elevated but relatively stable.  On review, her creatinine is stable from the time of the steroid pulse for acute rejection in August.  We would have preferred to have seen it decrease, but the addition of cyclosporine may be contributing to this increase also.  We will recheck this in one week.  Because her hematocrit had been low we will check her iron stores and reticulocyte count.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, December 31, 1996.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca offers no complaints today.  Her blood pressure is elevated today in clinic.

Her current medications include:
     IMURAN 125 mg q.d.
     PROCARDIA XL 60 mg b.i.d.
     ZANTAC 75 mg b.i.d.
     PREDNISONE 20 mg q.d.
     NEORAL 175 mg b.i.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F

Francesca's physical exam was notable for:
     BP 146/105   P 67   R 14   WT 70.1kg   
     Her blood pressure was 146/88 with a heart rate of 68 after 10 mg of oral Nifedipine
     General: well appearing, comfortable, in no distress.
     Skin: without lesions.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm .
     Abdomen: soft without tenderness.
     Extremities: positive trace bipedal edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.012           WBC/HPF     3-5        
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  2+              RBC CAST    N          
     BLOOD UA    N               GRAN CAST   1-2        
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             

Laboratory studies at this time include:
          K           4.3  MMOL/L       MCH        28.6      PG    
          CA          9.1   MG/DL       MCHC       32.9    G/DL    
          CR          4.7   MG/DL (C)   RDW        14.0       %    
          CYA          88   MCG/L       HDW        2.60    G/DL    
          GLU          78   MG/DL       MPV         9.5      FL    
          FE           42  MCG/DL (L)   PLT UNC     250   K/MM3    
          PHOS        3.2   MG/DL       NEUT         45       %    
          BUN          51   MG/DL (H)   LYMPH        35       %    
          NA          135  MMOL/L       MONOS        16       % (H)
          CL          105  MMOL/L       EOS           4       %    
          CO 2         21   MEQ/L (L)   CELLS C     100    
          TIBC        196  MCG/DL (C)   ABS NEU    2.52   K/MM3    
          WBC        5.59   K/MM3       ABS LYM    1.96   K/MM3    
          RBC        3.39   M/MM3 (L)   ABS EOS     .22   K/MM3    
          HGB         9.7    G/DL (L)   MORPH    NORMAL    
          HCT.       29.5       % (L)   RET         1.6       %    
          MCV        87.1      FL       

Francesca is hypertensive.  We will give her a 10 mg dose of oral Nipedipine and observe her response.  We have advised her to restart checking her blood pressures at home.  We would like to increase her Procardia to 90 mg bid.  Her creatinine is substantially increased.  We will recheck it and consider a repeat biopsy if it is elevated again.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, January 14, 1997.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca continues to feel well following her biopsy last week.  There has been no pain and no discomfort.  Francesca has noted some elevated blood pressures at home and her blood pressure is elevated today.  Francesca has had some abdominal discomfort related to her menstrual period over the last few days.  This has been relieved by Tylenol.

Her current medications include:
     PROCARDIA XL 60 mg b.i.d.
     ZANTAC 75 mg b.i.d.
     PREDNISONE 20 mg q.d.
     BICITRA 10 mEq t.i.d.
     NEORAL 175 mg b.i.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F

Francesca's physical exam was notable for:
     BP 153/103    WT 70.1kg   
     General: alert, attentive, in no distress.
     Skin: no lesions.
     HEENT: normal.
     Neck: lymph nodes negative.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm.
     Abdomen: soft, graft non tender.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     1-2        
     WBC ENZ UA  N               RBC/HPF     tntc       
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  1+              RBC CAST    N          
     BLOOD UA    3+              GRAN CAST   1          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             
Francesca is having her period.

Laboratory studies at this time include:
          K           5.1  MMOL/L (H)   MCHC       30.5    G/DL    
          CA          8.9   MG/DL       RDW        13.6       %    
          CR          5.4   MG/DL (C)   HDW        2.43    G/DL    
          CYA         182   MCG/L       MPV         8.8      FL    
          GLU          80   MG/DL       PLT UNC     314   K/MM3    
          PHOS        4.7   MG/DL (H)   NEUT AB    2.05   K/MM3    
          BUN          43   MG/DL (H)   LYMPH A    1.48   K/MM3    
          NA          138  MMOL/L       EOS ABS     .10   K/MM3    
          CL          111  MMOL/L (H)   NEUT-A     48.4       %    
          CO 2         21   MEQ/L (L)   LYMPH-A    35.0       %    
          WBC        4.23   K/MM3 (L)   MONO-A     10.5       % (H)
          RBC        3.63   M/MM3 (L)   EOS-A       2.3       %    
          HGB         9.6    G/DL (L)   BASO-A       .7       %    
          HCT.       31.4       % (L)   ATYP LY     3.2       %    
          MCV        86.6      FL       HYPO-A        +    
          MCH        26.4      PG       LEFT SH  ABSENT    

Francesca 's blood pressure has been persistently elevated and this may be related to her recent change in renal function.  We will increase her Procardia XL to 90 mg bid in an effort to better control her hypertension.  Francesca will begin her prescribed dose of Cellcept today.  The beginning date had been delayed due to difficulty in ordering the medication at her pharmacy.  We will also decrease the Neoral to 150 mg bid.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Sabie Romanov, M.D.          RE: Francesca Gibson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/02/76

Dear Dr. Romanov:

We had the pleasure of seeing Francesca in the Renal Transplant Program on Tuesday, January 21, 1997.  She has chronic renal failure secondary to membranoproliferative glomerulonephritis.  She had a renal transplant on 11/4/88.

Francesca has been doing well with no complaints.  She underwent a biopsy a week ago for increase in creatinine, her last creatinine was 5.4 mg/dl.  She had no history of hematuria or abdominal pain.

Her current medications include:
     BICITRA 10 mEq t.i.d.
     PROCARDIA XL 90 mg b.i.d.
     ZANTAC 150 mg b.i.d.
     PREDNISONE 15 mg q.d.
     NEORAL 150 mg b.i.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     FOLIC ACID 1 mg q.d.
     CELLCEPT 1 g b.i.d.

Francesca's physical exam was notable for:
     BP 141/79   P 85   WT 68.8kg   

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

Laboratory studies at this time include:
          K           4.6  MMOL/L (H)   MPV         9.6      FL    
          CA          8.6   MG/DL       PLT UNC     291   K/MM3    
          CR          4.9   MG/DL (C)   NEUT         54       %    
          CYA          62   MCG/L       LYMPH        25       %    
          GLU          90   MG/DL       MONOS        13       % (H)
          PHOS        4.2   MG/DL       EOS           3       %    
          BUN          35   MG/DL (H)   ATYP LY       4       %    
          NA          139  MMOL/L       BAND          1       %    
          CL          109  MMOL/L       CELLS C     100    
          CO 2         18   MEQ/L (L)   ABS NEU    2.06   K/MM3    
          WBC        3.74   K/MM3 (L)   ABS LYM     .94   K/MM3    
          RBC        3.41   M/MM3 (L)   ABS EOS     .11   K/MM3    
          HGB         9.3    G/DL (L)   ANISO        1+    
          HCT.       28.9       % (L)   MICRO        1+    
          MCV        84.7      FL       MACRO        1+    
          MCH        27.3      PG       HYPO         1+    
          MCHC       32.2    G/DL       POIK         1+    
          RDW        13.6       %       OVALO        1+    
          HDW        2.35    G/DL       

Francesca continues to show a decline in renal function.  We plan to do a C3 nephritic factor level at her next visit.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Reginalf Sanders, M.D.          RE: Hedda Xavier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/08/85

Dear Dr. Sanders:

We had the pleasure of seeing Hedda in the Endocrine Program on 1/18/94 for insulin dependent diabetes mellitus.

History: As you know, Hedda is now 8 and 11/12 year old who at the time of her last visit had a glycosylated hemoglobin of 9%.   She has been growing normally.   Length is along the 50th percentile,  though she has had slightly accelerated weight gain growing to approximately the 75th to 90th percentile.   Since her last visit, she has had no significant illness and no significant episodes of hypoglycemia though at lunch time frequently has blood sugars in the 60 mg/dL range.   School is reportedly going well and Hedda is starting skating lessons in approximately one week's time.

Hedda's current insulin dose is 4 units of Regular and 25 units of NPH in the morning, 19 units of NPH in evening, giving her a total daily dose of 1.2 U/kg/day.

Review of systems:  Notable for lack of nocturia or evidence of nocturnal hypoglycemia.   Hedda's diet is notable for having significantly altered her meal plan since its institution with discontinuation of the morning snack.   Hedda's blood sugars averaged 200 mg/dL pre-breakfast, 140 pre-lunch, 180 pre-dinner and 140 pre-bedtime.

Physical exam:  
Height: 133.9 cm        Weight: 39.1 kg         BP: 118/76              
Pulse: 80               Breast: Tanner II       Pubic hair: Tanner I    
HEENT:  Oropharynx was moist, extraocular movements were intact.   Pupils were equal, round and responsive to light.
Neck:  Notable for thyroid edges palpable.
Lungs:  Clear to auscultation and percussion.  
Heart:  Regular rate and rhythm without murmur.
Abdomen:   Soft without hepatosplenomegaly or masses.    
Neurologic:   Showed 2+ and equal deep tendon reflexes with normal relaxation phase.

Impression: Currently, Hedda is entering puberty with development of early breast buds and accelerated linear growth.   Somewhat out of proportion to this accelerated linear growth is accelerating weight gain and it is possible the parents have escalated Hedda's dose at home slightly excessively at 1.2 U/kg.   This is rather large in a child at this stage of pubertal development.   We suggested limiting Hedda's meal time intake and had her meet with the nutritionist today to restructure the meal plan accordingly.   We would hope to see how Hedda's blood sugars are controlled on this diet and hopefully be able to lower her dose.   We also suggested ensuring the morning snack to avoid lunch time hypoglycemia and have repeated glycosylated hemoglobin and blood glucose today.  We hope to see Hedda again in three months time.

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

Sincerely,


Maureen Shields, MD


CONTENT:
Reginalf Sanders, M.D.          RE: Hedda Xavier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/08/85

Dear Dr. Sanders:

We had the pleasure of seeing Hedda in the Endocrine Program on 5/2/95 for in follow up of insulin dependent diabetes mellitus.

History: As you know, Hedda is now a 10 and 3/12 year old who at the time of her last visit had a near normal glycosylated hemoglobin at 8%.  Over the past one to two weeks she has exhibited slightly increased frequency of hypoglycemia awaking this morning with a blood sugar of 62 mg/dl  associated with a fine tremor of the hands.  Prior to this, her parents have been gradually increasing Hedda's dose to a total of 1.5 U/kg/day because of intermittent episodes of hypoglycemia.  She exhibits no symptomatic hypoglycemia during the day subsequent to the early morning and overall maintains a normal energy level.  Christina's current dose of insulin is 3 units of Regular, 31 NPH in the morning, 28 units of NPH in the evening, giving her a total daily dose of 62 units or 1.5 U/kg/day.  

Review of blood sugars is notable for morning blood sugars approximately 160 mg/dL, pre-lunch 150 mg/dL, pre-dinner 160 mg/dL and before bedtime 80-100 mg/dL.

Physical exam:  
Height: 144.6 cm        Weight: 42.8 kg         BP: 104/70              
Pulse: 80               Breast: Tanner IV       Pubic hair: Tanner III  
General: Notable for a well appearing girl.  

Urine dipstick was negative for glucose and ketones.  The remainder of the exam was unremarkable.

Laboratory studies:  glucose 74 mg/dL, glycosylated hemoglobin 6.7%

Impression: Our impression is that based on her intermittent low blood sugars and rather large insulin dose, though going through puberty, we believe it appropriate to slightly decrease the NPH to 26 units NPH in the evening and to 29 in the morning to attempt to minimize subsequent hypoglycemia.   With her current dose she has maintained normal linear growth including pubertal growth adn weight gain.   

For ongoing assessment we are obtaining glycosylated hemoglobin and blood glucose and would like to see Christina back again in three months time.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Reginalf Sanders, M.D.          RE: Hedda Xavier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/08/85

Dear Dr. Sanders:

We had the pleasure of seeing Christina Xavier in the Diabetes Program  on August 22, 1995 in follow-up of diabetes mellitus.  As you know,  Christina is now a 10-6/12 year old girl who at the time of her last  visit to the Diabetes Program had a glycosylated hemoglobin of 6.7%  (within the normal range).   

At this time, because of intermittent low blood sugars and slightly  accentuated weight gain, her dose was decreased slightly.  Because of her  increased pubertal progression, the patients found it necessary to  increase the dose because of intermittent hyperglycemia.  She has  exhibited no recent illnesses and is on no medications other than her  insulin.  Of note, she had recent onset of menarche two months ago  though had continued to exhibit rapid linear growth over the previous  six months.   

Current insulin regimen is 3 regular, 31 NPH in the morning, 27 NPH  before dinner for a total daily dose of approximately 1.3 units/kg./day.   

Review of log book reveals morning blood sugars 120 mg./dl., prelunch  140/mg./dl., predinner 150/mg./dl. and pre her nighttime snack 90  mg./dl.

Physical exam:  
Height: 147.3 cm        Weight: 46.3 kg         
BP: 104/76              Pulse: 84               
On examination, Christina was a well-appearing girl.  Funduscopic  examination revealed no significant retinopathy.  Thyroid was not  enlarged.  Deep tendon reflexes were 2+ and equal with normal  relaxation.  There was no injection site hypertrophy.

By report Christina exhibits excellent blood  glucose control, and  in light of her recent glycosylated hemoglobins, this  is substantiated.  Her recent menarche is on the early side, but she is likely  to obtain a reasonable final adult stature given her current height of  4'10",  at the 75th percentile.  We suggested the parents  obtaining a bone age today so we could actually predict final stature  but the parents were not anxious to pursue intervention to delay puberty  at this point.   

We are also obtaining as part of our ongoing assessment blood glucose, and glycosylated hemoglobin but are initiating no change in insulin regimen currently. 

We hope to see Christina again in three or four months time.  Thank you  for allowing us to participate in her care.


Sincerely,




Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Glycoyslated hemoglobin was again excellent at 8.6%.


CONTENT:
Reginalf Sanders, M.D.          RE: Hedda Xavier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/08/85

Dear Dr. Sanders:

I saw Hedda in the Diabetes Program on 9/10/96 for follow-up of insulin-dependent diabetes mellitus.

History: Christina is now 11 and 7/12 and has had diabetes for 5 and 1/2 years.  She said she has been healthy and active all summer and her blood sugars have been pretty good.  She had her yearly eye exam which was normal.  Her review of systems is entirely non-contributory.   

Her insulin dose is 3 units Regular, 35 units NPH in the morning, 5 and 1/2 units Regular at supper and 32 units  NPH at bedtime for a total of 1.36 u/kg/day.  She rotates her injection sites but does see some insulin leaking when she uses the stomach site.  She is only moderately active.  She has blood sugars ranging from around 60 to the low 200s and has up to several reactions each month usually associated with activity.  There was however, one very recent one in the nighttime period.

Physical exam:
HT: 152 cm    WT: 55.2 kg      BP: 114/52        Pulse: 101              
Her thyroid is normal.  She does have marked lipohypertrophy and bruising at the abdominal injection sites.  The rest of the exam is normal.

Laboratory studies:  HGB A1C 7.5%, glucose 199 mg/dL,TSH 1.50 uU/mL. Microalbumin 04  mg/gCr

Impression: Christina is in good control of her insulin-dependent diabetes mellitus, albeit on a rather high dose of insulin.  This may reflect her rapid growth over the last year.  She needs no change in her insulin now.  They are raising questions about whether she is ready to take over giving her shots herself.  I stressed that even were she to do that, I would want her at this age to be supervised, and for the family to still be involved.  They will discuss it before our next visit.  The  lipohypertrophy is rather marked on her abdomen and she was told to avoid those sites for the time being.

Disposition: We would like to see Hedda back in 3 months.  Thank you for letting us share in her care.



Sincerely,




Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Reginalf Sanders, M.D.          RE: Hedda Xavier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/08/85

Dear Dr. Sanders:

I saw Hedda in the Diabetes Program on 12/10/96 for .

History: I had the pleasure of seeing Hedda when she returned to the Diabetes  Clinic in follow-up of insulin-dependent diabetes mellitus.  She has  generally been healthy, but has for the past two weeks been congested  and with a sore throat, cough and general malaise.  She denies fever.   Her mother stated that a rapid strep test was negative today.   

Her blood sugars generally have been good, although her parents have  recently increased the insulin 1 unit of NPH in the morning and 1-1/2  units of Regular in the evening with good results.  She had her eyes  checked in the fall and apparently had a normal exam.  She has no  symptoms referable to the diabetes except polydipsia.  She says she  drinks water all the time but denies polyuria or nocturia.  Her menses  are regular and she is doing well in school.

A review of her blood sugar log reveals tests from around 50 or 60 mg/dL  at  the lowest to the 200's mg/dL with only rare tests higher than that.

Current medications: Her current insulin is 3 units Regular and 38 units NPH in the  morning, 5 units Regular before supper and 33 units NPH at bedtime for a  total of 1.38 U/kg/day.

Physical exam:
HT: 153.4 cm    WT: 56.7 kg
BP: 108/60              Pulse: 115              
She has gained 1.4 cm and 1.5 kg in three  months.  She has hypertrophy on her arms.  The rest of the exam was  deferred for today.


Laboratory studies:  HGB A1C 10.5%, random plasma glucose 373  mg/dL

Impression: Hedda appears to be in good control, although on a high dose of  insulin.  I have encouraged her mother to be judicious about increasing  the dose, looking to see whether some mild exercise or the use of  calorie free foods in place of extra snacks might be of more benefit.   As well, she is on a disproportionate amount of NPH to Regular and at  this age we often find that Regular is more useful.

Disposition:  In any case, I have made no change in her current insulin  dose.  She receives prescriptions for syringes, test strips and insulin.   She has an appointment to return in three months.   

Thanks for letting us share in Hedda's care.



Sincerely,




Maritza Brezny, MD             
                             




cc:


CONTENT:
Yvette Seinfeld, M.D.          RE: Cesar Dirksen
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/11/85

Dear Dr. Seinfeld:

     We had the pleasure of seeing Cesar in the Renal Program on 8/11/94 for IgA nephropathy.

     Cesar has done well since his last visit here.  He has had a few very minor episodes of abdominal pain.  None required visits to the Emergency Room.  He has had two episodes of rashes, however.  One of these was clearly poison oak.  The other was described as Rbeing like chicken poxS.  It lasted 2-3 days, covered his trunk and thorax but not his extremities.  It was not pruritic and he had no fever or other constitutional symptoms.

Physical exam:
     BP 111/73   P 86   R 16   HT 140.3cm   WT 30.3kg
     General: Appears well, in no distress.
     Skin: No lesions
     HEENT: Negative, fundi benign, neck supple, lymph nodes no adenopathy
     Chest: No rales or wheezes
     Heart: S1 normal, S2 split, no S3 S4 or murmur
     Abdomen: Benign, no masses, tenderness or organomegaly
     Extremities: No edema

Urinalysis:
     SPEC GR UA  1.008           PH UA       6          
     PROTEIN UA  trace           BLOOD UA    3+         
     GLUCOSE UA  N               WBC/HPF     2-4        
     RBC/HPF     3-5             CASTS       N

     Cesar has done quite well.  I have reviewed his biopsy and I agree with previous findings that it is most consistent with IgA nephropathy.  Of course, this would also be consistent with Henoch-Schonlein purpura, but his course is very atypical for that disorder.  Without any significant proteinuria or hypertension, I think that his prognosis should be excellent.  He does not need to have any diagnostic studies today and I will see him back in one year.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Yvette Seinfeld, M.D.          RE: Cesar Dirksen
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/11/85

Dear Dr. Seinfeld:

     We had the pleasure of seeing Cesar in the Renal Program on 4/13/95 for IgA nephropathy.
     Cesar had an episode of gross hematuria about three weeks ago.  He had had a viral URI over a weekend..  On Monday evening he developed obvious gross hematuria and he felt tired.  He was seen in the emergency room the next day.  He had no abdominal pain and no other symptoms.  His urinalysis showed 3+ protein, 3+ blood and a urine culture was negative.  His sedimentation rate was 22, BUN 11, Creatinine 0.6.  His total protein was 7.4 and his albumin was 3.5.  He had no episodes of abdominal pain during this entire time.  His parents wanted to see me again sooner than planned because of the increased protein associated with the macroscopic hematuria.

Current medications include:


Physical exam:
     BP 113/59   P 89   R 12   T    HT 143.5cm   WT 35kg
     General: Appears well, in no distress.
     Skin: No lesions noted.
     HEENT: Negative, fundi benign. 
     Neck: Lymph nodes no adenopathy
     Chest: No rales or wheezes.
     Heart: Core S1 normal, S2 split, no S3, S4 murmur.
     Abdomen: No masses or tenderness.
     Extremities: No edema

Urinalysis:
     SPEC GR UA  1.010           WBC ENZ UA  N          
     PH UA       7               PROTEIN UA  N          
     BLOOD UA    3+              GLUCOSE UA  N     mg/dl
     WBC/HPF     0-1             RBC/HPF     5-10       
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    N     


Laboratory studies at this time include:


     Cesar's episode seems classic for IGA nephropathy.  That is at a time of intercurrent illness he had macroscopic hematuria.  It is significantly better now.  Although he still has blood in his urine by dip stick and by microscopic examination, he basically has no proteinuria now.  Thus, I think that this type of episode is classic and likely to repeat to continue with intercurrent illnesses.  Happily, there was no abdominal pain associated with this.  I did want to see him in the emergency room with this episode because of a previous history of severe abdominal pain.  When he has further episodes of gross hematuria there is no reason to repeat the visit in the emergency room or get repeat lab tests.  If he does have abdominal pain however it might be reasonable to do an abdominal ultrasound at that point just to see if there is any other evidence of possible disorders.  I had planned to see him over the summer, but I think that it cam be delayed till one year from this visit.

     We have asked Cesar to return in .

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

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Milorad Lear, M.D.          RE: Cesar Dirksen
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/11/85

Dear Dr. Lear:

     We had the pleasure of seeing Cesar in the Renal Program on 4/11/96 for IgA Nephropathy.
     Cesar has done reasonably well since his last visit here.   He has had several intercurrent illnesses and his urine becomes a dark  brown color during that time.  However, the frequency of symptomatic  abdominal pain is lower than it had been previously.  He has not had to  have any visits in the Emergency Room.  He seems to have developed some  reactive airway disease, however, since his last visit.  He had episodes  of constant coughing particularly at bedtime over the year.  When he  demonstrated overt wheezing, he was placed on Ventolin inhalers.  Most  recently, he returned from a vacation in Hawaii and developed an upper  respiratory infection.  At the present time he is receiving Prednisone  as well as his inhalers because his wheezing was not getting  significantly better.  He feels comfortable now and can go to school  full-time.

His current medications include:
     PREDNISONE 10 mg t.i.d.
     VENTOLIN INHALER 2 puffs q.i.d.
     BACLOVENT INHALER 2 puffs q.i.d.

Cesar's physical exam was notable for:
     BP 102/55   P 91   R 12   T    HT 149cm   WT 36.5kg
     Appears well, in no obvious distress, awake,  alert and cooperative. 
      HEENT: negative.  Fundi are benign.  Vessels  appear normal.  
     Lymph nodes: no adenopathy.  
     Chest: slightly increased  expiratory phase but no obvious wheezing.  No rales or rhonchi heard.   
     Abdomen: soft and flat, no masses, tenderness or organomegaly.   
     Extremities: no edema.
A urinalysis revealed:
     SPEC GR UA  1.020           WBC/HPF     0-1        
     PH UA       6               SQUAM EPI              
     WBC ENZ UA  neg             RBC CAST    none       
     BLOOD UA    2+              WBC CAST    none       
     PROTEIN UA  neg             GRAN CAST   none       
     GLUCOSE UA  neg             WAXY CAST   none       
     RBC/HPF     3-5             BACTERIA    neg   

Laboratory studies at this time include:


     Cesar seems to be doing reasonably well.  I think that  the pattern of the constant microscopic hematuria with episodes of  apparent gross hematuria at the time of illness is still consistent with  IgA nephropathy.  I don't think that there is any connection between his  asthma and this disorder other than the fact that episodes of asthma may  also stimulate episodes of gross hematuria.  I don't think that many  laboratory tests are necessary at this point.  Without proteinuria or  hypertension, there is no need to be concerned about significant renal  disease at this point.  I think it would be reasonable for me to see him  yearly unless more significant renal problems arise.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Loocie Crane, M.D.          RE: Adele Spitz
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/05/86

Dear Dr. Crane:

We had the pleasure of seeing Adele in the Endocrine Program on 8/25/94 for evaluation of precocious puberty.

History: Adele is an 8 and a half year old female who is referred for Tanner II pubic hair and Tanner III breast.  In December of 1993, she had a DHEAS of 44, and an androstenedione of 34.   In September of 1993, her bone age was 10 years at a chronological age of when she was 7 and a half years.  

