# BIGPATS_DOC_ATTRIBUTES

VALUE:
follow-up for growth and puberty progression status post of a resection of an astrocytoma in 1981 adn recurrence  of astrocytoma in 1984.


VALUE:
evaluation of x linked hyperphospotemic rickets


VALUE:
evaluation of x linked hypophosphotemic rickets


VALUE:
follow-up of x-linked hypophosphatemic rickets


VALUE:
evaluation of hypocalcemia and hyermagmagnesemia


VALUE:
follow-up of hypocalcemia and delayed puberty


VALUE:
follow-up of hypercalcemia and delayed puberty


VALUE:
follow-up evaluation of Type I glycogen Storage disease


VALUE:
follow-up of insulin dependent diabetes mellitus


VALUE:
evaluation of insulin dependent diabetes mellitus


VALUE:
evaluation of short stature and possible Turner syndrome


VALUE:
follow-up of short stature/constitutional delay


VALUE:
follow up evaluation of his short stature


VALUE:
follow up of her congenital hypothyroidism and possible end organ resistance to thyroid hormone.


VALUE:
follow-up of short stature and  growth hormone deficiency


VALUE:
follow-up evaluation of growth hormone deficiency


VALUE:
evaluation of  growth hormone deficiency


VALUE:
follow-up of short stature and delayed puberty


VALUE:
follow-up evaluation of diabetes mellitus


VALUE:
panhypopituitarism status post astrocytoma treatment


VALUE:
panhypopituitarism, status post treatment of astrocytoma


VALUE:
follow up of her growth and pubertal devleopment


VALUE:
in follow up of insulin dependent diabetes mellitus


VALUE:
follow-up of insulin-dependent diabetes mellitus


VALUE:
follow up of x-linked hypophosphatemic rickets


VALUE:
evaluation of familial hypophosphatemic rickets


VALUE:
evaluation of her growth on GH for Turner's syndrome


VALUE:
follow up of her Turner syndrome and growth hormone therapy


VALUE:
follow-up of her response to growth hormone therapy


VALUE:
follow-up of her response to growth hormone treatment


VALUE:
follow up of her response to growth hormone therapy


VALUE:
follow-up for insulin dependent diabetes mellitus


VALUE:
for evaluation of short stature and hyperphagia


VALUE:
in follow-up for ? type of phosphatemic rickets


VALUE:
follow-up of his response to growth hormone therapy


VALUE:
asess response to growth hormone treatment


VALUE:
follow up of his response to growth hormone therapy


VALUE:
rule out  polyglandular autoimmune disease


VALUE:
follow up of hypothyroidism secondary to hashimoto's thyroiditis


VALUE:
follow-up for  precocious puberty associated with neurofibromatosis


VALUE:
follow-up possibility of premature adrenarche


VALUE:
follow-up  of insulin dependent diabetes mellitus


VALUE:
follow up of insulin-dependent diabetes mellitus


VALUE:
obstructive uropathy and follow up blood pressure control


VALUE:
for follow up of growth retardation in the setting of chronic renal insufficiency


VALUE:
follow-up evaluation of vitamin D intoxication


VALUE:
follow-up of congenital adrenal hyperplasia


VALUE:
evaluation of  amino deficiency, possible osteopetrosis


VALUE:
evaluation of possible endocrinological dysfunction


VALUE:
evaluation of Decreasing growth velocity


VALUE:
follow-up of mild beta 3 of a mild beta steroid dehydrogenase deficiency


VALUE:
follow-up evaluation of congenital hypothyroidism


VALUE:
to consider the use of growth hormone treatment


VALUE:
neonatal adrenal leukodystrophy, rule out adrenal insufficiency


VALUE:
follow-up of neonatal adrenal leukodystrophy


VALUE:
follow up  evaluation of his treatment for salt losing CAH


VALUE:
follow up of  his congenital adrenal hyperplasia


VALUE:
lupus nephritis, focal proliferative glomerulonephritis


VALUE:
in follow-up of Camuratin Engelmann syndrome and hypothyroidism


VALUE:
follow-up of camurati-engelmann syndrome and hypothyroidism and elevated gonadotropins on provocative testing


VALUE:
GH-DEFICIENCY                Start: 06/11/91  End:          Invalid:


VALUE:
growth hormone deficiency status post irradiation


VALUE:
follow-up evaluation of his response to growth hormone therapy


VALUE:
evaluation of his response to growth hormone therapy


VALUE:
Delayed onset of puberty, decreased PTH, elevated T4, and isolated insulin antibody


VALUE:
renal transplant and recent surgery for gynecological problems and abdominal pain


VALUE:
evalautionof growht failure, poorly defined syndrome


VALUE:
evaluation of hypothyroid and precocious puberty


VALUE:
evaluation of hypothyroidism and precocious puberty


VALUE:
congenital hypothryodiism vs. iodine exposure


VALUE:
ngential hypothyroidism vs. iodine excess in the perinatal period


VALUE:
follow up of idiopathic premature adrenarche


VALUE:
follow-up of Idiopathic premature adrenarche and accelerated growth velocity


VALUE:
follow-up of idiiopathic premature adrenarche


VALUE:
follow-up of insulin-dependent diabete mellitus


VALUE:
follow-up of craniopharyngioma and growth hormone deficiency


VALUE:
failure to thrive with resulting short stature


VALUE:
renal dysplasia, vesicoureteal reflux and obstructive uropathy


VALUE:
renal dysplasia, vesicoureteral reflux and obstructive uropathy


VALUE:
renal dysplasia, vesico-ureteral reflux and obstructive uropathy


VALUE:
follow up evaluation of precocious puberty


VALUE:
evaluation of her height and pubertal development


VALUE:
urinary tract infections and vesicoureteral reflux


VALUE:
evaluation of his insulin dependent diabetes for which he has been treated for 4 1/2 years.


VALUE:
obesity, question small phallus and poor height growth


VALUE:
follow-up of insulin-dependent diabetes mellitus diagnosed January, 1990


VALUE:
renal transplant for ESRD secondary to hyperoxaluria


VALUE:
past refluxing megaureter (grade 5 reflux bilaterally), IVP reflux nephropathy


VALUE:
review anatomy after ureteric reimplantation


VALUE:
follow-up of  insulin-dependent diabetes mellitus diagnosed in February 1995


VALUE:
follow-up of insulin-dependent diabetes mellitus diagnosed February, 1995


VALUE:
past nephrotic syndrome now in remission


# BIGPATS_DOC_STORE

CONTENT:
Nekia Blue, M.D.          RE: Xavier Hunter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/20/77

Dear Dr. Blue:

We had the pleasure of seeing Xavier in the Endocrine Program on 8/1/91 for evaluation of .

History: I most recently saw Xavier in Endocrinology on August 1, 1991.  As you know, he is a 13 10/12 year old boy who I'm following, being status posttreatment for an astrocytoma.  Since his last visit,his endocrine history is unremarkable.  He is scheduled for a repeat head MRI in the next few weeks.  His review of systems is entirely benign.

Physical exam:  

Physical exam revealed a height of 61.9 cm.,upper to lower ratio 0.93, weight 55.6 kg.  Fundoscopic exam was benign.  There was no thyromegaly. He had axillary hair and trace facial hair above his upper lip.  G.U. exam revealed Tanner 5 pubic hair, with testes measuring  2.6 x 4.8 cm. on the left, and 3.0 x 4.8 cm. on the right.  The remainder of the exam was unremarkable.

Laboratory studies:
Laboratory studies revealed normal thyroid functions with a T4 of 7.8 mcg/dl, TGB and X 1.07, total T3 118 ng/dl, and TSH 1.2 mc/ml.  Pubertal hormones revealed FSH 1.3 miu/ml, LH 1.7 miu/ml, DHEA Sulfate 194 mcg/dl, and Testosterone 357 ng/dl.  A bone age was 15 1/2 years at a chronologic age 13 10/12.

In summary: At this point, Xavier continues to display no evidence of pituatary-hypothalamic dysfunction.  He is progressing normally through puberty on his own.  His growth velocity is beginning to slow down, at a current rate of 4.8 cm. per year.  Based on his bone age, he has an estimated adult height prediction of 5'5" and 5'6" .

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

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

Sincerely,


Etta Kramer, MD                      Etta Kramer, MD


CONTENT:
Antonio Lear, M.D.          RE: Xavier Hunter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/20/77

Dear Dr. Lear:

We had the pleasure of seeing Xavier in the Endocrine Program on 7/21/92 for follow-up evaluation of growth and puberty as he is status post treatment of an astrocytoma in 1981 and recurrence of strocytoma in 1984.

History: Xavier, who is now a 14 and 10/12 years old complains of having frontal headaches every two weeks, for the past 1 to 2 months. This is an increase in the frequency of headaches. The headaches are relieved with Tylenol and do not waken him. He denies blurry vision with the headaches or visual field changes. His mother feels he has never regained his stamina since he had irradiation. He has just finished eighth grade with high honors. Mother is also concerned with his gait because he loses balance often when walking. He denies any complaints concerning sleeping problems, heat or cold intolerance, polyuria, polydipsia, and nocturia. He started shaving approximately 12 months ago.

Physical exam:  
Height: 163.5 cm        Weight: 58.4 kg         BP: 100/62              
Pulse: 92               U/L ratio:  0.97        Arm span: 161.5         
Pubic hair: Tanner V    R. testis: 5.3 x 3.3 cm L. testis: 5.2 x 3.2 cm 
Phallus length: 8.8 cm  Mid-shaft diam.: 2.4 cm 
Skin: Axillary and facial hair.  HEENT: Fundi disc margins sharp bilaterally.  Neck: No thyromegaly, supple.  Chest: Lungs clear to auscultation, acne on back and shoulders.  Heart: Regular rate and rhythm, no murmur.  Abdomen: Soft, nontender.  Genitourinary: As above.  Extremities: DTRs +2/4 bilaterally.  Upper and lower extremities strength +5/5.  Gait: Stable but slightly, asymmetric.  DTR's +2/4 bilaterally in UE and LE.    Proprioception: Intact.

Laboratory studies:  FSH 1.4 mIU/mL, LH 3.6 mIU/mL/prolactin 7.1 ng/mL.  Thyroid Function tests revealed a TSH of 1.2 uU/mL, T4 8.5 ug/dL, TBGI 1.06, TT3 116 ng/dL - all normal.  DS 244,  cortisol 6.6 mcg/dL, and testosterone 444 ng/dL.

Impression: Xavier continues to do well, with no clinical or laboratory evidence of pituitary dysfunction.  He is growing normally, and is progressing through a normal puberty.  We plan to see Xavier in one year.

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

Sincerely,


Rahul Hagen, MD           Etta Kramer, MD           
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Mitsuko Animal, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. Animal:

We had the pleasure of seeing Raymond in the Endocrine Program on 4/14/94 for x-linked hypophosphatemic rickets.

History: Raymond is doing reasonably well.   He hurt his back in January and has been receiving physical therapy.   He did not slip a disc.  He does exercise regularly which has improved his muscle strength but has caused him some achiness.   He was taking 500 mg of Phosphate four times a day instead of three times a day, and felt better on this dose.  He is now back to three times a day.

Current medications: Rocaltrol 0.25 mg tid, phosphorous 500 mg tid.

Physical exam:  
Height: 154.7 cm        Weight: 59.6 kg         BP: 120/80              
Pulse: 66               
General: Well developed, well nourished.  
Skin: Normal. 
HEENT: Normocephalic atraumatic.   Poor dentition.
Neck: Supple.
Chest: Clear.
Heart: Regular rate and rhythm without a murmur.
Abdomen: Benign.
Back: Spine was normal.
Extremities: No change.

Laboratory studies:  PTH=26 pg/ml, calcium=8.5 mg/dl, phosphorous=2.5 mg/dl, urine calcium=13 mg/dl, urine phosphorous=123.8 mg/dl, urine creatinine=132.4 mg/dl.

Impression: Raymond's symptoms have improved on 2 grams of phosphorous a day as compared to 1.5 gms/day.

Disposition: Increase Phosphorous to 500 mg qid.   Return to clinic in six months.
Thank you for letting us share in the care of Raymond.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Etta Gonzo, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. Gonzo:

We had the pleasure of seeing Raymond in the Endocrine Program on 9/6/94 for x-linked hypophosphatemic rickets.

History: Raymond is 27 years old.  He was recently started on Amitriptyline was because of trouble sleeping due to achiness from being in one position for a long period of time.  He has felt better since starting on this medication; he has slept better as well.  However, he has been nauseated which he attributes, in part, to the phosphorous and in part to Amitriptyline.   His complaints of being disoriented in the morning have  improved since he started on Amitriptyline.  The reason he started the  He continues to lift some light weights, and this he feels has helped his achiness.   His bone pain has improved and he has been more comfortable on an increased dose of phosphorous.  He smokes a pack of cigarettes a day.

Current medications: Amitriptyline,  Phosphorous 500 mg four times a day, Rocaltrol 0.25 mcg three times a day.

Physical exam:  
Height: 154 cm          Weight: 51.9 kg         BP: 105/70              
Pulse: 90               Pubic hair: Tanner V    
General: Well developed, short male in no apparent distress.   Skin: Normal. HEENT: Normocephalic, atraumatic.   Neck: No thyromegaly.   Chest: Clear. 
Heart: Regular rate and rhythm without a murmur.  Abdomen: Benign. Genitourinary: Not examined.   Extremities: Normal appearing without soreness or tenderness.   Neurological: Deep tendon reflexes are 3+ and equal.  He is slightly shakey.

Laboratory studies:  ALB         4.3    G/DL       ALKP        208     U/L (H)
MG          2.2   MG/DL       CO 2         33   MEQ/L (H)
CA          9.2   MG/DL       CAU        14.9   MG/DL    
CHOL        195   MG/DL       CRU       171.3   MG/DL    
CR          1.0   MG/DL       GLU          89   MG/DL    
LDH         170     U/L       PHOS        2.5   MG/DL (L)
PHOSU     216.3   MG/DL       TP          8.1   GM/DL    
AST          23     U/L       ALT          19     U/L    
BUN           7   MG/DL       NA          141  MMOL/L    
K           4.0  MMOL/L       CL          103  MMOL/L    
PTH1         38   pg/mL       25OHD        30   ng/mL    
1,25OHD      30   pg/mL
His bicarbonate level elevated, this may be in part due to the phosphorous.  His urine calcium to creatinine ratio is normal, as is his vitamin D metabolytes.

Impression: Stephencontinues to do well on Phosphorous four times a day.  His hyperreflexia may be secondary to a combination his Amitriptyline, caffeine and nicotine intake.

Disposition: Continue the Rocaltrol and Phosphorous.   Return to clinic in six months.
Thank you for letting us share in the care of Raymond.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Mitsuko Animal, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. Animal:

We had the pleasure of seeing Raymond in the Endocrine Program on 4/27/95 for X-linked hypophosphatemic rickets.

History: Raymond is 26 years old.  He went without medications for 1 month while transferring Medicare, but has since been on medications.  Side effects include nausea and dizziness.  He also complains of trouble sleeping, for which he takes amytriptylin.  He drinks a fair amount of coffee a day, and smokes cigarettes daily.  He feels better on phosphate and Rocaltrol, with less bone pain.

Current medications:  Neutraphos 500 mg qid
Rocaltrol 0.25 mg tid

Physical exam:  
Weight: 59.2 kg         BP: 115/70              Pulse: 80               
General:  Well-developed, no distress
HEENT: Fundi normal
Chest:  Clear
Cardiac:  Regular rate and rhythm, no murmur
Abdomen:  Benign
Extremities:  No changes.  No pain on palpation, swelling, redness, or tenderness

Impression: Raymond is stable on the current medication routine.  Urine Ca/creat is normal.  Raymond is more comfortable on phosphate and Rocaltrol, and I will continue this regimen.  I recommended that he stop smoking and drinking coffee to help him sleep better.

Laboratory studies: AlkP=143 U/L,CaU=16.0 mg/dl, UCreat=162.9 mg/dl, UCa/UCreat=0.1, UPhos=253.6 mg/dl, Creat=0.9 mg/dl, Phos=2.8 mg/dl, 25OHD=23 ng/mL.

Disposition: I will continue to follow Raymond on this medication regimen.
Thank you for letting us share in the care of Raymond.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Nilto Daley, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. Daley:

I saw Raymond in the Endocrine Program on 10/19/95 for x-linked hypophosphatemic rickets.

History: Steven is 28 years old.  He has experienced an increase in his joint pain, particularly in his hips, knees, and ankles.  He has trouble putting weight on his left knee in particular.  He had spinal x-rays done recently which showed a vertebral anomaly that was felt to explain at least some of this pain.  His constant ache has not been worsened, but in fact seems to be a little bit better.  He has been seen by an orthopaedic surgeon, who has felt that the alignment of his legs is somewhat off, explaining the new pain.

Current medications: Rocaltrol 0.25 mg. t.i.d.; Neutraphos 500 mg. q.i.d.; Nortriptyline for sleeping.

Physical exam:
WT: 57.5 kg
BP: 110/75              Pulse: 80                      
Breast: Tanner I        Pubic hair: Tanner V    
General appearance:  well-developed, well-nourished in no apparent distress.  Skin: normal.  HEENT:  normocephalic, atraumatic, pupils equal round and reactive to light.  Neck:  no thyromegaly, although thyroid is palpable.  Chest: clear.  Cardiac: regular rate and rhythm.  Extremities: no change in his bowing, no point tenderness.

Laboratory studies: 25OHD=43, PTH=38, CA=9.2, CAU=15.4, CRU=160.4, PHOSU=125, ALK PHOS=148, MG=2.3, PHOS=2.3

Impression: There has been no change in Steven's underlying bone pain.  However, he is experiencing increased pain in his joints, which may be related to the X-linked rickets, or to a problem with the alignment of his legs, as suggested by the orthopaedic surgeon.  We will increase his Rocaltrol to 0.250 mg qid (1.25 mg qd total).  His renal ultrasound was not done, due to a scheduling problem.  We will do this study at his next visit.

Disposition: Increase Rocaltrol to 0.25 4 times a day.  Return to clinic in 6 months.  Obtain renal US at the next visit.


Sincerely,





Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Etta Gonzo, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. Gonzo:

I saw Raymond in the Endocrine Program on 6/27/96 for X-linked hypophosphatemic rickets.

History: Raymond's bone pain has been stable, and has not worsened.  However, he has increasing pain in his joints, particularly his left ankle.  He does a fair amount of weight lifting, which may be contributing to his pain.  However, he feels that the weight lifting overall makes him feel good, and is not interested in giving it up.  Raymond also complains of nausea, which he feels is due to the phosphorous, and the nausea makes it difficult for him to eat at times.  Over the past several months, he has lost about 10 lb.  He feels that this is due to an increased activity since he is exercising more than he used to.

Current medications: Rocaltrol 0.25 mg q.i.d., K-phos 500 mg q.i.d., nortriptyline (for sleep but not over the summer).

Physical exam:
WT: 57.7 kg       BP: 118/53     Pulse: 71               
Raymond's physical exam is notable for him being fairly thin.  His teeth have been removed and he now wears dentures.  His extremities are unchanged in terms of their alignment, but there is grinding of some of his joints, noted in his left shoulder, knee and ankle.


Laboratory studies:  Renal US was normal

CRU       140.1   MG/DL       MG          2.1   MG/DL    
ALKP        134     U/L (H)   CAU         3.2   MG/DL    
PHOSU     129.3   MG/DL       PHOS        3.0   MG/DL    
CA          8.8   MG/DL       PTH1         47   pg/mL

Impression: A number of factors may be playing into Raymond's weight loss.  He has been on phosphorous for a long time, but the associated nausea still may be part of the problem.  His increased activity certainly could be contributing.  We strongly recommend that Raymond stop smoking as this would likely lead to an increase his appetite.  In addition, we will try decreasing his K-phos to 500 mg t.i.d. and see if there is an improvement in his appetite without a worsening of his bone pain again.  His joint pain is probably related to his hypophosphatemic rickets, as this is a fairly common problem in this disorder.  His laboratory studies were all stable, his urine calcium/creatinine ratio was 0.022, which is normal, and his renal US was normal.

Disposition: We plan to see Raymond back in the clinic in 12 months.



Sincerely,




Penelope Hagen, MD              
Attending in Endocrinology   


cc:  Raymond Dreiser   69 Green Ave   Castleton , NY  12033


CONTENT:
DeNiro, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. DeNiro:

We had the pleasure of seeing Raymond in the Endocrine Program on 10/29/92 for evaluation of x linked hyperphospotemic rickets.

History: Raymond is now 25 years old with history of x-linked phosphatemic rickets. He has not been on phosphorous or vitamin D since18 years of age.  In May of 1991, he developed bone pain with arthritis-type symptoms on extended sitting or walking.  He has experienced some improvement on Voltrane as well as potassium phosphate and Rocaltrol.   He also complained of two days of bilateral flank pain which resolved spontaneously Raymond was seen today by Dr. Hall of Orthopedics who did not feel that surgery was necessary at this time. Raymond drinks about a quart of 2% milk  a day and eats several quarts of ice cream a week.

Current medications: Potassium phosphorous 250 mg 6 times a day, Rocaltrol 0.25 mcg 3 x a day, Voltrane 50 mg a day.

Physical exam:  
Weight: 61.9 kg         BP: 120/72              Pulse: 78               
General: Short and well developed white male in no apparent distress.  Skin: Normal.  HEENT: Normocephalic, atraumatic. His dentition was quite poor. 
Neck: No thyromegaly.  Chest: Clear.  Heart: Normal without murmur. 
Abdomen: Soft.  Genitourinary: Normal adult male.  Extremities: Legs were  bowed. There was no pain or redness on any of his joints and he had full range of motion. There was some cracking of his knees as he bends them.

Laboratory studies: Calcium 9.1 mg/dL, phosphorous 3.6 mg/dL, alkaline phosphatase, 140 mcU/mL, PTH, urine Ca 9.7 mg/dL, urine phosphorus 274 mg/dL, urine creating 131.4 mg/dL, urine CA/Cr 0.09, BUN 16 mg/dL, albumin 4.1 gm/dL, Magnesium 2.0 mg/dL, Creatinine 1.0 mg/dL, Bicarbonate level 30 mEq/L. We also feel that Raymond needs a renal ultrasound in the near future to rule out any nephracalcinosis or kidney stones given his recent bout of flank pain.

Impression: Raymond's symptoms are most likely related to his rickets. I don't feel that he has true arthritis, since he doesn't have inflammation or redness of his joints. Instead, I think that his joint problems are most likely due to misalignment of his joints  and pain due to this reason. It is encouraging that he has improved on phosphate and Rocaltrol. He should be continued on these medications. Raymond should be followed every three months with serum calcium, phosphorous, alkaline phosphate, PTH, vitamin D metabolites and urine calcium, phosphorous, and creatinine to be sure that he is not getting too much 125-Vitamin D, especially considering his large intake of milk.

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

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Hugo, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. Hugo:

We had the pleasure of seeing Raymond in the Endocrine Program on 2/11/93 for evaluation of x linked hypophosphotemic rickets.

History: Raymond continues to have bone pain with sitting, greater on the right than the left.  He also has joint pain walking up stairs which is better  when he walks less. His activity has been quite decreased from this bone pain and stiffness.  He continues on Voltraine which has improved his joint pain. He is scheduled to get his teeth re-capped and replace some of his missing teeth.  Raymond has also had trouble recently with cluster headaches.

Current medications: Amitryptoline 25 mg tid, Voltraine 50 mg tid, Rocaltrol .25 mg tid, K-phos Neutra (250 m g) 2 tabs tid.

Physical exam:  
Height: 154.5 cm        Weight: 59.8 kg         BP: 110/70              
Pulse: 78               Pubic hair: Tanner V    
General:  Well developed, well nourished.   Skin:  Normal.  HEENT: Very poor dentition and missing a number of teeth.   Neck: No thyromegaly.   Chest: Clear.   Heart: Regular rate and rhythm without murmur.   Abdomen: Benign.   Extremities: Legs are bowed. There is some crepitance of his shoulders.   Neurological: Normal.

Laboratory studies:  Calcium=9.1 mg/dL,  phosphorous=2.9 mg/dL, alkaline phosphatase=135 mU/mL,  PTH=55 pg/mL, creatinine=1.1 mg/dL, 25 vitamin D=21 ng/mL, urine calcium-7.3 mg/dL, urine creatinine=173.9 mg/dL, urine phosphate=244.9 mg/dL.

Impression: Raymond has experienced some improvement of his joint pain on anti-inflammatory medications. His bone pain improved on Phosphate and vitamin D, although there has been some recurrence pain recently.

Disposition: Continue Rocaltrol and K-Phos Neutra. Return to clinic in four months.

Laboratory studies pending at this time include: 1,25 vitamin D  and  renal ultrasound are pending.
Thank you for letting us share in the care of Raymond.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Mitsuko Animal, M.D.          RE: Raymond Dreiser
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/17/67

Dear Dr. Animal:

We had the pleasure of seeing Raymond in the Endocrine Program on 11/11/93 for follow-up of x-linked hypophosphatemic rickets.

History: Raymond is 26 years old.  He is currently on no medication for pain, and continues to have bone pain in his left ankle, right and left knees, in front of his right hip, and occasional flank pain.  He has more pain if he stays in one position for a period of time, and thus tends to get up and walk around.  In addition, he does not sleep well because of his discomfort.

Current medications: Rocaltrol 0.25 mg TID, K-phos 500 mg TID.

Physical exam:  
Height: 154.6 cm        Weight: 58 kg           BP: 110/80              
Pulse: 78               Pubic hair: Tanner V    
General: Well developed, well nourished, no apparent distress.  Skin: Normal.  HEENT: Normocephalic, atraumatic.  Poor dentition.  Neck: Normal.  Chest: Clear.  Heart: Regular rate and rhythm, no murmur.  Abdomen: Benign.  Genitourinary: Adult male Tanner stage V.  Extremities: He has bowed lower extremities.  Neurological: Grossly intact.

Laboratory studies:  Serum calcium=9.0 mg/dL, phosphorus=2.4 mg/dL, creatinine=1.0 mg/dL, PTH=32 pg/mL, alkaline phosphatase=110 mU/mL.  Urine calcium=7.3 mg/dL, urine creatinine=230 mg/dL, urine phosphate=224 mg/dL.  1,25-dihydroxy vitamin D=29 pg/mL, 25-hydroxy vitamin D 32 ng/mL.

Impression: Raymond's bone pain is still a problem.  I suggested that he takes 250 mg of phosphate six times  a day in order to maintain a more stable serum level.  In addition, I recommend he try a heating pad for his pain to see if this helps.

Disposition: Continue current regimen with the changes as outlined above.  Return to clinic in four months.
Thank you for letting us share in the care of Raymond.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Topher Neptune, M.D.          RE: Lucy Graves
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/01/81

Dear Dr. Neptune:

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

History: Tinmarie is a 14 year old girl referred to us for evaluation of exopthalmus and elevated thyroid function tests.    Although the patient and her father have not noted the changes in her eyes, they have noted a decreased requirement for sleep.  In the summer she may only sleep 2-3 hours.   Her father also notes large appetite with frequent snacking between meals as well as a significant thirst.   She drinks up to greater than 2 liters of diet soda per day as well as water and ice tea.    The patient also notes a 40 pound weight loss over a 5-6 month period during which time she was dieting actively and was exercising frequently.    The patient notes that she tends to be heat intolerant.   At night time she sleeps in pajamas without any covers or blankets and prefers her room temperature to be 60 degrees.   She does not palpitations after exercise and occasionally becomes quite anxious when having them leading to further palpitations she feels.   Her father notes that she has become more short tempered and more emotional than she had been previously.  She angers easily.   Her school performance has deteriorated.   She use to be an A and B student, now she is doing poorly and receiving F's.   Her teacher has noted that she also confabulates.

Current medications: Advil prn and Erythromycin for strep throat.

Past medical history:  The patient was a full term infant who father notes as having been always heavy and tall for age.

Review of systems:  Significant for frequent headaches without photophobia or nausea, relieved with rest.   She denies constipation, diarrhea, nocturia or polyuria or visual changes.

Family history:  Significant for maternal hypothyroidism requiring thyroid replacement during her pregnancy.  There are no other endocrine or auto immune diseases noted.

Physical exam:  
Height: 161 cm          Weight: 79.8 kg         BP: 132/66              
Pulse: 120              
General: Slightly obese, alert and cooperative.   
Skin: Revealed warm, dry skin without a rash. 
HEENT: Significant for slight exopthalmus.  Pupils were equal, round and reactive to light.   Extraocular movements were intact.   There was no notable eye movement lag.   Her tonsils were enlarged and slightly erythematous although there was no exudate.  
Neck: Supple.  Thyroid measured 4.5x3 cm on the right and 3.5x2.5 cm on the left.  No nodules were appreciated.   There was no adenopathy.  
Chest: Revealed clear breath sounds.   
Heart: Revealed tachycardia but no murmur.
Abdomen: Significant for quiet bowel sounds and a quite palpable and prominent aorta.   
Genitourinary: Tanner IV genitalia.  
Extremities: Pulses were bounding throughout.  
Neurological: Brisk ankle reflexes.   There was also a mild tremor.

Impression: Tinmarie is a 14 year old with hyperthyroidism likely due to Grave's disease.  We discussed treatment options with her and have started her on PTU.   We have prescribed 100 mg three times a day and have discussed its associated side effects, especially the lowering of the granulocyte count.   She has been instructed to return to your clinic if she develops any fever or mouth sores.   We have also started Atenolol 25 mg q day to be increased to bid after one to two weeks for symptomatic improvement of her palpitations.


Laboratory studies pending at this time include: ALKP        211     U/L       AST          17     U/L    
ALT          16     U/L       BILI TO     0.4   MG/DL    
BILI DI     0.1   MG/DL       

Disposition: We stressed that it is important for her to avoid gym and extra exercise so as to decrease her cardiac output requirements.   For similar reasons, we have suggested taht she avoid caffeine and over the counter cold preparations.   We have suggested taht she seek an ophthamology referral for evaluation of her proptosis.    We discussed the fact that we would like have to treat her for up to a year with the PTU and there is a chance that she could relapse later and require further treatment.   We also discussed the possibility of treatment with radioactive iodine.   

We look forward to see Lucy in one month at which time we will assess her symptoms and determine if any modification of her drug regimen is necessary.

We also reassured the patient and her father that her poor school performance and emotional and behavioral symptoms would likely improve but this would take some time.   We also wrote a note to notify the school of the need for her to be excused from gym in that her medical condition required treatment.

Today we have sent her for additional laboratory studies including baseline liver function tests, an anti-peroxidase antibody, TSI and a TBII.
Thank you for letting us share in the care of Lucy.

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology   


Addendum: Lauren Smith, M.D.
Resident in Pediatrics

Problem list to date:

Transcribed by Fahey


CONTENT:
Topher Neptune, M.D.          RE: Lucy Graves
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/01/81

Dear Dr. Neptune:

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

History: Lucy is a 14 year old girl referred to us for evaluation of exopthalmus and elevated thyroid function tests.    Although she and her father have not noted the changes in her eyes, they have noted a decreased requirement for sleep.  In the summer she may only sleep 2-3 hours.   Her father also notes large appetite with frequent snacking between meals and a significant thirst.   She drinks up to greater than 2 liters of diet soda per day as well as water and iced tea.    The patient also notes a 40 pound weight loss over a 5-6 month period during which time she was dieting actively and was exercising frequently.    She notes that she tends to be heat intolerant:   at night time she sleeps in pajamas without any covers or blankets and prefers her room temperature to be 60 degrees.   She does have palpitations after exercise and occasionally becomes quite anxious when having them leading to further palpitations.   Her father notes that she has become more short-tempered and emotional.   Her school performance has deteriorated:  she used to be an A and B student, now she is doing poorly and receiving F's.   Her teacher has noted that she confabulates.

Current medications: Advil prn and Erythromycin for strep throat.

Past medical history:  The patient was a full term infant.  Father reports her as having been always heavy and tall for age.

Review of systems:  Significant for frequent headaches without photophobia or nausea, relieved with rest.   She denies constipation, diarrhea, nocturia or polyuria or visual changes.

Family history:  Significant for maternal hypothyroidism requiring thyroid replacement during her pregnancy.  There are no other endocrine or auto immune diseases noted.

Physical exam:  
Height: 161 cm          Weight: 79.8 kg         BP: 132/66              
Pulse: 120              
General: Slightly obese, alert and cooperative.   
Skin: Revealed warm, dry skin without a rash. 
HEENT: Significant for slight exopthalmus.  Pupils were equal, round and reactive to light.   Extraocular movements were intact.   There was no notable eye movement lag.   Her tonsils were enlarged and slightly erythematous although there was no exudate.  
Neck: Supple.  Thyroid measured 4.5x3 cm on the right and 3.5x2.5 cm on the left.  No nodules were appreciated.   There was no adenopathy.  
Chest:  Clear breath sounds.   
Heart:  Tachycardia but no murmur.
Abdomen: Significant for quiet bowel sounds and a prominent aortic pulse.   
Genitourinary: Tanner IV genitalia.  
Extremities: Pulses were bounding throughout.  
Neurological: Brisk ankle reflexes.   There was also a mild tremor.

Impression: Lucy is a 14 year old with hyperthyroidism likely due to Grave's disease.  We discussed treatment options with her and have started her on PTU:  we prescribed 100 mg three times a day and have discussed its associated side effects, especially the lowering of the granulocyte count.   She has been instructed to return to your clinic for a CBC and diff if she develops any fever or mouth sores.   We have also started Atenolol 25 mg q day to be increased to bid after one to two weeks for symptomatic improvement of her palpitations.


Laboratory studies pending at this time include: ALKP        211     U/L       AST          17     U/L    
ALT          16     U/L       BILI TO     0.4   MG/DL    
BILI DI     0.1   MG/DL       

Disposition: We stressed that it is important for her to avoid gym and extra exercise so as to decrease her cardiac output requirements.   For similar reasons, we have suggested that she avoid caffeine and over the counter cold preparations.    She should seek an ophthalmology referral for evaluation of her proptosis.    We discussed the fact that we would like have to treat her for up to a year with the PTU and there is a chance that she could relapse later and require further treatment.   We also discussed the possibility of treatment with radioactive iodine.   

We look forward to see Lucy in one month at which time we will assess her symptoms and determine if any modification of her drug regimen is necessary.   We also reassured her and her father that her poor school performance and emotional and behavioral symptoms would likely improve but this would take some time.   We also wrote a note to notify the school of the need for her to be excused from gym in that her medical condition required treatment.

Today we have sent her for additional laboratory studies including baseline liver function tests, an anti-peroxidase antibody, TSI and a TBII.
Thank you for letting us share in the care of Lucy.

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology   


Addendum: Lauren Smith, M.D.
Resident in Pediatrics


CONTENT:
Fozzie Sanders, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Sanders:

We had the pleasure of seeing Edna in the Endocrine Program on 1/23/92 for  evaluation of hypocalcemia, hypomagnesimia.

History: Edna is a 12 and 7/12 year old with congenital heart disease consisting of a double outlet right ventricle, subvalvular pulmonic stenosis, complete AV canal, and pulmonary vein stenosis.  She underwent a modified Fontan procedure 5 years ago for paliation.  She had a right-sided cerebrovascular accident 3 years ago.  She also has a history of protein-losing enteropathy with albumin of 1.6 to 1.8, and total protein of 2.9 to 3.2.  She requires chronic treatment with diuretics.  She presented to Children's Hospital Medical Center on December 15, 1991 with a headache, tingling in her left hand, left carpal spasm and eye twitching.  Her initial labs were notable for calcium of 5.8 mg/dl, ionized calcium 0.67, and magnesium 0.8 mg/dl.  Repeat labs were notable for calcium of 6.1 mg/dl, magnesium 0.8 mg/dl, phosphate 4.3 mg/dl, albumin 1.6, total protein 3.1.  At that time her PTH was 225 pg/ml, 25-OHD 5 ng/ml and 1,25-OHD 2 D 34 pg/ml.  She received treatment with calcium, magnesium and vitamin D.  Prior to this event she had had a 25-hydroxy D of 4 ng/ml in June 1990.  She was drinking less than 4 oz of milk daily and not eating yogurt or cheese.  She had been in the sun last summer.  Since her hospitalization, she has been drinking three 8 oz glasses of milk per day, and eating 2 slices of cheese per day and 1 cup of yogurt per day.

Current medications: Tums extra strength 4 tabletes per day (1200 mg calcium/day),  Vitamin D 0.6 cc q day, magnesium gluconate 3 tablets per day, Lanoxine, Aldactone, Diuril, Inderal, aspirin, vitamin K, Carafate and Omeprazole.

Past medical history:  Birth: She was the 7 1/2 lb product of a full-term gestation, delivered vaginally without complications.  Additional medical problems include gastritis diagnosed January 19, 1992.  Her last hospitalization was January 7, 1992 for diuretic treatment.  

Review of systems:  She has intermittent temporal headaches but no tingling, parathesia seizures, or carpal pedal spasms.  She has 7-10 watery stools per day.  She has no polyuria, polydipsia, nocturia, cold or heat intolerance, hair loss, or change in weight, although she has noticed increased leg edema.  She developed breast and pubic hair at about 10 1/2 years of age.  She has not had menarche.

Family history:  There is adult onset diabetes mellitus in the maternal grandmother and arthritis in the maternal and paternal grandmothers.  There is no thyroid disease or calcium or bone disorders.

Physical exam:  
Height: 153.7 cm        Weight: 56.8 kg         BP: 94/                 
Pulse: 99               Breast Tanner: 3        
Skin: No lesions.
HEENT: Pupils equal, round and reactive to light.  Extraocular movements intact.  Normal fundi.  
Neck: No thyromegaly.
Chest: Right areola 3.3 X 2.6 cm, right breast 12 cm, left areola 3.4 X 2.6 cm left breast 13 cm.  Lungs clear.
Heart: Distant heart sounds with regular rhythm.
Abdomen: Soft, mild diffuse tenderness.  No hepatosplenomegaly.
Genitourinary: Pubic hair Tanner stage II-III.
Extremities: Cyanotic nailbeds, ankle edema.
Neurological: No Trousseau or Chvostek signs.  Deep tendon reflexes with normal relaxation phase.

Laboratory studies:  1/19/92:  Magnesium 1.0 mg/dl, calcium 6.3 mg/dl, phosphate 3.7 mg/dl, albumin 1.4.  At that time her calcium was increased from 3 Tums to 4 Tums per day

In summary: Impression:  Edna has a history of hypocalcemia and hypomagnesimia.  She has multiple reasons for these electrolyte abnormalities including chronic diuretic use with renal calcium and magnesium wasting, G.I. malabsorption with her protein-losing enteropathy, and vitamin D deficiency.  In addition, she may have had an arrest in her pubertal development.

Disposition: Return to Endocrine Clinic in 1 month.  Magnesium gluconate was increased to 4 tablets per day.

Laboratory studies pending at this time include: Calcium 7.0 mg/dl, albumin 1.6, ionized calcium 0.99, magnesium 1.0 mg/dl, phosphate 4.9 mg/dl, PTH 110 pg/ml, urine calcium <3/creatinine 95.9 mg/dl. E2 <20 ng/dl. Other studies ordered include  25-hydroxy D, 1,25-hydroxy 2D, LH, and FSH.  In addition, a bone age was obtained.

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

Sincerely,


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


CONTENT:
Fozzie Sanders, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Sanders:

We had the pleasure of seeing Edna in the Endocrine Program on 2/20/92 for  hypocalcemia, hypomagnesemia.

History: Edna continues to have loose stools now down in frequency to 10 per day since starting Imodium yesterday.  She has no seizures, carpal pedal spasm, tingling, parethesias, headaches, polydipsia, polyuria or nocturia.  She has not had menarche.  In the interim since her last visit, she has had an upper respiratory infection and right otitis media treated with Amoxicillin.

Current medications: Tums extra strength 4 tablets per day for 1200 mg elemental calcium per day; vitamin D2 0.6 cc q day for approximately 4800 IU/day; magnesium gluconate 500 mg TID for 81 mg elemental magnesium/day; Lanoxin, Aldactone, Diuril, Inderal, Lasix, aspirin, vitamin K, Imodium, Amoxicillin and other medications.

Physical exam:  
Height: 154.7 cm        Weight: 51.8 kg         Breast Tanner: 4        
Tanner pubic hair: sparse IV.
General: Awake and alert.
 HEENT: Optic discs flat.  
Neck: No thyromegaly.
Chest: Lungs clear.  
Breasts:  Right areola:  3.3 cm with breast 7 cm diameter. Left areola:  2.9 cm with breast diameter  6 cm. 
Heart: Regular rate and rhythm.
Abdomen: Liver down 7 cm at right costal margin.
Genitourinary: Minimal estrogenization of vaginal mucosa.
Extremities: Warm and well-perfused without edema.
Neurological: Deep tendon reflexes with normal relaxation phase.

Laboratory studies:  Bone age 1/23/92:  14 and 6/12 years old with 1 Standard Deviation equal to 14 months and chronologic age 12 and 5/12 years old.

1/23/92:  ionized calcium 0.99 mmol/L, PTH 110 pg/ml, 25-hydroxy D 5 ng/ml, 1,25 hydroxy 2 D 64 pg/ml, urine calcium/creatinine ratio: <3/95.9, LH <0.12 IU/L, FSH 0.5 IU/L, E2 <20 pg/ml.

2/25/92: ionized calcium 0.91 mmol/L, calcium 6.3 mg/dl, albumin 1.6 gm/dl, vpH 7.33, magnesium 0.9 mg/dl, phosphate 5.1 mg/dl.

In summary: Impression:  1.  Hypomagnesimia may be due to malabsorption or renal wasting.  She is only receiving 1.75 mg elemental magnesium/kg/day.  Therefore, she has been changed to magnesium oxide 400 mg BID for approximately 480 mg/day of elemental magnesium.  2.  Hypocalcemia may be due to malabsorption and/or vitamin D deficiency and/or decreased enterohepatic circulation of vitamin D metabolites and/or renal wasting.  Her calcium level when corrected for a low albumin is at the low end of normal.  A more utilizable form of vitamin D for her may be 125 hydroxy vitamin D and therefore she has been changed to Rocaltrol 0.25 mcg BID.  3.  Edna seems to have an arrest in her pubertal development with no menarche and a low estrogen level.  The etiology of this is unclear. Since she is 12 and 1/2 years old, we will continue to follow her pubertal status clinically for now.

Disposition: Return to Endocrine Clinic in 2 weeks.

Laboratory studies pending at this time include: PTH, vitamin D metabolites, and IGF-1 and growth hormone levels to look at her nutritional status.

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

Sincerely,


Leif Pavarotti, MD             Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Fozzie Sanders, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Sanders:

We had the pleasure of seeing Edna in the Endocrine Program on 3/9/92 for  hypocalcemia, hypomagnesemia.

History: Edna has been doing well since her last visit 2/20/92.  She has had no seizures, carpal pedal spasm, paresthesias, headaches, polyuria or polydipsia.  She did have some left lower arm pain with a palpable vein.  No swelling.  This was associated with erethmia approximately three weeks ago.  She has not had menarche.

Current medications: She continues on Tums Extra Strength 4 tablets per day and was changed to magnesium oxide 100 mg bid and Rocaltrol 0.25 mcg bid on February 25th.  There has been no change in her other medications of Lanoxin, Aldactone, Diuril, Inderal, Lasix, aspirin, vitamin K, Imodium and others.

Physical exam:  
Height: 154.3 cm        Weight: 52.1 kg         BP: 82/56               
Pulse: 88               
There was an intermittent Chvostek sign bilaterally but no Trousseau sign.

Laboratory studies:  2/25/92:  growth hormone 2.6 ng/ml, IGF-1 95 ng/ml, PTH 268 pg/ml (elevated), 25-hydroxy D 17 ng/ml, 1,25-hydroxy D level still pending.  Laboratory studies 3/9/92:  calcium 7.5 mg/dl, ionized calcium 1.10 mml/L, phosphate 5.1 mg/dl, magnesium 1.1 mg/dl, alkaline phosphatase 75 mU/ml.

Impression: Edna calcium and magnesium levels are improving on her current regimen and therefore we will continue these dosages of medications.  In order to complete our growth and pubertal evaluation we'd appreciate it if you could send us any growth data that you have.

Disposition: Return to Endocrine Clinic in one month.

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

Sincerely,


Leif Pavarotti, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Fozzie Sanders, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Sanders:

We had the pleasure of seeing Edna in the Endocrine Program on 3/9/92 for  hypocalcemia and hypomagnesemia.

History: Edna has been doing well since her last visit 2/20/92.  She has had no seizures, carpal-pedal spasm, paresthesias, headaches, polyuria or polydipsia.  She did have some left lower arm pain with a palpable vein but no swelling.  This was associated with erythema approximately three weeks ago.  She has not had menarche.

Current medications: She continues on Tums Extra Strength 4 tablets per day and was changed to magnesium oxide 100 mg bid and Rocaltrol 0.25 mcg bid on February 25th.  There has been no change in her other medications of Lanoxin, Aldactone, Diuril, Inderal, Lasix, aspirin, vitamin K, Imodium and others.

Physical exam:  
Height: 154.3 cm        Weight: 52.1 kg         BP: 82/56               
Pulse: 88               
There was an intermittent Chvostek sign bilaterally but no Trousseau sign.

Laboratory studies:  2/25/92:  growth hormone 2.6 ng/ml, IGF-1 95 ng/ml, PTH 268 pg/ml (elevated), 25-hydroxy D 17 ng/ml, 1,25-hydroxy D level 78 pg/ml.  Laboratory studies 3/9/92:  calcium 7.5 mg/dl, ionized calcium 1.10 mml/L, phosphate 5.1 mg/dl, magnesium 1.1 mg/dl, alkaline phosphatase 75 mU/ml.

Impression: Edna calcium and magnesium levels are improving on her current regimen and therefore we will continue these dosages of medications.  In order to complete our growth and pubertal evaluation we would appreciate it if you could send us any growth data that you have.

Disposition: Return to Endocrine Clinic in one month.

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

Sincerely,


Leif Pavarotti, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Fozzie Sanders, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Sanders:

We had the pleasure of seeing Edna in the Endocrine Program on 8/17/92 for hypocalcemia and hypomagnesmia.

History: Samalice is a 13 year old who is s/p modified Fontan operation for single ventricular physiology.  She has a protein-losing enteropathy and a history of hypercoagulability.  She was started on Prednisone one month ago at initially a dose of 60 mg, presently 55 mg, and to be weaned to 50 mg tomorrow.  Her corrected calcium level has been normal and her magnesium has been running in the 1.5 to 1.6 mg/dL range.  She has had no seizures, carpal-pedal spasms or paresthesias.  She now has three regular stools per day, although she had an episode of diarrhea two days ago.  She has not had menarche.

Current medications: Magnesium oxide 400 mg bid for .7 mEq/kg/day; Tums extra strength tablets bid for 21 mg/kg/day of elemental calcium; Rocaltrol 0.25 mcg bid; Prednisone , Aldactone, Coumadin, Lanoxin, potassium and Lasix.

Review of systems:  She had an infection of her right 4th finger two weeks ago that was treated with Keflex.

Physical exam:  
Height: 154.4 cm        Weight: 55.6 kg         BP: 118/72              
Pulse: 104              Breast Tanner: 4        Pubic hair Tanner: 5    
General: Cushingoid appearance.  Skin: Striae present on the upper arms and back.  HEENT: Pupils equal round and reactive to light.  Extraocular movements intact.  Neck: No thyromegaly.  Chest: Clear.  Heart: Regular rate and rhythm with distant heart sounds.  Abdomen: Soft without hepatosplenomegaly.  Extremities: Cyanotic nailbeds.  Neurological: Normal deep tendon reflexes.  No Trousseau or Chvostek sign.

Laboratory studies:  August 17, 1992:  Calcium 9.3 mEq/L, phosphate 5.5 mEq/L, magnesium 1.7  mEq/L, albumin 2.2 , total protein 3.7.  Urine calcium/creatinine ratio = 8.5/86.1 = 0.1.

Impression: Samalice now has normal calcium levels and low but slowly increasing magnesium levels that are at a safe level.  In addition, her puberty now appears to be advancing, with Tanner staging of her breasts advancing from stage III to stage IV.

Disposition: We will continue her magnesium, calcium and vitamin D supplements at their present dosages.   Magnesium and calcium levels should be checked at least monthly.  On her next blood draw, please send a glycosylated hemoglobin to rule out glucose intolerance secondary to the steroids.  She is to return to the Endocrine clinic in three months.
Thank you for letting us share in the care of Edna.

Sincerely,


Leif Pavarotti, MD             Lancelot Blue, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Fozzie Sanders, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Sanders:

We had the pleasure of seeing Edna in the Endocrine Program on 1/25/93 for evaluation of hypocalcemia and hypomagnesemia.

History: Edna is now 13 and 5/12 years old. She denies any symptoms of hypocalcemia including seizures, carpalpedal spasms, or paresthesias. She developed avascular necrosis of the right hip in December of 1992. She has not had menstrual periods.

Current medications: Prednisone 40 mg qod, Rocaltrol 0.25 mcg bid, magnesium oxide 400 mg bid, Tums extra strength 2 tabs bid, Aldactone, Lanoxin, Lasix, Propanolol, Coumadin, and potassium.

Physical exam:  
Height: 154.5 cm        Weight: 58.6 kg         BP: 100/72              
Pulse: 64               Breast: Tanner IV       Pubic hair: Tanner II   
General: Cushingnoid appearance.   Skin: Striae present on the upper arms and back. No acne.   Neck: No thyromegaly.   Chest: Clear lung fields. Axillary hair stage I.   Heart: Regular rate and rhythm with distant heart sounds.   Abdomen: Soft without hepatosplenomegaly.   Genitourinary: Deferred.   Extremities: Cyanotic nail beds.   Neurological: Normal deep tendon reflexes.

Laboratory studies:  September 28, 1992: glycosylated hemoglobin 7.2%  January 15, 1993: calcium 8.1 mg/dL, magnesium 1.7 mg/dL, phosphorous 4.0 mg/dL, albumin 1.8 mg/dL.

Impression: Samalice's electrolytes remain stable on her current regimen. Of more concern is her arrested state of puberty with questionable regression of adrenarche. Her adrenal gland is probably suppressed on her high dose of Prednisone. Her chronic illness is likely causing suppression of her hypothalamic-pituitary-gonadal axis. With this suppression, she can be expected to have low estrogen levels. This is of concern, because estrogen is necessary to maintain bone density.

Disposition: If there is evidence of suppression of her hypothalamic-pituitary-gonadal axis, hormonal replacement should be considered. This could be accomplished with an oral contraceptive pill. In addition, it may be useful to follow bone densitometry. She  will return to endocrine clinic in three months.

Laboratory studies pending at this time include: Estrogen, FSH, LH, glycosylated hemoglobin, glucose, urine calcium to creatinine ratio when she has other tests obtained on February 1, 1993.
Thank you for letting us share in the care of Edna.

Sincerely,


Leif Pavarotti, MD             Penelope Hagen, MD              
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Resa Carter, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Carter:

We had the pleasure of seeing Edna in the Endocrine Program on 4/22/93 for follow-up of hypocalcemia and delayed puberty.

History: Edna is now 13 and 8/12 years old.  Her calcium supplements were increased a few weeks ago because she was told she had low serum calcium levels. She has had no signs of hypocalcemia, denying seizures, carpalpedal spasms, or paresthesias. She is on a Prednisone taper for her protein-losing enteropathy and has had decreased serum albumin and protein levels.  She continues to have problems with bilateral  a vascular necrosis of the hips. She has noticed increased fatigue, headaches, and dizziness.  She has not had menarche.

Current medications: Prednisone 15 mg qod, calcium as Tums extra strength 8 tablets a day, Rocaltrol 0.25 mg bid, magnesium oxide 400 mg bid, Aldactone, Lanoxin, Coumadin, Potassium, Iron, and Percocet.

Physical exam:  
Height: 155.3 cm        Weight: 63.5 kg         BP: 90/62               
Pulse: 56               Breast: Tanner III      Pubic hair: Tanner II   
General:  Alert.  Skin: Normal texture. Striae present on upper arms and back.   HEENT: Pupils equal, round, and reactive to light.   Extraocular movements intact.   Neck: No thyromegaly.   Chest: Clear.   Axillary hair stage I.   Heart: Regular rate and rhythm without murmur.   Abdomen: Soft without hepatosplenomegaly. Striae present.   Extremities: Cyanotic nail beds.  Neurological: Normal deep tendon relaxation phase.

Laboratory studies:  February 18, 1993: LH 0.23 IU/L, FSH 2.3 IU/L, E2 <20 pcg/mL, glycosylated hemoglobin 7.7%, glucose 91 mg/dL, urine calcium 9.2 mg/dL, urine creatinine 8.0 mg/dL, urine calcium to creatinine ratio  0.5.
March 31, 1993: calcium 7.8 mg/dL, albumin 1.8 mg/dL, magnesium 1.4 mg/dL, phosphate 4.5 mg/dL
4/5/93 calcium 8.1 mg/dL, albumin 1.8 mg/dL, total protein 3.4 mg/dL, magnesium 1.4 mg/dL, phosphate 5.0 mg/dL.

Impression: On review of Edna' lab records, her serum calcium was 7.8 mg/dL on March 31, 1993 and 8.1 mg/dL on April 15, 1993; however, her serum albumin was only 1.8 mg/dL so her ionized or active fraction should be normal (her total serum calcium corrects to 9.5-9.8 mg/dL).  Of concern is that her last urinary calcium/creatinine ratio done February 18, 1993 was 9.2/18.0 = 0.5 -- higher than normal.  We would like to decrease her calcium supplementation back to 4 tabs QD of Tums EX -- she may even need less if her dietary intake is adequate.

We are also concerned about her estrogen status.  She has not had menarche and has not progressed through puberty.  She has had some regression of her pubic hair, which may inpart be due to adrenal suppression by prednisone.  Although the prednisone may also be responsible for some of her pubertal arrest, the lack of progression had started before treatment and can be explained by her chronic illness and malabsorption suppressing the hypothalamic-pituitary-gonadal axis.  Because of her severe osteoporosis, we are concerned about her lack of estrogen (February 18, 1993: E2 <20 mg/mL, LH 0.23 IU/L, FSH 2.3 IU/L).  Given her history of a CVA, the risks and benefits of estrogen replacement need to be weighed (although she is receiving Coumadin for anticoagulation).  Choices include oral contraceptive pills (e.g., the mini-ill), Premarin, or an estrogen patch (which doesn't past though the liver, but the dose would be harder to quantitate).  This decision should be made in conjunction with the adolescent and cardiology decision.  IN the meantime, we are trying to arrange bone densitometry at the Brigham.

Edna will return for follow-up in the Endocrine Clinic in three months.  In the interim, please obtain a repeat urinary calcium to creatinine ratio and continue to follow her calcium and magnesium levels.

Please feel free to call us with any questions.

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

Sincerely,


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


CONTENT:
Resa Carter, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Carter:

We had the pleasure of seeing Edna in the Endocrine Program on 7/1/93 for follow-up of hypercalcemia and delayed puberty.

History: Edna is a13 and 11/12 years old with multiple medical problems including complex congenital heart disease status-post a modified fontan operation which has been complicated by the development of a protein losing enteropathy. She also has had  a right basil ganglia infarction. She is currently on a Prednisone taper for treatment of the protein losing enteropathy which has been complicated by development of bilateral vascular necrosis of the hips. She was hospitalized for abdominal pain 6/7-6/17/93 at which time she received a 7 day course of IV ???

Current medications: Prednisone 10 mg qod, Tums extra strength 2 tabs po bid, magnesium oxide 400 mg bid, Peptamen Nutritional Supplements 5 cans a day, Rocaltrol 0.25 mg bid, Mylanta, Zantac, Digoxin, Lasix, Aldactone, Coumadin, Diuril, Casiel, and Perkoset.

Review of systems:  She complains of pounding headaches three times a day lasting for 15 minutes with one episode of decreased vision in the left eye on the day of her clinic visit with her headache. She fell on the day prior to the visit with increased pain from her left knee and upper leg. She also has increased fatigue. She denies fluttering of her eyelids,  seizures, carpal pedal spasm or ?? She no longer has diarrhea, having formed stools three times a day. She has not had onset of menses. She receives sun exposure daily for approximately three hours.

Physical exam:  
Height: 64 cm           BP: 110/70              Pulse: 94               
Breast: Tanner III      Pubic hair: Tanner III  
General: Alert. 
Skin: Normal texture. Striae on the upper arms and back. 
HEENT: Decreased on the cushionoid faces. 
Neck: No thyromegaly. 
Chest: Clear. 
Heart: Regular rate and rhythm with just heart sounds. 
Abdomen: Soft without hepatosplenomegaly. 
Extremities: Cyanotic nail bed. 
Neurological: Normal deep tendon reflex relaxation phase.

Impression: Edna serum calcium level has remained normal when corrected for albumin. Therefore, we will continue the same doses of medication as supplements. Of concern, with treatment of Lasix chronically is the development of calcium kidney stones. Therefore, we will continue to follow urine calcium to creatinine ratios. Her magnesium level is low but stable. Therefore, we will also continue the same dose of magnesium supplementation. Edna still has not had onset of menses. This is probably secondary to suppression of the hypothalamic pituitary gonadal axis  by chronic illness and malnutrition. With this state however, she has low estrogen levels which is concern because it will exacerbate her decreased bone density. Therefore, in spite of the history of of ??  vascular accident, treatment with estrogen either in the form of Premarin or of oral contraceptives needs to be considered. We will attempt to schedule bone densitometry.

Disposition: Return to endocrine clinic in three months.

Laboratory studies pending at this time include: Calcium phosphate, magnesium, albumen, glycosylated hemoglobin, FSH, LH, E2 and a urinary to calcium creatinine ratio.
Thank you for letting us share in the care of Edna.

Sincerely,


Leif Pavarotti, MD             Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Wesley Neptune, M.D.          RE: Edna Levenson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/06/79

Dear Dr. Neptune:

We had the pleasure of seeing Edna in the Endocrine Program on 7/1/93 for follow-up of hypocalcemia and delayed puberty.

History: Edna is a 13 and 11/12 year old with complex congenital heart disease s/p a modified fontan operation, complicated by the development of a protein losing enteropathy.  She also has had a right basal ganglia infarction.  She is currently on a Prednisone taper for treatment of the protein losing enteropathy and has developed a vascular necrosis of the hips.  She was hospitalized for abdominal pain June 7 to June 17, 1993 at which time she received a 7 day course of IV Cefuroxime.

Current medications: Prednisone 10 mg qod, Tums extra strength 2 tabs po bid, magnesium oxide 400 mg bid, Peptemen Nutritional Supplement 5 cans a day, Rocaltrol 0.25 mg bid, Mylanta, Zantac, Digoxin, Lasix, Aldactone, Coumadin, Diuril, KCI and Percocet.

Review of systems:  She complains of pounding headaches three time a day lasting for 15 minutes, with one episode of decreased vision in the left eye on the day of her clinic visit.  She fell on the day prior to her visit with the result of increased pain in her left knee and upper leg.  She also has increase fatigue.  She denies fluttering of her eyelids, seizures, carpal pedal spasm or parasthesias.  She no longer has diarrhea, having formed stools three times a day.  She has not had onset of menses.  She receives sun exposure daily for approximately three hours.

Physical exam:  
Height: 64 cm           BP: 110/70              Pulse: 94               
Breast: Tanner III      Pubic hair: Tanner III  
General: Alert.  Skin: Normal texture.  Striae on the upper arms and back.  HEENT: Decreased Cushingoid facies.  Neck: No thyromegaly.  Chest: Clear. Heart: Regular rate and rhythm with distant heart sounds. Abdomen: Soft, without hepatosplenomegaly.  Extremities: Cyanotic nail beds.  Neurological: Normal deep tendon reflex relaxation phase.

Laboratory studies:  July 12, 1993: Calcium 7.6 mg/dL, phosphate 4.7 mg/dL, magnesium 1.7 mg/dL, albumin 1.6 gm/dL, glycosylated hemoglobin 6.6%.

Impression: Edna' serum calcium level has remained normal when corrected her low albumin level.  Therefore, we will continue the same doses of Tums and Rocaltrol.  The development of calcium kidney stones with chronic Lasix treatment is of concern.  Please send a urine calcium to creatinine ratio at her next visit.  Her magnesium level is low but stable.  Therefore, we will also continue the same dose of magnesium supplementation.  Edna still has not had onset of menses.  This is probably secondary to suppression the hypothalamic-pituitary-gonadal axis by chronic illness and malnutrition.  With this state however, she has low estrogen levels which is concerning because it will exacerbate her decreased bone density.  Bone densitometry of the lumbar spine and wrist has been scheduled at the Brigham & Women's Hospital for August 11, 1993 at 1:45PM.

Disposition: Return to the Endocrine Clinic in three months.

Laboratory studies pending at this time include: FSH and LH.
Thank you for letting us share in the care of Edna.

Sincerely,


Leif Pavarotti, MD             Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Etta Blue, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Blue:

We had the pleasure of seeing Anna in the Endocrine Program on 1/11/94 for .

History: I saw Anna, nearly 21 years in follow up for glycogen storage disease.  