Breast enlargement was first noted in September of 1993 at 7 1/2 years of age.  Adele developed axillary odor one year prior to this.    She has not had menarche.  Mother and maternal grandmother had menarche at age 12.

Past medical history:  Unremarkable.

Physical exam:  
Height: 144.8 cm        Weight: 48.2 kg         BP: 110/65              
Pulse: 80               Breast: Tanner III      Pubic hair: Tanner II   
Height: 144.8 cm (n the accelerated curve, 50% for an 11 year old)
Weight:  48.2 kg (on the accelerated curve)
General: Adele is alert and well appearing.   
Skin: Two cafe-au-lait spots on the left and right thigh.  
HEENT: Revealed good venous pulsations.   Discs sharp.  Tympanic membranes are pink.  
Neck: Supple with palpable thyroid but no thyromegaly. No lymphadenopathy.  
Chest: Clear to auscultation.  Axillary hair noted sparsely bilaterally.   
Heart: Regular rate and rhythm, no murmurs.   
Abdomen: Soft, no masses.  
Genitourinary: Tanner II pubic hair and an estrogenized vaginal mucosa.  
Extremities: Reveal 2+ pulses.
Neurological: Nonfocal.   Visual acuity was grossly normal.

Laboratory studies:  September 1993:  Bone age of 10 years, December 1993:  DHEAS=44, androstenedione=34.
August 1994:  FSH=2.4 IU/L, LH=1.10 IU/L, estradiol=9.0 pg/ml, TSH=1.10 uU/ml, TT3=154 ng/dl, TBGI=0.89, T4=9.1 mcg/dl, IGF-1=455 ng/ml.  Bone age=12 years with a SD of 11 months at a chronological age of 8 years 6 months.

Impression: At this time, Adele has early puberty, most likely to be idiopathic in etiology.   Based on her bone age today, Adele's anticipated final height is 63.3".  Ff she continues to grow as anticipated so there is probably not a need to suppress her puberty as her height will be fairly normal.   It is evident that she is more estrogenized than androgenized which is also reassuring for an idiopathic etiology as opposed to a pathologic lesion.

Disposition: We  plan to follow up with Adele in six months to assess her growth.   If you have any further questions, please feel free to call.
Thank you for letting us share in the care of Adele.

Sincerely,


Juillermo Simpson, MD                Penelope Hagen, MD              
                             Attending in Endocrinology   


Addendum: Resident in Pediatrics

Problem list to date:
SEXUAL-PRECOCITY                             09/16/94  
Transcribed by Sullivan_ma


CONTENT:
Korie Hagen, M.D.          RE: Bart Park
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/12/84

Dear Dr. Hagen:

We had the pleasure of seeing Bart in the Endocrine Program on 12/1/94 for .

History: Bart is a 10 and 9/12 year old boy with x-linked hypophosphatemic rickets s/p three osteomies, most recently a left osteotomy in May.  His compliance with medical regimen remains poor.  He continues to experience leg pain.

Current medications: Neutrophos  500 mg qid; Rocaltrol 1 cap bid.

Physical exam:  
Height: 134.7 cm        Weight: 32.2 kg         BP: 94/74               
Pulse: 72               
Skin:  Normal temperature and texture.  Chest:  No rachiatic changes; Extremities: No rachitic changes but prominent leg bowing present bilaterally.

Laboratory studies:  alk phos 482 U/L, calcium 8.8 mg/dL, creatinine 0.4 mg/dL, phosphorous 3.2 mg/dL.

Impression: Bart continues to have a difficult time with his rickets.  Better Compliance was urged.

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

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Ellastine Adler, M.D.          RE: Bart Park
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/12/84

Dear Dr. Adler:

We had the pleasure of seeing Bart in the Endocrine Program on 3/2/95 for follow-up of x-linked hypophosphatemia.

History: Bart is an 11 year old with X-linked hypophosphatemia seen on 3/2/95 for routine follow-up.  At his last visit, Bart was noted to have a moderately elevated alk phos.  He continues to be poorly compliant.  He was seen by Dr. Shapiro 3/1/95 who reportedly felt that Bart was stable.

Current medications: Neutra phos K 500 mg qid-tid; Rocaltrol 0.25 mg bid.

Physical exam:  
Height: 112 cm          Weight: 19.8 kg         BP: 98/55               
Pulse: 78               
General: Well developed, well nourished.
Skin:  Normal temperature and texture.
HEENT:  Fundi not well visualized.
Neck:  No goiter.
Heart:  Regular rate
Abdomen: Benign.
Genitourinary:  Prepubertal.
Neurological: Cranial nerves II-XII grossly normal.

Laboratory studies:  12/1/94:  alk phos  482 U/L (increased), phos 3.2 ng/dL (decreased), Ca 8.8 mg/dl, PTH 61 pg/ml, creatinine 0.4 mg/dl.

Impression: Bart is only moderately well controlled on present regimen.  We discussed the need for more frequent dosing and will assess his response at his next visit.

Disposition: Increase neutrophos K to 500 mg 5 times daily.  We will check labs at his next visit in three months.
Thank you for letting us share in the care of Bart.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology   


Problem list to date:
X-LINKED-HYPOPHOS.-RICKETS                   05/03/93  
Transcribed by Sullivan_ma


CONTENT:
Ellastine Adler, M.D.          RE: Bart Park
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/12/84

Dear Dr. Adler:

We had the pleasure of seeing Bart in the Endocrine Clinic on  August 31, 1995.  Bart is an 11-1/2 year old with X-linked  hypophosphatemic rickets who is here for routine follow-up.  Bart  has not been compliant with his medical regimen.  He has no complaints.

Physical exam:  Height: 137.5 cm        Weight: 34.1 kg         
On physical examination, Bart is short and has bowing of the lower  extremities as previously.   Extremities: bowing as previously with no marked epiphysical flaring or ricketic rosary.

Impression: Bart remains noncompliant with his medical regimen but  appears to be stable at present.

Disposition:  We are switching Bart to K-Phos Neutral 250 mg 5x a day and  Rocaltrol 0.25 mcg daily.  Bart is to return to clinic in 3 months.


Sincerely,




Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Cavinder Simpson, M.D.          RE: Bart Park
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/12/84

Dear Dr. Simpson:

We had the pleasure of seeing Bart in the Endocrine Program on 8/27/92 for evaluation of familial hypophosphatemic rickets.

History: Bart is now 8 and 6/12 years old and has not been seen by a physician in over a year, until recently when he developed some oral surgical problems. He stopped his phosphorous supplement and vitamin D supplement three years ago when he was last seen here. At the time of his last visit here in 1989 he was status-post pin removal for one of his osteotomies. 

Mother feels that his bowing has markedly improved following his last surgery, but the bowing has deteriorated over the past year. None of this has gotten in the way of his vigorous activity in sports but mother says that he has had some recent increase in discomfort in his knees and hips. 

Nutritionally, he takes 3-4 glasses of milk per day and no dietary supplements or medications.

Physical exam:  
Height: 123.3 cm        Weight: 24.5 kg         BP: 85/50               
Pulse: 80               U/L ratio:  1.06        Arm span: 134.5         
Pubic hair: Tanner I    
U/L segment ratio 1.05.

General: No abnormalities were noted except for the obvious bowing of his legs. His gait is clearly affected by this as well.

Impression: Bart should take Rocaltrol 0.25 mg bid and Nutriphos 500 mg qid. Follow-up with Dr. Shapiro will be arranged by him. Because this patient was lost to follow-up for three years due to difficulty of coming this far, he will be followed by Dr. Elmo Domingo in Tewksbury.


Laboratory studies pending at this time include: Blood tests were ordered for serum calcium, phosphorous, alkaline phosphatase, 125-hydroxy vitamin d level, 25-hydroxy D level, parathormone level, and a spot urine specimen for calcium, creatinine, and phosphorous. An x-ray was done for his bilateral femurs and tibia and Dr. Shapiro plans to come over to see him on the day of his visit.
Thank you for letting us share in the care of Bart.

Sincerely,


Nilto Carter, MD             Elmo Domingo, MD                 
                             Attending in Endocrinology   


Addendum: 1, 25 OHD=47 pg/mL (15-60), PTH=35 pg/mL (10-65), serum Ca=9.5 mg/dL, phos=3.4 mg/dL, alk phos=273 mU/mL.  Spot urine creatinine=10.3 mg/dL, phos=5.8 mg/dL.  

Enclosure


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

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

History: I have taken over the endocrine follow up of Edith in our program now that Dr. Najjar has moved back to Beirut where he is the Dean of the American University of Beirut Medical School.

I saw Edith on 5/10/94 in follow up for the Protropin treatment of her growth deficiency secondary to Turner Syndrome.  She is now doing beautifully on 1.5 mg of Protropin daily, 0.5  mg/kg/day.  She has also been on Ritalin 25 mg slow release each  school day morning for her hyperactivity and she is mainstreamed in a first grade classroom with children three years younger than she and is doing quite well.   This is because of her significant developmental and language delay.

Physical exam:  
Height: 122.5 cm        Weight: 31.3 kg         BP: 100/60              
Pulse: 60               U/L ratio:  1.08        Breast: Tanner I        
Pubic hair: Tanner II   
Upper to lower segment ratio is 1.12.

Impression: This growth now places her between the 90-95th percentile for height for Turner Syndrome.  She is not gaining excessively as she  has only gained half a kg with a 2.5 cm growth increment since December.   In 12/7/93, her bone age was 8 and 10/12 showing that her bone age is now more closely approximating chronologic age.

No additional studies were ordered today and she will continue her present dose.   Because she is with school children three years her junior, there is no pressure to add estrogen early and certainly it is not in her long term growth interest either.   I believe we would be considering estrogen addition no sooner than three years from now.

Thanks for allowing me to share in her care.  I plan to see her again in six months.

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

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 12/6/94 for .

History: I had the pleasure of seeing Edith 12/6/94 for follow up of growth hormone treatment of her Turner syndrome.  She continues to grow beautifully along the 5th percentile and has had no evidence of estrogenization.   She has some pubic hair but no breast development or vaginal mucous changes.   In September an MRI was done due to her cardiac murmur and high blood pressure noted in upper extremities.   No evidence of coarctation was noted.   

Now at 9 and 11/12 years of age, she has been taking 1.5 mg of Protropin nightly, 6 days a week which gives her 0.26 mg/kg/week or 0.37 mg/kg/day.   She is also on Ritalin slow release Monday through Friday for hyperactivity.

Physical exam:  
Height: 128.6 cm        Weight: 34.7 kg         BP: 138/70              
Pulse: 91               U/L ratio:  1.13        Arm span: 114.3         
Breast: Tanner I        Pubic hair: Tanner II   
She looks entirely well.   There is no palpable increase in her thyroid or clear evidence of thyroid deficiency.   The remaining part of her examination is negative.

Laboratory studies:  T4 10.0 ug/dL, TBGI 1.01, TSH 1.70 uU/mL, E2 <5 pg/mL.  These are normal.  At 9 11/12 years her bone age is 10-11 years.

Impression: Normal Protropin response, hypertension of uncertain etiology which has been investigated by the cardiologists.

Disposition: She will continue her present dose and return to see me in six months.
Thank you for letting us share in the care of Edith.

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology   


Addendum: fax copy of report to Kathleen Michael at Caremark, 708-559-3590 including a copy of the growth chart.


CONTENT:
Hugo, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Hugo:

We had the pleasure of seeing Edith in the Endocrine Program on 3/1/95 for .

History: I received a copy of a Bioran slip from blood drawn on Edith on 2/14/95, which showed a very pubertal Estradiol level of 48 pg/ml. This is in contrast to an undetectable level based on our own lab in December.

Is she showing breast budding or other feminine pubertal changes, other than the pubic hair noted on my exam?

If so, I would like to see her within 2 months.

Physical exam:  




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

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 5/23/95 for evaluation of her growth on gh for turner's syndrome.

History: I saw Edith in the Endocrine Program ion 5/23/95 for evaluationof her groth on Protropin Recombinant Human Growth Hormone therapy for Turner's Syndrome.  She is now 10 4/12 years of age and has grown 2 cm in the past five months which converts to an acceptable 4.36 cm per year growth velocity.  She has increased also an appropriate 2.7 kg in that interval.   She has had some mood swings and further development of adrenarche with progression of axillary and pubic hair.  She has no breast budding however.

Current medications: She remains on Protropin 1.5 mg qhs six nights per week which converts to 9 mg per week or 0.24 mg/kg/week (0.03 mg/kg/day).  She is also on Ritalin 20 mg slow release tablet with a 5 mg Kaelin acting tablet taken together 5-7 days per week.

Physical exam:  
Height: 130.6 cm        Weight: 37.4 kg         BP: 133/73              
Pulse: 100              Arm span: 116           Breast: Tanner I        
Pubic hair: Tanner II   
U/L ratio = 1.11.
Genitourinary: No evidence of estrogenization of her vaginal mucosa.  She has no clitoromegaly and the remainder of her exam ais unremarkable.

My reading of her bone age today appears to be approximately 10 years 6 months.

Impression: I am concerned because of the increased estroadiol level that was 48 pg/ml noted on the sample taken by you 2-14-95.  That would suggest a more central puberty may be occurring and her growth spurt could be related to estrogen effect coupled with the GH.  The fact that her bone age doesn't look further accelerated is reassuring, but if she becomes estrogenized early that may negate the benefits that she is seeing from GH treatment which currently places her on the 5% for the non Turner's curve, and if followed to a normal curve conclusion, could get her to 60-61" tall. 

I have drawn an LH, FSH, estradiol, and TFT's.  If the estrogen level is elevated I will schedule her for GNRH stimulation tests and consider the possibility of putting her on Lupron depo (GNRH analog to suppress central puberty).

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

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology   


Addendum: 5/23/95:  Lab results are reassuring:  LH 1.6 Iu/L, FSH 37 IU/L (increase consistent with gonadal germ cell failure), estradiol <10 pg/ml (appropriately low), T4 9.2 ug/dL, TSH 1.4 uU/ml, normal.


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

I saw Edith in the Endocrine Program on 11/7/95 for Turner's syndrome.

History: She looks very well at the time of this visit at age 10 and 10/12 growth hormone treatment.  She has had further development of adrenarche but no growth acceleration of note and no acceleration of bone age (her bone age 6 months ago was 10 and 6/12).  She has certainly not had any estrogenic changes nor would I expect them considering her Turner's syndrome.

I note a slight reduction in growth velocity since over the past year and this is possibly because her dose of Protropin has not been increased accordingly as she has gained weight.

Current medications: Her current medication includes Protropin 1.5 mg. daily 6 days a week which gives her 0.225 mg/kg/wk.  She is also on Ritalin 5 mg. plus a 20 mg. slow release each morning on school days.

Physical exam:
HT: 132.2 cm    WT: 40.1 kg    Arm span: 119 cm    U/L ratio:  1.07
BP: 90/50               Pulse: 80               
Breast: Tanner I        Pubic hair: Tanner III  
On physical, except for the further progression of adrenarche, there is no sign of any further development.  No thyromegaly.  No abdominal masses.

Impression: No further studies were done today but I have decided to increase her to 0.3 mg/kg/wk of Protropin given 6 days a week which would increase her dose to 2 mg/day.  I would like to see her back in 4 months.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

I saw Edith in the Endocrine Program on 3/12/96 for follow-up of Turner's syndrome.  She is doing beautifully, taking 2 mg daily of recombinant human  sequence  growth hormone six days a week giving her 0.3 mg/kg/week.  She has now been moving well along the 95th percentile growth line for Turner's syndrome which is essentially at the 5th percentile on the standard female chart! 

She has not had any estrogenic changes but continues to have some adrenarche with pubic hair, the beginnings of axillary hair and some apocrine odor.  She also has had a further deviation in size between her feet with the left foot being approximately 1 to 1-1/2 sizes smaller than the right and she has this relative hemihypertrophy with the right side being larger than the left throughout her body.

Physical exam:
Height: 133.1 cm    Weight: 39.4 kg
BP: 115/72              Breast: Tanner I        Pubic hair: Tanner III  


Impression: It is fortunate that her classmates are 9 years of age, so she fits in quite well in terms of stature.  This will also make it less necessary to push towards estrogen treatment, something that we would like to delay as long as possible to maximize her growth potential.  Once we start estrogens, her epiphyseal fusion will take place sufficiently quickly to negate some of the benefits of growth hormone treatment.

Disposition: I did no additional studies today but when I see her again in four months, I will do thyroid functions, and IGF-I and review her bone age.   

Thanks for allowing me to share in her care.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   


cc:  Mrs. Ellen Brandeis  116 Paradise Road Swampscott , MA  01907


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

History: She is now 11-6/12 years old and is doing very well in her growth hormone therapy for Turner's syndrome.  She recently underwent surgery for excision of a web between her 2nd and 3rd fingers of her right hand and that was only done one week ago and the healing looks good.  She is also having a palate widening performed with an intraoral device. 

She has has further progression in terms of androgenic pubertal development, primarily in terms of pubic hair and apocrine odor.  She has had no estrogenic signs, nor would I expect her to.

Current medications: Her dose of 2 mg. of human sequence growth hormone taken 6 days a week gives approximately 0.3 mg/kg/week.

Physical exam:
HT: 135 cm              WT: 39.4 kg              U/L ratio:  1.04
BP: 110/75              Pulse: 106                      
Breast: Tanner I        Pubic hair: Tanner III  
She has grown 2.5 cm. since she was last here in March and 1.8 kg. increase during that interval.  It is impossible to do an arm span due her recent surgery.   A bone age is pending.  The remaining aspects of her exam was unremarkable.

Laboratory studies: IGF-I 277 ng/mL, TSH 2.70 uU/ML, T4 9.3 UG/DL, 
E2 <10 PG/ML, TBGI 1.08.       

Impression: I ordered an IgF-1 thyroid function and estradiol and did a bone age and will keep her on her present dose regimen and see her again in 4 months.  Obviously we are going to delay the initiation of any estrogen treatment as long as possible to give her maximum time for growth. 

Thanks for allowing me to share in her care.

Sincerely,






Nilto Carter, MD             
Associate in Endocrinology   

cc: Mrs. Ellen Brandeis   116 Paradise Road  Swampscott , MA  01907


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

I got caught up to date by Mr. & Mrs. Brandeis on Edith's recent problems with respect to pericarditis during this episodic visit today for assessment of growth hormone treatment.  

I won't fill you in on details you already know, but she has had inflammatory pericarditis with significant pericardial effusion since early August, when she was initially admitted to this hospital on 08/02/96.  To date there has been no specific etiologic agent associated with this although it is thought to be a reactive inflammatory response to infection such as Coxsackie B.  She has no serologic evidence consistent with a rheumatologic cause.

Her response to the Prednisone has been good cardiacwise although she is  scheduled for repeat echocardiogram today.  She has, however, had significant weight increase, hypertension, and by report she has had glycosuria.

Current medications: She was begun on Prednisone 20 mg BID in early September and most recently decreased to 30 mg a day a week ago.

She remains on human recombinant growth hormone 2 mg subcutaneously of Protropin 6 days per week.

Physical exam:
Height: 136.5 cm        Weight: 49.4 kg
BP: 166/107             Pubic hair: Tanner III  
This is virtually 10 kg increase in the past 3-1/2 months.  She has no breast development.  Her most recent bone age done in July was 6 months advanced at 12 years.

Impression: Because growth hormone has been implicated in both insulin resistance and in causing edema in older individuals, I thought it would be best to discontinue it during this period of time when pharmacologic doses of glucocorticoids are being used.

Disposition: I therefore advised the family to stop the growth hormone, to restrict sweets and to also reduce sodium intake and I will wait to see whether the cardiologist would want her to use any diuretics as well.  Because of her glucose intolerance, I would probably prefer not to see her on any thiazides. 

Once the cardiac status is stabilized and she is off glucocorticoids and, if her echocardiogram is normal, then I think we could reinstitute growth hormone.  There has never been an association of pericarditis directly or indirectly related to growth hormone treatment so I don't put that into the equation.  

I look forward to seeing her in 4 months and hope that this process is  transitory. 

Give me a call if there are any other issues such as if her blood sugars start to shoot up into the 300-400 range.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   


cc:  Ellen Brandeis   116 Paradise Road   Swampscott , MA  01907


CONTENT:
Antony Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 07/29/91 for evaluation of turner's syndrome.

History: Edith has been well since her previous visit.  She was off her Ritalin medication for three weeks, between the end of school and the beginning of her summer program; at present she takes 7.5mg once daily.

Current medications: Ritalin as above and growth hormone 1.0mg subcutaneously 7 time per week.  Shots well tolerated.

Physical exam:  
Height: 109.1 cm        Weight: 19.6 kg         U/L ratio:  1.14

In summary: Edith has grown 3.6cm over the last four months, given her an annualized growth velocity of 10.8cm per year on growth hormone.  This is an excellent response.  There are no side effects at present, apart from noted enlargement of her feet.

Disposition: Continue present medication.

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

Sincerely,


Steve Hugo, MD                      Kendell Simpson, MD
Fellow in Endocrinology               Clinical Director

MY/SN/smp


CONTENT:
Antony Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 12/2/91 for evaluation of turner's syndrome.

History: Edith has been in good health since her previous visit.  On review, she commenced her growth hormone therapy in September 1989.  She receives 7 shots per week given daily as 1 mg per shot.  Formerly this was given into the outer upper arm, but more recently into the legs.  There have been no apparent side effects, and her hands and feet appear to be growing normally.

Current medications: Growth hormone as above. Ritalin 10 mg per day.

Physical exam:  
Height: 110.6 cm        U/L ratio:  1.13        Breast Tanner: 1        
Pubic hair Tanner: 1    
General: Edith has grown 1.5 cm over the past 4 months giving her an annualized growth veloctiy of 4.5 cm per year.  Overall, her growth hormone therapy has taken her from the 25th centile on the Turner's growth chart to the 75th centile, which is now equivalent to the 5th centile on the National Center for Health Statistics growth chart.  Her upper to lower segment ratio remains abnormal at 1.13.

Laboratory studies:
Bone age 5 years 9 months at a chronological age of 6 years 11 months.

In summary: Edith has responded well to the growth hormone therapy though her growth velocity is now falling off as expected in the third year of therapy.  Her present dose is at the maximum normally used in Turner's syndrome i.e. 0.05 mg/kg/day.  We hope that this will maintain present growth velocity and ultimately result in increased final adult height.

Disposition: See again in four months.

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

Sincerely,


Steve Hugo, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Antony Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 9/15/92 for follow up of her turner syndrome and growth hormone therapy.

History: Edith has been well since last seen on 04/16/92.  She has been off Ritalin this summer  and the past two weeks of school; she has been well.  She had no intercurrent illness and the review of systems was negative.  Her parents have noticed an increase in her appetite and in her weight.  She was also seen in cardiology on 04/16/92.  No definite abnormality was noted, no VSD seen, aortic valve was not well visualized but the images were not suggestive of a bicummisural valve.

Current medications: Protropin 1.2 mg six days a week.

Physical exam:  
Height: 116.1 cm        Weight: 26.8 kg         BP: 130/82              
Pulse: 86               Breast: Tanner I        Pubic hair: Tanner I    
Previously noted stigmata of Turner syndrome and heart murmur, otherwise negative.

Impression: Edith grew very well in the past five months (3.2 cm).  It is possible that this is related to discontinuing the Ritalin.  A bone age and thyroid function tests were ordered.

Disposition: Edith is to continue on the same dose of Protropin.  She will be reassessed in four months.  A prudent diet was recommended as girls with Turner syndrome have a tendency to become obese and she is already overweight.

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

Sincerely,





Kendell Simpson, MD             
Clinical Director


CONTENT:
Antony Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 01/12/93 for follow-up of her response to growth hormone therapy.

History: Since last seen on 09/15/92 Edith has been well.  She is back on Ritalin (20 mg sustained release preparation) now that she is in school.  She had no significant intercurrent illness and the review of systems was negative.

Current medications: Protropin 1.0 mg daily, Ritalin 20 mg daily.

Physical exam:  
Height: 118.2 cm        Weight: 26.5 kg         Pubic hair: Tanner II   
The  pubic hair has been present for the past year.  Her left foot is smaller than the right.  A murmur over the LSB and the stigmata of Turner syndrome was unchanged. The rest of the physical examination was negative.

Laboratory studies:  T4 was 7.5 mcg/dL, T3RU 31.4%, TSH 1.1 mcU/dL.

Impression: Edith grew 2.1 cm in four months.  She is almost on the 90th centile of the Turner growth chart and the 5th centile of the normal NCHS growth chart.

Disposition: She is to continue the same dose of Protropin and will be reassessed in four months.

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

Sincerely,





Kendell Simpson, MD             
Clinical Director


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 7/20/93 for follow-up of her response to growth hormone treatment.

History: Since last seen on January 12, 1993, Edith has been well.  She had no significant intercurrent illness.  The review of systems was negative.  There has been some increase of her pubic hair according to her mother.

Current medications: Protropin 1.10 mg daily.

Physical exam:  
Height: 120.4 cm        Weight: 28.1 kg         BP: 80/60               
Pulse: 78               Breast: Tanner I        Pubic hair: Tanner II   
The physical examination was unchanged.