Her general health has been good and her dietary schedule is unchanged.  She has regular menstruation.  She had no symptoms of hypoglycemia or other problems related to her underlying disease.

She is currently on Allopurinol 100 mg daily, one Feosol daily, two Extra Strength Tums  and a Multi-Vitamin once daily.

Physical exam:  
Height: 154.7 cm        Weight: 61 kg           BP: 145/83              
Pulse: 81               
I repeated the blood pressure which was 136/86.   
Skin:  She had a sallow skin complexion but pink mucous membranes.   
Chest:  Clear.
Heart:  Normal.
Abdomen:  The liver edge was dull and was approximately 11-12 cm below the right costal margin.   The remainder of the exam was unremarkable.   

Weight has increased 2.7 kg.   Blood pressure has increased over the past one year.

Laboratory studies:  Plasma glucose was 68 mg/dL, blood lactate 2.9 mmol/L,  BUN 18, creatinine 0.7 mg/dL.    The venous pH was 7.34 and bicarb 28 mEq/L.   Total cholesterol 235, HDL 55, LDL 141, triglyceride 268 mg/dL.   Urine albumin/creatinine ratio was 25 mcg/mg, slightly increased (normal is <20).

Impression: Overall, her biochemical control is unchanged and no changes in her medications are necessary at the present time.

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

Sincerely,


Bernardo Bird, MD         
Attending in Endocrinology


CONTENT:
Etta Blue, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Blue:

We had the pleasure of seeing Anna in the Endocrine Program on 4/25/94 for .

History: Anna returned for a repeat MRI of the abdomen on March 6, 1994.  

She has a large, irregular lesion measuring 6.8 cm in the posterior aspect of the right lobe of the liver.   This is partially necrotic with gadolinium enhancement.  It was slightly larger than on the prior examination.  The other hepatic lesions are smaller.   There is a small lesion in the right lobe of the liver that now measures only 1 cm.  It previously measured 1.4 cm and another lesion that was previously seen is no longer visible.   

The radiologist's report stated that hepatomegaly was stable with adenomas, some of which are decreasing in size and one which is necrotic and has increased in size.   

I discussed these findings with Dr. Maureen Jonas, Department of Gastroenterology and Nutrition.  Specifically, the question has been raised whether or not a biopsy is indicated to establish the nature of the large lesion with central necrosis.   Dr. Jonas has agreed to provide a consultation to discuss these issues with Anna and her family if they wish to do so.   Her number is 735-7964

Physical exam:  




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

Sincerely,


Bernardo Bird, MD         
Clinical Director            


Addendum: Associate Professor of Pediatrics, HMS


CONTENT:
Cornelius Bear, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Bear:

We had the pleasure of seeing Anna in the Endocrine Program on 2/13/95 for .

History: I saw Jennifer, age 22 years, for follow up of type I glycogen storage disease.   

Medications:  Allopurinol 100 mg daily; one iron tablet daily; chewable vitamins with extra calcium one daily; two extra strength Tums per day.   

She will be graduating from Brandeis University with a degree in sociology.   She plans to work and then go on to graduate school.  

She has enjoyed good health.   Menstruation is regular, q4 weeks lasting 5 days.   There has been no change in her dietary habits or schedule of cornstarch administration.   She does not eat red meat and has a largely vegetarian diet.  She does have white chicken and tuna fish.  She has starches daily and frequently has sandwiches.   

She reports no abdominal pain; occasional bright red blood after bowel movements.   She also has perianal pruritus.   She stated that she has lots of vegetables in her diet and is not constipated.

Physical exam:  
Height: 154 cm          Weight: 58.5 kg         BP: 120/82              
Pulse: 84               
She looked well and had good color and hydration.   There was mild nasal congestion.   No thyromegaly.   Chest clear and heart normal.   The liver edge was deep, blunt and difficult to define; the edge was approximately 12 cm below the right costal margin.   Neurologic exam was intact.  

Hemoglobin 10.6 g/dL, hematocrit 32.8%, MCV 85.1, white cell count 7.29 k, platelets 389 k, PH 7.36, PCO2 50, bicarb 28 mEq/L; serum iron 44, TIBC 316 5g/dL, serum electrolytes were normal.   BUN 15, creatinine 0.6, plasma glucose 94 mg/dL, blood lactate 1.4 mmol/L.   Serum calcium, phosphorous, magnesium were 9.6, 3.9 and 2.0 mg/dL, respectively.   Uric acid 5.1, cholesterol 191, triglyceride 203 mg/dL.   Liver function tests were within the normal range and her total protein and albumin were 7.6 and 3.9 g/dL, respectively.   HDL cholesterol was 34 mg/dL.   Alpha feta protein 1.0 IU/mL, CEA less than 0.8 ng/mL, normal.

Impression: Anna appears healthy.   Her glycogen storage disease is well controlled.  She has deliberately taken off 2.5 kg.   She does have intermittent rectal bleeding caused by ??hemorrhoids.   I did not perform a rectal examination and have asked her to bring this to your attention at her forthcoming office visit.   

No changes were made in her current nutritional regimen.

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

Sincerely,


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


CONTENT:
Cornelius Bear, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Bear:

I saw Anna, age nearly 23 years, for follow up of type I glycogen storage disease. 

Medications:  Allopurinol 100 mg daily; 1 iron tablet daily; Tums ES 2 at  night; one multivitamin daily.  

She has enjoyed good health.  She is currently working as a writer in  Arlington, VA.   She lives on her own and satisfactorily manages her diet.  On weekdays, she takes 40 gm of uncooked cornstarch at 10 a.m., 2:30 a.m. and  7:30 p.m.; 50 gm at midnight and at 5 a.m.  In addition, she has three meals daily.  

She reports normal bowel function, no urinary symptoms, and regular menstrual cycles.  She has had no episodes of hypoglycemia or other health problems.

Current medications: None.

Physical exam:
HT: 154.4 cm    WT: 57.7 kg      BP: 120/82          Pulse: 87               
She looked well but mucous membranes were slightly pale.  Skin  was smooth and warm. There was no thyromegaly.  Chest was clear.  She has normal heart sounds, no murmurs.  Liver edge was not palpable but by percussion appeared to extend approximately 12 cm below the right costal margin.  There was no costovertebral angle tenderness and the remainder of the exam was unremarkable. 

Her weight has decreased 0.8 kg since her last visit.

Laboratory studies:  Serum electrolytes were normal, BUN 18, creatinine 0.7, plasma glucose 121 mg/dL; total protein 8.1, albumin 3.7 g/dL; AST, ALT, alkaline phosphatase 93, 84, and 159 U/L, respectively.  Serum iron 70, TIBC 330 5g/dl.  Hemoglobin 9.6 g/dL, hematocrit 30.7%, MCV 84.7, MCHC 31.3, white cell count 7.86 K, 28% neutrophils, 55% lymphs, 11% atypical lymphs.  Spot urine microalbumin/creatinine ratio was 15 mg/g, normal;  serum a-fetoprotein 1.5 IU/mL, CEA <0.8 ng/mL.

Impression: Jennifer's glycogen storage disease seems to be well controlled.  Her repeat abdominal ultrasound shows that she has two lesions, likely representing adenomas, and the overall size of these lesions is comparable to the measurements obtained in February, 1995.   

She has a chronic anemia which is probably due to chronic disease.  Clearly, her iron status is normal and she has been taking an iron supplement for many months but has not had an increase in her hemoglobin or hematocrit.  I have not changed her cornstarch regimen.  I plan to  see her again in six months.



Sincerely,




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


cc:  Ms. Anna Dubinsky 63 Nakomis drive Warwick, RI 02888


CONTENT:
Cornelius Bear, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Bear:

I saw Jennifer, age 23 years six months, for follow-up of glycogen storage disease type 1. 

Medications:  Allopurinol 100 mg daily; one iron tablet daily; two ES Tums at night (600 mg daily); during the winter she takes one multivitamin daily. 

She is currently working as a camp counselor until she returns to school in the fall to begin an MPH program at Emory University.  She has enjoyed good health and has had no serious health issues since my last report.   

She takes 50 mg uncooked cornstarch at 11 pm and 4 am; 40 gm at 9 am, 1:30 pm and 6:30 pm.  She does vary the times slightly according to her work schedule.  In addition, she has breakfast, lunch and supper and occasional snacks.  Jennifer reported no symptoms of hypoglycemia.  Bowel function has been normal; her energy level was described as good; menstruation is normal.

Physical exam:
HT: 154.1 cm            WT: 58.7 kg
BP: 121/71              Pulse: 90               
She looked well, had good color and hydration.  Skin was smooth and warm.  Physical exam was unremarkable except for a liver edge palpable approximately 12 cm below the right costal margin.  Weight has increased 1.0 kg since her last visit.

Laboratory studies: Serum electrolytes were normal; BUN 13, creatinine 0.5, glucose 82 mg/dl.  Blood lactate 2.0 mmol/L, uric acid 5.9 mg/dl; total cholesterol 220, HDL 62, triglyceride 204 mg/dl.  Total protein 7.8, albumin 3.8 g/dl; AST 38, ALT 26, alkaline phosphatase 129 IU/L.  Hemoglobin 10.3 g/dl, hematocrit 30.3%, MCV 83.6%, WBC 6.09K, platelets 422K.  Serum alpha-fetoprotein 3.7 IU/ml, CEA less than 0.8 ng/ml, both normal.

Impression: Asymptomatic and good biochemical control of GSD.

Disposition: I have asked Jennifer to obtain a 24 hour urine specimen for measurement of creatinine clearance and 24 hour urinary microalbumin excretion.


Sincerely,






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

cc: Ms. Jennifer Dubinsky  63 Nakomis Drive,  Warwick, RI 02888


CONTENT:
Etta Blue, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Blue:

We had the pleasure of seeing Anna in the Endocrine Program on 3/27/92 for .

History: I saw Jennifer, age 19 years 1 1/2 months, in follow-up for Type I Glycogen Storage Disease.  

She is currently on Allopurinol 100 mg daily, Beconase nasal spray; Ferrous sulfate one tablet daily, Tums 2-4 per day and one chewable vitamin D tablet daily.  

She has enjoyed good health.  There have been no episodes of hypoglycemia or epistaxes.  She has regular menses.  She reports feeling breathless when out in the cold or following exercise.  The dyspenia subsides after resting.  She is coping well with her freshman year at college.

Her dietary schedule begins with 40 g uncooked corn starch at 10:00AM, lunch at 1-1:30PM, 40 g corn starch at 2:30PM, dinner at 6:15PM, 40 g corn starch at 7:30PM, 50 g at midnight and again at 5:00AM.

Physical exam:  
Height: 154 cm          Weight: 61.5 kg         BP: 112/70              
Pulse: 72               
She appeared healthy, well-developed, well-nourished.  Color and hydration were good.  She has completed secondary sexual development.  Heart was normal, chest clear, abdomen was protuberant.  The liver edge was 11-12 cm below the right costal margin.  I was unable to discern any distinct masses.  Neurological exam was grossly intact.  Skin was smooth and warm.

She has gained 2 kg since her last visit.  Otherwise, there have been no changes and her Glycogen Storage Disease seems to be well controlled on the current nutritional regimen.

Laboratory studies:  Hemoglobin 10.5 g/dL, hematocrit 30.5%, MCV 83.9, white cells count 6.27k, platelets 344k.  Nonfasting cholesterol 207, triglyceride 174, uric acid 4.9 mg/dL, creatinine 0.7, AST 17, ALT 21 mU/mL.  Urine micro-albumin 20 mcg/mL, all 71 mcg/mg creatinine.  No changes are necessary in her current regimen.


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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology   


Problem list to date:
                             

Transcribed by Sullivan


CONTENT:
Etta Blue, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Blue:

We had the pleasure of seeing Anna in the Endocrine Program on 03/27/92 for follow-up evaluation of Type I Glycogen Storage Disease.

History: Anna is 19 and 1/12 years old.

Current medications: She is currently using Beconase nasal spray, Allopurinol 100 mg daily, ferrous sulfate 1 tablet daily, Tums 2-4 per day; 1 chewable vitamin D daily.

Past medical history:  Her menstruation is regular, and her general health has been good.  There have been no episodes of hypoglycemia, and no epistaxes.  She does become breathless if she exercises in the cold, or engages in strenuous exercise in the gym.  

Her dietary schedule includes 40 g of uncooked cornstarch at 10 AM, 2:30 PM, and 7:30 PM, and 50 g at midnight and 5 AM.  In addition, she has a small snack at approximately 10 AM, lunch between 1 and 1:30 PM, and dinner at 6:15 PM.  She also has a midnight snack.

Physical exam:  
Height: 154 cm          Weight: 61.5 kg         
BP: 112/70              Pulse: 72               
General: Color and hydration were good.  She looked well.  Physical exam was unremarkable except to note a liver edge approximately 11-12 cm below the right costal margin.  There were no masses.  Skin was smooth and warm.  Weight has increased 2 kg. Neurological: Exam intact.

Laboratory studies:  Hemoglobin 10.5 g/dl, hematocrit 30.5%, and MCV 83.9.  This is similar to the value obtained in your office on 12/17/91 (hemoglobin 11.3 g/dl).  Serum creatinine 0.7, uric acid 4.9, cholesterol 207, triglyceride 174 mg/dl.  AST 17, ALT 21 mcU/ml.  Urine microalbumin 20 mcg/ml (71 mcg/mg creatinine).

Impression: Anna's hyperuricemia is well controlled on her current dose of Allopurinol.  Her serum lipid levels are in an acceptable range.

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

Sincerely,



Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Etta Blue, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Blue:

We had the pleasure of seeing Jennifer in the Endocrine Program on 9/9/92 for follow-up of glycogen storage disease.

History: Jennifer is now 19 and 6/12 years of age. She stated that she felt well and that she had no health problems or problems related to hypoglycemia. 

She continues to take uncooked corn starch in a dose of 40 grams at 10 a.m., 2:30 p.m., 7:30 p.m., and a dose of 50 grams at midnight and 5 a.m.

She does not eat breakfast; has lunch at 11:30 a.m. a snack at 2:30 p.m. and dinner between 5 and  8 p.m.  Her appetite has been good and there have been no problems related to bowel dysfunction. She has moderate aerobic exercise on a bicycle 3-4 times a week and swims daily. She completed her first year at Brandeis University. 

Her menstruation has been regular, lasting 5-7 days.

Current medications: Allopuriol 100 mg daily. Ferrous sulfate 1 tab. daily; Tums 2 daily; Multivitamins 1 daily during the winter.

Physical exam:  
Height: 154.5 cm        Weight: 60.7 kg         BP: 132/82              
Pulse: 78               Breast: Tanner IV       
Skin: Smooth and warm; mucous membranes were slightly pale.   Chest: Clear.   Heart: There was no heart murmur. The edge of the liver was palpable, approximately 8 cm below the right costal margin. The spleen was not palpable.   Abdomen: No masses.  Genitourinary: She has completed secondary sexual development.

Laboratory studies:  hemoglobin 11.4 g/dL, hematocrit 33.6%, MCV 85.9, WBC 7.2. Plasma glucose 91 mg/dL, blood lactate 27 mg/dL (normal 6-22); uric acid 4.2 mg/dL, total cholesterol 248, HDL 70, and triglyceride 191 mg/dL. SGOT 32, SGPT 20, alk-phos 111 IU/mL, IU creatinine 0.8 mg/dL and serum albumin 5 g/dL.

Impression: Overall, Jennifer is doing well. Her weight is down 0.8 kg. No changes in her current regimen are necessary.

Disposition: At a future date, I would be in favor of bringing Jennifer into the Clinical Research Center to study her response to a single very large dose of corn starch at night in an effort to determine whether we could further simplify her corn starch therapy. This could be done at her convenience.  Thank you for letting us share in the care of Jennifer.

Sincerely,



Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Etta Red, M.D.          RE: Anna Dubinsky
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/11/73

Dear Dr. Red:

We had the pleasure of seeing Anna in the Endocrine Program on 2/23/93 for glycogen storage disease.

History: I saw Jennifer, age 20 years, in follow-up for Type I Glycogen Storage Disease.

She currently uses Allopurinol 100 mg daily, one Ferrous Sulfate tablet daily,  two Tums daily and one multivitamin daily.  

She reports feeling well.  She is a sophomore at Brandeis University.  There have been no problems related to hypoglycemia.  She exercises approximately four times per week.  

She has normal menstruation and review of systems was unremarkable. 

She has paid strict attention to her nutritional regimen.  She has 50 mg. of corn starch at midnight and at 5:00AM and 40 g at 10:00AM, 2:30PM and 7:30PM.  In addition, she has lunch between 12:00 and 1:00PM, an afternoon snack, and dinner at approximately 6:00PM.  She often omits breakfast.  Her appetite is good.

Physical exam:  
Height: 154.8 cm        Weight: 59.9 kg         BP: 120/70              
Pulse: 72               
She appeared healthy, well developed, well nourished.  HEENT was unremarkable.  Chest was clear.  Heart was normal.  A grade 1/6 systolic ejection murmur was heard at the right sternal border at approximately the third  intercostal space.  The abdomen was soft, nontender.  Liver was palpable approximately 7 cm. below the right costal margin.  Neurological exam was unremarkable.

Height was essentally unchanged from her last examination, weight was down 0.8 kg.

Laboratory studies:  Random plasma glucose 99 mg/dL, uric acid 5.4 mg/dL, blood lactate 1.7 mmol/L, venous pH 7.38, pCO2 45, bicarbonate 26 mEq/L.  AST 16 U/L, ALT 25 U/L, LDH  57 U/L.  Alkaline phosphatase 59, nonfasting total cholesterol 211, HDL 64, triglycerides 215, calculated LDL 104 mg/dL.  hemoglobin 9.9 g/dL, hematocrit 29.7%, MCV 86, WBC 5600, platelets 397k.  CEA 0.8 ng/mL, alpha feto protein 0.5, both normal  Serum TSH 2.6 mcU/mL, normal.  Urine albumin/creatinine ratio 16 mg/creatinine, at the upper limit of normal.

Impression: In summary, Jennifer appears to be in good health.  The biochemical data indicates excellent biochemical control of the glycogen Storage Disease.    She has no evidence of renal dysfunction.  She has been successful in maintaining control of her weight.  The soft systolic ejection murmur heard at the parasternal border is probably related to the mild anemia.   A chronic anemia unresponsive to iron therapy has been noted in patients with Glycogen Storage Disease, but the etiology is not understood at this time.  Attempts to correct the anemia with iron have not been successful.  

Jennifer should continue on her current nutritional regimen.  Thank you for the opportunity to share in her care.

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

Sincerely,


Bernardo Bird, MD         
Associate in Endocrinology


CONTENT:
Neptune, M.D.          RE: Antoine Eaton
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/01/78

Dear Dr. Neptune:

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

History: I saw Antoine, age 12 year 11 months, for a re-evaluation of his metabolic control on his current nutritional regimen with supplemental uncooked cornstarch.

He is currently on no medications other than 1 tablet of Poly-vi-sol daily.  He takes no mineral or iron supplements.

His general health has been good.  In August 1990 he had excessive bleeding after the loss of a tooth and this required application of pressure.  He has had no subsequent episodes of bleeding except for occasional epistaxes which tend to occur at night and last for 30-60 seconds and are easily stopped.  He had a ? viral throat infection in August 1990, and a subsequent upper respiratory infection in April 1991.  He recovered well from each of these illnesses.

He will enter the 7th grade having completed 6th grade with "almost straight A's".  He has an active social life and enjoys a variety of sports.  He appears to be able to exercise without experiencing symptoms of hypoglycemia.  Appetite is very good.  He has 3-4 bowel movements daily.  He denied any abdominal pain or cramps and is not troubled by flatulence.  He denies symptoms attributable to hypoglycemia except that he gets "tired" if he forgets his uncooked cornstarch.  Symptoms are usually apparent approximately 1 hour after he is due for a feeding.  

He takes 20 g of uncooked cornstarch with meals and 3 hours after meals, and 49 g at 9:00 pm and 2:00 am.  The cornstarch at 7:00 am and 7:00 pm are taken with skim milk and all the others are taken in water.

Physical exam:  
Height: 140.7 cm        Weight: 44.3 kg         BP: 120/80              
Pulse: 90               Arm span: 141.3         R. testis: 3. x 1.8 cm  
L. testis: 3. x 1.8 cm  Phallus length: 7. cm   Mid-shaft diam.: 2.1 cm 
General: 
Skin: Smooth and warm.
HEENT: Stained teeth which appeared otherwise healthy. Fundi showed sharp discs and normal vessels.  
Neck: Thyroid gland was not palpable.
Chest: Clear.
Heart: There was a grade 1/6 systolic ejection murmur.
Abdomen: Liver span was 12 cm with the edge 8 cm below the right costal margin.  Spleen was not palpable.  
Genitourinary: No axillary or pubic hair.
Extremities: 
Neurological: Cranial nerves were intact.

In summary: He has grown 4.8 cm and gained 4.2 kg in the past year.  Testes have increased in size suggesting that he has begun puberty.  Bone age was between 8 years 10 months and 10 years. Ultrasound showed that the liver was enlarged and had a diffuse increase in echogenicity but no focal hepatic lesions; kidneys were enlarged. 

Hemoglobin was 11.9 g/dl, hematocrit 34.2%, MCV 80.5, MCH 28, platelets 278K, reticulocytes 1.0% and white cell count 8.45.  Urine SG 1.021, pH 6.0, microscopic and chemical analysis was normal.  BUN, creatinine, and electrolytes were normal.  Venous pH just before breakfast was 7.37 and CO2 26.  Calcium, magnesium, and phosphorus were 9.6, 1.5 and 5.0 mg/dl.  AST, ALT  and alkaline phosphatase were 119, 155, and 107 miU/ml.  Total bilirubin 0.5 mg/dl.  Total cholesterol 229, HDL 22, LDL 88, VLDL 119, triglycerides 43 mg/dl.  Uric acid was 6.1 mg/dl.  The thyroid function tests were normal, IGF-1 0.28, DS 43, LH 0.76, FSH 0.8, testosterone <20 ng/dl.  Total protein 7.6, albumin 4.5 g/dl, plasma amino acid pattern was normal.  

Metabolic and hormonal monitoring during a 24 hour period with 20 g of cornstarch with meals and 3 hours after meals, and 50 g of cornstarch at 10:00 pm and 3:00 am showed normal blood glucose levels with the lowest value, 55 mg/dl just before breakfast.  His blood lactate ranged from 2.34 to 5.26 mmol/l and serum free fatty acid ranged from 605 to 1340 microEQ/L.  

Antoine is growing and gaining weight normally.  As indicated above, his physical exam suggests that puberty has just begun.  His metabolic control is superb on the current nutritional regimen.  He was discharged with instructions to continue the current regimen and to take an iron supplement for at least 6 weeks to replenish his iron stores.  He should have a hemoglobin and hematocrit rechecked in 6 weeks time.

Disposition: 

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

Sincerely,


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


CONTENT:
Meisner, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Dr. Meisner:

We had the pleasure of seeing Freda in the Endocrine Program on 3/14/94 for follow up of graves disease.

History: Freda was not seen since November 12, 1992.  During this period she admits at not having been compliant with Tapazole which she has not been taking for the past three months.  She claims she has not been able to afford buying the medication.

Lately she has been complaining of easy fatigability, palpitation, perspiration, irritabiltiy but no loss of weight or increased number of bowel movements.  She does have heat intolerance.  Menstrual periods have been irregular.

Current medications: None.

Physical exam:  
Height: 169.2 cm        Weight: 83 kg           BP: 120/70              
Pulse: 104              
Freda was fidgety but healthy looking.
Skin: Thin, and warm.  Very smooth skin over the elbows.
HEENT:  Prominent eyes, no stare, no lid lag.
Neck: Thyroid 2X normal size, diffusely enlarged.  No lymphadenoapathy.
Chest: Clear lungs.
Heart: Normal S1 and S2, no murmurs.
Abdomen: Soft, not tender.
Extremities: Mild tremors of the outstretched fingers.

Laboratory studies:  T4 14.8, TSH <0.05, T3     , TBGI 1.22.

Impression: Graves Disease in relapse.  The various options of treating Graves disease were once more discussed with Freda who refused surgery or I122 ablation.  She prefers medical therapy.

Disposition: Start Tapazole 15 mg bid.  She should return to clinic in two months.
Thank you for letting us share in the care of Freda.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Freda,

I will be seeing you in Dr. Najjar's absence in the Endocrine Program on May 9.

I note from the thyroid tests done last month that you were quite hyperthyroid at that time.

I hope you have been taking your Tapazole so this can get into control.

See you on the 9th.


Sincerely,





Nilto Carter MD
Attending in Endocrinology


CONTENT:
Meisner, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Dr. Meisner:

We had the pleasure of seeing Freda in the Endocrine Program on 5/19/94 for .

History: Dear Ms. Meisner:

Freda came back on 5/19/94 for follow up of Graves disease.  She insisted she has been taking her Tapazole 15 mg bid since we emphasized its need two months ago.   She was thyrotoxic at that time.  Currently she is in a two year job corp program in Chicopee.  She is now 22 years of age and has been taking 15 mg of Tapazole bid.

Physical exam:  
Weight: 87.4 kg         BP: 131/69              Pulse: 78               
She has gained some weight, as expected for coming under thyroid control.  She has no tremor noted today.  The eyes are slightly prominent but there is no lid lag and the thyroid is two times normal size.

Impression: She appears euthyroid today clinically and I have drawn thyroid studies to confirm this and have insisted that she maintain her current therapy of 15 mg of Tapazole bid and she will return to see me in approximately three months.

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

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology   


Addendum: May 19, 1994 tests show she is becoming hypothyroid and should add Synthroid 0.05 mg qd to her current Tapazole regimen.


CONTENT:
Nilto Carter, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Freda,

Your thyroid tests from 8/19 show that your thyroid gland is being oversuppressed by your Tapazol medication. Rather than stop the medicine and become hyperthyroid again, I suggest that you take Synthroid in addition to your Tapazol. The Synthroid dose is one pill a day (0.05 mg daily) and you can take it at any time of day.

A prescription is enclosed.

Come in for a visit and repeat blood tests in 6-8 weeks.



Sincerely,





Nilto Carter, M.D.
Assistant in Endocrinology


CONTENT:
, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Dr. Weinberg,

Thanks for the lab reports on Freda, which show that, on her antithyroid medication plus added synthroid at 0.05 mg per day, she is hypothyroid biochemically with TSH of 8.6 uU/ml and T4 5.5 ug/dL.

I prefer to increase her synthroid to 0.075 mg per day rather than just reduce here antithyroid Rx, because she has had relapse of thyroxicosis and this may bW the best way of making her euthyroid while keeping her thyroid gland in check.  Please raise her dose accordingly and I would appreciate it if your would check her TFTs with TSH in about 6 weeks.



Sincerely,





Nilto P. Carter MD
Attending in Endocrinology


CONTENT:
Sebastian Carter, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear


CONTENT:
Meisner, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Dr. Meisner:

We had the pleasure of seeing Freda in the Endocrine Program on 10/22/91 for evaluation of .

History: Freda was seen in our Endocrine Program on October 22, 1991 for follow up of her thyrotoxicosis.

She claimed to have been well since last seen on July 8, 1991.  She denied any symptoms suggestive of hyper or hypothyroidism and claims to have been fairly compliant with her medication (Propylthiouracil 100 mg bid).

On physical examination her weight was 94.2 kg (gained 4.5 kg in 3.5 months).  Blood pressure was 100/70 and pulse was 80.  The skin had a normal texture, it was neither warm nor diaphoretic.  She had no exophthalmos or lid-lag.  The thyroid gland was not enlarged.  She had no tremors of the outstretched fingers.  The rest of the physical examination was unremarkable.

T4 was      mcg/dl, TBGI     , TT3     ng/dl and TSH     mcU/ml.

Freda is to continue on the same medications and was urged to cut on her caloric intake and exercise more.

Physical exam:  



In summary: 

Disposition: 

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

Sincerely,


Kendell Simpson, MD             Kendell Simpson, MD             
Clinical Director            Clinical Director


CONTENT:
Meisner, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Dr. Meisner:

We had the pleasure of seeing Freda in the Endocrine Program on 2/24/92 for  graves disease.

History: Over the past three months, Freda has decreased her Propylthiouracil to 100 mg bid from 100 mg tid.  Since this decrease, she has noticed increased shakiness and activity.  Freda has found it hard to concentrate, and hard to sleep at night.  She is only able to sleep about 5 hours, and has been quite tired during the day.  She occasionally has some tightness in her chest after exercise.  She is exercising quite extensively, lifting weights every day.  She feels much more energetic.  Freda has experienced no change in heat or cold intolerance (always been warm), change in weight, change in skin texture, or problems in her menstrual period.

Physical exam:  
Weight: 93 kg           BP: 120/80              Pulse: 72               
Breast Tanner: 5        Pubic hair Tanner: 5    
Respirations:  16
General: 
Skin: Slightly dry.
HEENT: There was no stare or lidlag.  
Neck: No thyromegaly.
Chest: Normal.
Heart: Normal.
Abdomen: Normal.
Genitourinary: 
Extremities: She had no tremor and had normal deep tendon reflexes.
Neurological:

Laboratory studies:  Thyroid function tests showed: T4 7.2 mcg/dl, TBGI 1.10, TT3 115 ng/dl, TSH <0.05 mcU/ml, microsomal antibodies 1:1600, thyroglobulin antibodies were negative and TSI 107%.

Impression: Freda has symptoms of hyperthyroidism, but has no clinical signs of hyperthyroidism.

Disposition: Based on the normal thyroid function tests, Freda should continue her current dose of 100 mg of Propylthiouracil twice a day.  Dr. Najjar will see her in follow-up in about three months.

Laboratory studies pending at this time include: We have been unable to contact Freda directly at school, but have left a message with the nurse that the thyroid function tests were normal.

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

Sincerely,


Penelope Hagen, MD              Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Meisner, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Dr. Meisner:

We had the pleasure of seeing Freda in the Endocrine Program on 6/9/92 for followup of graves disease.

History: Freda stopped her anti-thyroid medication one month ago.  She ran out of her supply and did not have insurance coverage to buy PTU.  Since then, she has not noted any change in her mood, sleeping pattern, appetite, bowel movements or level of activities.  Her menses remained regular.  She did not diet.

Physical exam:  
Height: 168.9 cm        Weight: 89.9 kg         BP: 108/68              
Pulse: 92               Breast: Tanner V        Pubic hair: Tanner V    
General: Freda is overweight but calm.
Skin: Normal texture.
HEENT: No lid lag.  No exophthalmos.  EOM intact.  No conjunctivitis.  Normal oropharynx.
Neck: Thyroid not enlarged.
Chest: Lungs are clear.
Heart: Tachycardic.  Normal S1 and S2.  No murmurs.
Abdomen: Soft.  No masses.  No tenderness. No hepatosplenomegaly.
Extremities: No tremors of extended fingers.
Neurological: DTR 2+ symmetrical.  Normal cranial nerves.

Impression: Freda is clinically euthyroid.  She is however tachycardic and has lost weight.

Disposition: Freda will continue off treatment pending lab results.

Laboratory studies pending at this time include: TFT, TSI, TBII.
Thank you for letting us share in the care of Freda.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Meisner, M.D.          RE: Freda Meiggs
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/21/71

Dear Dr. Meisner:

We had the pleasure of seeing Freda in the Endocrine Program on 11/12/92 for follow-up of graves disease.

History: Freda has been well since last seen on June 9, 1992.  She has no symptoms suggestive of hyperthyroidism except may be for easy irritability and some heat intolerance.  Her menses are regular.  She has been complaining of knee pain, particularly on the right, usually brought about by exertion.  She did not have any other joint symptoms.  She admits to forgetting her medication on occasions.

Current medications: PTU 100 mg bid.

Physical exam:  
Height: 169.4 cm        Weight: 86.7 kg         BP: 120/74              
Pulse: 78               Breast: Tanner V        Pubic hair: Tanner V    
Freda was calm and composed, no hyperactivity noted.  Skin: Normal texture.  Not warm or diaphoretic.  HEENT: No exophthalmos.  No lid lag.  No conjunctivitis.  Neck: Thyroid not enlarged.  Chest: Lungs are clear.  Heart: Precordium is not overactive, normal S1 and S2, no murmurs.  Abdomen: Soft, no tenderness, no hepatosplenomegaly.   Extremities: No tremors of out-stretched fingers.  Neurological: Non-focal.

Impression: Freda is clinically euthyroid.

Disposition: Freda will continue on the same dose of PTU pending her lab results.  She is to return to the Endocrine clinic in four months.

Laboratory studies pending at this time include: TFT's, TSI, TBII.
Thank you for letting us share in the care of Freda.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Sanford Benise, M.D.          RE: Cecil Gutzkow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/15/78

Dear Dr. Benise:

We had the pleasure of seeing Cecil in the Endocrine Program on 11/4/93 for evaluation of delayed puberty.

History: Cecil is a 14 year old boy and, according to him, he feels that he is not as tall as he should be, and is lagging behind in sexual development.  He has no particular medical problems apart from asthma which is quiescent.  He is doing well in school, achieving excellent grades.  He has one brother age 11 who is also small.

Past medical history:  Mother notes no particular problems during pregnancy.  He was the product of a Cesarean delivery for poor progress in labor.  He achieved normal milestones.  His past medical history is otherwise normal except for an inguinal hernia.

Family history:  Father had constitutional growth delay and slow development of puberty, shaving at the age of 18 or 19.  Mother's family history is not known.  paternal grandmother has a possible history of hypothyroidism.

Physical exam:  
Height: 144 cm          Weight: 50.1 kg         Pulse: 86               
U/L ratio:  0.82        Arm span: 148           Breast: Tanner III      
Pubic hair: Tanner II   R. testis: 3.0 x 2.0 cm L. testis: 3.0 x 2.0 cm 
Phallus length: 8.0 cm  Mid-shaft diam.: 3.0 cm 
General: Obese. Skin: Some axillary hair, no body odor. HEENT:  Negative
Neck: No palpable thyroid. Chest: Gynecomastia. Heart: No murmur. Abdomen: No masses.  Genitourinary: Early pubertal sexual development. Extremities: normal. Neurological:  Normal.

Laboratory studies:  Bone age was assessed at 13 years and 6 months.  This was at chronologic age 14 years and 9 months.  Somatomedin C, drawn at an outside lab,  was 96 which is low for the chronological age but not the bone age.  Thyroid function tests were normal.  Testosterone was 32 ng/dL.

Impression: Cecil was reassured as to normal sexual and growth development.  His mid-parental height being 67 inches which he should achieve.  The problem of gynecomastia has been addressed and at the moment is it not regarded as a serious problem by Cecil or his father and may actually regress with his growth spurt.

Disposition: We plan to see Cecil again in three months.
Thank you for letting us share in the care of Cecil.

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology   


Addendum: Robert Skelley, M.D.
Fellow in Endocrinology


CONTENT:
Tinisha Crane, M.D.          RE: Allie Robson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/08/80

Dear Dr. Crane:

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

History: Allie appears to be doing quite well now although she had some elevated blood sugars over the summer for no apparent reason.  She has started middle school recently and is doing well.  She is on insulin doses of 7 units of Regular and 12  of NPH and in the morning, and 3 units of Regular and 7 of NPH in the evening, for a total daily dose of 0.7 units/kg/day.  Blood sugars have been running in the 80 to 240 mg/dl range.

Physical exam:  
Height: 146.4 cm        Weight: 38.9 kg         BP: 120/60              
Pulse: 66               Breast Tanner: 1        Pubic hair Tanner: 1    
Skin was of normal temperature and texture and there was no goiter.  The injection sites were entirely clear.

Laboratory studies:
Glycosylated hemoglobin 8.4%.  Bone age: 11 years (predicted adult height: 63.6").

In summary: Allie continues to do extremely well despite her slight abberation over the summer.  She seems to have increased somewhat in her growth velocity and weight gain and remains at her ideal body weight.  This small increase in growth velocity and Allie's bone age are consistent with teh earlies evidence of puberty.  She was seen by the dietrician for further nutritional guidance.  I plan to see her back in four months.


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

Sincerely,


 , MD


CONTENT:
Tinisha Crane, M.D.          RE: Allie Robson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/08/80

Dear Dr. Crane:

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

History: Allie is now 12 and 2/12 years old. She has no complaints and checks her blood sugars three times a day. Her overall control, she feels has been good. She is currently on Pure Pork insulin at .9 units/kg/day divided bid. She occasionally feels slightly low in the afternoon. She uses a One Touch Machine and report blood sugars in the 100-200 range most of the time.

Physical exam:  
Height: 152.1 cm        Weight: 42.9 kg         BP: 125/70              
Breast: Tanner II       Pubic hair: Tanner II   
Physical exam was unremarkable. She does have some atrophy on her right buttuck from previous usage of beef insulin.

Impression: Allie is doing well with her diabetes control. I have kept her on the same dose of insulin which is 8 of Regular and 17 of NPH in the morning, 5 of Regular and 9 of NPH at night and sent a hemoglobin-A1 and a blood sugar. I plan to see her back in three months.

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

Sincerely,


M Joan Hammer, MD         
Associate in Endocrinology


CONTENT:
Stanwood Leary, M.D.          RE: Allie Robson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/08/80

Dear Dr. Leary:

We had the pleasure of seeing Allie in the Endocrine Program on 4/13/93 for evaluation of insulin dependent diabetes mellitus.

History: Allie is a 12 and 6/12 year old girl with insulin dependent diabetes mellitus since age 2. She has been very compliant with her diabetes care, checking her blood sugars three times a day. Her parents are very much involved. Her current insulin dose is .9 units/kg/day divided bid of pork insulin. She occasionally notes some low blood sugars before lunch. Her log book has numerous blood sugars in the 40-70 range at varying times during the day.

Physical exam:  
Height: 153 cm          Weight: 45.2 kg         BP: 100/70              
Breast: Tanner III      Pubic hair: Tanner III  
The general physical exam was unremarkable.

Impression: Allie is mid-pubertal and is doing a very good job managing her diabetes. She has had some leveling off of her growth with continued weight gain since her last visit. If this pattern continues, we may have to back off on her calories. It is very encouraging that she continues to be physically active. Our plan was to increase the morning snack adding a protein and to back off to 18 of NPH in the morning with a sliding scale of 7-9 of regular, a sliding scale 3-7 of regular with 9 of NPH in the evening.

Disposition: Return to clinic in four months.

Laboratory studies pending at this time include: Hemoglobin-A1 and a blood sugar.
Thank you for letting us share in the care of Allie.

Sincerely,


M Joan Hammer, MD         
Associate in Endocrinology


CONTENT:
Kermit Seinfeld, M.D.          RE: Wanda Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/81

Dear Dr. Seinfeld:

We had the pleasure of seeing Wanda in the Endocrine Program on 11/14/91 for evaluation of osteopenia.

History: Wanda is a 10 and 5/12 year old white female with a history of intractable epilepsy and developmental delay, referred to the Endocrine Clinic for decreased bone density noted on a chest x-ray done on October 24, 1991.  This chest x-ray was obtained as part of a protocol to commence a new drug, Phelbamate, two weeks ago to control her seizures.  Patient  in the past has been on ACTH for six months at the age of 9 months, Phenobarbital for 9 months at the age of 3 months and restarted again in September 1991, Valproic acid for 9 years, Diamox for 5 years, Zorantin for 5 years which has been recently discontinued as well as intermittent trials of Dilantin, Tegretol, Clonipin., Nitrozepam and 
L-Carnitine. 

Patient's diet includes milk, dairy products, eggs, cereal.  She does not take any supplemental vitamins.  Her history is significant for a left humerus fracture at the age of 7 and a collies fracture at the age of 8 years.  She does spend a significant amount of time outdoors especially in the summer.  Dad reports that she had a significant tan.  She does lead however,  a fairly sedentary life though she goes to school and receives physical therapy twice a week there.  She does ambulate on her own.  She complains of no bone weakness, or muscle weakness, complains of no bone or joints pains.

Birth history is unremarkable.

Current medications: Phenobarbital, Valproic acid, Tranzene, Diamox, L-Carnitine, and Phelbamate as well as Valium prn which has been used to control seizures at home by her parents which was needed once in the last 2 weeks.

Family history:  Unremarkable for metabolic bone diseases except for an interesting history of a paternal grandfather who developed some sort of anemia related to chronic lead exposure from his work.

Physical exam:  
Height: 134. cm         Weight: 37.7 kg         BP: 100/60              
Pulse: 90               
Pleasant, engaging white female in no acute distress.  Very scant facial acne. Bilateral right lateral nystagmus. Otherwise unremarkable with no bone or joint pain on palpation.

In summary: In reviewing the films she indeed does have osteopenia.  There is no evidence of rickets on chest x-rays and the current feeling is that possibly her sedentary life as well as her chronic exposure to multi-anticonvulsants some of which can cause osteopenia or acidosis may be the etiology for her osteopenia. At this time we would like to get calcium, phosphate, magnesium, vitamin D, alkaline phosphatase and parathyroid hormone levels as well as a venous pH, UA and a urinary calcium/creatinine and re-x-ray her wrist, knees and ankles as the film we have is just a chest x-ray. We would like to wait for the results to come in, have her return to Clinic in 4 weeks and review the information.

Disposition: 

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

Sincerely,


Kendell Simpson, MD             Kendell Simpson, MD             
Clinical Director            Clinical Director


CONTENT:
Benise, M.D.          RE: Wanda Montale
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/22/81

Dear Benise:

We had the pleasure of seeing Wanda in the Endocrine Program on 12/12/91 for evaluation of her osteopenia.

The results of the various blood tests obtained on 11/20/91 to evaluate the mineral metabolism of her skeleton were all normal.  Calcium 9.5, phosphorous 4.1, Magnesium 1.9, Ionized Calcium 1.29, Alkaline Phosphatase 250, PTH 31, Urine Calcium 5.8 mg/dl, urine creatinine 90.4 ng/dl, 25 OHD3 2D, 1,25 (OH)2D3 27, venous pH 7.33, Bicarbonate 22.

Radiographs of the wrist, knees and ankles revealed diffuse moderate osteopenia but no rachitic changes.

In summary: Wanda has osteoporosis  rather than osteomalecia.  The cause of the osteoporosis is not clear, it may be Juvenile osteoporosis.  No therapy is indicated at present except for the increased vitamin D requirement due to anticonvulsants.

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

Sincerely,





Kendell Simpson, MD             
Clinical Director


CONTENT:
Antony McPherson, M.D.          RE: Naomi Buckley
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/23/82

Dear Dr. McPherson:

We had the pleasure of seeing Naomi in the Endocrine Program on 7/20/95 for subclinical hypothyroidism.

History: Nichole is a 13 year and 3 month old female referred for the evaluation of thyroid function tests.  She was placed on Lithium for treatment of aggressive behavior, and has been on Lithium since April of this year.  Thyroid function tests performed on June 15, 1995 showed TSH=10 and a T4=5.  Repeat thyroid function tests on July 6, 1995 showed TSH=11.8 and T4=5.2.  She has no symptoms of hypo- or hyperthyroidism.  She denies changes in her bowel habits, menstrual cycle, weight, or energy level.

Current medications: Lithium 300 mg tid taken under supervision.
Zoloff 50 mg po qd
Ventolin on a prn basis.

Past medical history:  Nichole is the product of a normal pregnancy and vaginal delivery.  She had early closure of the anterior fontanelle.  She was hospitalized at Pembroke Hospital in January and April of 1995 for aggressive behavior.  She has a history of alcohol abuse and has smoked cigarettes in the past.  She has previous history of asthma.  She has allergies to pollen.

Review of systems:  Negative

Family history:  Mom is 5 feet 7 inches tall.  Dad's height is unknown.

Physical exam:  
Height: 157.6 cm        Weight: 43.6 kg         BP: 104/70              
Pulse: 88               Breast: Tanner V        
General: Well appearing female in no apparent distress.
Skin: No viteligo.
HEENT: Pupils reactive, mucous membranes moist.
Neck: No thyromegaly.
Chest: Clear to auscultation.
Heart: Regular rate and rhythm with no murmurs.
Abdomen: Soft with no organomegaly.
Extremities: No edema.
Neurological: DTR +2.  Sensory intact with no proximal myopathy.

Laboratory studies:  At HCHP:  TSH=11.8, T4=5.2, LH=0.64.

Impression: Nichole has subclinical hypothyroidism, most likely related to the Lithium she is on.  At this stage, we would like to hold off on treating her with Synthroid, as her T4 is within the normal range for HCHP's lab, and Nichole has no symptoms of hypothyroidism.  We recommend putting her on an alternative medication instead of Lithium, if there is another medication available that could be used to treat her aggression.  If not, we recommend that her thyroid functions be monitored every few months.  If her T4 decreases, or her TSH increased to over 20, and she becomes symptomatic, we would recommend starting Synthroid.  She will need close follow-up.

Disposition: Primary pediatrician to follow TFT's carefully on Lithium and off of Synthroid.  Return to Clinic as per Dr. McPherson's request for follow-up.
Thank you for letting us share in the care of Naomi.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology   


Addendum: Susan Haden, M.D.
Fellow in Endocrinology


CONTENT:
Hamud Swartzenegger, M.D.          RE: Sam Healy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/15/81

Dear Dr. Swartzenegger:

We saw Sam in the Endocrine Program on 9/28/95 for evaluation of slow growth.

History: Billy is a 14-0/12 year old boy who was noted by you to have a decreasing growth rate over the last several years.

Billy is a healthy boy who has not had any recent history of intercurrent illnesses.  He has a good appetite, and no recent weight loss.  There is no history of heat or cold intolerance, no double vision or other changes in vision, no excessive thirst or urination.  Billy has begun his puberty, noting the first onset of pubic and axillary hair as well as acne approximately one year ago.

Billy has a history of chronic low grade migraine headaches.  In the  past he would suffer from migraines 1-2 times per month, but now has only 1 episode every few months, and usually these are managed well with Ibuprofen and moving into a quiet, darkened room.  He has never needed prescription medication for his migraines.  Billy also has a  history of an unspecified back injury approximately 2 years ago.   Apparently he developed severe lower back pain and stiffness one day which required stretching exercises and other physical therapy  interventions to restore his normal movement.  A series of x-rays done at that time were essentially unrevealing.

Billy himself is not especially troubled by his decreasing growth rate.   He is still significantly taller than several of his peers.  Billy's  mother was unaware that his rate of growth had changed recently, and was only alerted to the fact when you pointed it out to her at his last visit.

Current medications: None.

Past medical history:  Pregnancy: full-term, no problems.  Delivery: without complications.  Birth weight 7 lbs. 1 oz.   Growth and  development: within normal limits.  Immunizations: up-to-date. Hospitalizations:  None.  Injuries:  Sustained significant laceration to left ankle while jumping  over a fence last year.

Family history:  Billy has a 10 year old sister and a 16 year old brother, both healthy and with no medical problems.  Both mother and father are 46 years old and healthy.  Father does suffer from very mild asthma.  There is a history of type II diabetes mellitus in a  maternal grandmother.  Mother had her menarche fairly late at 16 years of age,  and does say that she was a "late bloomer".  Father's pubertal development was unremarkable by mother's report.  Mother's height is 5'5", father's  height 6'2".  Billy is in eighth grade and active in sports.

Physical exam:
Ht: 163.1 cm    Wt: 44 kg    Arm span: 165.5 cm    U/L ratio:  0.81
BP: 110/70              Pulse: 78               Breast: Tanner I        
Pubic hair: Tanner II   R. testis: 2.5 x 1.5 cm L. testis: 2.5 x 1.5 cm 
Phallus length: 7.5 cm  Mid-shaft diam.: 2 cm   
General appearance: alert and active, no distress.   
Skin: several scaly erythematous, slightly excoriated patches on left forearm (patient says these are poison ivy).  
HEENT: normocephalic, atraumatic, pupils equal and reactive to light,  oropharynx clear.   
Neck: supple, no thyromegaly.  
Lymph nodes: within normal limits.   
Chest: clear to auscultation.  
Cardiovascular: regular rate and rhythm,  normal S1 and S2, no murmurs.  
Abdomen: soft, no masses, nontender, nondistended.  
GU: normal circumcised male, testes normal texture,  tanner 2 pubic hair.  Extremities: within normal limits, except for well-healed scar on left ankle.  No scoliosis noted.  
Neurological:  within normal limits.

Laboratory studies:  8/10/95:  IGF-1 170 ng/ml (low for age), IGF-BP3  3.0 mg/L
TSH 0.58 mU/L ESR 16, Calcium 9.8, Phosphate 3.9. Electrolytes  within normal limits.  CBC within normal  limits.  Urinalysis within normal limits
Bone age: 14 yrs,   Chronologic age: 13 11/12 yrs.

Laboratory studies 9/28/95: T4 8.7 ug/dL, LH 0.37 IU/L, TBGI 0.88, FSH 1.80 IU/L, 
TSH 0.70 uU/mL, testosterone <10 ng/dL.  IGF-1 Pending

Impression: Billy is a 14-year-old boy with a decrease in growth velocity over the past 2 years.  However, over the last 2-3 months Billy has shown a normal growth rate.  Previous studies show a borderline low IGF-1 level, with  normal IGF-BP3 level; a repeat level drawn today is pending.  Thyroid function tests are all within normal limits.  Billy's bone age is essentially consistent with chronologic age.  

Billy's LH, FSH, and Testosterone levels are all consistent with his very early pubertal stage.  We would expect that Billy will be starting puberty shortly; his relatively late start into puberty may be part of the explanation for his recent decrease in his rate of growth.

Disposition: We would like to see Billy back in Endocrine Clinic in 6 months' time, to reassess his growth and pubertal development.  Should his IGF-1 level be abnormal, we will contact you with further recommendations.



Sincerely,




Yale Neptune, MD                 Penelope Hagen, MD              
Fellow in Endocrinology           Attending in Endocrinology   


Addendum: IGF-1  265 ng/ml  (nl for age: 202-957)
This value is in the normal range, and it appears that Billy has sufficient growth hormone at this time.  We suggest close follow up of his growth velocity over time, and as noted above, we would like to see him again in Endocrine Clinic in 6 months.


CONTENT:
Hamud Swartzenegger, M.D.          RE: Sam Healy
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/15/81

Dear Dr. Swartzenegger:

We saw Sam in the Endocrine Program on 4/11/96 for slow growth.

History: Billy is a 14 and 7/12 year old boy whom we last saw in Endocrine Clinic on September 28, 1995.  Since that time, he has been well overall with no significant intercurrent illnesses or problems.  He did sustain a small right forehead laceration after being stuck by a piece of glass earlier this year.   

Mother feels that Billy has had a fairly good growth rate since his last visit, and she has recognized that he has continued to make progress.  Of some concern was the fact that you had noted during a recent well child visit that Bill had lost some weight over the course of a few month interval.   This was felt to be secondary to exercise over the winter months in basketball.  Mother reports that his appetite continues to be excellent. 

In addition, Billy had a urine evaluation at his last visit with you to check for glucose, and this was negative.   

Billy does report that he is using deodorant now to help with axillary odor, though he denies development of any facial hair.  He also denies having any acne, although he says he regularly uses a Clearasil-type soap. 

He is currently in the 8th grade and doing very well.  He is active in sports, especially basketball over the winter months, and he is getting ready now to start baseball season.

Current medications: None.

Physical exam:
Height: 165.2 cm    Weight: 46.5 kg
BP: 114/60          Pulse: 95               Breast: Tanner I        
Pubic hair: Tanner III  R. testis: 2.8 x 1.6 cm L. testis: 2.6 x 1.6 cm 
Phallus length: 8.4 cm  Mid-shaft diam.: 2.2 cm 
General appearance:  alert, active, well-appearing white boy in no distress.  
Skin:  no acne, no other lesions.  
HEENT:  normocephalic, atraumatic, pupils equal and reactive to light.  
Neck:  supple, no thyromegaly, no adenopathy.  
Lungs:  clear to auscultation.  
Breasts:  Tanner I.   1+ axillary hair.  
Heart:  regular rate and rhythm, normal S1 and S2.  No murmur.  
Abdomen:  soft, non-tender, non-distended, no organomegaly, no masses.  
GU:  normal early pubertal male genitalia, circumcised.  Testes descended bilaterally.  Pubic hair Tanner III.  
Extremities:  no clubbing, cyanosis or edema.  
Neurological:  within normal limits.

Impression: Billy is a 14 and 7/12 year old boy who is here for continued follow-up of slow growth.  Billy has made good progress since his last visit, gaining approximately 4.2 cm in one year.  This is an appropriate growth velocity for a child in early to mid-puberty, as his physical examination supports.  Our continued feelings regarding Billy's growth are that he simply represents a case of constitutional delay, with a relatively delayed pubertal growth spurt.  We would expect his growth velocity to increase over the course of the next one to two years with continued growth through his later teen years.  

According to our records, he has gained weight over the course of the last six months,  approximately 2.5 kg in that time period.  Because of mother's and Billy's concerns regarding the weight issue, we suggested that addition of a Carnation instant breakfast-type shake each morning as a supplement to his regular diet.  Other than this, we do not feel that Billy needs any intervention at this time.

Disposition: We would like to follow Billy's growth carefully over the next six months, when we would like to see him back in Endocrine Clinic to ensure that he is making adequate gains in his overall growth.



Sincerely,




Yale Neptune, MD               Nilto Carter, MD             
Fellow in Endocrinology         Associate in Endocrinology


CONTENT:
Montse Simpson, M.D.          RE: Irene Dobie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/11/82

Dear Dr. Simpson:

We had the pleasure of seeing Irene in the Endocrine Program on 8/6/92 for evaluation of short stature and possible turner syndrome.

History: Irene is a 10 year old girl who was born at 40 weeks after premature rupture of membranes for 9 weeks.  She was born by Caesarean section secondary to breech presentation.  She was born with club feet treated with casting for 10 months.  Mother does not recall any lymphedema at birth.  Irene has a history of formula intolerance as an infant and improved on soy formula.  Her height and weight according to the mother have always been <5th percentile until the age of 4 when she remained approximately on the 5th percentile for height and between 10th and 50th for weight.

Current medications: She does use a Ventolin inhaler prn for asthma.

Past medical history:  Multiple UTI, the last being six months ago.  She has never had a VCUG performed.  She also has a history of microscopic hematuria which was diagnosed as an IgA nephropathy.  Recently she was seen in the GI clinic for an evaluation of a year long history of abdominal pain and diarrhea with evaluation revealing a positive lactose breath test and resolution of abdominal pain on a lactose free diet.  During her evaluation of her gastrointestinal problems, her physical exam was notable for features consistent with Turner syndrome.  She was referred to the Endocrine clinic.  She had a bone age done 5 months ago by the report of mother which was 6 years done at East Boston Health Center.  TFT were also sent at that time, the results are unknown.  Also notable for pneumonia which she has had twice in her early years.  Hospitalization at 9 months for a viral syndrome, a fractured right wrist at 7 years of age and reactive airways disease.

Review of systems:  Skin with multiple nevi, no history of blurred vision or headaches, no cardiac disease.  She is lactose intolerant with diarrhea associated with lactose ingestion.  She also has a history of polydypsia and nocturia.  She had "spotting" in her underwear noted in 1992 which occurred for one to two days and has not reoccurred.  These is a question of vaginal vs urinary source of this spotting.  She is a good student, receiving A's and B's in school.

Family history:  Diabetes in a maternal aunt and grandmother.  Also a history of short stature on the paternal side of the family.  Father is 5'3", paternal grandmother and great-grandmother heights are 4'5" and 4'7" according to mother.  Mother's height is 5'7 3/4".

Physical exam:  
Height: 125.6 cm        Weight: 31.5 kg         BP: 98/72               
Pulse: 88               U/L ratio:  0.85        Arm span: 47            
Breast Tanner: 1        Pubic hair Tanner: 1    
General: Irene was a cooperative, small girl in no apparent distress.
Skin: Freckles noted on her back, upper arms and skin exposed areas.  Pigmented nevi on her back, trunk and extremities.
HEENT: Slightly high arched palate, discs sharp and flat bilaterally.
Neck: Mild webbing, low posterior hair line, no thyromegaly.
Chest: Wide spaced nipples.  Lungs are clear.
Heart: Regular rate and rhythm, S1, S2 without murmur.  2+ femoral dorsal and posterior tibial pulse.
Abdomen: Soft, nontender, non-distended, no hepatosplenomegaly.
Genitourinary: Normal external female genitalia.
Extremities: Short 4th metacarpal, mild cubitus valgus normal fingernails.
Neurological: Cranial nerves intact.  Motor strength tone, DTR symmetric.

Laboratory studies:  done ate East Boston Health Center:  bone age and TFTs results are unknown.  These results will be brought to Irene's next clinic visit.

Impression: Irene is a 10 year old girl with short stature and stigmata of Turner syndrome on physical exam.  Our plan was to send a chromosome analysis for the question of Turner syndrome and to check the results of the TFTs and bone age.  Because of Irene's history of polyuria and polydypisa as well as significant family history of diabetes, a hemoglobin A1 and a blood glucose will be checked.  Because of her history of UTI, hematuria and the association of renal anomalities associated with Turner syndrome, she will obtain a renal ultrasound.  We would like to see Irene and her family back in two months to determine the results of the karyotype as well as the implications of Turner syndrome if this diagnosis is made.

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

Sincerely,


Rusom Pulanski, MD       Kendell Simpson, MD             
                             Clinical Director            


Addendum: Glucose 76 mg/dL, HbA1 5.9%.  Urine pH 5, ps. gr. 1.025, WBC 2-4, RBC 0-1, Bacteria trace, blood 2+, protein and glucose negative.  

Renal ultrasound: normal appearing kidneys.


CONTENT:
Edwin Lear, M.D.          RE: Irene Dobie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/11/82

Dear Dr. Lear:

We had the pleasure of seeing Irene in the Endocrine Program on 12/21/92 for follow up of short stature.

History: Since last seen on August 6, 1992, Irene and her mother think they have identified the cause of her abdominal pain followed by diarrhea and jitteriness.  On at least three occasions, these symptoms were precipitated by intake of chocolate (hot chocolate once, chocolate ice cream and chocolate cake on the two other instances), she had no symptoms following ingestion of milk.  Otherwise she has been well.  Recently Mrs. Dobie was diagnosed to have multiple sclerosis.

The karyotype performed on August 6, 1992 was normal 46XX.

Physical exam:  
Height: 127.3 cm        Weight: 34.8 kg         BP: 84/60               
Pulse: 78               Breast: Tanner I        Pubic hair: Tanner I    
Irene gained 3.5 kg. and grew 1.7 cm. in four months.  Skin: Normal texture.  HEENT: Negative.  Neck: Thyroid not enlarged.  Chest: Clear lungs.  Heart: Normal S1 and S2, no murmurs.  Abdomen: Soft, no tenderness, no hepatosplenomegaly.  Extremities: Normal.  Neurological: Non-focal.

Impression: Short stature - familial.  Irene is presently growing and gaining at a normal rate.

Disposition: Irene is to return to the Endocrine clinic in one year for reassessment.

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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Milorad Lear, M.D.          RE: Nancy Leo
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/06/82

Dear Dr. Lear:

I saw Nancy in the Endocrine Program on 8/6/96 for insulin-dependent diabetes mellitus.

History: Sashian was last seen in our Diabetes Clinic on 05/07/96.  Since then, she has done well, with no interval illnesses.  She will be starting the ninth grade in the fall.  She performs all insulin injections and fingerstick blood glucose determinations on her own, without supervision by her parents.  Her daily schedule during the summer has been quite irregular, with breakfast often eaten as late as 11:30 in the morning.  She does not wear a MedicAlert tag (despite counseling to the contrary).  Last menstrual period was approximately one month ago.   

Current insulin dose is 8 units regular 28 units NPH mornings, and 8 units regular 21 units NPH before dinner, for a total of 65 units per day or 1.1 units/kilo/day. 

She follows no specific meal plan, and describes herself as being very active throughout the day.  Mild insulin reactions are experienced approximately twice a week, at random times, associated especially with activity level. 

The blood sugars which have been noted in Sashian's log book correspond with readings on the Glucometer memory for the past two weeks; however, prior to that the Glucometer and log book readings are quite discrepant.  Numbers from the book recently are as follows: 80-160 mg/dl before breakfast, lunch values not available, 50-140 mg/dl before dinner, and 40-160 mg/dl before bedtime, with overnight blood sugars never checked.

Physical exam:  Deferred today.

Laboratory studies:  Hemoglobin A1C 8.2% (4-6%), blood sugar 200 mg/dl, TSH 3.0 microunits/ml.

Impression: Sashian is a 13-8/12 year old girl with type I diabetes mellitus under fair control, complicated by a highly variable schedule, no specific diet plan, and minimal parental supervision.  Sashian may be slightly over insulinized, as evidenced by frequent low blood sugars throughout the day, and a lower than expected hemoglobin A1C.  In addition, neither Sashian nor I have an explanation for the discrepancy in blood sugar readings between the Glucometer and her log book.

Disposition: I would like to reduce total insulin dosage slightly to: 8 units regular 26 units NPH mornings, and 6 units regular 20 units NPH evenings.  I again encouraged Sashian to obtain and wear a MedicAlert tag.  The importance of a regular diet and schedule was reemphasized.  In addition, the need for adequate parental supervision has been discussed repeatedly in the past.  Finally, I have encouraged Sashian to call us for unexplained variability in blood sugar.  Follow-up is recommended for three months.