Impression: Turner syndrome.  Edith grew 2.2 cm. in six months, she remains on the 90th centile for height on the Turner growth chart having started on the 25th centile before instituting growth hormone treatment.

Disposition: I would like to see Edith in four months for follow-up.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Niall Kaelin, M.D.          RE: Edith Brandeis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/26/84

Dear Dr. Kaelin:

We had the pleasure of seeing Edith in the Endocrine Program on 12/07/93 for follow up of her response to growth hormone therapy.

History: Since last seen on 07/20/93 Edith has been well.  She has had no significant intercurrent illness.

Current medications: Protropin 1.5 mg daily.

Physical exam:  
Height: 122.6 cm        Weight: 30.6 kg         BP: 110/70              
Pulse: 82               Pubic hair: Tanner II   
Edith is growing on the 90th percentile of the Turner growth chart (5th percentile on the NCSH growth chart).  The physical examination revealed the previously noted stigmata of Turner syndrome and the cardiac murmur.

Laboratory studies:  The bone age was determined to be 8 years 10 months with two standard deviations equal to 21 months for this age patient.  Therefore, the bone age is well within the normal range. 

The 4th and 5th metacarpals are slightly shortened in this patient with Turner's syndrome.

TSH 1.4 mcU/mL, T4 9.5 mcg/dL, Thyroid antibodies are pending.

Impression: Turner syndrome.  She is responding well to growth hormone treatment.

Disposition: She is to continue on the same dose of Protropin.
Thank you for letting us share in the care of Edith.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Timothy Green, M.D.          RE: Kelly Baldwin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/14/85

Dear Dr. Green:

     The results of the laboratory tests obtained on Christopher during his visit on December 29,1992:

     T4 9.1 mcg/dL, TSH 3.5 mcU/mL, cortisol 15.3 mcgm/dL, testosterone 242 mcg/dL, LH .18 IU/L, FSH 0.4 IU/L, IGF1 234 ng/mL.

     All these values are normal except for the testosterone which is low but not low enough to explain his symptomatology.  The blood sample was obtained three weeks after the last dose of Testosterone Enanthate, he usually gets his dose every two weeks.



Sincerely,   





Samir Najjar, M.D.
Clinical Director


cc:  Stephen Skapeck, M.D., Jimmy Fund Clinic, DFCI
     Michael Scott, M.D., Dept. of Neurology, TCH
     Nancy Tarbell, M.D., Joint Center for Radiation Therapy


CONTENT:
Gayla Brezny, M.D.          RE: Errol Agee
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/16/81

Dear Dr. Brezny:

We had the pleasure of seeing Errol in the Endocrine Program on 10/22/92 for evaluation of short stature.

History: Errol is an 11 and 4/12 year old boy with a history of asthma since age 7 who was referred for evaluation of short stature. Mother states that although Errol is short, he has been growing just below the 5th percentile and the concern was that he may be  hormone deficient. She states that he is eating well without anorexia, constipation, diarrhea. He denies irritability, headaches, abnormal hair growth. He is doing very well at school.

Current medications: Intal inhaler and Ventolin PRN. He does not take any prednisone. He does use a hydrocortisone cream occasionally for eczema.

Past medical history:  Pregnancy was term with a vaginal delivery. His weight was 7 lbs. 12 oz. His length was 20 inches. He had a cephal hematoma at birth which resolved within three months. Growth and development were normal with normal acquisition of motor skills. He was breast fed for five months and then switched to formula. He had some ear infections and chicken-pox. His vaccines are up to date. He was hospitalized in 1988 for asthma at age 7. He had a soft palette laceration without surgery. No operations.

Review of systems:  Skin: rare eczema treated with hydrocortisone containing cream. Otherwise, review of systems was noncontributory.

Family history:  Mother's height is 5'4". Father's height 5'7". On the father's side a paternal grandfather is 5'4", a paternal brother 5'7", and two sisters 5'4" and 5'3".

Physical exam:  
Height: 131 cm          Weight: 24.7 kg         BP: 110/60              
Pulse: 80               Arm span: 134           Breast: Tanner I        
Pubic hair: Tanner I    R. testis: 2 x 1 cm     L. testis: 2 x 1 cm     
Phallus length: 6 cm    Mid-shaft diam.: 2 cm   
General: Errol is a thin boy in no apparent distress. He is alert and cooperative. Skin: Warm and dry without rashes or abnormal hair growth. HEENT: Moist mucous membranes and clear oropharynx. Pupils equal, round, and reactive to light. Extraocular muscles intact. Discs flat.  Neck: Without lymphadenopathy or thyromegaly.  Chest: Clear to auscultation. No gynecomastia.  Heart: Regular rate and rhythm with no murmurs, gallops, or rubs.  Abdomen:  Soft without tenderness or masses.  Genitourinary:  Normal male.  Extremities: No clubbing, cyanosis, or edema. No laxed joints. 
Neurological: Normal strength. Cranial nerves intact. 2+ bilaterally.

Laboratory studies:  IGF1 135 ng/mL (normal 117-771), TSH 1.10, T4 7.6, bone age 11-11 and 6/12 years. Predicted adult height is 64.5 inches.

Impression: With the normal IGF1, TSH  T4, and bone age, it is most likely  that Errol has familial short stature. His predicted adult height is within two standard deviations of his mid-parental target height.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Addendum: Demetrious Herodotou, MD

Problem list to date:
ACHONDROPLASIA               Start: 10/22/92  End:          Invalid: 

Transcribed by Cassells


CONTENT:
Eldre Hagen, M.D.          RE: Dean McClure
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/05/83

Dear Dr. Hagen:

We saw Dean in the Endocrine Program on 12/4/95 for short stature.

History: Jessie's mother reports that he has been short for as long as she can remember, although he is not the shortest in his class and is not as short  as his brother is.  She denied any problems in him with headaches, nocturia, polydipsia, visual problems, or heat or cold intolerance.  He is generally healthy, although he has a problem with oral Candidiasis, for which he has had multiple investigations and which was poorly responsive to normal therapy.  He is starting to go into puberty and says that he has had a few pubic hairs present for about eight months.  He denies deodorant use.  His appetite is good.

Current medications: He is on no medications, although he takes vitamin supplements of amino acids.

Past medical history:  Past medical history is significant for an uncomplicated pregnancy.  He was delivered by C-section.  Mom was unclear of the reason for this.  Birth weight was 7 lbs, 2 oz.  Reviewing his old Children's Hospital chart, it appears that he had developmental delay and was investigated for hypotonia at around 5-6 years of age.  He had a significant seizure disorder with complex partial seizures and was treated with anticonvulsants until approximately 3 years ago when he was taken off  treatment after a normal EEG.  He has been seizure free since that time.  A CT done in 1989 showed mild cerebellar atrophy and prominent lateral ventricles.  It also appears that he had a low IgA level at one point, although mom says he received no therapy for this.  He also has problem with persistent oral thrush. 

Social history:  Jessie is in sixth grade of a special school which he started approximately 1 year ago.

Review of systems:  Review of systems was remarkable for the fact that Jessie has had a few pimples recently on his face.  HEENT has chronic oral thrush and chronic chancres which are slightly improved recently.  Cardiorespiratory system: unremarkable.  GI: no constipation or diarrhea.  GU and urological systems: unremarkable.

Family history:  Mother is 5' tall and 45 years old.  She is healthy.  Her menarche was at 11 years.  His father is 46 years of age; he is 6' tall and was a late bloomer in all areas, according to Jessie's mother. Jessie's brother, Devon, was also being evaluated in the clinic today; he is 8 years old and growing along the delayed curve.  There is a family history of diabetes in Jessie's maternal great-grandmother and of hypertension in  his paternal grandfather.

Physical exam:
HT: 134.5 cm    WT: 32.7 kg   Arm span: 137.6 cm    U/L ratio:  0.91
BP: 95/75               Pulse: 95               Pubic hair: Tanner I    
R. testis: 3.0 x 1.7 cm L. testis: 3.2 x 1.6 cm Phallus length: 8.25 cm 
Mid-shaft diam.: 2.5 cm 
He looked well; he was cooperative.  His skin had a few  pustules, especially over the nasolabial folds.  Mouth appeared clear,  no obvious inflammation or coating suggestive of thrush.  Neck was  supple, with a palpable thyroid which was not thought to be enlarged; he  had some shotty lymph nodes in the anterior and posterior cervical  groups.  Lungs were clear.  Breasts: no tissue.  Heart: S1 + S2 + 0.   Abdomen: nontender, nondistended, no hepatosplenomegaly or masses.  GU:  he was Tanner I pubic hair, Tanner II genitalia; he had been  circumcised.  Extremities: unremarkable.  Neurological: he has brisk  reflexes, grossly normal visual fields.

Laboratory studies:  There were no prior laboratory studies performed.  A bone age was between 11 years 6 months and 12 years 6 months in this boy who is 12 years and 3 months of age.  The standard deviation at this age is 10 months.

In summary, Jessie is a 12 year old boy who has a significant past history for neurologic problems with a seizure disorder, hypotonia and developmental delay.  It appears that he has been healthy recently, with his only problem being persistent oral thrush which is of unclear etiology.  He has been growing along his own curve, which is midway between the normal and the delayed case on our curves in the clinic here.  We feel that this is satisfactory growth, and that he probably has an element of constitutional delay with an adequate final height.   In order to give his mother a prediction of what this may be, we performed a bone age at the clinic today.  We will let Jessie's mom know the results of this investigation, but do not feel that he needs further follow up in the clinic at this time.



Sincerely,




Helena Thornley, MD           Lancelot Blue, MD             
Resident in Pediatrics        Attending in Endocrinology


CONTENT:
Rogelio Benise, M.D.          RE: Margot Aldrin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/22/85

Dear Dr. Benise:

We had the pleasure of seeing Margot in the Endocrine Program on 3/5/92 for  pubic hair.

History: This 6 and 7/12 year old white girl was referred for evaluation of development of pubic hair. Her mother tells us that for the last 2 years she has been aware of her sexuality and that she has been thinking in a way older than her age. Six months ago she started to develop body odor and has been using deodorant on a daily basis. In February of this year pubic hair was noted and so she was referred to us for evaluation. She has no axcillary hair or breast development. There is no vaginal bleeding or discharge. The patient is in her first year of school and she is doing well.

Current medications: None.

Past medical history:  She was given a diagnosis of mild cerebal palsy at which time she had hypertonia. She has developed slowly as a child. She was rolling over later than usual. She walked at 2 years of age. She was also much stronger in the arms than legs. However, currently she looks normal. There was a question of a hearing problem according to the mother but the school exam was normal. She has occasional chest pain that lasts a few seconds which is not bothersome.

Family history:  Her mother is 37 years old and is healthy. Her father is 43 years old and is healthy. She has a family history of diabetes on both sides of the family. There is no thyroid disease.  There is no family history of premature precocious puberty. The father's height is 6'4" and the mother's height is 5'7".

Physical exam:  
Height: 124.4 cm        Weight: 28.2 kg         BP: 104/60              
U/L ratio:  1.04        Arm span: 120           
General: Healthy looking 
HEENT: Normal
Chest: Clear.  No breast development.
Heart: Normal
Abdomen: Normal
Genitourinary: No axcillary hair, no clitoromegaly or posterior vaginal fusion, no estrogen effect on vaginal mucosa.

Impression: This young girl  presents with a small amount of pubic hair and body odor. This is most likely premature adrenarche.  It is therefore decided to observe her and see her in 6 months time. Should she develop more quickly or other signs or symptoms of virilization then further endocrine testing will be done.


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

Sincerely,


M Joan Hammer, MD         
Associate in Endocrinology


CONTENT:
Milagros Stalin, M.D.          RE: Margot Aldrin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/22/85

Dear Dr. Stalin:

We had the pleasure of seeing Margot in the Endocrine Program on 10/22/92 for evaluation of premature adrenarche.

History: Margot is a 7 and 3/12 year old girl who is followed for the development of early pubic hair. Since her last visit she has had increasing pubic hair and occasional acne and continued apocrine odor. Her appetite remains good but not excessive. She has had no vaginal discharge or bleeding. She is in the second grade and is enjoying dance classes. The parents are concerned about any hormonal abnormalities and would like some blood tests done. There is no family history of any hirsutism or irregular menses.

Physical exam:  
Height: 130.7 cm        Weight: 32.8 kg         U/L ratio:  0.84        
Arm span: 127.5         Breast: Tanner I        Pubic hair: Tanner II   
General: Margot was cheerful and cooperative. She had two areas of faint hyperpigmentation on her back and one area of hypopigmentation on her abdomen. There was no acne and no axillary hair. She had Tanner II pubic hair which was moderate and curly on the labia only. She had no clitoromegaly and no maturation of the vaginal mucosa. She had no thyroid enlargement, no breast development, and she had four permanent teeth.

Impression: Margot has benign premature adrenarche. Although she does have some increase in her growth rate since the last visit, there is no evidence of any excessive androgen levels from her physical exam. A repeat bone age was 7 and 4/12 years old showing no acceleration from her last visit. I arranged to have her go to the Franny Lab to have a LH, FSH, estradiol, thyroid function test, DHEA, DS, and 17-hydroxyprogesterone done at 8 a.m. to rule out any endocrine abnormalities. I plan to see her back in six months and her parents will call if they see a change in development sooner.

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

Sincerely,


M Joan Hammer, MD         
Associate in Endocrinology


CONTENT:
Blue, M.D.          RE: Christine Clair
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/04/82

Dear Dr. Jawa,

     we had the pleasure of seeing Christine for evaluation of preococious puberty in the Endocrine Program on 1/29/91.

Blue: Christine is an 8 5/12 year old female last seen 12/3/90 at which time she had non-detectable gonadotropins and on exam no axillary hair, minimal pubic hair and Tanner III breast development. Since the last visit there has been no vaginal bleeding, no further breast development, no development of axillary hair and no progression of her pubic hair. She has occasional headaches but is otherwise well.

Physical exam:
Weight: 32.8 kg, height: 132.5 cm, breast Tanner stage: 3, pubic hair Tanner stage: 1
General: Well appearing female in no apparent distress.
Skin:  2 hyperpigmented macules on the right chest
HEENT:  fundi benign, PERRL, EOMI
Neck:  no thyromegaly
Chest: CTA; 2.3 cm areolae, nipple 0.4 mm, 5-6.5 cm breast bilaterally
Heart: RRR without murmurs
Abdomen: soft, no hepatosplenomegaly
Genitorurinary: few terminal hairs
Neurological: non-focal exam

In summary: Both growth and development do not reveal significant advancement of puberty over the last two months.

Recommendations: Given the lack of pubertal progression we feel comfortable recommending follow-up in June.

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

            Sincerely,


                        Blue, Lancelot MD                        Simpson, Mitsuko MD
                        Fellow in Endocrinology             Chief Emeritus


CONTENT:
Goldwater, M.D.          RE: Christine Clair
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/04/82

Dear Dr. Goldwater:

We had the pleasure of seeing Christine in the Endocrine Program on 7/1/91 for evaluation of premature thelarche.

History: Christine is an 8 10/12 year old girl last seen on 1/29/91 for follow up of premature thelarche.  Since her last visit, there has been no change in her breast size noted, there has been no menarche or adrenarche.  She has been using deodorant for a one year period.  There is also no history of nocturia or headaches.

Physical exam:  
Height: 135.5 cm        Weight: 33.5 kg         BP: 98/54               
Pulse: 82               Breast Tanner: 3        Pubic hair Tanner: 2    
Skin:  No axillary hair 
HEENT: MMM, PERRL, EOMI
Neck:  no thyromegaly
Chest: 4-5 cm breast tissue bilaterally
Heart:  Regular rate and rhythm without murmur
Abdomen: No hepatosplenomegaly 
Genitorurinary:  Sparse terminal hair on labia 
Extremities: no deformities 
Neurological: non-focal

Laboratory studies:
(Prior) 12/3

DS 110 mg/dl
LH <3 mIU/ml
FSH<3 mIU/ml
EL< 20 pg/ml

In summary: Christine is a 8 10/12 year old with premature thelarche. The presence of pubic hair on exam suggests that she may be entering into true puberty (although her prior DS levels were low) but this would place the timing of her menarche within the normal range.

Disposition: There is no need for further follow up at this time. If however Christine or her mother have further questions or new findings of concern, we would be glad to answer them by phone or in clinic.

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

Sincerely,


Lancelot Blue, MD                      Rahul Ibsen, MD


CONTENT:
Barney Carter, M.D.          RE: Christine Clair
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/04/82

Dear Dr. Carter:

We had the pleasure of seeing Christine in the Endocrine Program on 7/1/91 for evaluation of premature thelarche.

History: Christine is an 8 10/12 year old girl last seen on 1/29/91. Since her last visit, there has been no change in her breast size noted,and no menarche. She has been using deodorant for a one year period.  There is also no history of nocturia or headaches.

Physical exam:  
Height: 135.5 cm        Weight: 33.5 kg         BP: 98/54               
Pulse: 82               Breast Tanner: 3        Pubic hair Tanner: 2    
Skin:  No axillary hair 
HEENT: MMM, PERRL, EOMI
Neck:  no thyromegaly
Chest: 4-5 cm breast tissue bilaterally
Heart:  Regular rate and rhythm without murmur
Abdomen: No hepatosplenomegaly 
Genitorurinary:  Sparse terminal hair on labia 
Extremities: no deformities 
Neurological: non-focal

Laboratory studies:
(Prior) 12/3

DS 110 mg/dl
LH <3 mIU/ml
FSH<3 mIU/ml
E2< 20 pg/ml

In summary: Christine is a 8 10/12 year old with early albeit indolent development breast suggestive of premature thelarche. The presence of pubic hair on exam and her elevated DS level suggest that she may be experiencing adrenal activation ("adrenarche") as well.

Disposition: There is no need for further follow up at this time. If however Christine or her mother have further questions or new findings of concern, we would be glad to answer them by phone or in clinic

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

Sincerely,


Lancelot Blue, MD                      Rahul Ibsen, MD


CONTENT:
Han Sanders, M.D.          RE: Suzanne Thorndike
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/22/86

Dear Dr. Sanders:

We had the pleasure of seeing Suzanne in the Endocrine Program on 11/28/94 for follow-up of androgen resistance.

History: Suzanne is 8 3/12 years old and has been well since we saw her one year ago.  The mother's principal concern at this time is when and how should Suzanne be told about her condition.

Current medications: none

Family history:  There has been no change in the health of any of the maternal family members with primary amenorrhea.  Several of these women have had in the past acute episodes of pain attributed to inguinal hernias.  These have resolved readily with surgery.

Physical exam:  
Height: 133.9 cm        Weight: 27.2 kg         Pulse: 84               
Breast: Tanner I        Pubic hair: Tanner I    
Healthy looking and talkative.  Skin normal texture.  Thyroid not enlarged.  Heart regular rate and rhythm.  GU vaginal mucosa pink.

Impression: Suzanne is growing well and is showing very early signs of estrogen effects.  The right time to explain more to Suzanne will be determined by her emotional maturity, her pubertal status, and her interest in the issues.  The parents' observations about her maturity and questions that she has about puberty will be invaluable in this regard.  We will be glad to help the family with  any future discussions with Suzanne about these matters.

Disposition: We would like to see Suzanne again in one year.
Thank you for letting us share in the care of Suzanne.

Sincerely,


Rene Daley, MD         Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Ricot Benise, M.D.          RE: Suzanne Thorndike
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/22/86

Dear Dr. Benise:

We had the pleasure of seeing Suzanne in the Endocrine Program on 11/08/93 for androgen resistance.

History: Suzanne is a 7 3/12 year old girl diagnosed with androgen resistance as an infant.  At birth, she was unambiguously female, but when a bilateral herniorrhaphy was performed at 4m of age, testis-like gonads were found, and the biopsies showed normal seminiferous tubules and Sertoli cells bilaterally.  Chromosomes were 46 XY and vaginoscopy demonstrated a blind pouch.   Gonadectomy was recommended at that time because of the possibility of virilization at puberty if the resistance were only partial and also because of an increased risk of malignant transformation of the gonads.   The family was reluctant to pursue this course.

Suzanne was last seen here in August, 1990. Since then she has been well.

Family history:  Remarkable for at least eight women on the maternal side who have primary amenorrhea, the oldest of which  is in her eighties and healthy.  Most of these women live in Haiti.

Physical exam:  
Height: 128.1 cm        Weight: 25.2 kg         BP: 98/62               
Pulse: 80               Breast: Tanner I        
Healthy looking girl.  Normal prepubertal exam with red vaginal mucosa.  There is a small glans without palpable  corpora.  There is no axillary hair.

Laboratory studies:  LH 0.14 IU/L, FSH 1.7 IU/L.  Bone age 6 years 10 months.

Impression: Suzanne is a healthy girl with androgen resistance, probably complete.  Given the strong family history of healthy, non-virilized women who probably have the same disorder, it is easy to understand the family's reluctance to agree to gonadectomy.  The risk of malignancy in the gonads in this condition is not well quantified at this time.  A more complete family history, to verify the health of the other women with amenorrhea, and DNA studies to identify the specific defect may help to clarify the need for intervention.

Disposition: We would like to see Suzanne again in one year.   In the meanwhile, the mother will attempt to obtain more information from her relatives.

Laboratory studies pending at this time include: DNA studies to look at the gene for the androgen receptor
Thank you for letting us share in the care of Suzanne.

Sincerely,


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


CONTENT:
Valentine Romanov, M.D.          RE: Helga Alcaeus
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/16/75

Dear Dr. Romanov:

We had the pleasure of seeing Helga in the Endocrine Program on 10/24/94 for insulin dependent diabetes mellitus.

History: As you know, Helga is now 19 and 8/12 year old who was recently admitted to Children's Hospital with an episode of gastroenteritis and elevated blood sugars in early October.   At this time, a glycosylated hemoglobin returned at 10.3%, indicating average blood sugars in approximately 220-240 mg/dL range.   Since this visit Helga reports improved compliance in blood sugar monitoring, checking blood sugars three times daily.  She reports mild hypoglycemia twice weekly, usually when breakfast is missed.  She currently has little exercise and recently has begun on Depo Provera as birth control.  Prior to this she had regular menstrual periods.   

Helga's insulin dose is currently 12 units of NPH, 10 units of Regular in the morning, 9 units of NPH and 5 units of Regular before dinner.  She rotates sites between upper and lower extremities, abdomen and buttocks frequently.   She has no nocturia, polydipsia, polyuria and her only significant hypoglycemias occur when meals are missed.   On reviewing her blood sugar monitoring; pre-breakfast her blood sugars average approximately 160 mg/dL, pre-lunch 150 mg/dL, pre-dinner 190 mg/dL and 240 mg/dL before bedtime.

Physical exam:  
Height: 164 cm          Weight: 64.3 kg         BP: 116/74              
Pulse: 76               
General: Helga was a well appearing woman.   
Neck: Thyroid was not enlarged.   
Chest: Lungs were clear to auscultation.   
Heart: Nonfocal.

Impression: Our impression is that Helga exhibits mild to moderate hyperglycemia by her recent monitoring, though her last glycosylated hemoglobin was approximately 1-2% higher than optimal currently.   Based on her current blood sugar readings, we elected to increase Helga's night time Regular to 6 units and morning NPH to 13 units and repeat glycosylated hemoglobin and TSH at the time of her next visit.

Disposition: We hope to see her again in four months time.
Thank you for letting us share in the care of Helga.

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Getro Brezny, M.D.          RE: Leah Corcoran
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/22/86

Dear Dr. Brezny:

We had the pleasure of seeing Leah in the Endocrine Program on 10/17/94 for hypothyroidism.

History: Leah is an 8 year old white female with Down's syndrome who is referred for an elevated TSH noted on routine screening.   Her parents note no symptoms except some problems with constipation in the recent past.  She has no cold intolerance, no behavioral changes or change in dietary habits.   She has an increased sleep requirement compared with her siblings but this is not a new finding.  No other complaints.

Past medical history:  Significant for ear infections in the past and the patient had ear tubes put in once in the distant past.   She has had two eye operations in 1990 and 1991.   She has no other hospitalizations.  She is up to date on her immunizations.   Mom is gravida 3, para 3 who was of advanced maternal age at the time of the patient's birth.  The patient was born by C-section delivery for breech presentation.  Growth and development have been appropriate for Down Syndrome child although the patient plots out to the 5th percentile for both weight and height on growth curves for non-Down syndrome children.  She has stayed on the curves however.

Review of systems:  Positive only for increased constipation.

Family history:  No other family members with Down syndrome.   She has no history of diabetes, other auto-immune disorder, no history of anemia.    Mother's height is 5'8", father's height is 5'10.5".

Physical exam:  
Height: 113.3 cm        Weight: 21.7 kg         BP: 98/64               
Pulse: 84               
General: Down Syndrome facies.   Skin: Dryness on the hands but no dryness on the upper arms or abdomen.   Neck: No thyromegaly or adenopathy.    Chest: Lungs were clear to auscultation.   Heart: Regular rate and rhythm without murmur.    Abdomen: Soft and nontender.    Extremities: Lower extremity reflexes are completely normal.