Sincerely,






Gleide Crane, MD             
Attending in Endocrinology


CONTENT:
Milorad Lear, M.D.          RE: Nancy Leo
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/06/82

Dear Dr. Lear:

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

History: Nancy was diagnosed with diabetes approximately 2 months ago. She has done well, without intercurrent illnesses. She is currently in the 5th grade, likes mathematics, and receives mostly A's and B's. A source of potential psycho-social stress is the father's reported drinking problem. 

Nancy receives Humulin insulin at a dose of 5 Regular, 11 NPH in the morning, 2 Regular and 6.5 NPH in the evening. This equals 24.5 units a day, or 0.65 units/kg/day. Nancy experiences approximately 1 episode of hypoglycemia a week, usually occurring in the late morning during gym class.  Review of systems is otherwise negative for polyuria, nocturia, or polydipsia. She eats three meals and three snacks a day, and participates in aerobic exercise about three times a week.

Blood sugar is checked on a Acu-Check III Monitor. Typical finger stick readings are 100-180 before breakfast, 80-180 before dinner, and 80-180 before bed.

Physical exam:  
Height: 145.5 cm        Weight: 37 kg           BP: 120/70              
Breast: Tanner III      Pubic hair: Tanner II   
Thyroid easily palpable, borderline large, homogeneous in consistency. The remainder of the physical exam was unremarkable.

Impression: In summary, Nancy is a 10 and 1/12 year old girl with newly diagnosed diabetes mellitus. She is in excellent glycemic control, attributable in part to the honeymoon period. She has demonstrated good growth, and is now entering puberty. The mother has recently been diagnosed with primary hyperthyroidism and is about to undergo treatment. 

Our plan is as follows: 1) continue current insulin dosage, anticipating increase in insulin requirements as puberty progresses and the honeymoon period ends. 2) in view of positive family history of thyroid disease, we will screen Nancy for autoimmune thyroiditis on a periodic basis. At the mother's request, we have postponed obtaining hemoglobin-A1 and thyroid function tests (with antibody studies) until the next visit. 3) We have arranged for a meeting between the Leo's and a social worker today, 4) We have provided Nancy with an application for a medic alert tag.

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

Sincerely,


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


CONTENT:
Milorad Lear, M.D.          RE: Nancy Leo
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/06/82

Dear Dr. Lear:

We had the pleasure of seeing Nancy in the Endocrine Program on 4/13/93 for follow-up of diabetes mellitus.

History: Nancy was diagnosed with insulin dependent diabetes mellitus in November 1992. She has generally done well with no significant management problems. The mother reports that father has a significant drinking problem at the present time. 

Humulin insulin is given twice a day according to the following schedule: 5 units regular and 15 units NPH in the morning, 2 units regular and 13 units NPH in the evening, which equals 35 units a day or 0.94 units/kilo/day. There are occasional symptoms of hypoglycemia following exercise, typically treated with several Life Savers. She eats three meals and three snacks a day and participates in daily exercise. Blood sugars are checked on an Accu-Check III meter and are typically between 100 and 200 mg per dL.

Physical exam:  
Height: 147.8 cm        Weight: 37 kg           BP: 110/60              
Breast: Tanner III      
Thyroid mildly enlarged, smooth, symmetrical. The remainder of the exam was unremarkable.

Impression: Nancy is a 10 and 4/12 year old girl with insulin dependent diabetes mellitus under good glycemic control. She is entering puberty and would be expected to require increased insulin dosages in the future. There is a positive family history of thyroid disease, and a borderline enlarged thyroid gland was noted on physical examination.

Thyroxine 8.6 mcg/dL, TSH 2.6 mcU/mL, thyroid antibodies negative (all normal).

We recommend a small increase in insulin to 6 units Regular and 16 NPH mornings, 3 units regular and 13 NPH evenings.  Nancy has been encouraged to consume extra snacks before vigorous exercise. Finally, Nancy and Mrs. Leo will be meeting with our social worker, Ellen Goodman, today regarding the father's reported alcoholism.

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

Sincerely,


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


CONTENT:
Milorad Lear, M.D.          RE: Nancy Leo
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/06/82

Dear Dr. Lear:

We had the pleasure of seeing Nancy in the Endocrine Program on 7/27/93 for follow-up of diabetes mellitus.

History: Nancy was diagnosed with diabetes mellitus in November of 1992. Interval health has been good, with no significant intercurrent illnesses.  Nancy is off for the summer, and plans to start sixth grade in the fall.

Current Novolin insulin doses 6 Regular and 17 NPH morning, 3 Regular and 16 NPH evenings for a total of 42 units a day or 1.1 units/kg/day. She denies symptoms of hyperglycemia, and has experienced no recent insulin reactions.  Her diet consists of three meals and three snacks a day, though eating habits are somewhat variable, (breakfast ranges from 7 a.m. to 11 a.m.). Exercise is obtained on a daily basis, usually in the afternoons and food is adjusted accordingly. 

Blood sugars are checked on a One Touch II monitor generally twice a day. Typical breakfast readings are 100-150 mg/dL, dinner 100-160 mg/dL, and bedtime 100-150 mg/dL.

Physical exam:  
Height: 150.3 cm        Weight: 38.8 kg         BP: 120/70              
Breast: Tanner III      
General: Alert, nontoxic adolescent girl.  HEENT: Fundi without retinopathy.  Neck: Thyroid gland slightly enlarged, homogeneous approximately 35 grams.  Chest: Lungs clear.  Heart: 1-2/6 systolic murmur.  Abdomen: Without hepatosplenomegaly.

Laboratory studies:  Hemoglobin-A1 8.9%.

Impression: Nancy is a 10 and 7/12 year old girl with Type I diabetes under reasonably good control. This is somewhat surprising in view of her large insulin requirements, variability in schedule, and absence of insulin reactions. Growth and development is good, and she is progressing satisfactorily into puberty.  She has a small goiter and positive family history of autoimmune thyroid disease, though recent thyroid function and antithyroid antibodies were normal. Finally, Nancy's home environment is reportedly troubled by father's alcoholism. 

We have stressed the importance of regular blood sugar monitoring and close adherence to her dietary schedule. No changes in insulin doses are currently recommended. Nancy is to check occasional 5 a.m. blood sugars, to evaluate whether TID insulin dosage (with NPH given at night) would be beneficial. Further, she is at risk for thyroid disease, and will require periodic thyroid function testing. Finally, with regard to the complicated home environment, the Leo's are continuing to meet with social services currently.

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

Sincerely,


Gleide Crane, MD             Nilto Carter, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Milorad Lear, M.D.          RE: Nancy Leo
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/06/82

Dear Dr. Lear:

We had the pleasure of seeing Nancy in the Endocrine Program on 9/5/83 for diabetes.

History: Notable for one episode of prolonged hypoglycemia requiring hospitilization overnight.  A question of glucometer malfunction was raised at the time, and the Leos currently have a new One Touch II monitor.  Nancy is currently in the sixth grade.  As mentioned previously, the whole environment is complicated by stressful relationship between Nancy and her mother, and father's reported alcoholism.  

Current Novolin insulin dose is mornings 6 regular/17.5 NPH, evenings 3 regular/17.5 NPH for total of 1.1 5 units per kg/per day.  She denies symptoms of hyper- or hypoglycemia.  Diet consists of three meals and two snacks a day (morning snack is omitted).  Blood sugar are check approximately three times a day and ranged; 120-240 mg/dl before breakfast, 80-180 mg/dl before dinner and 100-180 mg/dl before bedtime.

Physical exam:  
Height: 151.3 cm        Weight: 37.9 kg         Breast: Tanner III      
General: Thin, well appearing.
Neck:  Thyroid moderately enlarged, smooth, symmetrical. 
Chest:  Lungs clear.  
Heart:  Cardiac benign.
Abdomen: Without hepatosplenomegaly.  
Skin:  Injections sites without atrophy or hypertrophy.   
Glycosylated hemoglobin 10.5%.

Impression: Nancy is a 10 and 10/12 year old girl with type one diabetes mellitus under good glycemic control.  The large evening dose of NPH raises concern for a possible doctrinal hypoglycemia.  She is moderately underweight for height, but denies signs and symptoms of anorexia nervosa.  Physical exam is notable for a moderate sized goiter, and family history is positive for thyroid disease.  Finally, the home environment contains significant psychosocial stresses for Nancy.

Disposition: Nancy is to check 2:00 a.m. blood sugars for the next several nights and call us next week to discuss pm NPH dosing.  The advantages of TID insulin injections were emphasized to the Leos.  In addition, larger meals are encouraged.  Nancy's goiter will need to be followed, will antithyroid antibodies and thyroid function tests were normal in April.  Recommended follow up is for three months.
Thank you for letting us share in the care of Nancy.

Sincerely,


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


Problem list to date:
INSULIN-DEPENDENT-DM         Start: 05/21/93  End:          Invalid: 

Transcribed by Bryant


CONTENT:
Milorad Lear, M.D.          RE: Nancy Leo
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/06/82

Dear Dr. Lear:

We had the pleasure of seeing Nancy in the Endocrine Program on 9/5/93 for diabetes mellitus.

History: Interval history is notable for one episode of prolonged hypoglycemia requiring hospitalization overnight.  A question of glucometer malfunction was raised at the time, and the Leo's currently have a new One Touch II meter.  As mentioned in previous letters, the home environment is complicated by a stressful relationship between Nancy and her mother, and father's reported alcoholism.

Current Novolin insulin dose is 6 Regular/17.5 NPH in the morning and, 3 Regular/17.5 NPH in the eh evening for a total of 1.15 u/kg/day.  She denies symptoms of hyper- or hypoglycemia.  Diet consists of three meals and two snacks a day (morning snack is omitted).  Blood sugars are checked approximately three times a day and ranged between 120-240 mg/dL before breakfast, 80-100 mg/dL before dinner and 100-180 before bedtime.

Physical exam:  
Height: 151.3 cm        Weight: 37.9 kg         
General: Thin, well appearing.  Neck: Thyroid moderately enlarged, smooth, symmetrical.  Chest: Lungs clear  Heart: Cardiac benign.  Abdomen: Without hepatosplenomegaly.   Skin: Injection sites without atrophy or hypertrophy.

Laboratory studies:  Glycosylated hemoglobin 10.5%.

Impression: Nancy is a 10 and 10/12 year old girl with Type I diabetes mellitus under good glycemic control.  The large evening dose of NPH raises concern for a possible nocturnal hypoglycemia.  She is moderately underweight for height, but denies signs and symptoms of anorexia nervosa.  Physical exam is notable for a moderate sized goiter, and family history is positive for thyroid disease.  Finally, the home environment contains significant psychosocial stresses for Nancy.

Disposition: Nancy is to check 2:00AM blood sugars for the next several nights and call us next week to discuss PM NPH dosing.  The advantage of TID insulin  injections were emphasized to the Leos.  In addition, larger meals are encouraged.  Nancy's goiter will need to be followed, though antithyroid antibodies and thyroid function tests were normal in April.  Recommended follow up is for three months.
Thank you for letting us share in the care of Nancy.

Sincerely,


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


CONTENT:
Hooan Domingo, M.D.          RE: Sammy Jolson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/11/82

Dear Dr. Domingo:

We had the pleasure of seeing Sammy in the Endocrine Program on 10/31/94 for short stature.

History: Sammy is a 12 and 7/12 year old boy with short stature.  According to his records, he was growing along the 5th percentile, but has fallen beneath that over the past several months.   

On review of systems, he has a good energy level, evidenced by his participation in soccer and basketball.  He occasionally has problems with constipation but overall has one bowel movement per day of normal consistency.   He occasionally complains of feeling cold but has not had dramatic temperature intolerance.   He has a good appetite and seems to follow a balanced diet, including 2-3 cups a day of milk.   He sleeps through the night and has never had a problem with enuresis.   He has mild apocrine odor for which he uses a deodorant.  His mother notes that he has migraines almost every week.   They are typically late in the afternoon, one to two times a week with associated vomiting.   He typically has scotomata just prior to the headache's onset.   He takes no medication for these and they are typically better with sleep.

Current medications: Tavist prn for congestion.

Past medical history:  He was a full term gestation delivered by C-section.  The neonatal period was complicated by the fact that his mother's membranes ruptured prematurely and he was on two days of IV antibiotics in the nursery.   His birth weight was 8 pounds 13.5 ounces and his length was 20 inches.   He had an appendectomy in 5/94 and removal of a congenital nevus in 11/93.   Otherwise, his health issues include only migraine headaches and occasional otitis media.

Family history:  His mother has hypothyroidism and has been on Synthroid since the age of 4 years.  His father has migraine headaches.   There is a family history of short stature; his paternal grandmother is 4'10".  There are no other known endocrinopathies.  Maternal height 5'6"; paternal height 5'6".

Physical exam:  
Height: 135.2 cm        Weight: 36.9 kg         BP: 110/72              
Pulse: 72               U/L ratio:  0.9         Arm span: 140           
Breast: Tanner I        Pubic hair: Tanner I    R. testis: 2.1 x 1 cm   
L. testis: 1.9 x 1.1 cm Phallus length: 6 cm    Mid-shaft diam.: 1.7 cm 
General: Well appearing, in no acute distress.  
Skin: Occasional pimples along the nose and forehead.  
HEENT: PERRLA, EOMI.  Fundi normal.   
Neck: Edges of thyroid barely palpable but no goiter.  
Chest: Clear to auscultation.  
Heart: No murmur.  
Abdomen: Soft, no hepatosplenomegaly.  
Genitourinary: Normal male genitalia.  
Neurological: Nonfocal.  Reflexes 2+ and toes downgoing bilaterally.

Laboratory studies:  Low post-exercise growth hormone of 0.5 ng/mL; thyroid function tests performed in 8/94 were normal.  ESR 15 mm/hr, DS 107 ug/dL, IGF-1 85 ng/mL, IGF BP3 1.9 (2.1-6.2) mg/L.  Bone age (reviewed) - 11 0/12; chronologic age 12 7/12, standard deviation = 10.4 months.

Impression: 12 and 7/12 year old with probable constitutional delay, but we cannot rule out growth hormone deficiency given this patient's low IGF-1 and binding protein, as well as an exercise induced screen that was subnormal.  His thyroid function tests were normal in 8/94.   We reviewed the bone age obtained in 8/94 and found it to be delayed,  and checked a DHEA-S as a screen for his adrenal steroid production that was prepubertal.  We would like to proceed now to formal provocative testing for GH deficiency.

Disposition: We have talked to Mrs. Jolson and informed her of results of these tests.   As the results of the screening tests for growth hormone deficiency are abnormal, we have scheduled provocative testing for formal evaluation of growth hormone deficiency.   Sammy will have an insulin tolerance test on January 4, 1995 at 8:30 am in the Children's Hospital outpatient testing center (CAT-CR).
Thank you for letting us share in the care of Sammy.

Sincerely,


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


CONTENT:
Hooan Domingo, M.D.          RE: Sammy Jolson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/11/82

Dear Dr. Domingo:

We had the pleasure of seeing Sammy in the Endocrine Program on 6/1/95 for short stature.

History: Sammy is a 13 2/12 year old who was last seen in the Endocrine Clinic on October 31, 1994.  At that time, he was found to have a low IGF1 and binding protein, as well as abnormal exercise induced GH screen.  TFT's were within normal limits.  A bone age obtained in August, 1994, was also found to be delayed.  We went on to schedule provocative GH testing in January, 1995, that was within normal limits.  We elected to initiate a short course of intramuscular (t) Testosterone Enanthate to try to hasten his puberty and hopefully to induce a "growth spurt".  Sammy's first Testosterone injection was in February, 1995.  He has received four injections, his last injection during the first week in March.

Current medications: Testosterone enanthate 50 mg IM q month.

Review of systems:  He has had a good energy level as well as a good appetite.  He denies headaches or changes in urination or thirst.  He sleeps through the night without nocturia.  There have been no visual changes.  He has noted the development of a slight mustache, pubic hair and enlargement of his genitalia.

Physical exam:  
Height: 140.7 cm        Weight: 40.6 kg         BP: 102/70              
Pulse: 80               U/L ratio:  0.9         Arm span: 141           
Breast: Tanner I        Pubic hair: Tanner II   R. testis: 2.6 x 1.6 cm 
L. testis: 2.5 x 1.9 cm Phallus length: 8.2 cm  Mid-shaft diam.: 2.7 cm 
U/L ratio = 0.9.
General: Alert, in NAD.
Skin: Mild facial acne along nasal bridge and cheeks.
HEENT: PERRL, EOMI, oropharynx clear.
Neck: No thyromegaly, no lymphadenopathy
Chest: CTA.
Heart: RRR, without murmur.
Abdomen: Soft, no masses or hepatosplenomegaly.
Genitourinary: Tanner II genitalia with bilaterally descended testes.
Extremities: No clubbing, cyanosis or edema.
Neurological: Nonfocal, reflexes 2+, toes bilaterally downgoing.

Impression: Sammy is a 13 2/12 year old with probable constitutional delay given normal provocative GH testing.  There was good response to four intramuscular injections of (t)Testosterone Enanthate with noted growth acceleration and pubertal changes on physical exam.  We would recommend watching Sammy off GH therapy and checking his height/weight development in four months.

Disposition: We would like to see Sammy again in four months and at that time decide whether further GH treatments are necessary.
Thank you for letting us share in the care of Sammy.

Sincerely,


Sotiria Bonaparte, MD         Nilto Carter, MD             
                             Associate in Endocrinology


CONTENT:
Hooan Domingo, M.D.          RE: Sammy Jolson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/11/82

Dear Dr. Domingo:

We saw Sammy in the Endocrine Program on 10/16/95 for short stature/constitutional delay.

History: Sammy is currently 13 7/12 years old.  He was last seen in our program on 6/1/95.  At that time, he had just completed a four month course of testosterone enanthate, 50 mg IM qmonth.  He had shown advancement in his pubertal development, as well as increase in height velocity.  We elected to watch him four months off of hormonal therapy to reevaluate his growth and pubertal status.  Sammy has been doing well since that visit.  He has a good energy level and appetite.  He sleeps through the night.  He occasionally has headaches that are reportedly migraines, but they occur with decreased frequency from before.  He  denies visual changes.  There is no change in urination or thirst and no problems with constipation or diarrhea.  There has been no increased apocrine odor.  He has noted continued hair growth over his arms, legs, and in the pubic area.  He denies problems with acne.

Current medications: None.

Physical exam:
Ht: 144.4 cm    Wt: 44.1 kg    Arm span: 147 cm    U/L ratio:  0.98
BP: 110/70              Pulse: 90               Pubic hair: Tanner II   
R. testis: 2.9 x 1.4 cm L. testis: 3.0 x 1.3 cm Phallus length: 8.4 cm  
Mid-shaft diam.: 2.6 cm 
General appearance:  healthy-appearing adolescent boy, skin clear.  HEENT:  PERRL, EOMI, fundi within normal limits.  Neck:   no thyromegaly or lymphadenopathy.  Chest:  clear to auscultation.  COR:  normal sinus rhythm without murmur.  Abdomen:  soft without masses or hepatosplenomegaly.  GU: normal male genitalia.  Extremities: warm and well perfused.  Neurologic: nonfocal, reflexes 2+ and toes bilaterally  downgoing.

Impression: 13 7/12 year old with probable constitutional delay.  Good response seen after  months of testosterone enanthate monthly therapy.  Sammy has continued to advance both in pubertal development, as well as height, without exogenous testosterone.  We would like to continue to monitor him off therapy.  We would also like to see him again in 4 months for reevaluation.  We will obtain a repeat bone age and hormonal studies at that time.

Sincerely,




Sotiria Bonaparte, MD         Lancelot Blue, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Hooan Domingo, M.D.          RE: Sammy Jolson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/11/82

Dear Dr. Domingo:

We saw Sammy in the Endocrine Program on 4/25/96 for follow-up of short stature/constitutional delay.

History: Sammy is currently 14 1/2 years old.  He was last seen in our clinic in 10/95.  He has been off of testosterone enanthate therapy for 11 months now.  He has continued to show mild advancement in his pubertal development, but a decreased height velocity from before.  He has a good energy level and appetite.  He sleeps through the night.  He has occasional migraine headaches, but decreased from before.  There is no change in his urination or thirst and no problems with constipation or diarrhea.  He has noted mildly increased hair growth over his arms, legs and in the pubic area.  He denies problems with acne.

Current medications: None.

Physical exam:
HT: 144.6 cm    WT: 44 kg          Arm span: 144 cm
BP: 115/64              Pubic hair: Tanner III  R. testis: 3.3 x 1.7 cm 
L. testis: 3.2 x 1.6 cm Phallus length: 8.4 cm  Mid-shaft diam.: 2.6 cm 
General appearance: a healthy-appearing adolescent boy, skin clear.  On HEENT, fundi within normal limits.  Neck: no thyromegaly or lymphadenopathy.  Chest clear to auscultation.  COR: normal sinus rhythm without murmur.  Abdomen: soft, without  organomegaly.  GU: normal male genitalia.  Extremities: warm and well perfused.  Neuro: nonfocal.

Laboratory studies: Bone age: 12 6/12yo with chronologic age of 14 1/12.  Matured ~ 6mo since study one year ago.

Impression: A 14 1/12 year old with probable constitutional delay.  As a good response was seen to testosterone therapy one year ago and his current height velocity has leveled off, we would like to begin another short course of testosterone enanthate monthly therapy.  Our hope is to maximize his growth velocity and development over the summer.

Disposition: We restarted testosterone enanthate 50 mg IM q. month for four months.  We would like to see him again in four months to reevaluate.  

Thank you for letting us share in Sammy's care.  Please do not hesitate to call us with questions.


Sincerely,




Sotiria Bonaparte, MD            Rahul Ibsen, MD                
Fellow in Endocrinology         Attending in Endocrinology


CONTENT:
Hooan Domingo, M.D.          RE: Sammy Jolson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/11/82

Dear Dr. Domingo:

We saw Sammy in the Endocrine Program on 9/16/96 for follow-up of short stature/constitutional delay.

History: Sammy is currently 14 6/12 years old.  He was last seen in our clinic in April, 1996.  At that time, we reinitiated a four month course of testosterone to try to induce puberty.  He has had a good result to a four month course of low dose testosterone in January, 1995.   

On review of systems, Sammy has been doing well with a good energy level, as well as appetite.  He sleeps through the night.  He has had no change in bladder or bowel habits.  He has had intermittent problems with allergic rhinitis, but no fevers or purulent nasal discharge.  Sammy notes that he has had increased hair growth on the legs since initiating testosterone and feels like his height has increased.  He continues to have occasional migraine headaches, but they are not worse from before.

Current medications: Testosterone  50 mg IM, with the last injection in 8/96.

Physical exam:
HT: 148.2 cm            WT: 49.4 kg    
Arm span: 152 cm        U/L ratio:  0.9
BP: 105/66              Pulse: 80               Pubic hair: Tanner III  
R. testis: 3.2 x 1.8 cm L. testis: 3.2 x 1.7 cm Phallus length: 8.6 cm  
Mid-shaft diam.: 2.7 cm 
General appearance:  Healthy-appearing adolescent boy.  Skin:  occasional nasal comedones, otherwise clear.  HEENT:  PERRL, EOMI, oropharynx clear.  Neck:  without thyromegaly, lymphadenopathy.  Lungs:  clear to  auscultation.  Chest:  without gynecomastia.  Cor:  normal sinus rhythm without murmur.  Abdomen:  soft without organomegaly.  GU:  normal testicular consistency.  Extremities:  well-perfused.  Neuro:  non-focal.  Reflexes:  2+ and toes bilaterally downgoing.

Laboratory studies: LH .76 IU/L, PRL 8.30 ng/mL, FSH 2.30 IU/L.     

Impression: Probable constitutional delay.  Received recent course of low dose testosterone.  Surprising on our exam today was the fact that Sammy's testicular volume is virtually unchanged from before.  We therefore obtained screening gonadotropins to rule out end organ failure.  We are reassured that the LH and FSH levels are not elevated.  On the contrary, the FSH is low normal, and the LH just below the normal limits.  We also ordered a prolactin, considering the possibility of a central lesion, but the level was normal.

Disposition: We would like to see Sammy back in six months for reevaluation.  We have called his family with these results.  If spontaneous puberty does not occur in the next year, further work-up, including central imaging, would be considered.

Thank you for letting us share in Sammy's care.  Please call us with any questions.


Sincerely,






Sotiria Bonaparte, MD         Gleide Crane, MD, PhD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Steinbeck, M.D.          RE: Eleanor Baez
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/11/83

Dear Dr. Steinbeck:

We had the pleasure of seeing Nicole in the Endocrine Program on 9/19/91 for evaluation of precocious puberty and short stature.

History: This is an 8 and 2/12 year old female with a history from birth of a lumbar myelomeningiocele which was surgically corrected in infancy with a ventriculoparetenial shunt placed at the age of 3 weeks for hydrocephallus  The delivery was a forceps assisted delivery because of hydrocephallus  She is being seen now for early onset of puberty associated with a short stature.  She has had normal cognitive development.  

Her early puberty is manifested by some early breast development and very scant pubic hair noted by her mother in 5/91 (age 7 years 10 months).

Current medications: 1.Phenobarbital 20mg 1 1/2 teaspoons pu BID.  There is consideration of possibly tapering this medication in the next 1-2 years. 2. Ditrophan 1 teaspoon po TID, 3. Septra 1/2 teaspoon BID.

Past medical history:  Hydrocephallus at birth with vp shunt placed at age 3-4 weeks. G-tube was placed at age 6 weeks able to be removed at the age of 3-4 years to prevent aspirations during feeding.  She has had a trach placed because of Arnold-Chiar malformation at approximately 6 weeks that was also able to be removed and the patient now has functional vocal chords.  She has a seizure disorder dating back to the age of 8 months characterized  by petite mal seizures only and this is believed to be related to her myelomenigiocele.  She also has spastic bladder and is on a program regular cathezation as well as the Ditropan.  She had a normal renal ultrasound in 5/90 showing no evidence of hydronephrosis.

Family history:  Mother's height is 5'7" and father's height is 5'8".

Physical exam:  
Height: 101 cm          Weight: 16.7 kg         U/L ratio:  1.1         
Upper segment of 53cm.  Her head was large for her body.  She had generalized hypertricosis.  There was nestagnes bilaterally but no evidence of ? lage and extrocular muscles were intact.  Her thyroid was not enlarged.  She had Tanner II stage breast  with approximately 2cm of breast tissue bilaterally and no pubic hair was appreciated on examination by Dr. Simpson.  There was marked atrophy in the lower extremities particularly below the knee an absent sensation below the knee bilaterally.  Patient came in wearing braces below the knee and in wheelchair.

Laboratory studies:
She did not come to us with any prior blood work.

In summary: She most likely has a growth hormone deficiency accounting for her short stature which may be secondary to the perinatal birth trauma because of her hydrocephallus.  She is just in the beginning of pubertal development.  Because of her short stature  and the mother's interest in giving her growth hormone, we would recommend that after the appropriate endocrine testing she is indeed growth hormone deficient administering both growth hormone and LHRH analog to delay puberty.

Disposition: Discharged to home from the clinic with the return visit on the 2nd of October planned to do the dynamic testing involved including an insulin tolerance test, and glucagon stimulation test for growth hormone as well as a TRH stimulation test.  We are also recommending  a ? age stimulation test.

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

Sincerely,


Kendell Simpson, MD                      Kendell Simpson, MD


CONTENT:
Gleide Gonzo, M.D.          RE: Eleanor Baez
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/11/83

Dear Dr. Gonzo:

We had the pleasure of seeing Nicole in the Endocrine Program on 9/19/91 for evaluation of precocious puberty and short stature.

History: This is an 8 and 2/12 year old female with a history from birth of a lumbar myelomeningiocele which was surgically corrected in infancy with a ventriculoperitonial shunt placed at the age of 3 weeks for hydrocephalus  The delivery was a forceps assisted delivery because of hydrocephalus  She is being seen now for early onset of puberty associated with a short stature.  She has had normal cognitive development.  

Her early puberty is manifested by some early breast development and very scant pubic hair noted by her mother in 5/91 (age 7 years 10 months).

Current medications: 1.Phenobarbital 20mg 1 1/2 teaspoons po BID.  There is consideration of possibly tapering this medication in the next 1-2 years. 2. Ditrophan 1 teaspoon po TID, 3. Septra 1/2 teaspoon BID.

Past medical history:  Hydrocephalus at birth with V-P shunt placed at age 3-4 weeks.  G-tube was placed at age 6 weeks able to be removed at the age of 3-4 years to prevent aspirations during feeding.  She has ha d trach. placed because of Arnold-Chiari malformation at approximately 6 weeks that was also able to be removed and the patient now has functional vocal cords.  She has a seizure disorder dating back to the age of 8 months characterized by petite mal seizures only.  She also has spastic bladder and is on a program regular cathezation as well as Ditropan.  She had a normal renal ultrasound in May 1991 showing no evidence of hydronephrosis.

Family history:  Mother's height is 5'7" and father's height is 5'8".

Physical exam:  
Height: 101 cm          Weight: 16.7 kg         U/L ratio:  1.1         
Upper segment of 53cm.  Her head was large for her body.  She had generalized hypertricosis.  There was nystagmus bilaterally but and extrocular muscles were intact.  Her thyroid was not enlarged.  She had Tanner II stage breast  with approximately 2cm of breast tissue bilaterally and no pubic hair was appreciated on examination. There was marked atrophy in the lower extremities particularly below the knee an absent sensation below the knee bilaterally.  Patient came in wearing braces below the knee and in wheelchair.

Laboratory studies:
She did not come to us with any prior blood work.

In summary: Growth hormone deficiency be secondary to the perinatal birth trauma may account for her severe short stature. She is just  beginning pubertal development.  Because of her short stature  and the mother's interest in giving her growth hormone, we would recommend that if after the appropriate endocrine testing she does indeed have growth hormone deficiency both growth hormone and LHRH analog to delay puberty be administered.

Disposition: Discharged to home from the clinic with the return visit on the 2nd of October planned to do the dynamic testing involved including an insulin tolerance test, and glucagon stimulation test for growth hormone as well as a TRH and GnRH stimulation tests.  We are also recommending  a bone age determination.

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

Sincerely,


Kendell Simpson, MD                      Kendell Simpson, MD


CONTENT:
Gleide Gonzo, M.D.          RE: Eleanor Baez
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/11/83

Dear Dr. Gonzo:

We had the pleasure of seeing Nicole in the Endocrine Program on 10/15/91 for evaluation of .