Laboratory studies:  TSH of 7, a T4 of 6, T3 uptake of 28 and a free T4 of 1.7.  
(10/17/94)  T4 8.0 ug/dL; TSH 3.20   uU/mL; TPO AB  9.9  U/ML;  TG AB  0.4  U/ML.

Impression: Leah had an elevated TSH and normal T4 but no clinical signs of hypothyroidism.   As you know, there is an increase in auto immune related hypothyroidism in patients with Down Syndrome,  particularly patients over the age of 4-5.

Disposition: Labs are normal for thyroid hormone, with unchanged mild elevation of TSH.  Antibodies are present.  Thus we should repeat testing every six months to see if there is evolution toward frank hypothyroidism.
Thank you for letting us share in the care of Leah.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology
  


Addendum: Daniel Schust, M.D.
Endocrine Fellow, BWH


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

We had the pleasure of seeing Rudolf in the Endocrine Program on 12/27/93 for .

History: I saw Rudolf, age 8 years 8 months, in follow up for insulin dependent diabetes mellitus.

He is currently on human insulin, 2-3 Regular and 15.5 NPH before breakfast, 1.5-2.5 Regular and 6 ultralente before supper (25 units or 0.83 U/kg).   

Mother has observed improved blood glucose control and he no longer has ketonuria before breakfast.   

His appetite has improved.   He is doing well in the third grade.    He does have intermittent pain in the knees and ankles, especially at night, but this has persisted for the past one to two years and mother thinks it is caused by "growing pains".

He has no symptoms of uncontrolled diabetes but does have nocturia intermittently when blood glucose levels are high during the evening.    

Blood glucose monitoring is done three times daily.   Fasting glucose levels range from 77 to 268 mg/dL, pre-supper 50 to 192 and pre-bedtime 160 to 280 mg/dL.

Physical exam:  
Height: 130 cm          Weight: 30.1 kg         BP: 100/70              
Pulse: 80               
He looked well and had good color and hydration.   Examiantion was unremarkable other than to note mild lipohypertrophy at the injection sites in the upper extremities.    He did have scarred finger tips from overuse of particular areas for blood glucose monitoring.

Height is now at 50th percentile and weight is at 75th percentile.   Urine had 2% glucose, negative ketones and protein.    His diabetes control seems to be satisfactory.   His mother continues to be anxious about hypoglycemia and accordingly tends to use the minimum amount of insulin she feels is appropriate.    I have recommended pre-lunch glucose tests, and increasing the morning dose of Regular insulin by half a unit.  His hemoglobin A1 will be done at a local lab because of a previous bad experience at the Chidren's Hospital lab.


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

Sincerely,


Bernardo Bird, MD         
Attending in Endocrinology


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

We had the pleasure of seeing Rudolf in the Endocrine Program on 12/27/94 for .

History: I saw Rudolf, age 8 years 8 months, for follow-up of insulin- dependent diabetes mellitus.   

He had been healthy until recently when he developed an ear infection and is being treated with Biaxin.  

He is currently on 1.5-2.5 Regular plus 15.5 NPH before breakfast, 1-2 Regular and 6 Ultralente before supper (average daily dose 25 units or 0.7 U/kg).   

He does well in the 4th grade but still has has separation anxiety.  He sleeps well and usually does not have nocturia.   There have been no problems with hypoglycemia.  Appetite has been good and he has three meals and three snacks daily.  He is physically active.   

Blood glucose monitoring is done 2-3 times daily but there was no record for my review.   By report, fasting blood glucose is in the range 180-220, before dinner 80-180, before bedtime 80-180 mg/dL.

Height 135.2 cm.   Weight 31.6 kg.  Blood pressure 113/70.  Pulse 78 per minute.  He looked well and had good color and hydration.   Thyroid gland was palpable.   He has a grade I-II/VI vibratory systolic ejection murmur.   He had a rash on the dorsum of his hands, and warts on his fingers and on the soles of his feet.   

Urine had 5% glucose, negative ketones and protein.   Plasma glucose was 337 mg/dL, hemoglobin A1 11.2% (normal 5.2-7.8%), urinary microalbumin 2 mg/g creatinine.   

Rudolf is growing and gaining weight normally.   I recommended increasing the p.m. dose of Regular insulin by 0.5-1 unit to lower his bedtime glucose levels to a range of 80-180 mg/dL.  Thereafter, if blood glucose continues to be high before breakfast, I have recommended increasing the dose of Ultralente at supper by 0.5-1 unit.   His father has psoriasis and it is possible that the rash on his hands could be an early manifestation of this disorder.   I shall defer to you concerning this problem.   I renewed all his prescriptions at his mother's request.

Physical exam:  




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

Sincerely,


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


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

We had the pleasure of seeing Rudolf in the Endocrine Program on 4/10/95 for .

History: I saw Rudolf, age nearly 10 years, for follow up of insulin dependent diabetes mellitus.  

General health has been good.  

He is currently using Human insulin, 2-3 Regular and 15.5 NPH before breakfast, 1.5-3 Regular and 7 Ultralente before supper, 1-2 Regular at bedtime if blood glucose levels are high.  

Mother stated that blood glucose levels are frequently high at bedtime and therefore she addedf Regular insulin at the time of the pre-bedtime snack.  

He sleeps well without disturbance.  There have been no problems with severe hypoglycemia or loss of consciousness.  He has a good appetite and has three meals and three snacks daily.  Mother stated that he often eats candy when other children make it available.  

Blood glucose monitoring is done four times daily.  Glucose levels are erratic.

Physical exam:  
Height: 136.7 cm        Weight: 32.7 kg         BP: 90/54               
Pulse: 72               
He is prepubertal.  Thyroid gland was not palpable.  He had a grade II/VI systolic ejection murmur.  The remainder of the exam was unremarkable.  

Urine had 1+ glucose, negative ketones and protein.  His hemoglobin A1 was 10.1% (normal 5.2-7.8%).

Impression: He is growing and gaining weight normally.  Blood glucose monitoring data show that BG levels often are high before lunch and before dinner.  Accordingly, I have recommended increasing the dose of Regular insulin by 1 unit and subtracting 1 unit from the morning dose of NPH.

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

Sincerely,


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


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

I saw Rudolf, age 10 years 4 months, for follow up of insulin-dependent diabetes mellitus diagnosed 8-1/2 years ago. 

He has enjoyed good health, and there are no current problems.  He  sleeps without disturbance.  He is physically active.  He will soon be  entering fifth grade. 

He has no symptoms of uncontrolled diabetes, and there have been no  episodes of severe hypoglycemia.  He has a good appetite and has 3 meals  and 3 snacks daily.

Blood glucose monitoring is done three times daily but not before lunch.   Glucose levels are erratic and largely dependent on his diet.

Current medications: He uses human insulin, 2-3 regular plus 14.5 NPH before breakfast,  1.5-2.5 regular plus 7 ultralente before supper (average daily dose 26  units of 0.79 u./kg.).

Physical exam:  
Height: 138.2 cm        Weight: 33 kg                       
BP: 102/60              Pulse: 80               
He is a healthy appearing prepubertal child.  Physical exam was  entirely normal.

Laboratory studies: Urine glucose 0.25%, ketones and protein negative.  Hemoglobin A1 10.9 % (normal 5.2-7.8).

Disposition: To optimize his insulin regimen, it is important to obtain pre-lunch blood glucose measurements more consistently.  I plan to  see him again in three months.

Impression: Height and weight are in 50th percentile. He is growing  normally.  Diabetes is under satisfactory control.  Because recent research has shown that the risk of diabetic complications is significantly increased in individuals whose HbA1 is greater than 10%, my goal is to try to reduce Rudolf's hemoglobin A1 to 10% or less.





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


Sincerely,





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


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

I saw Rudolf, age 10 years 7 months, for follow up of insulin dependent diabetes mellitus diagnosed at age 20 months. 

General health has been good and he reported no diabetes-related symptoms.  He has had no problems with severe hypoglycemia.  He is physically active 4-5 times weekly.  He has a good appetite and consumes three meals and three snacks daily. 

Blood glucose monitoring is done 3-4 times daily.  Review of his log book shows variable blood sugar control with no consistent pattern, numerous values less than 180 mg/dl and intermittent glucose values in the mid-200's.

Current medications: Humulin insulin:  2-3 Regular plus 14.5 NPH before breakfast, 1-3 Regular plus 7 Ultralente before supper, 0-1 Regular prior to the bedtime snack; (average daily dose 26 units or 0.77U/kg.).

Physical exam:
HT: 139.2 cm            WT: 33.9 kg
BP: 96/60               Pulse: 80               Pubic hair: Tanner I    
He looked well and had good color and hydration.  Physical exam was entirely normal.

Laboratory studies: Urine had 5% glucose but no ketones; random plasma glucose 419 mg/dl at 3 p.m, hemoglobin A1 11.4% (nl 5.2-7.8).

Impression: He is growing and gaining weight normally.  Diabetes is in "fair"  control.  I would prefer to see his HbA1 10% or less.

Disposition: I encouraged him to record his pre-lunch glucose data obtained at school.   Meanwhile, no change in his insulin therapy seems to be necessary.  I encouraged Mrs. Capet to ensure that Rudolf has a ophthalmological examination done annually.


Sincerely,






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


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

I saw Rudolf, age 11 years, for follow up of insulin dependent diabetes mellitus.   

Insulin dose:  2-3 Regular plus 14.5 NPH before breakfast, 2-3 Regular plus 7.5 Ultralente before supper, 1-2 Regular before bedtime intermittently when BG level is high.  Average daily dose 28 units or 0.81 U/kg.  

He has enjoyed good health and reported no diabetes-related symptoms.  He recently had an eye examination which was reported as being normal.  He has three meals and three snacks daily.  He is physically active and reports infrequent symptomatic hypoglycemia, usually after gym and before lunch.  He reported no nocturnal hypoglycemia and no episodes of severe hypoglycemia.  

Blood glucose monitoring is done 3-6 times daily.  His record book shows no measurements before lunch.  Glucose levels range from 63-350 mg/dl.  He has no discernible pattern.

Current medications: None.

Physical exam:
HT: 140.6 cm            WT: 34.5 kg
BP: 100/57              Pulse: 76               
Physical exam was entirely unremarkable.  I noted a bruise from an insulin injection over the right deltoid.

Laboratory studies: Urine had 50 mg/dL glucose, negative ketones and protein.  HbA1c 7.6% (normal 4-6).

Impression: He is growing and gaining weight normally.  Hemoglobin A1c indicates satisfactory blood glucose control.

Disposition: I adjusted his doses and increased the sliding scales:  2-4 Regular before breakfast, 2-4 Regular before supper.  I suggested increasing the evening dose of Ultralente to 8 units.  Also, I encouraged Rudolf to attend diabetes camp during the summer.

Sincerely,





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


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Kahalil-Brezny:

I saw Rudolf in the Diabetes Program on 10/1/96 for insulin-dependent diabetes mellitus.

History: I saw Rudolf, age 11 years 5 months, for follow-up of insulin-dependent diabetes mellitus diagnosed in January, 1987, nearly 10 years ago.  I last saw Rudolf in April, 1996. 

Insulin dose:  Humulin 2-3 Regular and 15.5 NPH before breakfast, 2-3 Regular and 8.5 Ultralente before supper, 1 to 2 Regular before bed approximately 4 to 5 times per week (average daily dose approximately 0.79 U/kg). 

The major complaint today is that blood glucose levels have been high.  He does not have diabetes-related symptoms and there have been no episodes of severe hypoglycemia.  He has a large appetite and appears to be more hungry than usual.  He is physically active. 

Blood glucose monitoring is done 3 to 6 times daily but not usually before lunch.

Physical exam:
HT: 142.8 cm            WT: 37.3 kg
BP: 103/58              Pulse: 88                      
Breast: Tanner I        Pubic hair: Tanner I    
He appeared healthy, well developed and well nourished.  Color and hydration were normal.  Thyroid exam was not palpable.  He has 1 to 2+ deep tendon reflexes in the knees and ankles.  The remainder of the exam was normal.

Laboratory studies: Plasma glucose 399 mg/dl, HGBA1c 7.7 % (4-6); Total cholesterol 201, HDL 49, LDL117, triglycerides 177 mg/dL; urine microalbumin <2 mg/L (normal).

Impression: Rudolf is growing and gaining weight normally.  He is still prepubertal.  I made adjustments to his insulin dose so that he will now receive between 2 and 3.5 Regular on a sliding scale before breakfast and between 2.5 and 4 Regular on a sliding scale before supper.  The doses of NPH and Ultralente have not been changed.  Overall, glycemic control is satisfactory.  He has no complications of diabetes.


Sincerely,






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


CONTENT:
Pavarotti, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Kahalil-Pavarotti:

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

History: I saw Rudolf, age 6 years 5 months, for follow up of diabetes mellitus.  

He is currently using pure pork insulin, 2 Regular and 8 NPH in the A.M., 2.5 Regular and 5 NPH in the P.M.  

He is on no other medications.  His general health has been good.  Mother has noted that blood glucose levels are higher since returning to school and made minor adjustments.  There have been no episodes of severe hypoglycemia.  His diet is satisfactory and he is physically active.  Blood glucose levels are done 3-5 times daily  but there was no record for me to review.

Physical exam:  
Height: 119. cm         Weight: 23.6 kg         BP: 100/70              
Pulse: 80               
Physical exam was unremarkable.

Hemoglobin A1 was 11.2% (normal 5.6-7.6%); non-fasting total cholesterol 241, HDL 56 and triglyceride 268, calculated LDL 131 mg/dl.  Total cholesterol and LDL cholesterol are slightly elevated.  

He is growing and gaining weight normally.  I am satisfied with his level of control.  Thank you for the opportunity to continue to share in the care of this youngster.

In summary: 

Disposition: 

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

Sincerely,


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


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

We had the pleasure of seeing Rudolf in the Endocrine Program on 1/10/92 for  .

History: I saw Rudolf, age 6 years 8 1/2 months, in follow-up for insulin dependent diabetes mellitus.

He is currently on pure pork insulin, 2-2.5 Regular plus 9 NPH before breakfast, 1.5-3 Regular plus 5.5 NPH before supper.  He is on no other medications.  

His general health has been good except for a recent brief illness.  Blood glucose levels have been quite unstable.  

He continues to have 3 meals and 3 snacks.  His appetite is good.  He has nocturia once each night.  There have been no episodes of severe hypoglycemia.  

Blood glucose monitoring is done 2-3 times daily.  Fasting blood glucose ranges from 170 to 410 mg/dl, before supper 78 to 330 and before the bedtime snack 60 to 400 mg/dl.

Physical exam:  
Height: 120.5 cm        Weight: 23.9 kg         BP: 100/60              
Pulse: 100              
He appeared healthy, well-developed, well-nourished.  Physical exam was unremarkable except to note minimal induration at the injection sites in the left upper extremity.

Laboratory studies:  Urinalysis had 5% glucose, no ketones or protein, plasma glucose 555 mg/dl. Total glycosylated hemoglobin 11.7% (normal 5.6-7.6%).

In summary: Rudolf is growing in the 50th centile for height and at the 75th centile for weight.  The most likely explanation for the markedly unstable glucose values is erratic adherence to his meal plan.  Because he tends to be uniformly both high before breakfast and supper, I have empirically increased his NPH dose to 9.5 units before breakfast and 6 units before supper.


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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

We had the pleasure of seeing Rudolf in the Endocrine Program on 5/17/93 for follow-up of insulin dependent diabetes mellitus.

History: Rudolf is now 8 years of age and was diagnosed with insulin dependent diabetes in January, 1987.

I last saw him approximately 1 year ago. Subsequently, Rudolf saw Dr. Timothy Striker, an endocrinologist in Stoneham. 

He is currently on Humulin insulin, 0.5 units Regular and 15 NPH before breakfast, 0.5  Regular at supper, and 4.5 NPH at 8 p.m. with or without an additional 0.5 units of Regular insulin. The average daily insulin dose is 21 units or 0.77 u/kg. 

Apparently, blood glucose levels have been very erratic.  There have been no episodes of severe hypoglycemia but he does have intermittent mild hypoglycemia which he is able to recognize. 

Blood glucose monitoring is done approximately 3 times daily and glucose levels range from approximately 50 to over 350 mg/dL.

Physical exam:  
Height: 126.8 cm        Weight: 27.2 kg         BP: 106/64              
Pulse: 60               
He looked well but had flushed cheeks. Physical exam was entirely unremarkable except to note lipohypertrophy at the injection sites both upper extremities and in the buttocks.

Laboratory studies:  Urinalysis had 5% glucose but no ketones or protein.  Mrs. Capet wished to have Rudolf's blood work (hemoglobin-A1 and lipids) done at NE Memorial Hospital. She should see that the results are mailed to me but they have not yet reached my desk.

Impression: In summary, Rudolf is growing and gaining weight normally. He has injection site hypertrophy and I emphasized the importance of rotating his injection sites. We discussed the various options for insulin management and agreed to switch back to a twice daily insulin regimen consisting of 3 Regular and 12.5 NPH before breakfast, 2 Regular and 4 Ultralente before supper. The total daily dose will be 0.8 u/kg or 21.5 units/day.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Brezny, M.D.          RE: Rudolf Capet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/85

Dear Dr. Khalil-Brezny:

We had the pleasure of seeing Rudolf in the Endocrine Program on 7/19/93 for follow-up for insulin dependent diabetes mellitus.

History: I saw Rudolf, age 8 years 4 month, in follow-up for insulin-dependent diabetes mellitus.

He is currently on Humulin insulin, 2 Regular and 15 NPH before breakfast, 2 Regular and 5.5 ultralente before supper. Total daily dose 24.5 units or 0.89 u/kg.

He has enjoyed good health and has abundant energy. His mother reported that blood glucose levels are too high. She tests him before breakfast, supper and bedtime and glucose levels have ranged from 60-288 ng/dL.  Insulin doses have been adjusted per telephone communication. 

His appetite is great and he has three meals and three snacks daily. There have been no problems with severe hypoglycemia. He has no symptoms suggestive of uncontrolled diabetes.

Physical exam:  
Height: 128.7 cm        Weight: 27.6 kg         BP: 110/70              
Pulse: 72               
General: He appeared healthy and is prepubertal. The thyroid gland was palpable but not enlarged. The remainder of the exam was normal.

Impression: Rudolf is growing in the 50th centile for height and weight is between the 50th and 75th centiles. Urine had 0.1% glucose but no ketones or protein. We did not obtain blood tests today because mother prefers to have them done at the local lab. 

I have requested more frequent tests before lunch to guide dose adjustments in the morning. I suspect that Rudolf may need more regular insulin than he is currently receiving.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Piggy, M.D.          RE: Ernst Bellow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/24/86

Dear Dr. Piggy:

We had the pleasure of seeing Ernst in the Endocrine Program on 12/5/94 for precocious puberty.

History: Ernst is now 8 and 3/12 years of age.    He is here for possible precocious puberty.   He has been seen at the health center his yearly check up and during this last visit was noted to have increased pubic hair growth.   In actuality, the pubic hair growth was first noted when Ernst was an infant.  He was seen here at our endocrine clinic for evaluation but mom is unable to provide information regarding the work up and diagnosis.   She does report no increase in pubic hair growth for many years till about 1 year of age until about 6-7 months ago when Ernst began having an increase in number and length of pubic hairs.   He is presently in the second grade and is doing quite well.   He is very active  playing multiple sports.   He is a very good eater having three meals a day and occasional snacks.   Mom tries to enforce healthy foods most of the time.  Bedtime is around 11:00-11:30 at night and he has no problem sleeping.

Current medications: None.

Past medical history:  He is the product of a full term, normal spontaneous vaginal delivery.   He began walking at about 8 months of age, saying his first words at 7-8 months of age.  He has always been above the 95th percentile both in height and weight however, over the last three to four months he has gained a considerable amount of weight and has grown also in height.

Review of systems:  is negative for polydipsia and polyuria.    He does have headaches during the day however, he is not having any headaches at night.   He sometimes uses deodorant especially when he is active.

Family history:  There is a family history of cardiac disease and hypertension.   Ernst has an 18 year old brother who is 5'10" tall and began to have pubic hair growth at around 9-10 years of age.  Mom had her menarche at 12 years of age.   There is no other family history that is significant to Ernst's case.   Mom's height is 5'6" tall, dad is also 5'6" tall.

Physical exam:  
Height: 142.8 cm        Weight: 48.05 kg        BP: 105/63              
U/L ratio:  0.79        Arm span: 146           Pubic hair: Tanner II   
R. testis: 2.4 x 1.1 cm L. testis: 2.3 x 1.2 cm Phallus length: 10 cm   
Mid-shaft diam.: 2.2 cm 
General: Well developed, well nourished black boy.  
Skin: He did have one cafe au lait spot on the right arm with smooth borders.  No other lesions are noted on skin.  He did have mild axillary hair growth.      
Neck: Supple.   His thyroid was palpable however, did not appear to be enlarged.  
Chest: Clear.  
Heart: Regular rate and rhythm.   Negative murmurs, gallops or rubs.  
Abdomen: Soft, mildly obese, nontender.  Negative hepatosplenomegaly.   
Genitourinary: As indicated above, neurologically he was alert, active and his exam was nonfocal.

Laboratory studies:  DHA  12 ng/dL

Impression: Ernst is growing and following the accelerated case on the Bayer Bayley growth chart.  He does not appear to have had or be  having a pubertal growth spurt.   This is confirmed by his physical exam and testicular size.   Our impression is that of premature adrenarche however, we would like to rule out possible adrenal tumor or non-classical CAH, both of which are extremely unlikely given Ernst's history.  We would like to obtain a bone age, DHEA level and a 17 hydroxy progesterone level to rule out those possibilities.

Disposition: We would like to see Ernst again in 6 months time to follow his growth if the above tests are normal.   Also of note is the increase in his weight over the last year and a half.  It is important to stress both physical activity and decreased caloric intake to keep this under control.
Thank you for letting us share in the care of Ernst.

Sincerely,


Mitsuko Leary, MD           Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

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

History: Nate is a 12 and 5/12 year old boy with diabetes mellitus who has been in excellent general health since his last visit aside from several sports injuries.   He is doing well in the 7th grade and there are no specific complaints.   

His insulin dose is 16 units of Regular in the morning with 20 units of NPH and 12 units of Regular with 20 units of NPH in the afternoon for a total of 68 units daily or 0.99 U/kg/day.   All of the shots are observed and he has missed very few injections.

Review of systems:  Review of systems was unremarkable.  He has had no hypoglycemic reactions since his last visit.   He is on a no concentrated sweets diet but frequently eats sweets and other high sugar containing foods.  He exercises much less frequently than before as football season is now over.   Blood sugar monitoring is performed with a One Touch II meter.   

Review of his log book revealed that  most of his sugars that were a 100 to 300 mg/dL.

Physical exam:  
Height: 167.6 cm        Weight: 68.6 kg         BP: 100/60              
Pulse: 80               
He had Tanner IV pubic hair, Tanner IV genitalia.   His general physical examination was normal.

Laboratory studies:  Glycosylated hemoglobin 12.3%; random glucose 329 mg/dL.

Impression: Nate is a 12 and 6/12 year old boy with diabetes mellitus and less than optimal control.   Given his values, I suspect that he is somewhat underinsulinized and there is also a component of dietary non-compliance.   Our plan is to increase his insulin dose to 18 units of Regular with 24 units of NPH in the morning and 13 units of Regular with 22 units of NPH in the afternoon for a total of 77 units daily.   We had the family meet with our nutritionist, Laurie Higgins, and would like to have a call in a few weeks to review his blood sugar control.

Disposition: We would like to see him back in three months.
Thank you for letting us share in the care of Nate.

Sincerely,


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


CONTENT:
Mitsuko Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

I saw Nate in the Diabetes Program on 3/12/96 for insulin-dependent diabetes mellitus.

History: Stephen's last glycosylated hemoglobin was 11.1% (5.2-7.8%) in December 1995.  Since that time, I have had bi-monthly telephone calls with his mother to assess his blood sugar control.  Steve currently smokes four cigarettes per day and claims his last alcohol intake was on Thanksgiving weekend 1995.

Review of systems:  Steve has no dry skin, his acne is severe, but stable and his mother notes that he has swelling of his face and hands his left hand, greater than his right, on awakening.  The swelling dissipates over the next one to two hours.  He is not having any nocturia at present.  He is a 9th grade student who is doing poorly at Falmouth High School.  

His current Humulin insulin dose is pre-breakfast 16 Regular and 44 NPH, and pre-dinner 16 to 24 Regular and 37 NPH for a total of 1.3 u/kg/day.  His mother is observing all shots at present,  although shots were previously not consistently observed.  Steve is not following a meal plan and is not participating in an organized sports program.  He has occasional mild hypoglycemic reactions at school but none overnight or in the evening.  Blood sugar values are measured twice a day with a blood glucose meter with values between 63 and 574 mg/dl.

Physical exam:
Height: 176.9 cm        Weight: 86.3 kg
BP: 130/60              Pulse: 77               
In general, he is a well-developed, well-nourished, well-hydrated young man with significant facial acne, a thyroid gland has palpable edges,  he is Tanner IV in terms of his pubic hair and genitalia staging.  He also has quite significant lateral thigh hypertrophy.   

Laboratory studies:  HGB A1C  10.2%, random plasma glucose 333 mg/dL

Impression: Stephen has fair glycemic control and he is  overeating throughout the day.  At this visit, we had him talk to Lori Higgins, R.D., our nutritionist about his erratic eating habits and we will consider reducing the insulin dose if he has more mild hypoglycemic episodes.  We increased the pre-dinner Regular to 20 Regular.  We had a lengthy discussion about the importance of reducing cigarette smoking behavior and we would like Steve to return to clinic in two to three months.



Sincerely,




Rahul Hagen, MD           
Attending in Endocrinology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

I saw Steve for follow-up of insulin-dependent diabetes mellitus of 4 and 8/12 years duration.  Stephen's last hemoglobin A1C was 9.4% in June 1996.  On review of systems, he reports his acne is improved since you or his dermatologist started him on Acutane in November 1996.  The scars behind his ears are prominent, but seem to be healing.  Steve reports that he also needs new glasses.  He had his last dilated eye exam on January 15, 1997, and at that time, was told he has no background diabetic retinopathy.  Steve reports nocturia once per week and daily polydipsia in the afternoons.  His mother notes that he still has mild bilateral hand welling in the mornings and afternoons.  
He is in the tenth grade at Falmouth High School and doing well in school.  He continues to smoke cigarettes (about 1/2 pack per day).   

Current medications include Acutane b.i.d. since November 5, 1996.  His current Humulin insulin program is: 15 Regular and 35 NPH and pre-dinner: 20 Regular and 37 Ultra Lente for a total of 1.18 U/kg/day.  He reports mild hypoglycemic episodes before lunch at which time, he is shaky and dizzy.  He attributes these episodes to not eating breakfast.  For blood glucose monitoring, Steve uses a One Touch II blood glucose meter and comes to clinic with a logbook that reveals pre-breakfast readings between 137 and 472 mg/dl and pre-dinner readings between 99 and 400 mg/dl.  He denies missing insulin injections over the past two weeks but has missed his insulin.

Physical exam:
HT: 178.5 cm    WT: 90.3 kg      BP: 108/72    Pulse: 90               
He is a well-appearing happy adolescent with dry skin and severe acne.  His lips are notably dry.  The physical examination is also notable for a non-palpable thyroid gland and, as mentioned above, significant acne.  He has mild injection site hypertrophy in his left arm because he only uses his left arm for injections.   His hands are slightly swollen but he has no swelling of his ankles or lower extremities.

Laboratory studies:   Urine microalbumin, and albumin and total protein and sodium because he reports hand swelling.  A urinalysis obtained in clinic had a glucose of 500 and ketones that were trace.

albumin  3.8    G/DL, HDLC   34.1  mg/dL, cholesterol 172  mg/dL           glucose   194  mg/dL,  HGB A1C   10.7%, total protein    7.4   gm/dL, triglycerides      226  mg/dL,  gluocse  192   mg/dL

My assessment is that Steve has fair to poor glycemic control on his current Humulin insulin program because he over eats and misses insulin injections..  His weight is stable over the past four months, so I suspect that he is not missing too many insulin injections.  He notes that he is bored a lot and overeats after school.

Disposition: We made several suggestions about trying to incorporate breakfast into Steve's daily schedule.  The days that he is not going to eat breakfast, I encouraged him to decrease his pre-breakfast Regular to 12 units and increase the NPH to 38 units.  For his pre-dinner injection, I would continue to do 27 units of Regular and increase the Ultra Lente to 40 units.  If you have any insight about how he could obtain an afternoon job in Falmouth, Steve and his mother would greatly appreciate your help.  Working in the afternoons would be great so that he could be more active and eat a little bit less at that time of day.  If Steve should get another afternoon job, I would anticipate decreasing his pre-breakfast NPH and/or pre-dinner Regular insulin.  He should have another dilated eye exam in January 1998 and otherwise, his diabetes control is satisfactory and stable.  

I would like to see Steve back in clinic in one or two months at which time he will meet with our diabetes clinic nutritionist and teaching nurse to help him improve his blood sugar control. 

Thank you for letting me share in his care.


Sincerely,






Rahul Hagen, MD           
Attending in Endocrinology                             

cc:  Dr.  Mark Lisha  200 Jones Road  Falmouth, MA  02540


CONTENT:
Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

We had the pleasure of seeing Nate in the Endocrine Program on 7/21/92 for follow-up of diabetes mellitus.

History: Nate is an 11 year old boy, diagnosed with diabetes in May, 1992, who has been doing well since his last visit. The only major issue at this time is related to the cost of his care. His current dose of insulin is 8 units of NPH in the morning and 3 units of NPH in the afternoon, for a total of 11 units daily or 0.22 units/kg/day. He has only had one hypoglycemic reaction one month ago (blood sugar 54 mg/dL, related to activity). His symptoms at the time included headache and irritability and were easily treated with oral glucose.  His diet consists of approximately 2300 calories daily; they are not using the exchange program, but avoid concentrated sweets. He exercises daily, and uses a One Touch Two Meter to monitor his blood sugars. These sugars are recorded in a log book; the pre-breakfast blood sugars were in the 90-140 mg/dL range, as were the pre-lunch, pre-dinner, and pre-bedtime sugars.

Physical exam:  
Height: 154 cm          Weight: 50.1 kg         Pulse: 72               
Breast Tanner: 1        Pubic hair Tanner: 1    

General: Nate was an alert, pleasant boy in no acute distress. General physical examination was normal, aside from his cafe-au-lait spots.

Laboratory studies:  his glycosylated hemoglobin today was 7.7%, with a blood sugar of 122 mg/dL

Impression: Nate is an 11 year old boy with diabetes mellitus, clearly in the honeymoon period. We have recommended no change in his insulin dose and would like to see him back in three months. Given the concerns about finances, he will be seeing Ellen Goodman, a diabetes social worker, in the near future. The mother will also be speaking with Laurie Higgins (nutritionist) to get him used to a more formal exchange diet.

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

Sincerely,


Antonio Capulet, MD             M Joan Hammer, MD         
Fellow in Endocrinology      Associate in Endocrinology


CONTENT:
Mitsuko Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

We had the pleasure of seeing Nate in the Endocrine Program on 10/6/92 for follow-up of diabetes mellitus.

History: Nate is an 11 year old boy with diabetes mellitus since May of 1992, who has been doing well since his last visit, and has no major medical issues.

His current dose of insulin is 2 units of Regular and 9 units of NPH in the morning and 1 unit of regular with 5 units of NPH in the evening for a total of 17 units daily or 0.32 units/kg/day. The injection sites are rotated appropriately. He has had rare hypoglycemic reactions. His diet is approximately 2300 calories and he avoids concentrated sweets. He exercises daily, and monitors his blood sugar with a One Touch II meter.  Review of the log book  revealed most of his pre-breakfast, pre-lunch, pre-dinner and bedtime sugars in the 80-180 mg/dL range.

Physical exam:  
Height: 155.4 cm        Weight: 52.5 kg         BP: 100/50              
Pulse: 60               Breast: Tanner II       Pubic hair: Tanner II   
His general physical examination, aside from the previously mentioned cafe-au-lait spots, was benign.

Impression: Nate is an 11 and 3/12 year old boy with neurofibromatosis and  diabetes in the honeymoon phase. His mother is making appropriate adjustments in his insulin dose, and we have recommended no further change at this time. His glycosylated hemoglobin today was 8.6% with a random blood sugar of 174 mg/dL.

Disposition: We would like to see Nate back in three months.
Thank you for letting us share in the care of Nate.

Sincerely,


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


Problem list to date:
INSULIN-DEPENDENT-DM         Start: 10/06/92  End:          Invalid: 

Transcribed by Cassells


CONTENT:
Mitsuko Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

We had the pleasure of seeing Nate in the Endocrine Program on 2/16/93 for follow-up of diabetes mellitus.

History: Nate is 11 and 7/12 years old and has had diabetes mellitus since May1992.  He has been doing well since his last visit.    He is in the sixth grade and not doing very well in school. His current insulin dose is 15 units of NPH in the morning with 7 units of regular and 10 units of NPH in the afternoon with 7 units of regular for a total of 39 units a day or 0.66 units/kg/day. Most of the injections are in the lower extremities and are not supervised.

Review of systems:  Occasional vomiting episodes which seemed not to be related to blood sugars. He does get 2-3 mild hypoglycemic episodes per week including shakiness, headache, sweatiness and dizziness. They are usually related to decreased food intake or exercise. His current diet is 2300 calories daily although he often eats food that are not  on his diet.  Blood sugar monitoring is with a One Touch Meter and recorded in a log book. Pre-breakfast sugars are mostly in the 70-200 mg/dL range, with pre-lunch, pre-dinner, and pre-bedtime sugars mostly in the 80-180 mg/dL range.

Physical exam:  
Height: 157.7 cm        Weight: 58.8 kg         BP: 122/70              
Pulse: 80               Breast: Tanner I        Pubic hair: Tanner II   
The general physical examination was benign aside from the previously mentioned cafe-au-lait spots.

Laboratory studies:  Glycosylated hemoglobin 8.8 % and  blood sugar 329 mg/dL. Random urine dip 2+ protein.  Given the recent onset of diabetes, this proteinuria is not related to his diabetes.

Impression: Nate is an 11 and 7/12 year old boy with diabetes mellitus, doing well on his current regimen.  His glycosylated hemoglobin and weight curve suggest that he is overeating.  His dose seems reasonable given his stage of puberty so we have recommended that he watch carefully what he eats. We have recommended no change in his insulin dose and would like to see him back in three months. I will be asking the mother to bring you a first morning void to rule out orthostatic proteinuria, the most likely cause in a healthy youngster at this stage of diabetes.

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

Sincerely,



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


CONTENT:
Mitsuko Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

We had the pleasure of seeing Nate in the Endocrine Program on 6/1/93 for follow-up of diabetes mellitus.

History: Nate is a 11 and 11/12 year old boy with diabetes mellitus since May 1992 who has been doing well aside from a recent bout of otitis media. The current major family issues seem to be that Nate is quite independent and would like to be in control entirely of his diabetes care despite his age. He is also seeing a psychologist and dealing with these issues. His current insulin dose is 15 units of NPH and 7 units of Regular in the morning and 10 units of NPH with 7-10 units of Regular in the afternoon for a total of 39 units daily or 0.64 units/kg/day. He has had some mild hypoglycemic reactions in the last few months related to decreased food intake or increased exercise. He previously was on a 2300 calorie a day meal plan but over the last several months has been less compliant. He also frequently misses his snack at school. Review of his recorded blood sugars today revealed most of his pre-breakfast sugars in the 100-200 mg/dL range, pre-lunch between 80 and 180, pre-supper between 70 and 220 and at bedtime between 60 and 240 mg/dL.

Physical exam:  
Height: 159.5 cm        Weight: 61.2 kg         BP: 118/78              
Pulse: 80               
His general physical examination was normal.

Impression: Nate is an 11 and 11/12 year old boy with diabetes mellitus for approximately one year who seems to be doing well on his current therapy. We have stressed the importance of consistent daily food intake so that we can know an appropriate insulin dose for him. His glycosylated hemoglobin today was excellent at 8.7%. We have elected to make no changes in his current insulin dose. The major issue at this time seems to be control around his diabetes. We have reinforced with the mother and Nate that at his age, he is too young to be entirely in control and needs to be observed for his injections.

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

Sincerely,


Antonio Capulet, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Mitsuko Pulanski, M.D.          RE: Nate Lindbergh
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/08/81

Dear Dr. Pulanski:

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

History: Nate is a 12 and 3/12 years old boy with diabetes mellitus who has been in good general health since his last visit.  However, his blood sugars have been quite variable since he started school few weeks ago.  His insulin dose has also been quite variable of late.

Review of systems:  Today was positive for some abdominal pain occasionally with high blood sugars as well as some headaches.  He is on a no concentrated sweets diet but is cheating frequently according to the mother.

Physical exam:  
Height: 163.6 cm        Weight: 63.6 kg         BP: 100/60              
Pubic hair: Tanner III  Phallus length: 4 cm    
HEENT:  Benign. Neck:  Non palpable.  Chest: Lungs clear.  Heart: No murmur noted.  Abdomen: Benign.  Neurological: Deep general reflexes were normal.

Laboratory studies:  Glycosylated hemoglobin today was 10.7%.

Impression: Nate is a 12 and 3/12 years boy with diabetes mellitus, in mid-puberty.  We have discussed with the mother the importance of a consistent approach toward insulin and diet and had her meet with the dietitian today.  We have recommended an insulin dose of 12 units NPH in the morning with 10 units of regular and 12 units of NPH in the afternoon with 8 units of regular for a total of 42 units daily or 0.66 units kg/per day.  I suspect we may need to increase this further and have asked the mother to call us back in a few weeks with his blood sugar monitoring results.  We have also suggested that the mother take more control over his diabetes care.

Disposition: We would like to see Nate back in three months.
Thank you for letting us share in the care of Nate.

Sincerely,


Antonio Capulet, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Antonio Daley, M.D.          RE: Elizabeth Baekeland
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/20/87

Dear Dr. Daley:

We had the pleasure of seeing Elizabeth in the Endocrine Program on 3/28/94 for obesity and premature adrenarche.

History: Elizabeth is a 7 and 1/12 year old girl  whose mother had noted underarm hair approximately one and a half years ago.   There is no vaginal bleeding or body odor.

Current medications: None.

Past medical history:  Elizabeth is the product of a full term pregnancy.   Her birth weight was 7 pounds 5 ounces.  She was breast fed initially.

Review of systems:  No eczema.  She has no headaches or blurry vision.  No cardio-respiratory problems.  She has normal bowel movements with some abdominal pain.  She has had urinary urgency and frequency for approximately two years which has been worked up at Children's Hospital.

Physical exam:  
Height: 140.5 cm        Weight: 50.8 kg         BP: 110/50              
Pulse: 87               Arm span: 140           Breast: Tanner I        
Pubic hair: Tanner II   
General: Alert, in no acute distress.
Skin: Eczema as previously stated.
HEENT: PERRL, EOMI.  
Neck: No thyromegaly.
Chest: Lungs clear.  
Heart: Regular rate and rhythm.  
Abdomen: No organomegaly.
Genitourinary: Normal vaginal mucosa.  
Extremities: No clubbing, cyanosis or edema.
Neurological: Nonfocal.

Laboratory studies:  Bone age 8 10/12 years.

Impression: Elizabeth is an obese female who is at the upper limits of the normal on the growth chart therefore, it is unlikely that there is an organic cause for her obesity.   She has isolated premature adrenarche without other sexual characteristics therefore, this may just be simple  premature adrenarche or late onset of CAH depending on how advanced her bone age is.   She did not keep the appointment for an ACTH stimulation test on May 2nd as Sharmiane was nervous about the test.  Mother stated that she would rather wait until Elizabeth is older to do the test.

Disposition: Return to Clinic in six months for re-evalation.
Thank you for letting us share in the care of Elizabeth.

Sincerely,


Nanae Welby, MD              Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Shahin Adler, M.D.          RE: Cesar Oldcastle
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/26/83

Dear Dr. Adler:

     We had the pleasure of seeing Cesar in the Renal Program on 4/20/95 for renovascular hypertension.
     Cesar has done extremely well since his last visit here three years ago.  His blood pressure is checked every six months and it is generally satisfactory.  The most recent one was in December, 1994 when is was recorded as 118/80.  He apparently has been growing and developing well.  He is still bothered by nocturnal enuresis.  His mother said that he is occasionally dry for up for two nights at a time and he suggested that it might be as long as one week.  Nonetheless, it is clear that this problem is not yet resolved.  They said that it is getting more burdensome because of his desire to have friends sleep over, etc.

His current medications include:


Cesar's physical exam was notable for:
     BP 137/60   P 78   R 16   T    HT 155cm   WT 53kg
     General: Appears well developed, well nourished and in no acute distress.
     HEENT: Negative, fundi are benign and vessels appear entirely normal.
     Chest: No rales or wheezes.  
     Heart: Core S1 normal, S2 split, no S3 S4 murmur. 
     Abdomen: Soft and flat, obvious surgical scars, no masses, no tenderness, no organomegaly.
     Extremities: No edema.

A urinalysis revealed:
     SPEC GR UA  1.014           RBC/HPF     0-2        
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       6               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     
     Renal ultrasound demonstrated that the right kidney was 9.8 cm (compaired to 9.1 cm in 4/92).  The lower pole was smaller than the upper but the appearance of these appear stable without progression of any scarring.  There is no hydronephrosis.  The rest of the abdominal ultrasound was negative.

Laboratory studies at this time include:


     Cesar seems to be doing quite well.  He has no hypertension now and he has been off medications for over four years.  I am a bit concerned about the appearance of his kidney on ultrasound.  I think that I would have liked to have seen a bit more hypertrophy.  The lab tests are not yet back and I will reserve judgement on his residual renal function until I am able to see those.

The enuresis is getting to be an increasingly troublesome social problem for the family.  I doubt that there is any connection between his renal vascular problems and his enuresis.  I suspect that these are seperate problems.  Because of his discomfort with this, I think it is reasonable to try some sort of treatment for it.  I discussed several possible approaches for them.  I indicated that DDAVP would not be a cure for this but it certainly may get him over periods when he goes camping or has friends over so that he is not embarrased by that.  I don't see any problem with using it in a very limited fashion for those kinds of special events.  The dose of it would be the same as it would for anyone else.  I would not, however, suggest its chronic use.  It is also reasonable to use the other sorts of medications that are used for enuresis including Ritalin.  I think that if they are used, his blood pressure should be monitored much more closely, probably once or twice per week while he is actively using it.  I doubt that there would be any serious renal disorders associated with its use and I think that it is safe to do so for the short term.

I should see Cesar back here in about two years since he is entering an adolescent growth spurt and it will be important to monitor his kidney size, renal function and blood pressure during that time.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Yvette Seinfeld, M.D.          RE: Greta Snell
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/10/87

Dear Dr. Seinfeld:

We had the pleasure of seeing Greta in the Endocrine Program on 1/19/95 for .

History: Thank you for referring this 7 3/12 year old girl with a history of  autoimmune deficiency for evaluation of premature adrenarche.  We saw her on 1/19/95.  History: She was first diagnosed with  hypergammaglobulinemia in 1992 after recurrent sinus, urinary and kidney infections from approxiamtely the age of 3 weeks.  IV immune globulin every 2-3 weeks was begun at that time and continued until  October of 1994.  Since stopping thearpy, she has had no major infections.

Over the last year, the patient's mother has noted acceleration in her growth.  In addition, Greta has complained of calf pains in the morning which Mrs. Snell has attributed to growing pains.   She has noticed her shoe size increasing progressively as she has had  to get a new pair every six months.   Approximately two months ago,  mother noticed scant pubic hair and feels that this has increased.  She also has noticed an apocrine odor and Greta has been using deodorant for about the same period of time.   She denies any breast development.

Current medications: None.  Allergies:  Sulphonamides and Codeine.

Past medical history:  She is the product of a full term pregnancy, delivered by C-section because of breech presentation.   She was 7 pounds 12 ounces at birth and 19.5 inches.  She was bottle fed.   Her immunizations are up to date.  She had hospitalizations as above, most recently in 1993 because of sinusitis.  Operations include T&A and sinus repairs.

Review of systems:  She denies any history of rash or any birth marks.  She describes having skin blistering in the sun.  She denies any headache or visual changes.  She has no cardiac or respiratory complaints.   She denies any diarrhea, constipation,  nausea or vomiting.   She is an extremely good eater and eats 3 meals and 3 snacks a day.  She has no urinary complaints.   She is presently in the first grade and does well.

Family history:  Significant for a maternal niece with neurofibromatosis.   Maternal and paternal greatgrandmothers with diabetes.   The patient has no siblings.   Her mother is 30, father is 31.  There are two maternal aunts and uncles.  All are alive and well.   Mother underwent menarche at age 12 and father describes having shaved earlier than most of his siblings at  approximately 12 years of age.   Mother's height is measured at 159.3 cm or approximately 5'2.5" tall.   Father's height is measured at 174.6  cm which is approximately 5'8 and 3/4".

Physical exam:  
Height: 128.6 cm        Weight: 30.1 kg         BP: 110/68              
Pulse: 84               U/L ratio:  0.89        Arm span: 127           
Breast: Tanner I        
Breast Tanner I  Pubic hair Tanner II-III.   Bone age at chronologic age 7 3/12 is approximately 8 3/12.
General: She appears healthy and is in no acute distress.
Skin: Reveals no cafe-au-lait spots.  There is no axillary hair.  She did have some apocrine odor.   There is scant, coarse pubic hair limited to the labia.
HEENT: Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.   Optic discs were sharp bilaterally.
Neck: No acanthosis, no thyromegaly.  There is no lymphadenopathy.
Chest: Clear to auscultation.
Cardiac: Regular rate and rhythm without murmurs, rubs or gallops.
Breasts: Areolar 1.8x1.6 cm bilaterally without obvious breast tissue.
Abdomen: Within normal limits without masses.
GU: Reveals a normal female without clitoromegaly and a prepubertal vaginal mucosa.
Extremities: No clubbing, cyanosis or edema.
Neurologic: Within normal limits with reflexes 2+ symmetrically.

Laboratory studies:  None except x-ray of hand and wrist.

Impression: Premature adrenarche with acceleration of growth, especially since age 5 years, from the growth data you kindly forwarded.  Without evidence of gonadarche, a defect in adrenal steroidogenesis as a possible explanation for these findings needs to be investigated.  Her bone age is minimally advanced.   Her mid-parental target height is approximately 5'4" and her predicted  height from bone age is between 5'4"-5'7".

Disposition: In light of the above opinion, we have scheduled Greta for a cortrosyn tests on 2/10/95.  We will contact patient with When the results of this test are reported, we shall get back to you and her parents concerning additional recommendations and the need for further follow up.
Thank you for letting us share in the care of Greta.

Sincerely,


Mitsuko Simpson, MD             
Chief Emeritus               


Addendum: Jennifer Braimon, M.D.
Fellow in Endocrinology


CONTENT:
Van Hammer, M.D.          RE: Robert Dufferin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/87

Dear Dr. Hammer:

We had the pleasure of seeing Robert in the Endocrine Program on 02/28/94 for follow up.

History: Since last seen on 06/22/93 Robert has been well.  He had no significant intercurrent illness.  He is in first grade and is doing well.  He is receiving physiotherapy for his fine motor function.

Current medications: None.

Physical exam:  
Height: 102.4 cm        Weight: 14.2 kg         BP: 84/62               
Pulse: 86               Pubic hair: Tanner I    
Robert was short for his age but healthy looking.  Skin: Normal texture.  HEENT:  Normal fundi.  He has no six-year molars and no permanent teeth.  Neck:  Thyroid not palpable.  Lymph Nodes:  No lympadenopathy.  Chest:  Clear lungs.  Cor:  Normal S1 and S2, no murmurs.  Abdomen:  Soft, no tenderness, no hepatosplenomegaly. GU: prepubertal, descended testes.  Extremities:  Normal.  Neurological:  DTR 2+ symmetrical.  Cranial nerves II-XII intact.

Additional studies:  GH-BP was requested.

Impression: Robert continues to grow parallel, albeit below, the "Delayed Case" curve of the Bayer-Bayley developmental growth chart.  He grew 2.9 cm in eight months (4.3 cm/year). It is worthwhile determining his GH-BP to rule out a problem with growth hormone receptors, the high normal SmC obtained previously however is against such a possibility.

Disposition: To be reassessed in one year by Dr. Norm Spack.   He will need to have a bone age done at that time.
Thank you for letting us share in the care of Robert.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Van Hammer, M.D.          RE: Robert Dufferin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/87

Dear Dr. Hammer:

I saw Robert, for evaluation of short stature. 

He was last seen by Dr. Samir Najjar in February, 1994. 

In the interval, he has enjoyed good health.  He is currently on no  medications, vitamins or nutritional supplements. 

He will be entering the third grade and apparently has excellent oral  language skills but there is some concern about other aspects of his  schooling.  He is very active and participates in soccer and gymnastics.   He sleeps from 8 p.m. until approximately 6 a.m. without disturbance.  He occasionally has nocturia but does not have enuresis.  He has rare  headaches, good vision and hearing.  He has good coordination and is  quite athletic. 

His appetite is inconsistent.  He has three meals but does not eat large  quantities.  He appears to have little interest in food and tends not to  snack unless he is coaxed.  He has an aversion for tuna fish; he has a variety of nutritious foods in his diet, including fruit, vegetables and  dairy products.  Mother stated that he has between 14 and 21 oz of whole  cow's milk daily.  Bowel movements occur daily and are well formed.