History: The Insulin/GnRH/TRH/Glucagon stim test performed on Nicole revealed the following:

1.  Normal growth hormone response to both insulin-induced hypoglycemia and to glucagon
2.  Normal TSH response to TRH.
3. Pubertal LH and FSH response to GnRH>

GnRH analogue therapy (Lupron-Depot 7.5 mg IM every 4 weeks) is recommended to suppress her pubertal development.

Physical exam:  



In summary: 

Disposition: 

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

Sincerely,


Kendell Simpson, MD             Kendell Simpson, MD             
Clinical Director            Clinical Director


CONTENT:
Cornelius Frog, M.D.          RE: Eleanor Baez
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/11/83

Dear Dr. Frog:

We had the pleasure of seeing Nicole in the Endocrine Program on 8/6/92 for follow-up of precocious puberty.

History: Nicole is a 9 and 11/12 year old white female who has a history of lumbar myelomeningocele, a VP shunt placed at 3 weeks of age with two shunt revisions, breast development and pubic hair noted at 7 and 10/12 years of age, short stature, seizure disorder although she has had no seizures in the past five years, spastic bladder, s/p G-tube and s/p tracheostomy.  She is undergoing bladder stimulation at this point and self-catheterizes.  She will be entering the third grade in a special needs program.  She is allergic to latex gloves.

Current medications: Lupron 7.5 mg IM q 4 weeks, Phenobarbitol 30 mg bid, Ditropan 1 tablet tid, Bactrim 1 tsp qd.

Review of systems:  She denies constipation, diarrhea, change in urine volume, vaginal discharge or bleeding.  She is having normal activity and she has a good appetite.

Family history:  Positive for asthma in both sides of the family, coronary artery disease in the maternal grandfather, hypertension in paternal grandparents.  Mother's height is 67", father's height 68".

Physical exam:  
Height: 107 cm          Weight: 19.1 kg         BP: 92/70               
Pulse: 108              U/L ratio:  1.14        Arm span: 109           
Breast Tanner: 2        
measured while supine on the examining table
(up 2.4 kg in the past 10 months)
General: Nicole is a small girl in no apparent distress.  She is unable to walk due to the myelomeningocele.  Skin: Eczema on her abdominal wall and right arm.  HEENT: She has a large head, wide set eyes, PERRLA.
Neck: S/p tracheostomy with a scar midline.  No thyromegaly.
Chest: Areola elevation with no breast budding. Lungs clear to auscultation.  Heart: Regular rate and rhythm.  Abdomen: Soft, with 2 2" scars on her left hypochondriac region, s/p G-tube.  Genitourinary: Tanner pubic hair: stage I to II.  Extremities: She has no axillary hair.  Neurological: She is unable to bear weight.  She has no DTRs in her lower extremities although her upper extremities' DTRs were +2/4 bilaterally.

Laboratory studies:  done October 31, 1991. At that time it was noted that she had a normal TSH response to TRH, she had a normal growth hormone response to insulin-induced hypoglycemia and glucagon.  After the GnRH stimulation she had pubertal levels of LH and FSH.

Impression: Nicole's puberty is being suppressed on 7.5 mg of Lupron every four weeks.

Disposition: We would like to see Nicole again in six months.
Thank you for letting us share in the care of Nicole.

Sincerely,


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


CONTENT:
Cornelius Frog, M.D.          RE: Eleanor Baez
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/11/83

Dear Dr. Frog:

We had the pleasure of seeing Eleanor in the Endocrine Program on 9/14/93 for follow-up of her pubertal development.

History: Since last seen on August 6, 1992, Nicole has been well.  The Lupron Depot was discontinued this past March and since then, Mrs. Baez did notice some development of Nicole's breast as well as some pubic hair.  Earlier this summer, Nicole had chicken pox but no other significant illness.  She started fourth grade this fall.  She had no problems with the V-P shunt.

Physical exam:  
BP: 100/70              Pulse: 78               Breast: Tanner III      
Pubic hair: Tanner II   
The new findings on physical examination were breast development, the left much more than the right, the appearance of pubic hair and the development of the labiae minora.  The rest of the exam was unchanged.

Impression: Nicole's pubertal development is normal for her age.

Disposition: I would like to see Nicole again in one year.
Thank you for letting us share in the care of Eleanor.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Hamud Swartzenegger, M.D.          RE: Charles Wieland
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/26/81

Dear Dr. Swartzenegger:

Charles has a normal growth hormone resposne to insulin induced hypoglycemia (peak level 42.5 ng/mL, an exuberant response) and to Glucagon (peak level 14.5 ng/mL).  He also had a normal IGF1 level (113 ng/mL and GH-BP (171.0).  The latter is thought to reflect the growth hormone receptors density.  He also had a normal TSH resposne to TRH and a normal Cortisol response to hypoglycemia.


Sincerely yours,





Kendell S. Simpson, M.D.
Clinical Director


CONTENT:
Hamud Swartzenegger, M.D.          RE: Charles Wieland
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/26/81

Dear Dr. Swartzenegger:

We had the pleasure of seeing Charles in the Endocrine Program on 6/22/92 for evaluation of short stature.

History: As you know, Charles is currently a 10 and 10/12 year old white male with tetrology of Fallot. He is status-post definitive repair of his cardiac defect at 2 and 6/12 years of age. He most recently underwent a balloon dilatation of his right pulmonary artery in February of 92. Charles and his family have been concerned about his growth for a long time. They are now becoming more concerned as other children at school are getting taller and he is beginning to be teased in school by his classmates.  He is not hypoxic and has good exercise tolerance. Though he is small, he keeps up with the other children in sports.

Current medications: None. He has no known drug allergies.

Past medical history:  Pectus excavatum which was repaired when Charles was 7 years of age. He also has scoliosis. In addition, he has approximately five episodes of otitis media per year, mostly right sided.

Review of systems:  Not significant.

Family history:  Notable for coronary artery disease and prostate cancer. He has numerous male relatives on both sides of the family who are in the excess of 5'9" tall. His mother's height is 5'1". His father's height is 5'9". His twin brother is 4'10" and his 14 year old brother is 5'5".

Physical exam:  
Height: 126.7 cm        Weight: 21 kg           BP: 104/70              
Pulse: 68               U/L ratio:  0.95        R. testis: 2.0 x 1.1 cm 
L. testis: 1.9 x 1.0 cm Phallus length: 8 cm    Mid-shaft diam.: 1.8 cm 
General: Charles is a thin acyanotic youngster in no acute distress. His height and weight places him 2 standard deviations for age.  Charles is underweight for height. His weight is approximately 15% less than his ideal weight for height. Skin: Without rashes.  HEENT: Pupils equal, round and responsive to light bilaterally. extraocular motions intact. Discs sharp. Tympanic membranes within normal limits. 
Neck: Supple without lymphadenopathy or thyromegaly. Evidence of a webbed neck.  Chest: Clear.  Heart: Regular rate with a normal S1 and a single S2. There is a loud 3/6 systolic ejection murmur. It radiates the entire chest and can be heard from the back.  Abdomen: Soft and non tender, bowel sounds present in all four quadrants. No hepatosplenomegaly. Mild degree of scoliosis on his back.  Genitalia: Normal. No pubic hair.  Extremities: Without clubbing cyanosis or edema.  Neurological: His reflexes are 2+ and symmetric bilaterally and he has good capillary refill.

Impression: Charles is a 10 and 10/12 year old white male with a surgically repaired tetrology of Fallot being referred here for question of short stature. Of note: Charles is underweight for height by approximately 15% which leads us to believe the reason for his short stature is substrate in origin rather than endocrinologic. Charles perhaps has perhaps increased caloric requirements secondary to his heart disease. However, at this time, we would like to send some screening labs to rule out renal insufficiency. We would also question whether there is insufficient caloric absorption. He has no history of malabsorptive type symptoms with abdominal bloating or diarrhea. However, we think it is wise at this point to rule out celiac disease or inflammatory bowel disease. Also of note is Charles's webbed neck, his short arm span, and heart disease which all might go along with some field defect or branchial cleft abnormality. His history of frequent otitides leads one to believe that perhaps he has some immunological defect. Something that would go along with his field defect would be an absence of a thymus (DeGeorge syndrome). I would ask you at this time to obtain the following studies as Charles insurance is through Harvard Community Health: CBC with differential sed rate, lytes, TC02, BUN, and creatinine, as well as calcium and phosphorus. We would also recommend checking thyroid function tests and Somatomedin-C. Anti-endomysial antibodies should be sent to rule out Celiac disease. A UA should be sent to rule out signs out renal insufficiency. We would also like you to obtain a bone age at this time, in order to allow us to better predict what Charles's final height might be. We would also ask that you please compile the results of the tests in a timely fashion and send those results to us here in the endocrine division to the attention of Dr. Rahul Ibsen.

Disposition: We plan on seeing Charles again in six months time.
Thank you for letting us share in the care of Charles.

Sincerely,


Antonio Kramer, MD          Rahul Ibsen, MD                
                             Attending in Endocrinology   


Addendum: As you know, the lab results were largely normal.  The IGF1 level was a bit low but probably normal for bone age (I could be more certain with our own assay).  The predicted height, based on your reading of the x-ray, is 63-66 inches which overlaps the expected range given the parental heights.


CONTENT:
Hamud Swartzenegger, M.D.          RE: Charles Wieland
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/26/81

Dear Dr. Swartzenegger:

We had the pleasure of seeing Charles in the Endocrine Program on 12/28/93 for follow up evaluation of his short stature.

History: Since last seen on 06/27/92 Charles has not grown well according to his parents. His twin brother is 5'1" and started puberty.  He has had no significant illness.

Physical exam:  
Height: 131.2 cm        Weight: 23.4 kg         BP: 80/50               
Pulse: 78               U/L ratio:  0.82        Arm span: 130.5         
Charles was short and thin.  Skin:  Low hair line over the nape  Operative scar over the chest.  No ptosis.  Fundi Normal.  HEENT:  Normal fundi.  Neck:  Webbed neck. Thyroid not enlarged. Lymph Nodes:  No lymphadenopathy.  Chest:  Clear lungs.  Cor:  Rhythmic and regular rate.  Single S2.  Loud P2 Grade III-IV/VI systolic murmur over the precordium, also heard over the back.  Abdomen:  Soft, no tenderness, no hepatosplenomegaly.  GU:  Bilateral descended prepubertal testes. Extremities:  Normal.  Neurological:  Non-focal.

Impression: Charles grew only 4.5 cm in 18 months, a sub-normal rate of growth.   He needs to have a neuroendocrine work-up to rule out growth hormone deficiency.  It is probable that Charles has Noonan Syndrome (right sided congenital heart disease, webbing of the neck, short stature).

Disposition: He was scheduled to have an ITT, TRH and Glucagon stimulation test on January 26, 1994.  A bone age was also requested.
Thank you for letting us share in the care of Charles.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Cala Stalin, M.D.          RE: Heidi Greene
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/10/82

Dear Dr. Stalin:

On 12/30/93 the T4 on Heidi was 6.0 and the TSH 76.30.  I advised her mother to increase the Synthroid to 0.075 mg daily and repeat the T4 and TSH in six weeks.

Sincerely yours,






Kendell S. Simpson, M.D.
Clinical Director


CONTENT:
Cala Stalin, M.D.          RE: Heidi Greene
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/10/82

Dear Dr. Stalin:

We had the pleasure of seeing Heidi in the Endocrine Program on 05/23/94 for hypothyroidism.

History: Heidi is a 12 year old girl treated with Synthroid for hypothyroidism secondary to thyroiditis.  Her most recent doseage is 88 mcg per day.  Heidi reports missing two to three doses a week but she will double the dose the following day.  She denies fatigue, constipation, or cold intolerance.  She does report occaisional discomfort in her joints which pre-dates her diagnosis of hypothyroidism.

Current medications: SYNTHROID .88 mcg q.d.


Physical exam:  
Height: 145 cm          Weight: 51.5 kg         BP: 105/65              
Pulse: 66               
Heidi appeared cheerful and engaging.    Skin:  warm, not dry.  HEENT:  mucous membranes moist.  Neck:  Thyroid twice normal size bilaterally.  Could not appreciate delphian node.  Lymph Nodes:  No adenopathy.  Cor: regular rate. Abdomen:  no hepatomegaly.  Neurological:  reflexex brisk.

Laboratory studies:  05/18/94:  TSH 4.3 mcU/mL.

Impression: Heidi's most recent TSH of 4.3 mcU/mL is within the normal range.  I have suggested to her several techniques to overcome her forgetfullness regarding her thyroid supplementation.  I also noted that despite euthyroidism, she continues to gain weight fairly rapidly.  She should consider decreasing the fat and caloric content of her diet.

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

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Cala Stalin, M.D.          RE: Heidi Greene
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/10/82

Dear Dr. Stalin:

We had the pleasure of seeing Heidi in the Endocrine Program on 11/21/94 for follow-up of hypothyroidism.

History: Heidi is a 12 and 6/12 year old with a history of Hashimoto's thyroiditis who is on thyroid hormone replacement.  She admits to having problems remembering to take her Synthroid daily.  She has remembered in the last two weeks.  She has no palpitations, constipation or cold intolerance.

Current medications: Synthroid 88 mcg daily.

Physical exam:  
Height: 147.8 cm        Weight: 51.5 kg         Pulse: 60               
Breast: Tanner III      Pubic hair: Tanner IV   
Skin: Normal.  HEENT:  PERRLA, EOMI, fundi normal.    Neck:  Thyroid slightly increase size and normal consistency.  Chest:  Lungs clear.  Heart:  Regular rate and rhythm, no murmurs.  Abdomen:  Soft, nontender.  Neurological:  DTR 2+/4+ equal and bilateral

Laboratory studies:  3/2/94: T4 8.8, TSH 13.7;  5/18/94: TSH 4.3;  11/14/94: TSH 5.2, T4 10.3.  Bone age 13 6/12 years.

Impression: Heidi has continued to growth (3 cm/6 months) although on the delayed curve and has not gained weight since her last visit.  She will try to be more compliant .  She has normal thyroid function tests and bone age consistent with chronologic age today.

Disposition: Follow up in six months.
Thank you for letting us share in the care of Heidi.

Sincerely,


Ariel Adler, MD           
Attending in Endocrinology


CONTENT:
Cala Stalin, M.D.          RE: Heidi Greene
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/10/82

Dear Dr. Stalin:

I saw Heidi in the Endocrine Program on 9/7/95 for follow-up of hypothyroidism.

History: As you know, Heidi is a 13 year old with hypothyroidism.  She has had problems with compliance, and it is difficult to interpret thyroid function tests but in the last several weeks she has been very compliant with her medications.  Her menarche began in the winter of 1994 which is about 8 or 9 months ago.  She had not had a period until April/May of 1995 and then has had no further menses.  She has had some intermittent spotting.  She has had no symptoms of either hypo- or hyperthyroidism.

Current medications: 100 mcg. of Levothyroxine daily.
Physical exam:
Ht: 152 cm              Wt: 57.2 cm
BP: 78/106              Pulse: 62               
Breast: Tanner III      Pubic hair: Tanner III  
General: Alert and cooperative girl. Skin:  Normal turgor and texture. HEENT:  PERRLA.  EOMI.  Fundi were normal. Neck:  Supple.  Thyroid was just slightly enlarged.  No lymph nodes. Chest:  Clear to auscultation. Heart:  Regular rate and rhythm.  Abdomen:  Soft and nontender.  No hepatosplenomegaly. Neurological: DTR 2+/4+ and equal bilaterally.

Laboratory studies:  8/21/95:  T4 8.5 mcg/dl, TBGI 0.99 and TSH 2.7 IU/ml.

Impression: Heidi's thyroid functions are normal on her current dose of thyroid hormone.

Disposition: Continue Levothyroxine as directed and follow up in six months.  I have asked Heidi to keep a record of her menses.



Sincerely,




Ariel Adler, MD           
Attending in Endocrinology


CONTENT:
Cala Stalin, M.D.          RE: Heidi Greene
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/10/82

Dear Dr. Stalin:

I saw Heidi in the Endocrine Program on 5/20/96 for follow-up for hypothyroidism.

As you know, Heidi is a 14 year old with hypothyroidism.  She has been very compliant with taking her thyroid medication every day.  Her menses are more regular at the present time then they had been previously, however she does have occasional times where she doesn't have a period.  She has no signs of hypothyroidism, i.e. no diarrhea, no sweating, no tremor and no problems with sleeping.

Current medications: 88 mcg Synthroid per day.

Physical exam:
HT: 154.8 cm    WT: 58.6 kg      BP: 110/45       Pulse: 62               
Breast: Tanner V        Pubic hair: Tanner IV   
General appearance:  she is alert and cooperative, skin is normal turgor and texture.  HEENT: pupils are equal and equally reactive to light and accommodation.  Fundi are normal, the neck is supple. Her thyroid is not palpable.  She has no lymphadenopathy.  Lungs are clear to auscultation.  Breasts are Tanner IV.  Heart has a regular rate and rhythm.  Abdomen is soft, nontender with no hepatosplenomegaly.  Neurologic: deep tendon reflexes are 2+/4+ and equal bilaterally.

Laboratory studies:  5/16/96:  T4 of 13.3 mcg/dl, TBGI of 1.37, TSH  <0.03 IU/L

Impression: The assessment at this time is that clinically Heidi appears to be euthyroid and continues to grow 2.8 cm over the last year.  Her thyroid functions currently reveal a suppressed TSH indicative of subclinical hyperthyroidism.  The plan then is to decrease her Synthroid to 75 mcg per day.  She will repeat the thyroid functions in 6-8 weeks.  I would like to see Heidi again in six months.  

Thank you for allowing us to share in the care of Alison.



Sincerely,




Ariel Adler, MD           
Attending in Endocrinology


CONTENT:
Cala Stalin, M.D.          RE: Heidi Greene
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/10/82

Dear Dr. Stalin:

We had the pleasure of seeing Heidi in the Endocrine Program on 7/28/93 for evaluation of her hypothyroidism.

History: Heidi is an 11 and 2/12 years old girl diagnosed on June 23, 1993 with primary hypothyroidism secondary to Hashimoto thyroiditis.  The mother gives a classic description of symptoms and signs of hypothyroidism including poor growth, increase weight, fatigability, prolonged sleep and afternoon naps, puffy pale face, change in her voice, difficulty in school work, prominent calf muscles, weakness.  She did not have constipation or decreased appetite.  On examination she was found to have bradycardia (in the 40's) and a goiter.  Because of the severity of the hypothyroid state she was started on a relatively small dose of Synthroid which was gradually increased to 0.050 mg for the past two weeks.  Treatment was begun on June 26, 1993.  As far as the mother is concerned the first thing that changed was the "glitter in her eyes", she became more alert and gradually lost all the manifestations mentioned above.  Heidi thought the first thing to change was the loss of volume of the calf muscles.  She became more active, recouped her strength, lost the puffiness of her face, slept less, and lost the pallor of her skin.

It is of interest that the maternal grandmother and a maternal aunt had a thyroid problem and are on replacement therapy.

Past history and review of systems were noncontributory however, she has had pubic hair for sometime now.

Current medications: Synthroid 0.05 mg daily.

Physical exam:  
Height: 142.6 cm        Weight: 50.5 kg         BP: 96/58               
Pulse: 68               Breast: Tanner I        Pubic hair: Tanner III  
Heidi was healthy looking, chubby, very pleasant and cooperative. Skin: She had facial acne but skin texture was normal, no pallor, no carotenemia.  She had axillary hair. HEENT: Negative. Neck: Thyroid diffusely enlarged, 2X normal, soft in consistency. Chest: Clear lungs. Heart: Normal S1 and S2, no murmurs. Abdomen: Soft, no tenderness, no hepatosplenomegaly. Extremities: Normal, muscles were not prominent. Neurological: DTR 2+ symmetrical.  Cranial nerves II-XII intact.

Laboratory studies:  June 23, 1993:  T4 <1.5, TBGI 0.72, T3 <33, TSH 384.  Cr 1.6, BUN 15, Hb 11.5, Ht 33.6.  Normal electrolytes, Alk phosph 76.

Bone age 11-12 years.

Impression: Acquired hypothyroidism secondary to Hashimoto thyroiditis.  Heidi is clinically euthyroid at present.  Care should be taken to avoid enhancing the onset of her puberty and thus jeopardizing her final height by over treating her with Synthroid particularly that her bone age is 11 to 12 years.

Disposition: Heidi should continue on the same dose of Synthroid pending the results of the T4 and TSH.

Laboratory studies pending at this time include: T4, TSH.
Thank you for letting us share in the care of Heidi.

Sincerely,


Kendell Simpson, MD             
Clinical Director            


Addendum: T4 10 mcgm/dL, TSH 105 mcU/mL.


CONTENT:
Bear, M.D.          RE: Rudolf Markova
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/76

Dear Dr. Meyer-Bear:

     We had the pleasure of seeing Rudolf in the Renal Transplant Program on Tuesday, July 5, 1994.  He has chronic renal failure secondary to .  He had a Renal Transplant on .
     Rudolf has no new complaints since his last visit.  His parents state that his activity level has been normal and not diminished.

Current medications include:
     SODIUM BICARBONATE 1800 mg po t.i.d.
     MACRODANTIN 50 mg po q.h.s.
     ROCALTROL .25 mcg po q.d.
     TUMS EX 2 po t.i.d.
     VASOTEC 15 mg po b.i.d.
     PROCARDIA 60 mg po b.i.d.

Physical exam:
     BP 162/92   P 80   R 16   T    HT 174.6cm   WT 68.2kg   HC cm
     Skin: unremarkable
     HEENT: moist mucous membranes without any exudate or lesions 
     Neck: supple without lymphadenopathy
     Chest: clear to auscultation
     Heart: regular rate and rhythm without murmurs, gallops, or rubs
     Abdomen: soft, nondistended, nontender without masses.  There is a well healed midline surgical scar.
     Extremities: warm and well profused, no evidence of clubbing, cyanosis or edema.

Urinalysis:
     SPEC GR UA  1.008           WBC ENZ UA  N          
     PH UA       7.5             PROTEIN UA  2+         
     BLOOD UA    1+              GLUCOSE UA  1+    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:
          BUN 61  CR 6.4  NA 143  K 4.7  CL 108
          GLU 90  FE 52  TIBC 262  CO2 20
          WBC 3.59  HCT 23.1  HGB 7.4 MCV 83.1  PLT 190
          N - 45  L - 43  RET 1.0  FERR 55.9  PTH pending

     Rudolf has chronic renal failure secondary to reflux and repeated urinary tract infections.  We had a meeting today with the family for a more extensive discussion of therapeutic options.  We reviewed all of the options for treatment of end stage renal disease, including dialysis and renal transplantation.  We encouraged him to consider renal transplantation as the treatment of choice.  We indicated the living donor renal transplantation would provide the best option.  They will consider having histocompatability testing at their next return visit here.

     We have asked Rudolf to return in .

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

               Sincerely,


               Conrado Seinfeld, MD         Clotilde Goldwater, MD


CONTENT:
Bear, M.D.          RE: Rudolf Markova
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/76

Dear Dr. Meyer-Bear:

     We had the pleasure of seeing Rudolf in the Renal Transplant Program on Tuesday, January 10, 1995.  He has chronic renal failure secondary to reflux nephropathy.
     Rudolf has been complaining of headaches in the morning and the evening.  He has no diplopia or blurry vision associated with these headaches.

Current medications include:
     SODIUM BICARBONATE 1800 mg po t.i.d.
     ROCALTROL .25 mcg po q.d.
     MACRODANTIN 50 mg q.d.
     PROCARDIA XL 60 mg po b.i.d.
     TUMS EX 2 po t.i.d.
     VASOTEC 15 mg po b.i.d.

Physical exam:
     BP 170/85   P 80   R 20    HT 175cm   WT 68.2kg   
     General: healthy
     HEENT: moist mucous membranes without exudates or masses.  sharp disks with normal vasculature.  no evidence of cataracts. 
     Chest: clear 
     Heart: regular rate and rhythm without murmurs, gallops or rubs
     Abdomen: soft, non-tender, non-distended without masses or hepatosplenomegaly
     Extremities: warm and well perfused without edema
     Neurological: cranial nerves 2-12 functionally intact, strength 5/5 bilaterally, deep tendon reflexes 2/2 bilaterally, cerebella function intact, non-focal
Urinalysis:
     SPEC GR UA  1.008           WBC ENZ UA  N          
     PH UA       8.0             PROTEIN UA  1+         
     BLOOD UA    N               GLUCOSE UA  2+    mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          CO 2         24   MEQ/L       CA         11.0   MG/DL (H)
          CR          7.8   MG/DL (C)   GLU         111   MG/DL    
          PHOS        4.2   MG/DL       BUN          60   MG/DL (C)
          NA          144  MMOL/L       K           4.3  MMOL/L    
          CL          104  MMOL/L       WBC        5.12   K/MM3    
          RBC        2.76   M/MM3 (L)   HGB         8.4    G/DL (L)
          HCT.       23.6       % (L)   MCV        85.8      FL    
          MCH        30.3      PG       MCHC       35.4    G/DL    
          RDW        12.0       %       HDW        2.48    G/DL    
          PLT UNC     238   K/MM3       


     Rudolf has done well since his last visit except for some evening and morning headaches.  His systolic blood pressures have been slightly elevated.  The next time he has a headache he is going to check a blood pressure.  If his blood pressures remain elevated we will consider starting Atenolol.

     We have asked Rudolf to return in six months.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Bear, M.D.          RE: Rudolf Markova
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/76

Dear Dr. Meyer-Bear:

     We had the pleasure of seeing Rudolf in the Renal Transplant Program on Tuesday, June 27, 1995.  He has  secondary to .  He had a renal transplant on .
     Rudolf has been well since his last visit with us.  His creatinine has remained stable in the 6 to 8 range.  

He is not complaining of easy bruisability or spontaneous bleeding.

His current medications include:
     ROCALTROL .25 mcg po q.d.
     PROCARDIA XL 60 mg po b.i.d.
     SODIUM BICARBONATE 1 g t.i.d.
     MACRODANTIN 50 mg q.h.s.
     TUMS EX 750 mg t.i.d.
     VASOTEC 15 mg po b.i.d.

Rudolf's physical exam was notable for:
     BP 158/78   P 76   R 20   T    HT cm   WT 67.6kg   HC cm
     General: no acute distress.
     HEENT: moist mucous membranes without exudates or masses.
     Chest: clear. 
     Heart: regular rate and rhythm without murmurs, gallops or rubs.
     Abdomen: soft, non-tender, non-distended without masses or hepatosplenomegaly.
     Extremities: warm and well perfused without cyanosis or edema

A urinalysis revealed:
     SPEC GR UA  1.020           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       6.0             RBC CAST    N          
     PROTEIN UA  2+              GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  3+    mg/dl     SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          CO 2         20   MEQ/L (L)   CA         10.8   MG/DL (H)
          CR          7.6   MG/DL (C)   GLU         124   MG/DL (H)
          FE           39  MCG/DL (L)   PHOS        4.1   MG/DL    
          BUN          52   MG/DL (H)   NA          145  MMOL/L    
          K           3.2  MMOL/L       CL          112  MMOL/L (H)
          TIBC        268  MCG/DL       FER        22.4   NG/ML    


     Rudolf has done well since his last visit with us.  His hematocrits have been below 25 since the last visit with us.  We have discussed starting Epogen with Rudolf and his parents.  We will obtain iron studies today.

     Thank you for the opportunity to participate in Rudolf's care.  We would like to review him in  six months, with the discussion to start Epogen, check retic count and repeat iron studies.  In the interim, we would be happy to discuss or review Rudolf should you or the family wish it.

               Sincerely,


               Conrado Seinfeld, MD         Gleide Blue, MD
               Renal Fellow                 Attending, Pediatric Nephrology


CONTENT:
Bear, M.D.          RE: Rudolf Markova
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/76

Dear Dr. Meyer-Bear:

     We had the pleasure of seeing Rudolf in the Renal Transplant Program on Tuesday, June 27, 1995.  He has chronic renal failure secondary to reflux nephropathy.  
     Rudolf has been well since his last visit with us.  His creatinine has remained stable in the 6 to 8 range.  



His current medications include:
     ROCALTROL .25 mcg po q.d.
     PROCARDIA XL 60 mg po b.i.d.
     SODIUM BICARBONATE 1 g t.i.d.
     MACRODANTIN 50 mg q.h.s.
     TUMS EX 750 mg t.i.d.
     VASOTEC 15 mg po b.i.d.

Rudolf's physical exam was notable for:
     BP 158/78   P 76   R 20    WT 67.6kg   
     General: no acute distress.
     HEENT: moist mucous membranes without exudates or masses.
     Chest: clear. 
     Heart: regular rate and rhythm without murmurs, gallops or rubs.
     Abdomen: soft, non-tender, non-distended without masses or hepatosplenomegaly.
     Extremities: warm and well perfused without cyanosis or edema

A urinalysis revealed:
     SPEC GR UA  1.020           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       6.0             RBC CAST    N          
     PROTEIN UA  2+              GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  3+    mg/dl     SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          CO 2         20   MEQ/L (L)   CA         10.8   MG/DL (H)
          CR          7.6   MG/DL (C)   GLU         124   MG/DL (H)
          FE           39  MCG/DL (L)   PHOS        4.1   MG/DL    
          BUN          52   MG/DL (H)   NA          145  MMOL/L    
          K           3.2  MMOL/L       CL          112  MMOL/L (H)
          TIBC        268  MCG/DL       FER        22.4   NG/ML    


     Rudolf has done well since his last visit with us.  His hematocrits have been below 25 since the last visit with us.  We have discussed starting Epogen with Rudolf and his parents.  We will obtain iron studies today.

     Thank you for the opportunity to participate in Rudolf's care.  We would like to review him in six months, with the discussion to start Epogen, check retic count and repeat iron studies.  In the interim, we would be happy to discuss or review Rudolf should you or the family wish it.

               Sincerely,


               Gleide Blue, MD
               Attending, Pediatric Nephrology


CONTENT:
Bear, M.D.          RE: Rudolf Markova
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/76

Dear Dr. Meyer-Bear:

     We had the pleasure of seeing Rudolf in the Renal Transplant Program on Tuesday, June 27, 1995.  He has chronic renal failure secondary to reflux nephropathy.  He had a renal transplant on .
     Rudolf has been well since his last visit with us.  His creatinine has remained stable in the 6 to 8 range.

His current medications include:
     ROCALTROL .25 mcg po q.d.
     PROCARDIA XL 60 mg po b.i.d.
     SODIUM BICARBONATE 1 g t.i.d.
     MACRODANTIN 50 mg q.h.s.
     TUMS EX 750 mg t.i.d.
     VASOTEC 15 mg po b.i.d.