Physical exam:  
Height: 109.9 cm        Weight: 16 kg       Head circumference:  47.5 cm. 
BP: 84/60                      Pulse: 80               
U/L ratio:  1.02               Arm span: 105 cm.          
Breast: Tanner I               Pubic hair: Tanner I    
Right testis: 2.0 x 1.0 cm     Left testis: 2.0 x 1.0 cm 
Phallus length: 6.0 cm         Mid-shaft diameter: 1.6 cm 
He was a short boy with normal proportions, who appeared healthy.  Skin was smooth and warm and there were no rashes.  He had  nasal congestion and puffy eyes.  There were shotty cervical lymph  nodes.  Tympanic membranes were normal.  He had two permanent lower central incisors.  He had a total of 20 teeth.  Chest was clear; he had  normal heart sounds and a I/VI systolic murmur at the lower left  parasternal border.  Abdomen revealed no organ enlargement or masses.   He had normal appearing prepubertal male genitalia.  Extremities were  slender but muscular.  Neurological exam revealed 2+ symmetrical deep  tendon reflexes; intact vibratory sensation; PERL; EOMI; fundi revealed  sharp discs and normal vessels.

Robert has grown 7.5 cm and gained 1.8 kg in 17 months.  His  annualized growth velocity is 5.3 cm/year (25th percentile) and weight gain 1.27 kg/year.  His weight-for-height is less than 5th percentile.

Laboratory studies : Bone age 4 6/12 years (SD=10.8 months); serum total protein 7.1, albumin 3.8 g/dl, carotene 9 5g/dl (normal 10-85); ESR 18 mm/hr; antiendomysial antibodies, IGF-1 187 ng/ml, IGFBP-3 pending.

Impression: Although his growth pattern could be consistent with constitutional growth delay on a background of genetic short stature, he is underweight for height and his low serum carotene level raises the suspicion that he may have a gastrointestinal disorder causing asymptomatic malabsorption.  He currently has upper respiratory congestion, either an infection or nasal allergies.  If the IGFBP3 is normal, I would recommend that Robert have a consultation with a gastroenterologist.



Sincerely,




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


CONTENT:
Van Hammer, M.D.          RE: Robert Dufferin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/87

Dear Dr. Hammer: 

In follow-up to my letter dated August 15, 1995, Robert's remaining laboratory tests are now available. 

Serum IGF-1 187 ng/mL (normal 88-474); IGFBP-3 2.8 mg/L (normal 2.1-4.2); anti-endomysial antibodies negative. 

These results do not support a diagnosis of growth hormone insufficiency and effectively rule out gluten enteropathy as the cause of poor growth and weight gain. 


Sincerely yours, 





Bernardo Bird, M.D.
Clinical Director of Endocrinology
Associate Professor of Pediatrics, HMS


CONTENT:
Van Hammer, M.D.          RE: Robert Dufferin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/87

Dear Dr. Hammer:

I saw Robert, age nine years 1-1/2 months, for follow-up of short stature. 

Medications:  Ritalin 5 mg t.i.d.

He has enjoyed excellent health.  He sleeps from 8 p.m. without insomnia, nocturia or other sleep disturbance.  He has little interest in food and there has been no change in appetite since starting Ritalin.  He does eat a wide variety of foods and there has been an increase in the amount of protein in his diet.  He has dairy products including whole cow's milk, grilled cheese sandwiches, fruit and vegetables.  He has normal bowel function.   

Since starting Ritalin, concentration has improved .   

Mother is 147.8 cm, father 162.7 cm.

Physical exam:
HT: 113.7 cm            WT: 17.4 kg    
Arm span: 110.5 cm      U/L ratio:  0.96
BP: 113/55              Pulse: 86               
He looked healthy.  Skin was smooth and warm.  HEENT normal.  Chest and heart normal.  Abdominal exam unremarkable.  Neurological examination normal.  Fundi revealed sharp discs and normal vessels.  Deep tendon reflexes 2+ and symmetric.

Laboratory studies: Serum IGF-I 308 ng/mL, IGFBP3 3.4 mg/L (normal 2-4.8); T4 9.6 ug/dL, TBGI 1.00, TSH 2.60 5U/mL, all normal.

Bone age: 7 years

Impression: I last saw Robert 8-8-95.  In the 13 month interval since that visit, he has grown 3.7 cm, a growth velocity of 3.4 cm per year; weight has increased 1.4 kg.  Both his current height and his growth velocity are significantly below the 5th percentile.  His height is now average for a boy of 5-1/2.   

His current bone age was approximately seven years (standard deviation 11 months).  The radiologist reported a discrepancy between the epiphyses in the hand compared to those at the wrist.

Disposition: Based on the current bone age, his predicted adult height is approximately 63", close to his mid-parental or target height. 

Although he is growing at a subnormal growth velocity, the IGF-1 and IGFBP3 levels are within the normal range.  He probably has constitutional growth delay on a background of genetic (familial) short stature.  Some of these children are thought to have "partial" GH insufficiency.  However, with normal levels of IGF-1 and IGFBP3, it is extremely doubtful that his slow growth is the result of growth hormone insufficiency.  I am not certain that growth hormone provocative testing would assist us to further understand the cause of his very slow growth.  

I would be grateful for the opportunity to continue to monitor his growth and development.


Sincerely,






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

cc: Mr. & Mrs. Dufferin   76 Gulliver Street   Milton, MA  02186


CONTENT:
Van Brezny, M.D.          RE: Robert Dufferin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/87

Dear Dr. Brezny:

We had the pleasure of seeing Robert in the Endocrine Program on 1/27/92 for  follow up of his short stature.

History: Since last seen on 02/22/90, Robert has been well.  He has been active, had no significant intercurrent illness.  His appetite improved but he does not eat large quantities.  His development was reported as normal.  The review of systems was negative.

Physical exam:  
Height: 91.7 cm         Weight: 11.7 kg         BP: 80/50               
Pulse: 82               
Height -3.37 SDS (on 2/22/90 height was -2.78 SDS).  The skin was of normal texture.  HEENT; atraumatic, normocephalic.  Fundi normal, PERLLA, EOM intact.  Oropharynx and tympanic membranes were normal.  Thyroid was not enlarged.  No lymphadenopathy.  Chest, heart and lungs were  normal.  Abdomen was soft, no masses, no hepatosplenomegaly. Genitalia Prepubertal  Extremities: normal.

Laboratory studies:  Bone age was 2 years, 8 months.
IBF1-BP3: 2.4 mg/L (normal 1.4-3.0).

Robert continues to growth parallel albeit below the "Delayed Case" of the Bailey Bayer developmental growth chart.  This growth rate along with the bone age which is equivalent to his height age and a normal IGF1-BP3 continues to support the diagnosis of Constitutional delay.

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

Sincerely,





Kendell Simpson, MD             
Clinical Director


CONTENT:
Van Hammer, M.D.          RE: Robert Dufferin
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/87

Dear Dr. Hammer:

We had the pleasure of seeing Robert in the Endocrine Program on 6/29/93 for follow-up of his linear growth.

History: Since last seen on January 27, 1992 Robert has been well.  According to his mother he has grown, he outgrew the size of his clothes and shoes and he had no significant intercurrent illness.  He was in kindergarten and did very well, however, his is picked upon because of his size.  This has disturbed him to the extent that he has been seeing a psychologist.  He does however, have several good friend and is sociable.  He is very active and has an excellent appetite.  He did develop chicken pox.

His father is 5'4 1/2", his paternal uncles are 5'5" and 5'6", his paternal grandfather is 5'6".  His mother is 5', her brothers are 5'7" and 5'8".

Physical exam:  
Height: 99.5 cm         Weight: 13.2 kg         BP: 80/60               
Pulse: 88               
Robert was healthy looking but short for his age. Skin: Normal texture. HEENT: Atraumatic, normocephalic.  Fundi are normal.  Oropharynx is benign. Neck: Thyroid not enlarged.  No lymphadenopathy. Chest: Clear lungs. Heart: Normal S1 and S2,   he has a grade II/VI ejection systolic murmur heard best over the pulmonic area. Abdomen: Soft, no tenderness, no hepatosplenomegaly. Genitourinary: Prepubertal. Extremities: Normal. Neurological: Nonfocal.

Impression: Familial short stature with Constitutional Delay.  Robert grew well in the past 17 months (7.8 cm. or an annualized rate of 5.5 cm. per year).  This normal rate of growth is consistent with the above diagnoses.

Disposition: His linear growth needs to be monitored at regular intervals.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Wesley Rolf, M.D.          RE: Ernst Eliot
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/05/76

Dear Dr. Rolf:

I most recently saw Ernst in the Diabetes Program on January 24, 1992 for evaluation of his diabetes.  As you know, he is a 15 and 3/12 year old boy who has MELAS syndrome which was diagnosed last June.  He presented with seizures in 1989.  He has had several strokes, including a left occipital lobe stroke last May, and a frontal/perietal lobe stroke in December.  He is currently maintained on Dilantin and Clonipin for his seizures.  Last August, Ernst had a bout of pancreatitis, which resulted in hyperglycemia requiring treatment in the hospital with insulin for about one month.  Ernst also has a history of Decadron therapy, with treatment for a month last May and for most of Decmeber.  His last course of Decadron was from December 17th to the 29th.  On December 26th, Ernst was noted to have polyuria and polydipsia, and a blood sugar was found to be 400.  He was admitted to Nashua Memorial Hospital on the 27th of  December, and was started on subcutaneous insulin twice a day.  Ernst's current insulin dose is 2 of Regular and 7 of NPH before breakfast, and 1 of Regular and 3 of NPH before dinner, as Humulin insulin, giving him a total daily dose of 0.29 units/kg/day.  

Ernst experiences very rare symptomatic hypoglycemia, and his blood sugars are usually in the 80's at that time.  There have been no documented blood sugars less than 70.  Results of home glucose monitoring reveal blood sugars generally in the 80 to 120 range before breakfast and dinner.  He is maintained on a 3500 calorie ADA diet, with the avoidance of sweets.  His other meds include Verapamil and Carnitine.

Physical exam:  
Height: 154.8 cm        Weight: 45. kg          BP: 110/70              
There was no thyromegaly.  He had Tanner V pubic hair and genitalia.  There was no insulin site hypertrophy.  The remainder of the exam was unremarkable.

Ernst's bout of pancreatitis last May, with consequent frank diabetes lasting a month, is obvious evidence of beta cell damage.  The use of high dose steroids in December, with its consequent insulin resistance, probably tipped him over again to overt clinical diabetes. 

Ernst is currently on a small dose of insulin with normal glycemia based on home glucose monitoring which of course indicates fairly good endogenous insulin production.  Now that Ernst has been off steroids for a few weeks, it is quite possible that he may be able to be weaned down on his insulin dose, and even do well off insulin all together.  I have instructed Ernst's parents for the time being to decrease both NPH doses by one unit.  In addition, they will monitor blood sugars before lunch and bedtime as well as the breakfast and dinner times.  If blood sugars remain in  a normal range, I have instructed them to decrease the appropriate insulin doses every 4 or 5 days.  

If he is able to come off insulin altogether, I have recommended to the parents that Ernst undergo a standard 2 hour oral glucose tolerance test a week or two after the insulin is discontinued.  

For now, I have recommended Ernst receive blood work for a hemoglobin A1, thyroid functions (T4 and TSH), as well as a plasma C peptide level drawn 1-2 hours after eating a normal meal.  To avoid frequent blood drawing, the parents have decided to pursue these laboratory studies through your office.  If you would like any assistance in determining Ernst's insulin dosing, please don't hesitate to call.  I also gave Ernst the phone numbers of our diabetes nurse educator and the diabetes fellow on-call, if they have any problems or questions.

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

Sincerely,






Etta Kramer, MD           
Attending in Endocrinology


CONTENT:
Hammer, M.D.          RE: Hobart Ramsay
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/30/85

Dear Dr. Hammer:

We had the pleasure of seeing Hobart in the Endocrine Program on 03/02/92 for  evaluation of short stature and hyperphagia.

History: Hobart is a 6 and 7/12 year old white boy who had developed unusual eating and drinking patterns during the past three years.  He was noted to take food from the lunchboxes of other children and drink large amounts of cold water.  Despite an extraordinary appetite, his height has been constant during the past three years, and his weight has remained the same (by report).  His birth weight was about 9 lbs.  The patient has no regular primary pediatrician.  However, he has seen several doctors for this problem.  According to his father, celiac disease has been ruled out although lactose intolerance was mentioned . However, the restriction of dairy products didn't improve the problem.  Currently, Hobart is not on any special diet.  No information regarding the growth chart during the past six years was available at the time of the visit.

Current medications: None.

Review of systems:  Review of Systems:  Hobart denies diarrhea, polyuria or polydipsia.  He denies headache, change of vision or abdominal pain.  There is no nausea or vomiting, and he is not extremely thirsty.  He has no problem if he is put on fluid restriction of about 24 oz. of liquid intake/day.  He has no problems with bedwetting.  According to his father, he behaves aggressively sometimes.  However, he often lacks direction and ambition.

Family history:  No family history of short stature.  His parents are divorced. He is currently in the custody of his father.  His biological  mother had a history of substance abuse.  Mother's ht: 5'5"; father's ht: 5'7".
|

Physical exam:  
Height: 101.3 cm        Weight: 15.3 kg         BP: 100/56              
Pulse: 70               R. testis: 1.6 x .6 cm  L. testis: 1.6 x .6 cm  
Phallus length: 6.6 cm  Mid-shaft diam.: 1.8 cm 
HEENT: Normal.
Neck: Thyroid normal.
Chest: Clear.
Heart: Regular, without gallop or murmur.
Abdomen: Soft, without distension or hepatosplenomegaly. 
Neurological: No focal weakness.

Laboratory studies:  Blood was drawn one week prior to visit.  Sodium=142, potassium=4, chloride =107, bicarbonate=25, BUN=6, creatinine=.4, prolactin=2.4, Growth hormone=.5, T4=7.8, TSA=2.6, and TBGI =1.01, serum osmolarity=287, urine osmolarity=344, hematocrit=35. IGF-1, cortisol and ACTH are pending. Urinalysis: Neg.  Specific gravity=1.012.  Blood tests were done after overnight fasting.  MRI appeared normal except for posterior pituitary "bright spot" was not visualized.

Impression: Hobart in many ways fits the classic description of psychosocial dwarfism and it will be very interesting to review the results of his psychiatric evaluation.  We very much doubt an endocrinologic abnormality.

Disposition: The patient should be seen again in six months.  In the meantime, we will follow the results of the remaining hormone tests.

His father agreed to record his eating and drinking in detail during the weekend. We will analyze this for calorie count and fluid intake.

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

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Octavia Hammer, M.D.          RE: Hobart Ramsay
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/30/85

Dear Dr. Hammer:

We had the pleasure of seeing Hobart in the Endocrine Program on 11/12/92 for psycho and social dwarfism.

History: Hobart is a 7 and 3/12 year old with short stature thought to be due in part to psycho-social dwarfism.  Since his last visit, Hobart has been almost entirely well.  He is tolerating milk products without difficulty and his father feels there has been considerable growth and emotional development.  Hobart has also lost 5 deciduous teeth since his last visit.  He continues to crave food and occasionally helps himself to his classmates' lunches.  Nevertheless, otherwise unusual behaviors have diminished.

Review of systems:  Negative in detail.

Physical exam:  
Height: 107.5 cm        Weight: 18.1 kg         BP: 110/76              
Pulse: 114              
Hobart was a cheerful, cooperative youngster.  Skin: Normal temperature and texture.  Neck: No goiter.  Abdomen:  Benign.  Extremities: No tremor.

Impression: Hobart is growing at an annualized rate of 9 cm/yr., well above the mean for chronologic age and consistent with catch-up growth.  The factors responsible for his delay in growth appears to be resolving.

Disposition: Follow-up prn for growth velocity of <2.5"/yr.

Laboratory studies pending at this time include: IGF-1.
Thank you for letting us share in the care of Hobart.

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology


CONTENT:
Immaculee McPherson, M.D.          RE: Sam Burnside
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/30/86

Dear Dr. McPherson:

We had the pleasure of seeing Sam in the Endocrine Program on 12/28/92 for follow-up of short stature.

History: This is a return visit for a 6 year old white male who was first seen for short stature in 1988 and again in March1990. Sam's mother reports no problems since the last time we saw Sam. He continues to be a picky eater.  His parents report that he is extremely active and  plays multiple sports.  He is currently on Penicillin for strep throat but he has no other significant past medical history.  He is not on any other medications.

Review of systems:  Negative.

Family history:  Positive for familial short stature however, negative for any other endocrine abnormalities. Mom's height is 158.6 cm and dad's height is 165.5 cm.

Physical exam:  
Height: 105.6 cm        Weight: 18.1 kg         BP: 78/64               
Pulse: 69               U/L ratio:  1.01        Arm span: 101.5         
Breast: Tanner I        Pubic hair: Tanner I    R. testis: 1.9 x 1.0 cm 
L. testis: 1.7 x .9 cm  Phallus length: 6 cm    Mid-shaft diam.: 1.4 cm 
Skin:  Small erythemitous circular lesions on his anterior chest wall.  HEENT:  Atraumatic normocephalic. Pupils were equally reactive. Fundi normal bilaterally.  Neck:  Supple, negative thyromegaly. Negative masses.  Chest: Clear to auscultation.  Heart:  Regular rate and rhythm.  Abdomen: Soft. Negative tenderness or masses.  Genitourinary: Normal prepubertal male.  Extremities: Free range of motion. Good tone.  Neurological: Alert and active.

Laboratory studies:  (3/90) bone age 3 years which was consistent with his chronologic age.

Impression: We feel Sam has familial short stature; he continues to follow along the delayed case curve on the Bayer-Bailey growth curve. A  repeat bone age was read as 4  years 6 months, consistent with the above  impression.  Since his significantly short and he may become more concerned as he approaches puberty we would be happy to check him again in three years or sooner if there is slowing of his growth.

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

Sincerely,



Mitsuko Leary, MD           Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Tinisha Khan, M.D.          RE: Joanna Newman
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/11/88

Dear Dr. Khan:

     We had the pleasure of seeing Joanna in the Renal Program on 8/9/95 for recurrent UTI.
     Joanna has a long history of recurrent  UTIs, typically presenting with complaints of dysuria and urgency.  She  has no history of pyelonephritis, no history of fever, vomiting,  diarrhea, CVA tenderness, or abdominal pain.  Clinically her UTIs are  apparently episodes of cystitis.  Her most recent episodes were in  September of 1994 and July of 1995.  The organism isolated in each  episode was E. coli.  The most recent isolate was found to be resistant  to ampicillin and Bactrim, and sensitive to nitrofurantoin,  ciprofloxacin, and cephalosporins.  She was treated initially, until  this past July, with amoxicillin for 10 days but was changed to  Macrodantin for 10 days following recurrent bacteria.  She has had no  hospitalizations.  Her only other significant medical history includes  digital warts, for which she is followed by Dermatology.  She was  toilet-trained at 2 to 3 years of age but occasionally has episodes of  enuresis.

Her current medications include:
     MACRODANTIN  mg q.d.


Review of systems:
     Radionuclide cystogram on May 23, 1995 showed mild right-sided grade 1 vesicoureteral reflux, and a  repeat study on 6/19/95 was within normal limits.  A renal  ultrasound on May 10, 1995 was within normal limits.

Family history:
     unremarkable without history of renal disease, urinary  tract infection, deafness, and any deficiency or autoimmune disease.

Joanna's physical exam was notable for:
     BP 90/60   P    R    T    HT 125cm   WT 28.7kg
     General:   She was a well developed, well nourished female in no acute distress.
     Skin: No rashes 
     HEENT:  Benign. 
     Neck: Supple without lymphadenopathy. 
     Chest: Clear to auscultation. 
     Heart: Regular rate and rhythm and no murmur.
     Abdomen: Soft and nontender, nondistended, without hepatosplenomegaly, masses or CVA tenderness.  She had normal active bowel sounds. 
     Genitourinary: Tanner I female external genitalia.  
     Extremities: No clubbing, cyanosis or edema. 
     Neurological: Nonfocal.
     
     
A urinalysis revealed:
     SPEC GR UA  1.010           RBC/HPF     0          
     PH UA       5.0             WBC/HPF     0          
     BLOOD UA    N               SQUAM EPI   0          
     PROTEIN UA  N              BACTERIA    Neg   
     GLUCOSE UA  N          
     CASTS       0

Laboratory studies at this time include:


     Joanna is a well 7 year old girl with a history of uncomplicated recurrent cystitis which has been  responsive to oral antibiotics.  She has normal anatomy, as  determined by normal renal ultrasound and unremarkable renal cystogram scans.  We feel that she should be treated with suppressant antibiotics for at least one year.  We have prescribed Macrodantin 50 mg p.o. q.h.s. and have suggested urine cultures monthly.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Kenyola Montague, M.D.          RE: Paul Joliet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/16/87

Dear Dr. Montague:

We had the pleasure of seeing Paul in our Endocrine Program on 07/11/91 for evaluation of X-linked hypophosphatemic rickets.

History: Paul's mother reports that since his last visit he has been much more compliant with taking his phosphate supplementation since switching from capsules to tablets.  She also reports somewhat less clumsiness and improvement in the degree of bowing in his lower extremities.  Approximately two months ago, Paul had a renal ultrasound which was negative for nephrocalcinosis, as well as a 12 hour urine collection for calcium/creatine, which showed a negligible amount of calcium.

Current medications: Paul's medications continue to be two extra strength TUMS daily, Neutra-Phos #2 5 daily, and rocalatrol 2 twice daily.

Physical exam:  HR: 96, BP: 88/, weight: 16 kg, height: 96.2 cm
Paul was happy and active.  Head circumference was 53.2cm and length was 98.2cm.  Skin exam revealed no cutaneous lesions and good turgor.  HEENT exam showed intact extra ocular movements and equally responsive pupils.  Lungs were clear to auscultation and there were no cardiac murmurs.  Abdomen was soft with no hepatosplenomegaly.  GU exam was Tanner Stage I.  Deep tendon reflexes were 2+ and equal.  Muscle bulk and tone was normal.  Examination of the legs revealed approximately 3cm of bowing while lying down between the knees, which is significantly improved from previous exams.

In summary: In terms of his calcium and phosphorous replacement, based on physical exam, Paul is doing quite well.  Also in support of this, is a decreasing alkaline phosphatase from three days ago of 213 units/ml, down from 270 previously.  We would elect to continue Paul on his current supplementation and encourage mother to again follow-up with Dr. Millis in the Orthopedic Clinic to determine if any additional intervention would seem warranted.  Mother plans, at the time of her visit to Dr. Millis, to obtain repeat AP films of the lower extremities to determine any changes in epiphyseal fraying or bowing, which may have taken place.  Paul's rate of linear growth and weight gain continue to be entirely normal.

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

Sincerely,


Maureen Shields, MD                          Samir Najjar, MD
Fellow in Endocrinology                   Clinical Director

LM/SN/smp


CONTENT:
Kenyola Montague, M.D.          RE: Paul Joliet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/16/87

Dear Dr. Montague:

We had the pleasure of seeing Paul in the Endocrine Program on 11/11/91 for evaluation of x-linked hypophosatemic  rickets.

History: Since Paul's last visit, he has been doing quite well with no intercurrent medical problems.  His mother reports that he has been substantially more compliant taking his medications since switching from Tums to Oscal and from K-phos to nutra-phos #2.  He had labs obtained locally one week ago at Anna Jacques Hospital which included a calcium of 9.9 mg/dl, phosphorus 4.8 mg/dl, alkaline phosphatase 186, and urine calcium creatinine ratio 0.7.

Physical exam:  
Height: 99.8 cm         Weight: 16.2 kg         BP: 90/56               
Pulse: 84               
General: Happy boy in no acute distress.
Skin: Good turgor and no lesions.
HEENT: Unchanged frontal bossing and intact extraocular movements and equally responsive pupils.  
Chest: Clear to auscultation.
Heart: No cardiac murmurs.
Abdomen: Without hepatosplenomegaly.
Genitourinary: Normal Tanner I genitalia.
Neurological: 2+ equal deep tendon reflexes.  Muscle bulk and tone was normal.

In summary: Since his last visit, Kris has exhibited a normal pattern of growth.  His examination today revealed significant less bowing of the extremities than previously and this is probably secondary to increased compliance with his medications.  Of note, his urine calcium creatinine ratio is substantially elevated with normal being <.3.  This is probably also secondary to increased compliance with his calcium replacement.  Today we decreased Kris' calcium to 250 mg BID and plan on having the mother repeat a calcium/creatinine ratio in approximately 2 weeks.  Should it still be elevated we will continue to wean Kris from his calcium supplementation.  We hope to see Kris back in four months but would anticipate him seeing Dr. Millis from Orthopedic Surgery prior to then at which time repeat films of the lower extremities would be obtained.

Disposition: 

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

Sincerely,


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


CONTENT:
Kenyola Montague, M.D.          RE: Paul Joliet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/16/87

Dear Dr. Montague:

We had the pleasure of seeing Paul in the Endocrine Program on 3/12/92 for  in follow-up for x-linked hyophosphatemic rickets.

History: As you know, Paul is a 4 and 10/12 year old who one week ago had a renal ultrasound which revealed nephrocalcinosis without stone.  This is significantly different from previous ultrasound which did not show evidence of renal medullary hyperechogenicity.  At the time of his last visit, in November, Kris had a calcium/creatinine ratio of .7 for which his Tums were rapidly decreased to eventually being discontinued approximately 1 1/2 months ago.  His most recent calcium /creatinine ratio is 0.24 on no calcium replacement but 2 Rocaltrol bid, and 5 neutrophos daily.  Kris is also drinking 3-4 glasses of milk per day.  After the report of the ultrasound Dr. Lamont stopped all vitamin D and phosphate supplementation and Kris has been off his medications for approximately on week.

Physical exam:  
Height: 101.6 cm        Weight: 18.6 kg         BP:                         106/68
Pulse: 92               
General: Happy boy in no acute distress.
Skin: Turgor was good and there was no cutaneous lesions.
HEENT: Unchanged frontal bossing and intact extraocular movements, and equally responsive pupils.
Neck: without thyromegaly.
Chest: Clear to auscultation.
Heart: Soft without hepatosplenomegaly.
Abdomen: 
Genitourinary: Tanner stage I.
Extremities: Minimal bowing of the femurs.  There was approximately 1 cm space between the knees.
Neurological:

Impression: Our impression is that since his last visit, Kris has had a normal growth rate and currently has excellent appearance of his lower extremities.  The nephrocalcinosis on Kris' most recent ultrasound is worrisome, and of unclear long term significance.  We instructed Dr. Lamont to obtain a 24 hour urine collection for creatinine clearance as well as repeat chemistries.  Kris is currently off all replacement or we would expect some decrease in growth velocity and increased bowing of the extremities.  We also referred Kris to Nephrology Clinic.


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

Sincerely,


Maureen Shields, MD             Elmo Domingo, MD                 
Fellow in Endocrinology      Attending in Endocrinology   


Problem list to date:
                             

Transcribed by Sullivan


CONTENT:
Shahin Stone, M.D.          RE: Vasco Carew
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/25/85

Dear Dr. Stone:

We had the pleasure of seeing Vasco in the Endocrine Program on 11/10/94 for .

History: This 9 and 5/12 year old black male was sent for evaluation of  premature sexual development.  The patient has always been tall for his age and hasn't noticed any accelerated increase in his height or weight recently.   Over the summer he was seen by his primary physician who noted pubic hair.  At that time, laboratory evaluation at 16:00 included the following: DHEA sulfate 71.4 mcg/dL, progesterone 0.1 ng/mL, FSH 1.5 and LH 0.3 IU/L,  testosterone 9 ng/dL and 17-hydroxyprogesterone 0.3 mcg/L.   A bone age obtained on July 1, 1994 at which time the patient was 9 years 1 month was compatible with 11 year 6 month.  These values are all within normal limots for his developmental age but since the hormonal levels where obtained in the afternoon, non-classical congenital adrenocortical hyperplasia (CAH) is not excluded.

The patient first noted pubic hair around the time that the primary physician noted it.   He denied any acne, change in voice, wet dreams.   He stated that his shoe size has not accelerated recently.  He has noticed mild apocrine odor and has been using deodorant over the past half year.

Medications:  None at the present time.

Allergies:  He is allergic to sulphonamides.

Past medical history:  Significant for Sickle Cell Trait.  He is the product of a full term, normal spontaneous vaginal delivery.  There was no problems during the pregnancy.  He weighed 6 pounds 13 ounces at birth and he has always been tall for his age.   He is currently the tallest in his class.   His immunizations are up to date.  He has never been hospitalized and denies any fractures or other injuries.  He had bilateral TE tubes in the past that subsequently have been removed.

Review of systems:  No specific complaints.  Nutrition: he is a vegetarian and his father describes him as an average eater.  Skin: he denies any acne.  HEENT: he wears glasses for distance and he has not noted any change in his prescription.   Cardio-Resp: he has seasonal allergies and has had recent URI symptoms.  He denies any  GI or GU problems.   He is in the 4th grade and denies any problems in school.

Family history:  His father is 36 years of age.  He has a paternal uncle 30 years of age.  His paternal grandparents are 55 and his paternal grandfather is 58.    There are no medical problems on his paternal side aside from a paternal great grandmother with diabetes mellitus.  His mother is 35 years of age.  She has no siblings.   Her parents are 56 and her paternal grandfather is 58.  There are no medical problems identified on the maternal side. The patient's mother underwent puberty at approximately 9-10 years of age.   She was not at the visit today and it is unclear when she started menarche.  His father started undergoing puberty at 11-12 years of age.   Mother's height is approximately 5'9" tall, father's height is 6'0".

Physical exam:  
Height: 152.5 cm        Weight: 41 kg           BP: 102/74              
Pulse: 105              U/L ratio:  0.85        Arm span: 160.5         
Breast: Tanner I        R. testis: 1.8 x 1 cm   L. testis: 1.9 x 1 cm   
Phallus length: 9 cm    Mid-shaft diam.: 2.4 cm 
Height is 152.5 cm.  Weight is 41 kg.  Blood pressure: 102/74.  Pulse of 105.  Lower segment: 82.5 cm.  Arm span: 160.5.  Tanner breast: I.  Tanner Pubic Hair:  II-III.  Left testes measured 1.9x1 cm.  Right testes 1.8x1 cm.  Stretch penile length: 9 cm.  Mid shaft diameter of approximately 2.4 cm.  Bone age of 11.5 at a chronologic age of 9 years and 1/12.

General: The patient is a tall, well appearing young black male.
Skin: There was no evidence of acne.  There was no axillary, chest or umbilical hair.
HEENT: Pupils were equal, round and reactive.  Extraocular movements were intact.  His fundus revealed sharp discs bilaterally.  His oropharynx revealed engorged tonsils that were nonerythematous.
Neck: No thyromegaly.   He had shotty, nontender, bilateral cervical lymphadenopathy.
Chest: Clear.  Breast exam revealed areolar measuring approximately 1.2 cm.  There was no breast tissue.
Cardiac: Significant for tachycardia.  No murmurs.
Abdomen: Benign without hepatosplenomegaly.
GU: He was a circumcised male.   Testes were descended bilaterally.  He had Tanner II-III pubic hair and scrotum was not androgenized.
Extremities: Within normal limits. Significant for long fingers.
Neurologic: Within normal limits.  He had fair to good musculature.

Impression: Premature adrenarche - unclear etiology.  Possibly non- classical CAH.  Given a positive family history of tall stature and early puberty, he may only be showing normal development for his family.   The discrepancy between penile size (consistent with early puberty) and small prepubertal testes, however, is concerning and suggest that the pubertal changes to date are adrenal in origin.

His predicted height from his bone age is approximately 6'5" and from his parents heights is 6'1".  The decreased upper to lower ratio and the discrepancy in arm span and height, i.e. arm span is 8 cm more than his height, is consistent with the height prediction from his bone age and lack of gonadarche to date.

Disposition: We discussed the above thoughts with Vasco and his father and suggest that a Cortrosyn test would be appropriate to exclude CAH but was not urgent as we can watch his subsequent development to see if the current changes only represent the early stages of puberty for him.  We should like to see him again in 6 months to follow his growth and development.
Thank you for letting us share in the care of Vasco.

Sincerely,


Mitsuko Simpson, MD             
Chief Emeritus               


Addendum: Jennifer Braimon, M.D.
Fellow in Endocrinology

Problem list to date:
PREMATURE-ADRENARCHE                         11/30/94  
Transcribed by Sullivan_ma


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

We had the pleasure of seeing Sam in the Endocrine Program on 3/24/94 for follow up of his response to growth hormone therapy.

History: Since last seen on December 7, 1993 Billy has been well.  He had no significant intercurrent illness and the review of systems was negative.  He specifically had no headaches.  Mrs. Montale thinks he is growing rapidly (outgrew the size of his pants).

Current medications: Protropin 0.5 mg daily.

Physical exam:  
Height: 116.0 cm        Weight: 20.6 kg         BP: 80/60               
Pulse: 78               
Billy was healthy looking, he still has the triangular facies and the craniofacial  disproportion.
Skin: Prominent veins, otherwise normal.
HEENT: Normal fundi, EOMI.  Benign oropharynx.  He has one permanent incisor and three 6 year molars.
Neck: Thyroid not enlarged.  Small shotty cervical nodes.
Chest: Clear lungs.
Heart: Normal S1 and S2, no murmurs.
Abdomen: Soft, not tender, no hepatosplenomegaly.
Genitourinary: Prepubertal descended testes. 
Extremities: Normal without much subcutaneous fat.
Neurological: DTR 2+ symmetrical. Cranial nerves II-XII intact.

Impression: Hypopituitarism (isolated growth hormone deficiency) responding well to growth hormone.  He has gained 1.6 cm in three months and remains on the 50th percentile for height.


Laboratory studies pending at this time include: Bone age.  Thyroid function tests.
Disposition: Billy should continue on the same dose of Protropin (0.05 mg/kg/day) and return to the clinic in four months.
Thank you for letting us share in the care of Sam.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

We had the pleasure of seeing Sam in the Endocrine Program on 8/11/94 for follow up of his growth hormone deficiency.

History: Sam is now 6 years and 5 months old.  He has recently developed occasional headaches, but has had no other problems including no visual problems.

Current medications: Protropin 0.5 mg once a day (he has been on this dose for about a year).

Physical exam:  
Height: 118.6 cm        Weight: 21.3 kg         BP: 105/75              
Pulse: 100              Pubic hair: Tanner I    R. testis: 2 x 1.5 cm   
L. testis: 2 x 1.5 cm   Phallus length: 5 cm    Mid-shaft diam.: 1.2 cm 
General: Well developed thin white male in no apparent distress.     Skin: Normal.   HEENT:  Triangular face with prominent ears.   Neck: No thyromegaly.  Chest: Clear.   Heart: Regular rate and rhythm without murmur.  Abdomen: Benign.  Genitourinary: Prepubertal male.  Extremities: Grossly normal.

Impression: Sam is doing well on his current dose of growth hormone.   He is currently receiving 0.023 mg/kg/day of Protropin.   We will not increase his dose at this time,

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

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

We had the pleasure of seeing Sam in the Endocrine Program on 12/8/94 for growth hormone deficiency.

History: Sam is now 6 years and 9 months old.   He has had no problems since I last saw him three months ago.   He is in the first grade and appears to enjoy it.   Sam complains of occasional headaches, usually in the evening.   These resolve either spontaneously or with Tylenol.   He has had no problems with his vision or any other problems of note.

Current medications: Growth hormone 0.5 mg subcutaneously q day.

Physical exam:  
Height: 120.9 cm        Weight: 22.6 kg         BP: 90/60               
Pulse: 90               Breast: Tanner I        Pubic hair: Tanner I    
(Both height and weight are between the average rate of maturation and the delayed case.)
General: A small but well developed male in no apparent distress.    Skin: Normal.    HEENT: A triangular facies with prominent ears.   Throat is normal.  Pupils are equal, round and reactive to light.    Neck: No thyromegaly.   Chest: Clear.   Heart: Regular rate and rhythm.   Abdomen: Benign.   Genitourinary: Tanner stage I genitals and pubic hair.    Neurological: DTR's 2+ and equal.

Impression: Sam is currently on 0.022 mg/kg/day of growth hormone.   We will increase his growth hormone to compensate for his increase in weight gain.  We will obtain a bone age on his next visit in three months.

Disposition: Increase growth hormone to 0.6 mg q day which is 0.0625 mg/kg/day.   Return to clinic in three months.
Thank you for letting us share in the care of Sam.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

We had the pleasure of seeing Sam in the Endocrine Program on 3/16/95 for growth hormone deficiency.

History: Sam is a 7 year old male with growth hormone deficiency.   He is in the first grade and doing quite well.   He has no complaints of headache.  He does though occasionally have lower extremity pain, especially after playing soccer.

Current medications: Growth hormone 0.6 cc (12 units) SQ once a day

Physical exam:  
Height: 122.2 cm, Weight: 23.2 kg (Both between the average case and 1 SD below the mean)
BP: 90/65         Pulse: 90       Pubic hair: Tanner I    
General: Well developed, well nourished.  
Skin: Normal.  
HEENT: Frontal bossing with a triangular face. Fundi benign.    
Neck: No thyromegaly.   
Chest: Clear. 
Heart: Regular rate and rhythm without a murmur.  
Abdomen: Benign.   
Genitourinary: Prepubertal male.   
Neurological: Grossly intact.

Impression: Sam continues to do well.  He is currently getting 0.517 U/kg/d of growth hormone, and I will make no changes in his medications today.  I will be forwarding you a summary of his course to date in a separate letter.

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

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

We had the pleasure of seeing Sam in the Endocrine Program on 6/22/95 for growth hormone deficiency.

History: Sam is now 7 years and 3 months old.  He developed headaches recently, but was found to have otitis media.  Since treatment was begun, the headaches have improved.  He has no other complaints.

Current medications: GH 0.6 mg SQ qd (0.026 mg/kg/d)

Physical exam:  
Height: 124.3 cm        Weight: 23.4 kg         BP: 105/70              
Pulse: 72               Breast: Tanner I        Pubic hair: Tanner I    
Phallus length: 5 cm    Mid-shaft diam.: 1.2 cm 
Height is on the average case line
Weight is between the average case and 1 SD below the mean
General:  Well-developed, pleasant, and cooperative young boy
HEENT:  Normocephalic, atraumatic.  Triangular-shaped face.  Fundi with sharp discs.
Neck:  No thyromegaly
Chest:  Clear
Heart:  Regular rate and rhythm, no murmur.
Abdomen:  No masses
GU:  Tanner stage 1 male
Extremities:  Grossly normal

Laboratory studies:  T4 and TSH pending.

Impression: Sam is doing well.  He has no evidence for thyroid dysfunction, but given that he has GH deficiency, we will screen him for secondary hypothyroidism.

Disposition: Return to clinic is 4 months.
Thank you for letting us share in the care of Sam.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

I saw Sam in the Endocrine Program on 11/9/95 for GH deficiency.

History: Sam is now 7 years and 7 months old.  He has been doing well since he was last seen four months ago.  He has had an ear infection for the past 3 days, and is on amoxicillin.  He is in the 2nd grade and is doing well.

Current medications: Growth Hormone 0.6 mg SQ once a day (0.024 mg/kg/d).
Physical exam:
HT: 126.5 cm    WT: 25.2 cm
BP: 105/70              Pulse: 90               
General appearance: Well-developed, well-nourished, no apparent distress.  Skin: normal.  HEENT:  normocephalic, atraumatic, pupils equal and round and reactive to light, oropharynx clear, left ear was slightly injected and dull, right ear normal. Neck: no thyromegaly.  Lungs: clear.  Heart:  regular rate and rhythm, no murmur.  Abdomen: benign.  GU: prepubital.  Extremities: normal appearing.  Neurological: deep tendon reflexes 2+  and equal.

Impression: Sam is getting 0.024 mg/kg/day of growth hormone, and is growing well at the 50th percentile.   

Studies ordered: None.

Disposition: Anticipate an increase in his dose on his next visit.  Return to clinic in four months.



Sincerely,




Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

I saw Sam in the Endocrine Program on 10/24/96 for GH deficiency.

History: Sam is now 8 years and 7 months old.  He is doing quite well.  His headaches have improved, and mom feels that they were most likely due to either a problem with sinuses or to allergies.  He is quite active, playing soccer competitively after school.

Current medications: Growth hormone 0.7 mg a day, which is 0.025 mg/kg/day.

Physical exam:  HT: 132.4 cm    WT: 27.7 kg
Breast: Tanner I        Pubic hair: Tanner I    
Physical exam completely within normal limits.  Height is on the average case curve.

Impression: We will continue Sam on this current dose.  We anticipate going up on his dose in the next six months to a year.  On his next visit we will obtain a bone age and thyroid function test.



Sincerely,




Penelope Hagen, MD              
Attending in Endocrinology   


cc:  Ann Montale   15 Emerson Cir   Mansfield , MA  02048


CONTENT:
Kenyola Kramer, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Kramer:

We had the pleasure of seeing Sam in the Endocrine Program on 04/02/92 for follow-up of his response to growth hormone therapy.

History: Billy is doing very well according to his mother, he is active, goes to pre-school, compare favorably to his peers in height and has a voracious appetite.  He had no intercurrent illness since last seen on 11/19/91.  He had no side effects to Protropin and apparently he does not mind as much getting the daily injections.  He does have muscle cramps in his lower extremities every now and then.

Review of systems:  negative.

Physical exam:  
Height: 101.0 cm        Weight: 15.6 kg         BP: 80/52               
Pulse: 78               Pubic hair Tanner: 1    R. testis: 1.8 x 0.8 cm 
L. testis: 1.8 x 0.8 cm Phallus length: 5.5 cm  Mid-shaft diam.: 1.8 cm 
The physical examination was completely normal, however, he continues to manifest the craniofacial disproportion with a relatively large square cranium with frontal bossing and a small triangular face as well as a paucity of subcutaneous fat.  The genitalia are prepubertal.

Impression: Billy continues to show an excellent response to growth hormone; he grew 3.8 cm in four months and presently he is on the 25th centile.

Disposition: Today a bone age and thyroid function tests were obtained and the dose of Protropin was increased to 0.4 mg daily to adjust for his weight gain.
Thank you for letting us share in the care of Sam.

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Addendum: Lab tests drawn on 04/02/92 revealed:  T4 6.8 mcg/dl, TBGI .99, TT3 169 ng/dl, TSH 2.8 mcU/ml.

Problem list to date:
SHORT-STATURE                Start: 04/02/92  End:          Invalid: 
HYPOPITUITARISM              Start: 04/02/92  End:          Invalid: 
GH-DEFICIENCY                Start: 04/02/92  End:          Invalid: 
CONGENITAL-HYPOPITUITARISM   Start: 04/02/92  End:          Invalid: 

Transcribed by Nortonsh


CONTENT:
Kenyola Kramer, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Kramer:

We had the pleasure of seeing Sam in the Endocrine Program on 04/02/92 for follow-up of his response to growth hormone therapy.

History: Billy is doing very well according to his mother, he is active, goes to pre-school, compare favorably to his peers in height and has a voracious appetite.  He had no intercurrent illness since last seen on 11/19/91.  He had no side effects to Protropin and apparently he does not mind as much getting the daily injections.  He does have muscle cramps in his lower extremities every now and then.

Review of systems:  negative.

Physical exam:  
Height: 101.0 cm        Weight: 15.6 kg         BP: 80/52               
Pulse: 78               Pubic hair Tanner: 1    R. testis: 1.8 x 0.8 cm 
L. testis: 1.8 x 0.8 cm Phallus length: 5.5 cm  Mid-shaft diam.: 1.8 cm 
The physical examination was completely normal, however, he continues to manifest the craniofacial disproportion with a relatively large square cranium with frontal bossing and a small triangular face as well as a paucity of subcutaneous fat.  The genitalia are prepubertal.

Impression: Billy continues to show an excellent response to growth hormone; he grew 3.8 cm in four months and presently he is on the 25th centile.

Disposition: Today a bone age and thyroid function tests were obtained and the dose of Protropin was increased to 0.4 mg daily to adjust for his weight gain.
Thank you for letting us share in the care of Sam.

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Addendum: Lab tests drawn on 04/02/92 revealed:  T4 6.8 mcg/dl, TBGI .99, TT3 169 ng/dl, TSH 2.8 mcU/ml.


CONTENT:
Kenyola Kramer, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Kramer:

We had the pleasure of seeing Sam in the Endocrine Program on 8/4/92 for asess response to growth hormone treatment.

History: Billy has been well since last seen on April 2, 1992.  He has developed a right hydrocele and is scheduled for surgery in September.  He still complains about getting the injections and he still has a very good appetite.  His review of systems were negative.

Current medications: Protropin 0.4 mg daily.

Physical exam:  
Height: 104.4 cm        Weight: 15.7 kg         BP: 80/56               
Pulse: 82               
General: Billy is thin appearing with triangular face, relatively large cranium and a dirth of subcutaneous fat even in the face.
Skin: Normal texture, very little subcutaneous fat and prominent veins.
HEENT: Normal.
Neck: Thyroid not enlarged.
Chest: Lungs are clear.
Heart: Normal S1 and S2, no murmurs.
Abdomen: Soft, no masses, no tenderness, no hepatosplenomegaly.
Genitourinary: No evidence of hydrocele, prepubertal.
Extremities: Normal.
Neurological: Nonfocal.

Impression: Billy has growth hormone deficiency responding very well to growth hormone administration.  He grew very well in the past four months (3.4 cm) and is just below the 50th centile of the NCHS growth chart.

Disposition: Billy will continue on the same dose of Protropin and I would like to see him back in four months to reassess his growth.
Thank you for letting us share in the care of Sam.

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Problem list to date:
SHORT-STATURE                Start: 04/02/92  End:          Invalid: 
HYPOPITUITARISM              Start: 04/02/92  End:          Invalid: 
GH-DEFICIENCY                Start: 04/02/92  End:          Invalid: 
CONGENITAL-HYPOPITUITARISM   Start: 04/02/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Kenyola Kramer, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Kramer:

We had the pleasure of seeing Sam in the Endocrine Program on 12/1/92 for follow up of his response to growth hormone therapy.

History: Bill has been well since last seen on August 4, 1992.  He had a hernia repair at the Children's Hospital last month, otherwise he had no significant illness.  He continues to have  a very good appetite.

Current medications: Protropin 0.4 mg daily.

Physical exam:  
Height: 106.8 cm        Weight: 16.7 kg         BP: 90/58               
Pulse: 78               Phallus length: 5.0 cm  Mid-shaft diam.: 1.8 cm 
Bill had unchanged physical appearance.  Skin: Normal texture with prominent veins.  HEENT: Triangular facies, otherwise negative.  Neck: Thyroid not enlarged.  Chest: Lungs are clear.  Heart: Normal S1 and S2, no significant murmur heard.  Abdomen: Soft, no masses, no tenderness, no hepatosplenomegaly.  Genitourinary: Prepubertal.  Extremities: Normal muscle tone.  Neurological: Non-focal.

Impression: Billy grew 2.4 cm. and gained 1.0 kg. in the past four months.

Disposition: Billy is to continue on the same dose of PRotropin.  He should return to the Endocrine clinic in four months for reassessment.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Kenyola Kramer, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Kramer:

We had the pleasure of seeing Sam in the Endocrine Program on 04/06/93 for follow-up of his response to growth hormone therapy.

History: Bill has been well since last seen on 12/01/93.  He had the flu and an ear infection but no other significant illness.  He continues to have a voracious appetite.  He also continues to complain of pain in the lower extremities, usually at the end of the day, usually after a particularly active and but responding to Tylenol and disappearing by morning.

Current medications: Protropin 0.4 mg daily.

Physical exam:  
Height: 109.4 cm        Weight: 17.7 kg         BP: 80/60               
Pulse: 78               Pubic hair: Tanner I    
Sam was thin, his physical appearance was unchanged, with triangular facies. Skin:  Normal texture.  HEENT:  Normal.  Neck:  Thyroid not enlarged.  Lymph Nodes:  No lymphadenopathy. Chest:  Clear lungs.  Cor:  Normal S1 and S2.  He has a grade II/VI ejection systolic murmur best heard over the LSB.  Abdomen:  Soft, no  masses, no hepatosplenomegaly.  GU:  Normal prepubertal external genitalia.  Extremities:  Normal.  Neurological:  Non-focal.

Laboratory studies:  (04/06/93)  T4 7.7  mcg/dL;  TSH 2.60 mcU/mL; TBGI 1.00; TT3 pending.

Impression: Bill continues to grow at an accelerated rate (2.6 cm in four months, he grew a total of 8.3 cm in the past year).  He presently is on the 50th centile of the NCHS growth chart.

Disposition: The Protropin was increased to 0.45 mg/day to adjust for his weight gain.  He is to return to clinic in four months.

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

Sincerely,





Kendell Simpson, MD             
Clinical Director


CONTENT:
Kenyola Kramer, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Kramer:

We had the pleasure of seeing Sam in the Endocrine Program on 8/3/93 for follow-up of his response to growth hormone therapy.

History: Since last seen on April 6, 1993 Bill has been well.  He had no significant intercurrent illness and did not have headaches.

Current medications: Protropin 0.45 mg/day.

Physical exam:  
Height: 112.5 cm        Weight: 18.7 kg         
The physical examination was normal.

Laboratory studies:  April 6, 1993:  Bone age 5 1/2 years.  T4 7.7 mcg/dL, TBGI 1.0, T3 135, TSH 2.6.

Impression: Bill continues to have an impressive growth rate (3.1 cm. in four months).  He has also gained weight (1 kg. in four months).

Disposition: I have increased his Protropin to 0.50 mg. daily to adjust for his weight gain.  Bill should return to the Endocrine Program in four months for follow-up.
Thank you for letting us share in the care of Sam.

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Problem list to date:
SHORT-STATURE                Start: 04/02/92  End:          Invalid: 
HYPOPITUITARISM              Start: 04/02/92  End:          Invalid: 
GH-DEFICIENCY                Start: 04/02/92  End:          Invalid: 
CONGENITAL-HYPOPITUITARISM   Start: 04/02/92  End:          Invalid: 

Transcribed by Sullivan


CONTENT:
Ghada Seinfeld, M.D.          RE: Sam Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/17/88

Dear Dr. Seinfeld:

We had the pleasure of seeing Sam in the Endocrine Program on 12/07/93 for follow up of his response to growth hormone therapy.