Rudolf's physical exam was notable for:
     BP 158/78   P 76   R 20   T    HT cm   WT 67.6kg   HC cm
     General: no acute distress.
     HEENT: moist mucous membranes without exudates or masses.
     Chest: clear. 
     Heart: regular rate and rhythm without murmurs, gallops or rubs.
     Abdomen: soft, non-tender, non-distended without masses or hepatosplenomegaly.
     Extremities: warm and well perfused without cyanosis or edema

A urinalysis revealed:
     SPEC GR UA  1.020           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       6.0             RBC CAST    N          
     PROTEIN UA  2+              GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  3+    mg/dl     SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          CO 2         20   MEQ/L (L)   CA         10.8   MG/DL (H)
          CR          7.6   MG/DL (C)   GLU         124   MG/DL (H)
          FE           39  MCG/DL (L)   PHOS        4.1   MG/DL    
          BUN          52   MG/DL (H)   NA          145  MMOL/L    
          K           3.2  MMOL/L       CL          112  MMOL/L (H)
          TIBC        268  MCG/DL       FER        22.4   NG/ML    


     Rudolf has done well since his last visit with us.  His hematocrits have been below 25 since the last visit with us.  We have discussed starting Epogen with Rudolf and his parents.  We will obtain iron studies today.

     Thank you for the opportunity to participate in Rudolf's care.  We would like to review him in  six months, with the discussion to start Epogen, check retic count and repeat iron studies.  In the interim, we would be happy to discuss or review Rudolf should you or the family wish it.

               Sincerely,


               Conrado Seinfeld, MD         Gleide Blue, MD
               Renal Fellow                 Attending, Pediatric Nephrology


CONTENT:
Bear, M.D.          RE: Rudolf Markova
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/02/76

Dear Dr. Meyer-Bear:

We had the pleasure of seeing Rudolf in the Renal Transplant Program on Tuesday, July 2, 1996.  He has chronic renal failure secondary to reflux nephropathy.  He had a renal transplant on .
Rudolf returns to the renal program for follow up after a six month interval.  He has been doing well in the interim.  He has no complaints.

His current medications include:
     PROCARDIA XL 60 mg po b.i.d.
     MACRODANTIN 50 mg q.h.s.
     FERROUS GLUCONATE 325 mg po q.d.
     TUMS EX 750 mg t.i.d.
     VASOTEC 15 mg po b.i.d.
     ROCALTROL .25 mcg Tuesday and Thursday
     SODIUM BICARBONATE 3 po t.i.d.

Rudolf's physical exam was notable for:
     BP 140/71   P 76   R 14   T    HT cm   WT 69kg   HC cm
     General: pallor is present
     HEENT: eyes, nose and throat clear 
     Neck: supple, no significant lymphadenopathy
     Chest: clear to auscultation 
     Heart: S1 S2 normal, no murmur
     Abdomen: soft, no tenderness
     Extremities: mild pedal edema is present
     Neurological: no focal deficits or meningeal signs
A urinalysis revealed:
     SPEC GR UA  1.005           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       8               RBC CAST    N          
     PROTEIN UA  3+              GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  2+    mg/dl     SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           3.4  MMOL/L       MCHC       35.0    G/DL    
          MG          2.3   MG/DL       RDW        13.5       %    
          CR          8.2   MG/DL (C)   HDW        2.76    G/DL    
          GLU          97   MG/DL       MPV         8.4      FL    
          FE           59  MCG/DL (L)   PLT UNC     215   K/MM3    
          PHOS        3.7   MG/DL       NEUT         43       %    
          TRF         230   MG/DL       LYMPH        43       %    
          BUN          67   MG/DL (C)   MONOS         6       %    
          NA          144  MMOL/L       EOS           6       %    
          CL          112  MMOL/L (H)   BASO          2       %    
          CO 2         18   MEQ/L (L)   CELLS C     100    
          TIBC        240  MCG/DL (L)   ABS NEU    1.82   K/MM3    
          WBC        4.23   K/MM3 (L)   ABS LYM    1.82   K/MM3    
          RBC        2.63   M/MM3 (L)   ABS EOS     .25   K/MM3    
          HGB         7.6    G/DL (C)   ANISO        1+    
          HCT.       21.7       % (L)   POIK         1+    
          MCV        82.6      FL       OVALO        1+    
          MCH        28.9      PG       FER        37.3   NG/ML   
          CA          10.2              PTH        pending

Rudolf has had chronic renal insufficiency with relatively stable renal function over the course of the last 1 1/2 years.  His creatinine has increased over the last six months.  Rudolf has persistently had a low hematocrit ranging from 21.5%-24% during the same time interval.  He had iron studies done a year ago which were low and he was subsequently started on Ferrous Gluconate which does not appear to have any benefit.  We will start erythropoietin 50 units/kilo twice weekly today.  We will also repeat his iron studies today and send a serum PTH level.  His mother is currently being worked up as a transplant donor and has only an arteriogram remaining, which we will arrange here.  His bicarbonate is also low and we will increase the bicarbonate appropriately.

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

               Sincerely,


               Neal Sanders, MD       Clotilde Goldwater, MD
               Renal Fellow                 Director of Nephrology


cc:
W. Hardy Hendren, M.D.
Chief of Surgery
Children's Hospital Medical Center
Department of Surgery
300 Longwood Avenue
Boston, MA 02115

Philip Greenhill, M.D.
151 Route 10
Succasunna, NJ 07876

Charles Bushong, M.D.
151 Route 10
Succasunna, NJ 07876


CONTENT:
Kinze Domingo, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear Dr. Domingo:

     We had the pleasure of seeing Barbie in the Renal Transplant Program on Tuesday, June 14, 1994.  She has chronic renal failure secondary to .  She had a renal transplant on .
     Barbie continues to recover from a bout of pneumonia and urinary tract infection several weeks ago.  Her strength is improving.  Most recent  labs are notable for creatinine of 2.6, CYA of 234, WBC of 3.7, HCT 22.6.

Current medications include:
     PREDNISONE 10 mg q.d.
     IMURAN 50 mg po q.d.
     CYCLOSPORINE 125 mg b.i.d.
     MACRODANTIN 50 mg q.d.
     ATENOLOL 50 mg q.d.
     FOLIC ACID 1 mg q.d.
     IRON  (OTC) q.d.

Physical exam:
     BP 150/104   P 80   R 12   T    HT cm   WT 52.7kg   HC cm
     General: She is well appearing mildly cushingoid white female in no distress.
     HEENT: unremarkable
     Neck: no lymphadenopathy
     Chest: clear 
     Heart: regular without abnormal heart sounds
     Abdomen: soft with no tenderness or bruit over the graft
     Extremities: without any peripheral edema but some bruising

Urinalysis:
     SPEC GR UA  1.016           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  trace      
     BLOOD UA    3+              GLUCOSE UA  0     mg/dl
     WBC/HPF     0-2   /HPF      RBC/HPF     0-2   /HPF 
     WBC CAST    N     /LPF      RBC CAST    N     /LPF 
     GRAN CAST   N     /LPF      WAXY CAST   N     /LPF 
     SQUAM EPI   0-1   /HPF      BACTERIA    1+    


Laboratory studies at this time include:
          NA  139     K  4.0     CL  108     GLU  85
          BUN  40     CR  2.9     PHOS  4.0    CA  8.8  CYA 159
          WBC  3.56     HGB  7.7     HCT  23.1     MCV  97.0
          PLT  87     ABS N  1.38     NEUT  38.6     LYM  47.0     BASO  .6

     Barbie continues to recover.  She has ongoing evidence of chronic allograft dysfunction of unclear etiology.  Additional issues include, anemia, leukopenia,  hypertension, thrombocytopenia  and recurrent urinary tract infections.  Her iron stores are replete by repeated testing.

     We have asked Barbie to return in .

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

               Sincerely,


               Gleide Blue, MD


CONTENT:
Mitsuko Khan, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear


CONTENT:
Mitsuko Khan, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear Dr. :

     We had the pleasure of seeing Barbie in the Renal Transplant Program on Tuesday, October 18, 1994.  She has chronic renal failure secondary to chronic pyelonephritis.  She had a renal transplant on April 8, 1992.
     Barbie has had no problems since her last visit with us.  She says that her swelling is about the same.  She made a mistake and decreased her Atenolol dose to 50 mg bid instead of increasing it to 100 mg bid.

Current medications include:
     CYCLOSPORINE 125 mg b.i.d.
     IMURAN 50 mg q.d.
     PREDNISONE 10 mg q.d.
     ATENOLOL 50 mg po b.i.d.
     FOLIC ACID 1 mg po b.i.d.
     CIPROFLOX 250 mg po q.d.

Physical exam:
     BP 192/110   P 96     WT 53.2kg  
     General: healthy
     Skin: warm and dry
     HEENT: moist mucous membranes 
     Chest: clear
     Heart: regular rate and rhythm without murmurs, gallops or rubs
     Abdomen: soft, non-tender, non-distended 
     Extremities: 1+ pitting edema up to the ankles

Urinalysis:
     SPEC GR UA  1.012           WBC ENZ UA  N          
     PH UA       6               PROTEIN UA  trace      
     BLOOD UA    3+              GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     5-10       
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          CA          9.1   MG/DL       CR          4.6   MG/DL (C)
          CYA          95   MCG/L       GLU         113   MG/DL    
          PHOS        4.0   MG/DL       BUN          62   MG/DL (C)
          NA          142  MMOL/L       K           4.0  MMOL/L    
          CL          110  MMOL/L (H)   WBC        6.79   K/MM3    
          RBC        2.36   M/MM3 (L)   HGB         7.8    G/DL (C)
          HCT.       24.5       % (L)   MCV       103.9      FL (H)
          MCH        33.1      PG       MCHC       31.8    G/DL    
          RDW        15.9       % (H)   HDW        2.37    G/DL    
          PLT UNC     120   K/MM3 (L)   NEUT AB    4.21   K/MM3    
          LYMPH A    1.93   K/MM3       EOS ABS     .07   K/MM3    
          NEUT-A     62.0       %       LYMPH-A    28.4       %    
          MONO-A      5.4       %       EOS-A       1.1       %    
          BASO-A       .5       %       ATYP LY     2.6       %    
          MACRO-A      ++ (*)           HYPO-A        +    


     Barbie was hypertensive in clinic today.  She received a dose of sublingual Nifedipine which reduced her blood pressure to 145/86.

     We have asked Barbie to return in two weeks.

     Thank you for allowing us to share in Barbie'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:
Clotilde Goldwater, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear


CONTENT:
Kinze Brando, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear


CONTENT:
, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear


CONTENT:
Gleide Blue, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear


CONTENT:
Gleide Blue, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear Dr. :

     We had the pleasure of seeing Barbie in the Renal Transplant Program on Tuesday, December 26, 1995.  She has chronic renal failure  secondary to chronic pyleonephritis.  She had a renal transplant on 4/8/92.
     Barbie has bruising on both lower extremities.  These occur spontaneously as well as with trivial trauma.  Her weight is slightly up today because she ran out of Lasix yesterday.

Her current medications include:
     PREDNISONE 10 mg po q.d.
     ATENOLOL 100 mg po b.i.d.
     ROCALTROL 0.25 mcg po q.d.
     IMURAN 50 mg po q.d.
     CYCLOSPORINE 125 mg po b.i.d.
     EPOGEN 3000 units q.w.
     CIPROFLOXACIN 250 mg q.h.s.
     PROCARDIA XL 90 mg b.i.d.
     FOLIC ACID 1 mg po b.i.d.
     TUMS EX 1500 mg p.c.
     LASIX 60 mg b.i.d.

Barbie's physical exam was notable for:
     BP 116/74   P 84    WT 48.8kg   
     General: comfortable, alert
     Skin: bruising on both thighs and calves noted.
     HEENT: eyes and throat clear.
     Neck: supple, no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: S1, S2 normal with no murmur.
     Abdomen: soft, no tenderness over the graft site.
     Extremities: fistula on the left wrist is still working very well.
     Neurological: no focal deficits or meningeal signs.

A urinalysis revealed:
     SPEC GR UA  1.011           RBC/HPF     0-5        
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       7               RBC CAST    N          
     PROTEIN UA  2+              GRAN CAST   N          
     BLOOD UA    4+              WAXY CAST   N          
     GLUCOSE UA  1+    mg/dl     SQUAM EPI   many       
     WBC/HPF     0-2             BACTERIA    N     

Laboratory studies at this time include:
          K           4.0  MMOL/L       HDW        3.34    G/DL (H)
          CA          9.2   MG/DL       PLT UNC     167   K/MM3    
          CR          7.0   MG/DL (C)   NEUT AB    3.61   K/MM3    
          CYA          89   MCG/L       LYMPH A    2.06   K/MM3    
          GLU         104   MG/DL       EOS ABS     .07   K/MM3    
          FE          124  MCG/DL       NEUT-A     55.8       %    
          PHOS        5.6   MG/DL (H)   LYMPH-A    31.9       %    
          BUN          79   MG/DL (C)   MONO-A      7.2       %    
          NA          138  MMOL/L       EOS-A       1.1       %    
          CL          108  MMOL/L       BASO-A       .4       %    
          TIBC        161  MCG/DL (C)   ATYP LY     3.6       %    
          WBC        6.47   K/MM3       NF-2002  ABSENT    
          RBC        2.79   M/MM3 (L)   ANISO        2+ (*)
          HGB         8.7    G/DL (L)   MICRO        1+    
          HCT.       27.0       % (L)   MACRO        1+    
          MCV        96.6      FL       OVALO        1+    
          MCH        31.2      PG       TEAR       RARE (*)
          MCHC       32.3    G/DL       RET         1.6       %    
          RDW        16.5       % (H)   

     Barbie has chronic renal insufficiency.  We will check platelet count and blood coagulation studies at her next visit.

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

               Sincerely,


               Gleide Blue, MD
               Attending, Pediatric Nephrology


CONTENT:
Mitsuko Khan, M.D.          RE: Barbie Argyll
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/28/68

Dear Dr. :

     We had the pleasure of seeing Barbie in the Renal Transplant Program on Tuesday, January 30, 1996.  She has chronic renal failure  secondary to chronic pyleonephritis.  She had a renal transplant on 4/8/92.

     Barbie is doing better.  She was admitted last week for severe vaginal bleeding.  She is having minimal bleeding at this time.

Her current medications include:
     PREDNISONE 10 mg po q.d.
     ROCALTROL 0.25 mcg po q.d.
     IMURAN 50 mg po q.d.
     CYCLOSPORINE 125 mg po b.i.d.
     EPOGEN 2000 units sc b.i.w.
     CIPROFLOXACIN 250 mg q.h.s.
     PROCARDIA XL (hold if systolic <120, 120-140 take 90 mg b.i.d.)
     FOLIC ACID 1 mg po b.i.d.
     TUMS 2 after meals
     LASIX 60 mg b.i.d.
     ATENOLOL take 50 mg bid if systolic is 140 or greater
     ZANTAC
     DESIGEN (estrogen)

Barbie's physical exam was notable for:
     BP 120/78   P 90   R 16    WT 46.2kg   
     General: comfortable, alert
     Skin: bruising on both thighs and calves noted.
     HEENT: eyes and throat clear.
     Neck: supple, no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: S1, S2 normal with no murmur.
     Abdomen: soft, no tenderness over the graft site.
     Extremities: fistula thrill is present.
     Neurological: no focal deficits or meningeal signs.

A urinalysis revealed:
     SPEC GR UA  1.010           RBC/HPF     tntc       
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       5.0             RBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     BLOOD UA    large           WAXY CAST   N          
     GLUCOSE UA  N               SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          K           3.8  MMOL/L       MCH        29.3      PG    
          CA          9.2   MG/DL       MCHC       33.5    G/DL    
          CR          7.5   MG/DL (C)   RDW        17.7       % (H)
          CYA          60   MCG/L       HDW        3.12    G/DL    
          GLU          79   MG/DL       PLT UNC     218   K/MM3    
          FE          102  MCG/DL       NEUT AB    3.45   K/MM3    
          PHOS        5.8   MG/DL (H)   LYMPH A    1.52   K/MM3    
          BUN          88   MG/DL (C)   EOS ABS     .02   K/MM3    
          NA          136  MMOL/L       NEUT-A     61.0       %    
          CL          106  MMOL/L       LYMPH-A    26.8       %    
          CO 2         16   MEQ/L (L)   MONO-A      9.4       % (H)
          TIBC        205  MCG/DL (L)   EOS-A        .3       %    
          WBC        5.66   K/MM3       BASO-A       .2       %    
          RBC        2.83   M/MM3 (L)   ATYP LY     2.2       %    
          HGB         8.3    G/DL (L)   ANISO-A       +    
          HCT.       24.8       % (L)   MACRO-A       +    
          MCV        87.5      FL       LEFT SH  ABSENT    

     Barbie is doing better now.  We have advised her to resume Procardia XL 30 mg for blood pressures greater than 130/85.  We will hold her Atenolol for now.  We will start sodium bicarbonate 650 mg tid.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Saurabh Domingo, M.D.          RE: Luther Dalton
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/24/82

Dear Dr. Domingo:

We had the pleasure of seeing Luther in the Endocrine Program on 9/29/94 for anorchia.

History: I saw Luther on 9/29/94 in the Lexington Center at 11 and 11/12 years of age.  This now 7th grader, who was evaluated previously at Children's Endocrine program for anorchia,  is thought to have Vanishing Testicular Syndrome and failure of response in early childhood to HCG (no increase in Testosterone).  He has never been on hormonal treatment and he has not requested testicular prostheses to this point.  He is young for his school grade and has not been in a position to need to disrobe in front of his peers nor will he until the 9th grade.  He denies erections.   He plays basketball.

Current medications: None.

Review of systems:  Unremarkable.

Family history:  His mother is 70 inches, father is 65 inches which gives him a mid parental height of 70 inches.

Physical exam:  
Height: 146.5 cm        BP: 110/58              Pulse: 80               
U/L ratio:  0.93        Arm span: 147.5         Pubic hair: Tanner I    
Phallus length: 6 cm    Mid-shaft diam.: 1.2 cm 
Weight: 81 pounds. 
General: He looks age appropriate.    HEENT: Fundoscopic exam is normal.    Neck: No thyromegaly.   Genitourinary: Testes are not palpable.  He has an empty scrotum and a phallus that is small for his age.

Laboratory studies:  LH 18.6 IU/L, FSH 96.2 IU/L.

Impression: Anorchia, vanishing testes syndrome.

Disposition: Will begin him on low dose testosterone once the laboratory studies come back with the dose in the range of 25 to 50 mg Testosterone Enanthate monthly in the hope of stimulating some more phallic development in the early beginnings of puberty.  It will be important not to give an excessive dose as this might cause too rapid a rate of puberty and acceleration of bone maturation and ultimate limited height.  I am therefore likely to begin with the lowest dose and see him again in four months.
Thank you for letting us share in the care of Luther.

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology


CONTENT:
, M.D.          RE: Luther Dalton
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/24/82

Dear


CONTENT:
Kenyola Beaker, M.D.          RE: Luther Dalton
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/24/82

Dear Dr. Beaker:

We had the pleasure of seeing Luther in the Endocrine Program on 10/28/91 for evaluation of bilateral anorchia.

History: As an infant, Luther was noted to have undescended testes.  On exploration, there was no left testis and a hypoplastic right testis.  He underwent a five day HCG stimulation test with minimal testosterone response and was therefore felt to have vanishing testes syndrome.  Since his last visit two years ago, he has had no complaints or intercurrent illnesses.  He has not developed apocrine odor or pubic or axillary hair.

Current medications: none.

Past medical history:  Review of systems:
HEENT: no headache or blurry vision
Cardiorespiratory: no shortness of breath or palpitations
GI: no abdominal pain, constipation, or diarrhea
GU: no dysuria, frequency, or nocturia
Other: no cold or heat intolerance

Physical exam:  
Height: 130.8 cm        Weight: 29.8 kg         BP: 118/76              
Pulse: 100              Pubic hair Tanner: 1    Phallus length: 4.8 cm  
Mid-shaft diam.: 1.8 cm 
Skin: one hypopigmented 1 1/2 to 2 centimeter lesion of the abdominal right lower quadrant
HEENT: pupils equal, round, and reactive to light, extraocular movements intact
Neck: thyroid not enlarged
Chest: lungs clear
Heart: RRR without murmur
Abdomen: soft, no hepatosplenomegaly
Genitourinary: Tanner I, no testes present
Extremities: warm and well perfused
Neurological: 2+ symmetrical deep tendon reflexes bilaterally

In summary: Luther has congenital bilateral anorchia.  He will be referred to a urologist for testicular prostheses when he is ready.  He will need to start testosterone treatment at puberty, as judged by a rise in FSH and LH.

Disposition: Return to Endocrine Clinic in two years.  At that time, and FSH and LH will be obtained.

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

Sincerely,


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


CONTENT:
Massod Stalin, M.D.          RE: Carla Palma
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/07/71

Dear Dr. Stalin:

We had the pleasure of seeing Carla for evaluation of thyroid nodule in the Endocrine Clinic on 7/18/91.

History: As you know, Carla is a now 20 year old Hispanic woman who has a hot right lobe thyroid nodule, here for a follow up.  Since her last visit, she has had an episode of pharyngitis and right cerivical adenopathy with enlargement of a single anterior, superior node.  During the time of her pharyngitis and adenopathy she had a temperature of 100-100.1 and was begun on Penicillin with improvement in her throat and node pain.  She also felt an increase in pain in the area of her thyroid nodule at this time as well.  She denies headache, stomach ache, constipation, diarrhea, changes in menses and galacterrhea.

Current medications: Carla is currently on no medications.

Physical exam:  HR: 70, BP: 104/60, weight: 40.7 kg
Skin:  Texture was normal.  No cutaneous lesions.
HEENT:  Normal extra ocular movements and no lid lag.
Neck:  .8 x .8 cm anterior superior lymph node which was moderately firm and non tender. Palpation of the thyroid revealed a slightly more prominent right than left lobe with either increased firmness to the right upper lobe, or approximately 1.2 x 1.2 cm nodule.  The left lobe was also somewhat more firm than a normal thyroid gland and measured 1.2 cm in total dimension.   
Chest:  Lungs were clear to auscultation. 
Heart:  There was no cardiac murmur. 
Abdomen: Soft. 
Extremities: Deep tanner reflexes were 2+ in normal relaxation  time.

In summary: Carla has had little change in her thyroid examination and perhaps slight regression of her thyroid nodule, if anything.  On exam today, the nature of her gland also feels consistent with Hashimoto disease, however her negative antibodies on previous evaluation are somewhat against this. The right cervical adenopathy is somewhat worrisome in that it could present metastatic disease from a possible thyroid cancer, but we believe this is unlikely because it was associated with an acute viral syndrome, fever, and improved with antibiotics.

Recommendations: We plan on seeing Carla again in 2 to 3 months time to evaluate both her thyroid and cervical adenopathy.  We instructed Carla to contact  us sooner should she note any progression in the size of her lymph node or thyroid nodule for which we would see her sooner.

Laboratory studies:  T4 8.4mgm/dl, TBGI 1.00, TT3 130ng/dl, and TSH 0.9mIU/ml.  Anti-microsomal and anti-thyroglobulin antibodies: negative.

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

Sincerely,


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

LM/SN/smp


CONTENT:
Massod Stalin, M.D.          RE: Carla Palma
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/07/71

Dear Dr. Stalin:

We had the pleasure of seeing Carla in the Endocrine Program on 10/7/91 for evaluation of her hot thyroid nodule.

History: Since her last visit she reports no change in the size of the nodule.  Also, the submaxillary lymph node she had at the time of her previous evaluation has not been reported to have changed in size.  She denies heat intolerance though she does complain of feeling cold occasionally.  She has headaches three times weekly which she reports are associated with excessive reading.  She denies palpatations and her menses remain regular.  Her weight is unchanged and her activity level remains good.

Physical exam:  
Height: 152.5 cm        Weight: 40.8 kg      
BP: 108/60              Pulse: 72               
Skin: Mildly hirsute, normal texture.  There was a slightly less than 0.5 cm right submaxillary node which was nontender.  Neck: Revealed a 0.8 x 0.8 confirmed nodule on the upper right pole of the thyroid.  The remainder of the gland was slightly firm with edges minimally palpable.  HEENT: Flat optic discs and no lid lag.  Chest: Clear to auscultation.  Heart: No cardiac murmurs.  Abdomen: Soft without hepatosplenomegaly.  Neurological: 2+ and equal deep tendon reflexes with normal relaxation.  There was no resting tremor.

In summary: Carla has stable or slightly smaller thyroid nodule size and is clinically euthyroid.  To verify that her nodule is not surpressing the remainder of her thyroid function, we obtained repeat TFT's today and, because of the diffusely irregular nature of her gland are repeating antibodies once again. We would elect to wait before intervening with any further therapy because of the benign nature of her hot thyroid nodules and hope to see Carla again in clinic in 6 months.  Should you feel otherwise at the time of your visit, please do not hesitate to contact me.

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

Sincerely,



Maureen Shields                     Kendell Simpson                 
Fellow in Endocrinology          Clinical Director                                                 

ADDENDUM:  Carla's TSH returned 0.6 mIU/nl, with a T4 for 7.9 mcg/dl.


CONTENT:
Massod Stalin, M.D.          RE: Carla Palma
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/07/71

Dear Dr. Stalin:

We had the pleasure of seeing Carla in the Endocrine Program on 1/7/93 for follow-up of a thyroidenoma.

History: As you know, Carla is a 21 year old woman who was found to have an isolated hot thyroid nodule on an initial iodine scan. Since her initial evaluation, her thyroid nodule has remained stable in size until recently when she has felt slightly increased mass sensation in her throat especially when swallowing. Approximately one week ago. she had sudden onset of the nodule appearing slightly larger and much more firm in consistency with mild tenderness to palpation. It has remained stable in size since that time. Carla has had intermittent difficulty in the past with tachycardia though none recently. She has no heat intolerance but complains of feeling cold frequently. She has no constipation or diarrhea and her menstrual periods remain regular.

Current medications: None.

Physical exam:  
BP: 115/60              Pulse: 92               
Skin: Turgor was good. No cutaneous lesions.  HEENT:  Intact extraocular movements, equally responsive pupils.  Neck: Palpation of the neck revealed a firm nodule in the right lobe with the thyroid measuring 1.5 x 2.0 cm and moved easily with swallowing. Left lobe was still palpable and normal in size.  Chest: Clear to auscultation Abdomen:  Soft without hepatosplenomegaly or masses.  Genitourinary: Deferred. Extremities:  Normal texture and good turgor.  Neurological: Nonfocal. DTRs 2+ and equal with normal relaxation phase.

Impression: Carla has probably had recent hemorrhage into her area of thyroidenoma.  To document this, we are obtaining a repeat thyroid ultrasound which will be done 1/15/93. We are also repeating thyroid function tests to ensure she is not becoming mildly hyperthyroid from her previously hot nodule though this is unlikely. Because of the persistent difficulties Carla is experiencing with changes in size and intermittent pain we had discussed possibly having the nodule removed and the near future. She will be returning to your clinic for evaluation at which time this can be discussed further with her.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Thyrodi function tests were normal.  Ultrasound revealed a complex cystic nodule in the right thyroid similar in size to previous exams.  Now, an additional 3mm nodule on the left was visible.   We will arrange for a repeat iodine scan to determine if this additional nodule is hot or cold.  This may represent early appearance of a multinodular goitre.


CONTENT:
Massod Stalin, M.D.          RE: Carla Palma
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/07/71

Dear Dr. Stalin:

We had the pleasure of seeing Carla in the Endocrine Program on 4/22/93 for in follow-up for a hot thyroid nodule.

History: At the time of her last visit she was found to have some increase in the size of the nodule probably accounted for by a small amount of hemorrhage.  At this time an ultrasound was obtained which revealed a cystic lesion in the left lobe of the thyroid as well as the right suggesting early multiple nodular goiter.  Since her last visit she has had no recurrent neck pain and no change in the size of her thyroid nodule.  Recently she had strep throat (approximately two weeks ago) but otherwise has been well.  Her periods have been regular and she is on no medication.  She specifically denies heat or cold intolerance, palpitations, change in appetite although she is occasionally fatigued during the day.

Physical exam:  
Height: 151.6 cm        Weight: 42.2 kg         BP: 104/58              
Pulse: 72               
General: Well appearing, thin Hispanic girl.  Skin: Turgor was good, texture was normal.  HEENT: Intact extraocular movements, equally responsive pupils and moist oropharynx.  Neck: 1.1x1.0 firm nodule on the right lobe of the thyroid which moved with swallowing.  There was no abnormality palpable on the left, thought the borders were normal in size.    Chest: Clear to auscultation.  Heart: Regular rate and rhythm without murmur.  Abdomen: Soft without hepatosplenomegaly. or masses.  Genitourinary: Deferred.  Neurological: 2+ and equal deep tendon reflexes with normal relaxation.

Impression: Our impression overall is that Carla's persistent nodule is somewhat smaller than the previous evaluation suggesting resorption of hemorrhagic material in the nodule.  The left side, other than a somewhat irregular surface, is normal to palpation.  We have scheduled Carla for a repeat ultrasound to again document any additional abnormalities in the thyroid besides her hot nodule and sent repeat thyroid function tests.  We hope to see Carla again in six months time.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Massod Stalin, M.D.          RE: Carla Palma
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/07/71

Dear Dr. Stalin:

We had the pleasure of seeing Carla in the Endocrine Program on 9/2/93 for follow-up of a hot nodule.

History: Since her last visit, Carla has been doing quite well overall with no symptoms suggestive of hyperthyroidism.  She has had her usual trangent episodes of tachycardia which are decreased in intensity and frequency recently.  She denies pain in her thyroid or increase in the size of her nodule, though occasionally feels a lump in her throat upon swallowing.  She denies diaphoresis and her periods remain regular.

Physical exam:  
BP: 62/64               
General: Well appearing female. Skin: Texture was normal.  Turgor was good. HEENT: EOMI, PERRL, moist oropharynx. Neck: Notable for a firm nodule in the right lobe of the thyroid measuring 0.7x0.7 cm., it was not tender and mobile with swallowing.  There were no other palpable masses in the thyroid.   Chest: Clear to auscultation. Heart: Regular rate and rhythm. Abdomen: Without hepatosplenomegaly or masses. Neurological: 2+ and equal deep tendon reflexes with normal relaxation phase.

Impression: Our impression is that Carla exhibits no symptoms of hyperthyroidism currently and her nodule has remained unchanged on physical exam over the last several months.  We will repeat thyroid function tests today and plan on repeating a scan at the time of her next visit.  However, as Carla is currently 22 years old with probable long term follow-up required of this thyroid nodule, we gave her the option of obtaining follow-up at the Brigham & Women's Hospital.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Khabira Lear, M.D.          RE: Wanda Aubrey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/09/79

Dear Dr. Lear:

We had the pleasure of seeing Wanda in the Endocrine Program on 11/11/92 for evaluate obesity and amenorrhea.