History: Since last seen on 08/03/93 Sam has been well.  He had no headaches, polyuria, or polydipsia.  He continued to have the same level of activity.  He had no significant intercurrent illness. and the review of systems was negative.  He missed an occasional dose of Protropin.

Current medications: Protropin 0.5 mg daily.

Physical exam:  
Height: 114.4 cm        Weight: 19.6 kg         BP: 100/70              
Pulse: 86               Pubic hair: Tanner I    Phallus length: 5.0 cm  
Mid-shaft diam.: 1.5 cm 
Sam continues to have the triangular facies and the craniofacial disproportion.  HEENT:  Fundi were normal. Neck:  Thyroid not palpable.  Lymph Nodes:  No lymphadenopathy.  Chest:  Clear lungs.  Cor:  Normal S1 and S2 no murmurs.  Abdomen:  Soft,  no hepatosplenomegaly.  Extremities:  Normal with a dearth of subcutaneous fat.  Neurological:  Non-focal.

Impression: Sam grew 1.9 cm in four months.  He is growing presently on the 50th percentile.

Disposition: He is to continue on the same dose of Protropin and be reassessed in four months.
Thank you for letting us share in the care of Sam.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Emerson Bird, M.D.          RE: Rosemary Gosse
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/17/80

Dear Dr. Bird:

We had the pleasure of seeing Rosemary in the Endocrine Program on 8/11/93 for evaluation of rickets.

History: Rosemary is a 13 and 3/12 year old female who was noted to have bowed legs by her mom since about 5 or 6 years of age. She has always been short.  According to Mrs. Gosse, at 5 years of age, the pediatrician measured Rosemary's upper to lower segment ratio, which he said was normal, and did leg x-rays, which also apparently looked normal. Rosemary has developed pain in her knees especially when she walks. She has had a waddling gait since 5 to 6 years of age, which has progressed, especially over the past couple of years. She has had no fractures. Her growth continues to be slow. She eats a normal diet, and drinks about 24 oz. of whole milk a day. She has had a lot of cavities, but has had no dental abscesses.  Rosemary's breasts have begun developing, as well as pubic hair, but she has not had her periods yet.  Rosemary lives with her mother and two siblings. Her father has been completely out of the picture since Rosemary was very young, and mom does not know where he is and for personal reasons does not want to try to contact him.

Current medications: None.

Past medical history:  Normal pregnancy, labor and delivery. Birth weight was 6 lbs. Birth length was 19 inches. Growth and development have been normal.

Review of systems:  Completely within normal limits.

Family history:  Mom is 5'1" and does not have bowed legs or any bone problems. She has seven brothers and two sisters all of which have had no bone problems. Rosemary's maternal grandmother is about 4'5" and a maternal grandfather is about 5'6".  Rosemary has two siblings both by different fathers. She has a 17 year old sister who is 5'1" tall and a 6 year old sister who has cystic fibrosis. Rosemary's father is approximately 35 years old. He is 5'1" tall. Although mom has not seen him for a number of years, she states that he has a waddling gait. He also has a history of rickets and had operations to straighten his legs at 1-2 years of age. Mom does not know any further details on Rosemary's father's medical history. Rosemary's father has two brothers and two sisters all of which are normal and no signs of rickets. Rosemary's paternal grandmother is about 5'1" tall and her paternal grandfather is about 5'3" tall, neither which have any signs of rickets according to mom.

Physical exam:  
Height: 132.3 cm        Weight: 32.3 kg         BP: 100/70              
Pulse: 102              U/L ratio:  1.1         Arm span: 136           
Breast: Tanner III      Pubic hair: Tanner IV   

General: Well developed and well nourished girl in no apparent distress. 
Skin: Normal with a 2 cm cafe-au-lait spot on the stomach. HEENT: Normocephalic, atraumatic. PERRL. Fundi were both normal. Teeth crooked, cavities filled. Neck: No thyromegaly. Chest: Clear. Heart: Regular rate and rhythm with  no murmur. Abdomen:  Soft with no palpable masses. Extremities: Arms normal. Legs are quite bowed with the widest space between the knees being about 8.5 cm. Neurological: Grossly intact.

Laboratory studies:  Hematocrit 40.1, hemoglobin 13.5, white blood cell count 8.1, BUN 10, creatinine .6, calcium 9.1, phosphate 2.6, alkaline phosphatase 117, 25-hydroxy vitamin-D 46.3 mcg/L, 1,25-dihydroxy vitamin-D 45 ng/L (both of the vitamin-d metabolites are within normal limits for the lab for which they were drawn in).
Bone age: 11 years

Impression: Rosemary has a low serum phosphate, a high alkaline phosphatase, bowed legs, and her father has a history suggestive of rickets. There is no other positive family history. Even though we will be unable to get father to come in, it sounds like he may have rickets, the laboratory studies support the diagnosis of hypophosphatenuc rickets.   We recommend starting Neutra-phos (phosphate) 250 gm 4 times a day and Rocaltrol 0.25 mg once a day.   Eventually, we will increase both medications.   We will see her again when she comes in for her osteotomy.

Laboratory studies pending at this time include: 1.25 dihydroxy vitamin D.   We also obtained blood for DNA, which we obtained consent for our study on x-linked rickets.

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

Sincerely,



Penelope Hagen, MD              
Attending in Endocrinology   


Addendum: 25-hydroxy vitamin D = 45 ng/ml (normal = 9-74).  PTH = 24 pg/ml (normal = 10-65).  Urine calcium = 12.2 mg/dl, urine creatinine =110.5 ng/dl, urine phosphorous = 30 mg/dl, albumin =4.2gm/dl, alkaline phosphatase = 307 mU/ml, magnesium = 1.9 mg/dl, calcium = 9.56 mg/dl, creatinine = 0.4 mg/dl, glucose 96 mg/dl, phosphorous = 2.1 mg/dl, total protein = 7.0 mg/dl.  Urine = specific gravity = 1.026, ph=7.0.   All else negative.


CONTENT:
Seamus Red, M.D.          RE: Liza Lewisohn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/08/84

Dear Dr. Red:

We had the pleasure of seeing Liza in the Endocrine Program on 11/2/92 for rule out  polyglandular autoimmune disease.

History: Liza is a 8 and 7/12 year old female.  Liza has no complaints. She does not get sick often. She lives in Marlboro with a foster family. She has no heat or cold intolerance, anxiety, excessive sleeping, polyuria, polydipsia, nocturia, or bone pain. She eats a normal diet, takes several glasses of milk a day. She has breakfast, snack, lunch, snack, and dinner. She goes to bed between 8 and 9 o'clock and sleeps through the night.

Current medications: None.

Past medical history:  Unknown.

Review of systems:  Completely negative.

Physical exam:  
Height: 130.5 cm        Weight: 31.5 kg         BP: 90/60               
Pulse: 84               U/L ratio:  0.93        Arm span: 132           
Breast: Tanner I        Pubic hair: Tanner I    
General: Well developed, well nourished and in no apparent distress.   Skin: Normal without striae and bruising.   HEENT: Normocephalic atraumatic. Pupils equal, round and reactive to light and accommodation. Fundi had normal vessels, and the left disc was flat, (right disc was not visualized). Mouth was normal and dentition normal.   Neck: Thyroid was normal in size and consistency.   Chest: Clear.   Heart: Showed no glandular tissue. No axillary hair.  No murmur. Heart rate was varied somewhat with respiration but was normal.   Abdomen: Soft, without masses or tenderness.   Genitourinary: Normal, prepubertal female vaginal mucosa which was red and shiny. There was no discharge. The anal opening was normal.   Extremities: Normal.   Neurological: Deep tendon reflexes 2+ and equal. Normal symmetric strength.

Impression: Normal child with no evidence on history or physical examination for any endocrine disorder, including polyglandular autoimmune disease.

Disposition: To CCHP for vaccinations.
Thank you for letting us share in the care of Liza.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Octavia Ibsen, M.D.          RE: Sue Raeburn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Ibsen:

We had the pleasure of seeing Sue in the Endocrine Program on 12/15/94 for hypothyroidism.

History: Dear Octavia:  

I saw Sue for the first time on 12/15/94 for follow up of hypothyroidism for which she has been on Synthroid replacement, 0.1 mg daily.   She does miss pills frequently and doesn't always make them up.  Currently a freshman at Mass Bay Community College she is considering entering a four year school after two years at Mass. Bay.   She is doing well having no signs of hyper or hypothyroidism and has gained 9 kg in the past 15 months due to a change in dietary intake and decreased expenditure of calories.   She has been on estrogen/progesterone combination pills for four months and her thyroid function tests have not been checked since then.

Physical exam:  
Height: 179.8 cm        Weight: 74 kg           BP: 115/57              
Pulse: 76               
Her exam is entirely unremarkable.  Her thyroid is a bit rubbery and firm 2x1.5 cm bilaterally.

Laboratory studies:  T4 12.3 ug/dL (H), TBGI  0.86, TSH 1.00 uU/mL

Impression: She is clinically euthyroid even with  the estrogen treatment which can increase TBG binding and decrease the availability of free thyroxine.   Her  T4, TBGI and TSH should be repeated annually.    

I have urged her to use a 7 day pill pack as a reminder method for taking her pills and will be glad to see her again in a year.   

Warm personal regards.

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

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Luanne Pluto, M.D.          RE: Sue Raeburn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Pluto:

I saw Sue in the Endocrine Program on 11/2/95 for thyroiditis.  She is a 19 and 6/12 year old student at Mass Bay Community College who works 30 hours per week and is being followed for acquired hypothyroidism with 0.1 mg. of Synthroid daily.  She has also been on estrogen-progestin combination pills for more than a year, and although her thyroid functions a year ago were entirely normal, she has continued to gain approximately 6 kg. in the past year with a stable height.  She  does not much exercise.  Her menses are regular and she is showing no signs or symptoms of thyroid hypo or hyperfunction.

Physical exam:
Ht: 180.7 cm    Wt: 80.08 kg
BP: 132/67              Pulse: 84               
She has full adult pubertal development.   Her thyroid is barely palpable.  Her extremities are not cool and she has no tremor nor hyperreflexia.

Laboratory studies:  T4 10.9 ug/dL, TSH  1.10 uU/mL, TBGI  0.75 uU/mL, all normal.

Impression: I have ordered thyroid function tests and will continue her on the same dose of L-thyroxin and suggested that she needs to increase her physical expenditure of energy and to strongly consider reducing her smoking.  I would be glad to see her again in a year.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   

cc: Laurel Raeburn  54 Chase Ave  Lexington , MA  02173


CONTENT:
Luanne Pluto, M.D.          RE: Sue Raeburn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Pluto:

I saw Sue in the Endocrine Program on 1/16/97 for .

History: Sue looks excellent today, now at 20 years of age, and a junior at Regis College with a major in social work.  She has been taking her L-Thyroxine (Synthroid) at .1 mg daily, faithfully.  She is also on Triphasil 28, and has had follow-up with you regarding that. 

She states that her reliability with taking the L-Thyroxine is excellent and her last thyroid functions a year ago were normal.

Current medications: None.

Physical exam:
HT: 180.7 cm    WT: 80.8 kg
BP: 128/70              Pulse: 72               
She is identical in height and weight as she was a year ago.  Pubertal development is entirely normal.  She has no thyroid enlargement, although there is an area of subcutaneous tissue palpable in her neck.  It is not truly thyroid.

Laboratory studies pending at this time include: T4         13.3   ug/dL (H)   TSH         .50   uU/mL    
TBGI        .79 (C)   


Impression: Thyroid function tests were repeated and she will remain on the same dose, and will see me again in a year.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   




cc:
Sue Raeburn   54 Chase Ave   Lexington , MA  02173




Problem list to date:
HYPOTHYROIDISM                               09/08/93  
PRIMARY-HYPOTHYROIDISM                       09/08/93  
ACQUIRED-HYPOTHYROIDISM                      09/08/93  
HASHIMOTO'S-THYROIDITIS                      07/28/92  
Transcribed by Hasseman_s


CONTENT:
Octavia Ibsen, M.D.          RE: Sue Raeburn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Ibsen:

We had the pleasure of seeing Sue in the Endocrine Program on 7/28/92 for follow-up of hashimoto thyroiditis.

History: Sue has been well since last seen on September 4, 1990.  She had no symptoms suggestive of hypothyroidism, however she has noticed some prominence of the thyroid gland.  She claims to have been fairly compliant with the Synthroid and that she takes extra doses when she misses one or two.  She had her menarche a year ago.  She does not like the fact that she is tall.  Her review of systems were negative.

Current medications: Synthroid 0.100 mg daily.

Physical exam:  
Height: 178.8 cm        Weight: 65 kg           BP: 100/64              
Pulse: 82               Breast Tanner: 5        Pubic hair Tanner: 5    
Skin: Normal texture. HEENT: No proptosis.  EOM intact.  Oropharynx benign. Neck: Isthmus of the thyroid gland enlarged but not the lobes. Chest: Lungs are clear. Heart: Normal S1 and S2.  No murmurs. Abdomen: Soft.  No tenderness.  No hepatosplenomegaly. Extremities: Normal.

Impression: Sue has a slightly enlarged isthmus.  She is clinically euthyroid.

Disposition: Sue is to continue on the same dose of Synthroid pending the results of her TFTs.

Laboratory studies pending at this time include: TFTs.
Thank you for letting us share in the care of Sue.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Octavia Ibsen, M.D.          RE: Sue Raeburn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Ibsen:

We had the pleasure of seeing Sue in the Endocrine Program on 09/08/93 for follow up of hypothyroidism secondary to hashimoto's thyroiditis.

History: Except for having been involved in a car accident a few days ago resulting in some bruises, Sue had been well this past year.  She had no symptoms of hypothyroidism and had been compliant with the Synthroid; she usually misses a dose a week but makes up for it.  Her periods are regular.

Current medications: Synthroid 0.100 mg daily.

Physical exam:  
Height: 179.3 cm        Weight: 65.5 kg         BP: 100/60              
Pulse: 80               
The isthmus of the thyroid gland was enlarged but otherwise the physical examination was negative.

Impression: Hashimoto thyroiditis.  Sue is clinically euthyroid on Synthroid replacement.

Laboratory studies pending at this time include: T4 and TSH.

Disposition: Continue on the same dose of Synthroid pending laboratory results.

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

Sincerely,



Kendell Simpson, MD             
Clinical Director


CONTENT:
Cavinder Khan, M.D.          RE: Daniel Powell
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/26/85

Dear Dr. Khan:

We had the pleasure of seeing Daniel in the Endocrine Program on 9/7/95 for follow-up of short stature.

History: Daniel was initially seen by Dr. Chu Chen several years ago for evaluation of short stature.  Daniel was growing along the approximately 10th to 20th percentile but  following that centile well.  During the past 5 years, however, he has fallen  away from the lowest delayed case line on our growth chart.  For this  reason, the mother was concerned and arranged to have him seen again in  our clinic.  He has a significant history of atopy, including asthma, eczema, and allergic rhinitis.  He has been taking inhaled steroids for several years, oral predinsone once-three times per year for an asthma flair, topical steroids for minimal eczema, and nasal steroids for allergic rhinitis.

Current medications: He is on multiple asthma medications  including inhaled catecholamines such as Ventolin and Proventil in a  nebulizer, as well as Beclovent which he takes 3 puffs three times a day  and Nasocort which he takes two puffs three times.  Despite this he  requires systemic prednisone therapy with either two or three 5 to 6  days courses per year with a rapid taper over 6 days.  Other than this,  Daniel has chronic eczema for which he got an infection for the first  time last year successfully treated with sulfa antibiotics.

Past medical history:  Daniel' past medical history includes an almost  lifelong history of asthma, as above. Other past  medical history includes a full term pregnancy and normal vaginal  delivery.  He had pneumonia two years ago presumably related to asthma.

Physical exam:  
Height: 122.5 cm        Weight: 25.8 kg         Pubic hair: Tanner I    
BP: 120/80              Pulse: 80               
Right testis: 2 x 1.8 cm   Left testis: 2 x 1.5 cm   
Phallus length: 6.5 cm     Mid-shaft diam.: 2 cm   
General: normal appearing, cooperative Skin:   small amount of eczema behind right ear  HEENT: full EOMs.   Neck: Thryroid not enlarged  Chest: Clear, without wheezing  Heart: NRS, no murmurs Abdomen: soft, without masses Genitourinary: Prepubertal normal male  Extremities: normal  Bone age: 8 years

Impression: 1.  Growth deceleration over the past two to three years.   Prior short stature with low, but normal, growth velocity was probably due to genetic short stature.  The more recent growth deceleration may be due to a combination of the fact that he is receiving a fair amount of glucocorticoid, as well as that he may be in the growth-slowing phase seen just before the onset of puberty.  This latter possibility is less likely given his bone age of 8 years, at a chronologic age of 10 years 2 months.  I believe a vigorous attempt be made at decreasing all forms of steroids used including  topical, inhaled, and systemic.  I realize this will be very difficult,  but we should perhaps try to substitute other therapies for the  steroids.  If we can demonstrate during a period of 6 months in which he  is on reduced steroid levels his growth velocity increases, this would suggest  that in fact his primary growth problem at this point has been  exacerbated by the steroid use.  In addition, we have performed a growth hormone stimulation test (insulin hypoglycemia and glucagon) to rule out growth hormone deficiency.  The results of this should be available in one to two weeks.

Disposition: I have discussed the strategy to try to wean down his steroid therapy with Dr. Klein, Daniel' allergist, and his parents.  We will discuss further when growth hormone stimulation test results known.


Sincerely,




Bernardo Red, MD           
Chief, Division of Endocrinology


CONTENT:
Cavinder Khan, M.D.          RE: Daniel Powell
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/26/85

Dear Dr. Khan:

I saw Daniel in the Endocrine Program on 9/5/96 for short stature.

History: The patient was last seen on 09/07/95 for follow-up of short stature.  Since that time the patient was attempted to be weaned off of inhaled steroids, both by his own allergist as well as Dr. Lester at Children's Hospital here in Boston.  He was successful in staying off any inhaled steroids for 9 months.  However, he missed 31 days of school during the past academic year due to respiratory infections and asthma attacks associated with the discontinuation of his steroids.  Accordingly, the patient has been restarted on Beclovent and is currently taking two puffs 3 x a day.  He has not received any systemic steroids, but he also has been taking topical steroids for recurrent eczema, which has been a particularly bad problem over the past summer.  The patient's diet appears to be somewhat inadequate, although he does eat three meals a day.

Current medications: None.

Physical exam:
HT: 127.7 cm            WT: 27.3 kg    
Arm span: 131 cm        U/L ratio:  1.03
BP: 91/52               Pulse: 76                     
Breast: Tanner I        Pubic hair: Tanner I    
R. testis: 2 x 1.5 cm   L. testis: 2 x 1.5 cm   
Phallus length: 8 cm    Mid-shaft diam.: 2 cm   
General  appearance:  Eczema on all extremities.  Thin, but not wasted.  Lungs  clear.  Abdominal exam without masses.  Extremities without edema.

No studies were ordered today.

Impression: 1.  Short stature:  He has grown over 5 cm. during the past year.  This a low normal growth rate, and is consistent with his having both familial short stature as well as a component due to both steroid therapy as well as the chronic asthma.  I have discussed with the parents the need to attempt to always keep his steroid inhaled dose at the lowest possible level and with this we hope he will be able to continue his current growth rate and end up along the delayed case, which would result in a final height of approximately 5'5" to 5'6".  His prepubertal status is reassuring, in that it suggests he will be able to grow more during his adolescent years. I suggested he come back to see us in a year to assess his continuing growth.


Sincerely,






Bernardo Red, MD           
Chief, Division of Endocrinology

cc:  Donald Klein, M.D.  85 Pittman Street  Providence, RI 
     Mitchell Lester, MD  Allergy/Immunology  Children's Hospital
     Alicia Powell   126 Lepes Road   Portsmouth , RI  02871


CONTENT:
Hugo, M.D.          RE: Sam Boyd
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/28/75

Dear Dr. Hugo:

We had the pleasure of seeing Sam in the Endocrine Program on 9/12/91 for evaluation of .

History: I saw Bill, age 15 year 10 months,in follow-up clinic for insulin dependent diabetes mellitus.

He is currently on Novolin insulin 9 Regular and 30 NPH before breakfast, 10 Regular and 14 NPH before supper.  He has been in good health until one week ago when he developed a sore throat and began to wheeze.  He is currently using Ventolin by inhaler twice daily and Slobid capsules intermittently.  

He reports no episodes of severe hypoglycemia.  His appetite has been good.  He has been very active.  He does blood glucose monitoring twice  daily.  Glucose levels are rather variable and range from 90-260mg/dl. before breakfast and 88-400mg/dl before supper.

Height: 174.5cm., weight 60.3kg, blood pressure 96/60, heart rate 60.  He appeared well-developed and well nourished, had good color and hydration.  He has reached Tanner stage 5 pubertal development.  He had a lack otitis external  with a dull tympanic membrane.  There was nasal congestion but no sinus tenderness. He had obvious wheezing with bilateral ? and a moist ?.  

Urinalysis had 5% glucose, no ketones and no proteins.  Plasma glucose 157mg/dl, and total dycosalated hemoglobin 10.7% (normal 5.6-7.6%).

He appears to have an acute episode of asthma triggered by a respiratory infection with ?.  I gave him a prescription for Amoxicillin 500mg TID for 7 days.  I will also increase the insulin dose to 8-12 Regular and 32 NPH before breakfast, 8-12 Regular and 14 NPH before ?.  Thank you for the opportunity to share in the care of this fine youngster..

Physical exam:  



In summary: 

Disposition: 

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

Sincerely,


Bernardo Bird, MD                      Bernardo Bird, MD


CONTENT:
Hugo, M.D.          RE: Sam Boyd
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/28/75

Dear Dr. Hugo:

We had the pleasure of seeing Sam in the Endocrine Program on 9/12/91 for evaluation of .

History: I saw Bill, age 15 year 10 months,in follow-up for insulin dependent diabetes mellitus.

He is currently on Novolin insulin 9 Regular and 30 NPH before breakfast, 10 Regular and 14 NPH before supper.  He had been in good health until one week ago when he developed a sore throat and began to wheeze.  He is currently using Ventolin by inhaler twice daily and Slobid capsules intermittently.  

He reports no episodes of severe hypoglycemia.  His appetite has been good.  He has been very active.  He does blood glucose monitoring twice  daily.  Glucose levels are rather variable and range from 90-260mg/dl. before breakfast and 88-400mg/dl before supper.

Height: 174.5cm., weight 60.3kg, blood pressure 96/60, heart rate 60.  He appeared well-developed and well nourished, had good color and hydration.  He has reached Tanner stage 5 pubertal development.  He had a otitis externa  with a dull tympanic membrane.  There was nasal congestion but no sinus tenderness. He had obvious wheezing with bilateral rhonchi and a moist cough.  

Urinalysis had 5% glucose, no ketones and no proteins.  Plasma glucose 157mg/dl, and total glycosylated hemoglobin 10.7% (normal 5.6-7.6%).

He appears to have an acute episode of asthma triggered by a respiratory infection with bronchitits.  I gave him a prescription for Amoxicillin 500mg TID for 7 days.  I will also increase the insulin dose to 8-12 Regular and 32 NPH before breakfast, 8-12 Regular and 14 NPH before supper.  Thank you for the opportunity to share in the care of this fine youngster..

Physical exam:  



In summary: 

Disposition: 

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

Sincerely,


Bernardo Bird, MD                      Bernardo Bird, MD


CONTENT:
Xiajo Ibsen, M.D.          RE: Sam Boyd
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/28/75

Dear Dr. Ibsen:

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

History: I saw Sam, age 16 years 3 months, in follow-up for insulin depended diabetes mellitus diagnosed 3 years ago.

He reports good health and no problems.  

He is on Novolin insulin, 10 units Regular and 32 NPH before breakfast, and 10 units Regular and 14 NPH before supper.  He also uses Ventolin inhaler and Asmacort for asthma.  He reports no symptoms of uncontrolled diabetes and no episodes of severe hypoglycemia.  His appetite is good.  Blood glucose monitoring is done infrequently and there are no records.

Physical exam:  
Height: 176 cm          Weight: 63 kg           BP: 102/60              
Pulse: 60               
He looked well.  He had good color and hydration.  There was nasal congestion and pale, swollen turbinates.  The remainder of the exam was unremarkable.

Laboratory studies:  Urinalysis had 5% glucose, negative ketones and protein.  Plasma glucose 498 mg/dl, hemoglobin A1 9.7% (normal 5.6-7.6%). Nonfasting total cholesterol 116, HDL 42, triglyceride 98 mg/dl, all normal.

In summary: He is growing and gaining weight normally.  His IDDM is under good control.  

I encouraged him to check his blood glucose regularly and to keep records.  Without this information, it is not possible to guide insulin adjustments in a rational manner.


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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