History: Wanda is a 13 year old female who was diagnosed to have ALL in February of 1984.  She was treated with standard chemotherapy (including Adriamycin 333 mg/mc2) and CNS XRT 2800 cGy.  Wanda and her mother were seen today upon your advise.  They did not seem to be particularly concerned about her overweight and the fact that she did not have her menarche.

According to her mother, Wanda started to have breast development about 6 years ago, at about that time she also started to gain weight.  Both Wanda and her mother admit that she has a very good appetite and that Wanda is very inactive and leads a sedentary life.  Mrs. Aubrey has been limiting Wanda's intake to 1500 KCal per day and Wanda denies that she eats more than what her mother allows her to.  Both did not express any concern regarding the excess sexual hair that Wanda has but did acknowledge its presence.  Otherwise, Wanda has been enjoying good health.  A bone age obtained on October 27, 1992 at Day Kimball Hospital in Putnam, CT was read at 16 years.

Current medications: None at present.

Physical exam:  
Height: 157.0 cm        Weight: 90.3 kg         BP: 100/70              
Pulse: 72               Breast: Tanner V        Pubic hair: Tanner VI   
General: Generalized obesity without any Cushingoid facies.
Skin: Has multiple pink striae over the abdomen and thigh.  No acne.  Has heavy sideburns, significant amount of hair over the sternum and along the linea alba.
HEENT: Normal fundi, EOM intact, PERRLA.  Normal oropharynx.
Neck: Thyroid not enlarged.
Chest: Lungs are clear.
Heart: Normal S1 and S2, no murmurs.
Abdomen:  Obese, soft, no tenderness, no hepatosplenomegaly.
Extremities: Obese.
Neurological: Absent DTR otherwise normal.

Impression: Precocious puberty is a known side effect of XRT to the CNS.  At times it is "incomplete" and ends with hypogonadotropic hypogonadism.  Wanda by report started early puberty and the absence of menarche after so many years  maybe secondary to hypogonadotropic hypogonadism secondary to XRT.  However, because of the manifestations of hyperandrogenism and obesity she may as well have PCO.  The advanced bone age is most likely due to a combination of both early puberty and excess androgen.  With that degree of bone maturation one does not expect any further growth which is also suggested by her tapering height on the growth chart.


Laboratory studies pending at this time include: LH, FSH, E2, T, free T, DHEA, DS, androstenedione, 17-OHP, insulin, HbA1.
Thank you for letting us share in the care of Wanda.

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Khabira Lear, M.D.          RE: Wanda Aubrey
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/09/79

Dear Dr. Lear:

We had the pleasure of seeing Wanda in the Endocrine Program on 12/20/93 for follow up of her amenorrhea.

History: Mrs. Aubrey claimed she never received my letter requesting her contacting me since I could not reach her by phone.  Wanda's mother,  and I presume her grandmother, were very angry during the interview.  Apparently Wanda was put on a 1200 calorie diet but did not lose weight.  She remains amenorrhic.  She however does not exercise more than just a walk.

I strongly recommended that she go back on a 1200 calorie diet, exercise regularly and be placed on a contraceptive pill.

The mother and the grandmother decided that they will pursue this locally.  They left unhappy and dissatisfied.

Physical exam:  




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

Sincerely,


Kendell Simpson, MD             
Clinical Director


CONTENT:
Nabil Bonaparte, M.D.          RE: Flo Lopez
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/07/84

Dear Dr. Bonaparte:

We had the pleasure of seeing Flo in the Endocrine Program on 12/03/91 for evaluation of follow up of her congenital hypothyroidism and possible end organ resistance to thyroid hormone.

History: Since last seen on 12/03/90 Flo has been well on the equivalent of 0.175 mcg of Synthroid daily.  She had no symptoms to suggest hypo- or hyperthyroidism.  She is doing well in school, has a very good appetite.  She had been fairly well compliant with her Synthroid.  The review of systems was negative.

Physical exam:  
Weight: 29.4 kg         BP: 80/60               Pulse: 80               
The skin was of normal texture.  The thyroid was not palpable.  She was prepubertal.  The rest of the physical examination was normal.

Clinically Flo was euthyroid and growing well.

Laboratory studies:  T4 was 14.4 ugm/dl, TBGI 1.04, TT3 155 ng/dl and TSH < 0.05 mcU/ml.

In summary: The suppressed TSH suggests that her present dose of Synthroid is excessive.   I suggested that the dose be decreased to 150 mcg daily and have the TFT repeated in six weeks;  if the TSH remains suppressed the dose needs to be further reduced.

On this visit blood was obtained from Flo and her mother for Dr. W. Chin who will study their thyroid receptors.

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

Sincerely,






Kendell Simpson, MD             
Clinical Director


CONTENT:
Latoshia Piggy, M.D.          RE: Lee Svedberg
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/22/79

Dear Dr. Piggy:

We had the pleasure of seeing Lee in the Endocrine Program on 04/07/92 for evaluation of short stature .

History: Lee is a 12 and 10/12 year old white male who was referred for slowing of his growth rate.  Lee's growth data was plotted on a delayed type growth chart.  This chart shows that Lee grew around the 25th-30th percentile in his early years, and then his growth slowed down somewhat.  However, it followed the delayed  1 standard deviation of normal growth pattern according to our chart.  His slowing coincided with a prepubertal slowing and has increased with early puberty starting at about 11 and 6/12 years of age.  Lee gives us a history consistent with an early puberty.  He noticed pubic hair development.

Past medical history:  Benign.

Review of systems:  Reveals some chronic diarrhea on and off, which his brother also suffers from.  There is a family history of possible lactose intolerance.  Also significant is a history of migraine headaches which Lee has had for the past four years.  He is on treatment with verapamil for six months.  An MRI was done in 10/91 because of the history of headaches, and it was normal.

Family history:  As noted above, there is a family history of possible lactose intolerance.

Physical exam:  
Height: 148.5 cm        Weight: 37.8 kg         BP: 114/60              
Pulse: 72               Pubic hair Tanner: 3.5  R. testis: 4.7 x 2.3 cm 
L. testis: 4.7 x 2.3 cm Phallus length: 10 cm   Mid-shaft diam.: 2.7 cm 
General: Within normal limits.    
Neck: No thyromegaly.
Genitourinary: Axillary and pubic hair consistent with Tanner 3-4.

Impression: Lee represents a normal male who is now in early to mid-puberty. Growth follows a pattern which would be predicted by his genetic potential, as expressed by the mid-parental height of 5'4".  In addition, he has experienced a later pubertal development than his brother, who was also seen today, and, therefore, he has not entered his full growth spurt at this time.  We believe he will go on to have a normal growth-spurt and grow to a final adult height at or above his mother's height of 5'6".  No lab work is necessary.

Disposition: Lee does not need to follow-up in the Endocrine Clinic.
Thank you for letting us share in the care of Lee.

Sincerely,


Mitsuko Simpson, MD             
Chief, Emeritus              


Addendum: Dr. Tentindo
Beeper: 0412


CONTENT:
Fitzroy Carerras, M.D.          RE: Dolly Saud
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/19/78

Dear Dr. Carerras:

We had the pleasure of seeing Dolly in the Endocrine Program on 2/10/93 for .

History: I am writing in regard to the IND 39,387 permission to use Oxandrolone in a patient with Turner syndrome and AIDS.  Dolly Saud was maintained on Oxandrolone with a dose of 2.5 mg. qd from April to November, a period of eight months.  During this time, she had active HIV infection as detailed in the most recent note in her hemotologist.  She did not show any significant growth, her last height being 131.1 cm. and with 27.9 kg.  Thyroid function tests measured during this time were normal.  She had no difficulty tolerating the Oxandrolone.  She had no progression of her bone age however, due to the failure  in improvement in height and actually a weight loss over the three months prior to that visit, it was decided to discontinue Oxandrolone.  This was done in November.  She continues to be followed by Hematology and continues to have problems with frequent fevers and other complications of HIV.  I would not plan to resume the Oxandrolone in her unless improvement in her underlying infection and malabsorption from GI complications make further growth possible.  I very much doubt this will be the case.  I would therefore consider this protocol closed.  

Thank you very much for your help.

Physical exam:  




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

Sincerely,


M Joan Hammer, MD         
Associate in Endocrinology


CONTENT:
Sabina Bonaparte, M.D.          RE: Dolly Saud
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/19/78

Dear Dr. Bonaparte:

We had the pleasure of seeing Dolly in the Endocrine Program on 8/23/93 for follow-up of turner's syndrome.

History: Dolly is a 14 and 10/12 year old female with hemophilia, AIDs in addition to Turner's syndrome. She is here because she is concerned about her growth. Over the past several years she has developed AIDs, and has been quite sick. However, over the last year or so, she has been doing quite well. Dolly took Oxandrolne for about six months, with no improvement in her height. She has been on estrogen in the past, but cannot be on estrogen due to bleeding.

Current medications: DII (an experimental drug), Marinal (appetite stimulant), Prilosec, Dapsone, Difulcan, and Factor 8 daily.

Physical exam:  
Height: 134 cm          Weight: 24.3 kg         Pulse: 80               
Breast: Tanner I        Pubic hair: Tanner III  
General: A very thin girl in no apparent distress.  Skin: She had 2 mm papules all over her body.  HEENT: Normocephalic atraumic, thin hair. Oropharynx was normal.  Neck: Supple, without thyromegaly.  Chest: Normal. 
Heart: Regular rate and rhythm without a murmur. There is a portacath and g-tube in place.  Abdomen: Normal.  Genitourinary: Nonestrogenized vaginal mucosa.  Extremities: Thin. Neurological: Grossly intact.

Laboratory studies:  Bone age was between 9 and 10 years.

Impression: Dolly's is most likely short due to her Turner's syndrome, compounded by the fact that she has hemophilia and AIDs.

Disposition: I do not feel Dolly is a candidate for growth hormone therapy.  I do not know if there would be any growth effect given Dolly has AIDS.  In addition, I am concerned that growth hormone would worsen her HIV infection and that she would become sicker, therefore,  I cannot recommend growth hormone treatment.  After meeting with Dolly's hemophilia nurse, social worker and you, this was discussed with the family; it was suggested they seek a second opinion if they so chose.
Thank you for letting us share in the care of Dolly.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 1/6/94 for growth hormone deficiency.

History: Cesar is a 10 and 7/12 year old who has been receiving Protropin since 11/92.   His current dose is 0.95 mg q day.    He has a good energy level and has no signs or symptoms of hypothyroidism.

Medications: Protropin as above.

Physical exam:  
Height: 127.5 cm        Weight: 37.6 kg         BP: 100/60              
Pulse: 84               R. testis: 2.4 x 1.5 cm L. testis: 2.4 x 1.5 cm 
Phallus length: 6 cm    Mid-shaft diam.: 2 cm   
General:  Alert.  Skin:  Normal texture.  HEENT:  Pupils equal, round and reactive to light.   Extraocular movements intact with old finding decreased lateral gaze bilaterally.   Fundi not visualized.    Neck:  No thyromegaly.  Chest:   Clear.  Cor:   Regular rate and rhythm without murmur.     Abdomen:  Soft without hepatosplenomegaly.  GU:  Three long straight pubic hairs peri-scrotally unchanged from last visit.   Extremities:   Well perfused.     Neurologic:  Normal ankle deep tendon reflexes.

Impression: Cesar has grown 1.6 cm over the past four months which is an adequate growth velocity.   He has decreased 0.7 kg, which has been a conscious attempt at weight loss.   He will continue his present dose of Protropin at approximately of 0.025 mg/kg/day.

Disposition: Return to Endocrine Clinic in four months.

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

Sincerely,


Leif Pavarotti, MD             Ariel Adler, MD           
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 5/26/94 for growth hormone deficiency.

History: Cesar is almost 11 years old.   He has had a good energy level.   He denies dry skin, hair loss, constipation, polydipsia, polyuria, headaches or blurry vision.

Current medications: Protropin 0.95 mg q day.

Physical exam:  
Height: 129.1 cm        Weight: 37.6 kg         BP: 100/62              
Pulse: 72               U/L ratio:  0.74        Arm span: 137           
Pubic hair: Tanner I    R. testis: 2.8 x 1.8 cm L. testis: 2.8 x 1.8 cm 
Phallus length: 6.5 cm  Mid-shaft diam.: 2.2 cm 
General: Alert. 
Skin: Normal texture. 
HEENT: Old decreased lateral gaze bilaterally.   Pupils equal, round and reactive to light.   Fundi not visualized.  
Neck: No thyromegaly. 
Chest: Clear.
Heart: Regular rate and rhythm without murmur. 
Abdomen: Soft without hepatosplenomegaly.  
Genitourinary: A few long straight hairs peri-scrotally.  
Extremities: Well perfused.  
Neurological: Normal deep tendon reflexes.

Laboratory studies:  T4 8.7 mcg/dL, TT3 150 ng/dL, TSH 2.40 uU/ml.  Bone age 10 years 6 months.

Impression: Cesar has grown 1.6 cm over the past three and a half months.   His weight has remained stable which is a conscious attempt at weight loss with increased exercise.   His mild decrease in growth velocity needs to be followed, as this could indicate the normal slowing seen just prior to the onset of puberty.   We will continue the same dose of Protropin at 0.025 mg/kg/day for now.

Disposition: Return to Endocrine Clinic in three to four months.
Thank you for letting us share in the care of Cesar.

Sincerely,


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


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 8/18/94 for growth hormone deficiency.

History: Cesar is now 11 and 2/12 year old.   Since his last visit, he has had a one month history of nasal congestion.  He denies headaches, blurry vision, cold intolerance, constipation, polydipsia, polyuria, axillary odor,  or increase in pubic hair.  Of note, his brother's pubertal development started at approximately 12 years of age.

Current medications: Protropin 0.95 mg q day.

Physical exam:  
Height: 130.5 cm        Weight: 38.5 kg         U/L ratio:  0.79        
Arm span: 140           Pubic hair: Tanner II   R. testis: 2.7 x 1.6 cm 
L. testis: 2.8 x 1.7 cm Phallus length: 7 cm    Mid-shaft diam.: 2 cm   
General: Alert.  Skin: Normal texture.    HEENT: Pupils equal, round and reactive to light.  Extraocular movements intact.  Decreased lateral gaze bilaterally (old finding).   Neck: No thyromegaly.    Chest: Clear.    Heart: Regular rate and rhythm without murmur.    Abdomen: Soft without hepatosplenomegaly.    Genitourinary: A few long straight hairs periscrotally.     Extremities: Well perfused.    Neurological: Normal patellar deep tendon reflexes.

Impression: Although Cesar has a few additional periscrotal hairs, there has been no other increase in pubertal development.  I have increased his Protropin dose to 1 mg q day which is 0.026 mg/kg/day.  He may need a dose of 0.05 mg/kg/day during puberty.


Laboratory studies pending at this time include: None.
Disposition: Return to clinic in three to four months.
Thank you for letting us share in the care of Cesar.

Sincerely,


Leif Pavarotti, MD             
Assistant in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 12/8/94 for follow-up of growth hormone deficiency.

History: Cesar is now 11 and 6/12 years old.  His mother has noted an increase in shoe size since the last visit and occasional axillary odor.   He denies fatigue, cold intolerance, constipation, dry skin, hair loss, blurry vision, or headaches.

Current medications: Protropin 1 mg SQ qd.

Physical exam:  
Height: 131.6 cm        Weight: 41.8 kg         BP: 100/70              
Pulse: 76               U/L ratio:  0.88        Arm span: 141           
R. testis: 3.2 x 2.0 cm L. testis: 3.2 x 2.2 cm Phallus length: 6.5 cm  
Mid-shaft diam.: 2.3 cm 
Tanner pubic hair stage II-III
General:  Alert.
Skin: Normal texture.
HEENT:  PERRL, decreased lateral gaze bilaterally (odl finding),  normal left optic disc, right optic disc not visualized..   
Neck:  No thyromegaly. 
Chest: Clear.
Heart:  Regular rate and rhythm, no murmur.
Abdomen: Soft without hepatosplenomegaly.
Genitourinary:  Genitalia Tanner II
Extremities: Well-perfused.
Neurological: Normal ankle DTR relaxation phase.

Impression: Cesar has growth 1.1 cm over the past 3 1/2 months.  This has been a decreased growth velocity which is often seen just prior to the pubertal growth spurt.  He has gained 3.3 kg.  This may in part be due to his caloric intake.  His father has been insisting he drink a huge glass of milk prior to bedtime, and we suggested that he discontinue this.    Finally, we are concerned about his early puberty. Although it is within normal limits, it is earlier than expected with his family history of a mother with menarche at 12 years of age and a father with "late puberty".  He developed pubic hair prior to his increased testicular size and his bone age has been advancing at a greater rate than his height age.  Therefore, the  additional problem of nonclassical congenital adrenal hyperplasia needs to be considered, albeit less likely.  It might be prudent to obtain a GnRH stimulation test and an ACTH stimulation test if his puberty and bone age continue to progress at a rate that decreases his predicted final height.   Lupron could be added to the regimen to halt the progression of puberty.  Of note, his target height of 5'4" and his most recent bone age six months ago with a predicted height of 5'4" mean that a further compromise in height could leave him with significant short stature in adulthood.

Disposition: Increase Protropin dose to 1.05 mg qd for 0.025 mg/kg/day.  If his growth velocity continues at this same rate as he is progressing through puberty, we will need to increase his dose to 0.05 mg/kg/day to mimic the increased  growth hormone that is produced during puberty.  Return to clinic in 3-4 months.
Thank you for letting us share in the care of Cesar.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 4/6/95 for growth hormone deficiency.

History: Cesar is now 11 and 11/12 years old.  He is doing well in school.  He denies headaches, blurry vision, fatigue, dry skin, constipation, polydipsia, or polyuria.

Current medications: Protropin 1.05 mg SC qday.

Physical exam:  
Height: 133.4 cm        Weight: 43.5 kg         BP: 110/62              
Pulse: 80               U/L ratio:  0.88        Arm span: 143           
Pubic hair: Tanner III  R. testis: 3.2 x 2.2 cm L. testis: 3.2 x 2.4 cm 
Phallus length: 8 cm    Mid-shaft diam.: 2.3 cm 
General: alert. 
Skin: normal texture.
HEENT: PERRL, decreased lateral gaze bilaterally (old).
Neck: no thyromegaly.
Chest: clear to auscultation, no axillary hair.
Heart: regular rate and rhythm, no murmurs.
Abdomen: soft, no hepatosplenomegaly or masses.
Genitourinary: genitalia Tanner II.
Extremities: well-perfused. 
Neurological: normal ankle DTR relaxation phase.
Bone age: 12 years


Impression: Cesar has grown 1.8 cm over the past 4 months, but at this stage of puberty, we would expect a higher growth rate.  Because of the increased growth hormone secretion in puberty, I would like to increase his Protropin dose to 0.05 mg/kg/day.  Until I can contact the insurance company and Caremark, we will increase his Protropin dose to 1.1 mg QD, to continue a dose of 0.025 mg/kg/day based on his new weight.


Laboratory studies pending at this time include: T4, TT3, TSH.
Disposition: Return to endocrine clinic in 4 months.
Thank you for letting us share in the care of Cesar.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology   


Problem list to date:
SHORT-STATURE                                05/11/92  
GH-DEFICIENCY                                05/11/92  
Transcribed by Cohen_l


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 8/10/95 for growth hormone deficiency.

History: Cesar is now 12-2/12 years old.  Since his last visit, he  has been doing well.  He has a good energy level and is attending day  camp.  He denies headaches, blurry vision, cold intolerance, dry skin or  constipation.  He occasionally complains of right hip pain with a  negative X-ray evaluation by report.

Current medications: Protropin 2.2 mg subcutaneously q day.

Physical exam:  
Height: 137.0 cm        Weight: 46.6 kg                     
BP: 78/50               Pulse: 76               
U/L ratio:  0.88        Arm span: 145           
Pubic hair: Tanner III  
R. testis: 3.3 x 2.0 cm L. testis: 3.2 x 2.0 cm 
Phallus length: 10.0 cm Mid-shaft diam.: 2.3 cm 
General appearance:  alert.  Skin:  normal texture.  HEENT:  pupils equal, round and reactive to light.  Extraocular movements intact.   Discs not visualized.  Neck:  no thyromegaly.  Chest:  clear.  Cor:  regular  rate and rhythm without murmur.  Abdomen:  soft without  hepatosplenomegaly.  Extremities:  well perfused.

Impression: Cesar is in puberty and has grown 3.6 cm over the past 4 months, which is consistent with a pubertal growth spurt.  His body proportions are now within normal limits, however, a skeletal dysplasia cannot be ruled out given his previous measurements.

Disposition: Increase Protropin to 2.3 mg q day for 0.05 mg/kg per day.   Return to Endocrine Clinic in 4 months.

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

Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

I saw Cesar in the Endocrine Program on 12/28/95 for growth hormone deficiency.

History: Cesar is a now 12-7/12 years old.  He has been in good health since his last visit.  His mother says his energy level is fair, and he is doing little exercise during the winter.  He denies headaches, blurry vision, cold intolerance, hair loss, or constipation, and his heel pain has resolved.  He has some increase in dry skin during the winter.

Current medications: Protropin 2.3 mg subQ q.d.

Physical exam:
HT: 140.6 cm    WT: 49 kg    Arm span: 144 cm    U/L ratio:  0.9
BP: 112/82              Pulse: 82               Pubic hair: Tanner III  
R. testis: 3.8 x 2.2 cm L. testis: 3.7 x 2.2 cm Phallus length: 2.5 cm  
General appearance:  alert.  Skin: dry facial skin with tiny pink papules.  HEENT: PERRL, discs not visualized.  Neck: no thyromegaly.  Lungs: clear.  Heart: regular rate and rhythm without murmur. Abdomen: soft, without hepatosplenomegaly.  Extremities: well perfused.  Neurological: normal patellar deep tendon reflexes.

Impression: Since increasing Cesar's Protropin dose to 0.05 mg/kg/day to reflect the increased growth hormone production during puberty, he has had an improved growth velocity.  He has now grown 3.6 cm over the past 4-1/2 months which is consistent with the pubertal growth spurt.  He has also gained 2.4 kg.

Disposition: Increase the Protropin dose to 2.45 mg q.d. to continue a dose of 0.05 mg/kg/day.  We would like Cesar to return to endocrine clinic in four months and at that time, we will obtain thyroid function tests, an IGF-1 level, and a bone age.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc: Mr. and Mrs. Richard Morris  246 Lexington Street  East Boston, MA  02128


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

I saw Cesar in the Endocrine Program on 4/18/96 for follow-up for GH deficiency.

History: Cesar is 12 and 10/12 years old.  Other than a strep pharyngitis one month ago, he has been in good health.  He has a good energy level and has increased his exercise with karate 3 times per week and baseball two times per week.  His dry skin is unchanged.  He denies headaches, blurry vision, cold intolerance, constipation, or hair loss.

Current medications: Protropin 2.4 mg. subq q.day.

Physical exam:
WT: 52.2 kg
BP: 116/62              Pulse: 60               Pubic hair: Tanner IV   
R. testis: 4.0 x 2.2 cm L. testis: 3.9 x 2.3 cm  
Phallus length: 11 cm   Mid-shaft diam.: 3.0 cm 
General appearance: alert.  Skin: normal texture.  HEENT: PERRLA, EOMI, normal discs.  Neck: no thyromegaly.  Lungs: clear.  Heart: regular rate and rhythm without murmur.  Abdomen: soft, without hepatosplenomegaly.  Extremities: well perfused.  Neurological: normal patellar deep tendon reflexes.

Laboratory studies:  T4 6.0 ug/dL, TSH 2.60 uU/ml.  Pending IGF-1.
Bone age: 13 years

Impression: Unfortunately, after Cesar's visit we noted that our stadiometer was broken and therefore, a growth velocity over the past 4 months can not be determined.  However, it is obvious from exam that Cesar has had significant growth.

Disposition: Continue the same dose of recombinant growth hormone.  Return to Endocrine clinic in 4 months. 

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

Sincerely,





Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

I saw Cesar in the Endocrine Program on 9/5/96 for growth hormone deficiency.

History: Cesar is now 13-3/12 year old.  He has been very active this summer.  He attended day camp and is doing karate daily.  He has a good energy level.  His only intercurrent illness was one febrile illness.  He denies dry skin, coarse hair, constipation, cold intolerance, blurry vision, polyuria, nocturia, or polydipsia.  He does complain of headaches when it is hot outside, but they resolve when it cools down.

Current medications: Protropin 2.4 mg subq. q.day (0.05 mg/kg/day).

Physical exam:
HT: 148 cm    WT: 52.6 kg    Arm span: 156 cm    U/L ratio:  0.9
BP: 90/64               Pulse: 56               Pubic hair: Tanner IV   
R. testis: 4.0 x 2.5 cm L. testis: 3.8 x 2.4 cm Phallus length: 11 cm   
Mid-shaft diam.: 3.3 cm 
General appearance:  Alert.  Skin:  Normal texture.  HEENT:  PERRL, old decreased lateral gaze bilaterally, normal discs.  Neck:  No thyromegaly.  Lungs:  Clear.  Heart:  Sinus bradycardia without murmur.  Abdomen:  Soft, no hepatosplenomegaly.  Extremities:  Well perfused.  Axillary hair Stage II.

Impression: Cesar has grown 7.4 cm. over the past 8-1/2 months and 11 cm. over the past year, which is consistent with an excellent pubertal growth spurt.  He is well advanced in puberty at this point, although there is not significant interval change since his last visit.  He has only gained 0.4 kilograms over the past 4-1/2 months and I hope he will continue with his increased exercise.

Disposition: I will not change Cesar's growth hormone dose today as he is having an excellent growth velocity.  I would like to see him back in Endocrine Clinic in four months.   

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



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc:  Mr. and Mrs. Richard Morris   246 Lexington St   East Boston, MA  02128


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

I saw Cesar in the Endocrine Program on 12/26/96 for growth hormone deficiency.

History: Cesar is now 13-7/12 years old.  He continues to have a good energy level.  His broke his right arm (radius and ulna) on 09/06/96.  He denies headaches, cold intolerance, dry skin, constipation, coarse hair, polydipsia, polyuria, or nocturia.  He had one upper respiratory infection since his last visit.

Current medications: Protropin 2.4 mg SQ q.d. (0.043 mg/kg/day).

Physical exam:
Height: 150.4 cm    Weight: 56.0 kg
BP: 116/63              Pulse: 89               Pubic hair: Tanner IV   
R. testis: 4.8 x 2.4 cm L. testis: 4.5 x 2.6 cm Phallus length: 12 cm   
Mid-shaft diam.: 3.3 cm 
General appearance:  alert.  Skin:  normal texture.  HEENT:  PERRL, decreased lateral gaze bilaterally (old finding), normal optic discs.  Neck:  no thyromegaly.  Axillary hair stage II.  Lungs:  clear.  Heart:  regular rate and rhythm, without murmur.  Abdomen:  soft, without hepatosplenomegaly.  Extremities:  warm and well perfused.  Neurological:  normal patellar deep tendon reflexes.

Impression: Cesar has grown 2.4 cm over the past 3-1/2 months.  I would like to increase his dose of Protropin to 2.8 mg SQ q.d. (0.05 mg/kg/day).  We discussed that recombinant human growth hormone is now being used in adults with growth hormone deficiency.  Once Cesar achieves final height with epiphyseal fusion, we may want to consider retesting him to see if he has adequate growth hormone production for an adult.

Disposition: I would like to see Cesar back in Endocrine clinic in four months.  Thank you for letting me share in his care.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc:  Mr. & Mrs. Richard Morris   246 Lexington St   East Boston, MA  02128


CONTENT:
Clotilde Montague, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Montague:

We had the pleasure of seeing Cesar in the Endocrine Program on 10/7/91 for evaluation of short stature.

History: We had the pleasure of seeing Mr. and Mrs. Morris to discuss the results of Cesar's insulin tolerance test, glucagon stimulation test, TRH stimulation test, and GNRH stimulation test.  He had a minimal growth hormone response to insulin with a maximum level of 1.7 ng/ml and a partial response to glucagon with a maximum growth hormone of 5.2 ng/ml.  This may be consistent with a growth hormone deficiency.  Cesar is to return to Endocrine Clinic on 10/31/91.  At that time his height and an IGF-1, IGF-BP will be sent.  His parents agree with starting a trial of growth hormone at that time.

Physical exam:  



In summary: 

Disposition: 

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

Sincerely,


Leif Pavarotti                 Mitsuko Simpson


CONTENT:
Clotilde Montague, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Montague:

We had the pleasure of seeing Cesar in the Endocrine Program on 10/7/91 for evaluation of short stature.

History: We had the pleasure of seeing Mr. and Mrs. Morris to discuss the results of Cesar's insulin tolerance test, glucagon stimulation test, TRH stimulation test, and GNRH stimulation test.  He had a minimal growth hormone response to insulin with a maximum level of 1.7 ng/ml and a partial response to glucagon with a maximum level of 5.2 ng/ml.  This may be consistent with a partial growth hormone deficiency.  Cesar is to return to Endocrine Clinic on 10/31/91 where his height will be measured and an IGF-1 and an IGF-BP3 will be sent.  His parents agree with starting a trial of growth hormone at that time.

Physical exam:  



In summary: 

Disposition: 

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

Sincerely,


Leif Pavarotti, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Clotilde Montague, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Montague:

We had the pleasure of seeing Cesar in the Endocrine Program on 10/28/91 for evaluation of short stature.

History: Cesar has had no complaints or intercurrent illnesses since his last visit.  He is on no medications.  

Review of systems:  HEENT: no headaches or blurry vision.  
Cardiorespiratory: no shortness of breath, palpitations, or coughing.
GI:  no abdominal pain, diarrhea, or constipation.  GU:  no polyuria or dysuria.  Other:  no cold or heat intolerance.

Physical exam:  
Height: 110.4 cm        Weight: 28 kg           SBP: 96                
Pulse: 72               Pubic hair Tanner: 1    R. testis: 1.9 x 1 cm   
L. testis: 1.9 x 1 cm   Phallus length: 5.5 cm  Mid-shaft diam.: 1.9 cm 
Skin: no lesions, warm.  HEENT: right fundus not well visualized, left disc benign, decreased lateral gaze bilaterally (reportedly old finding), oro-pharynx clear.  Neck: thyroid not enlarged.  Chest: lungs clear.  Heart: RRR with I/VI systolic ejection murmur at left upper sternal border
Abdomen: soft, no hepatosplenomegaly, no masses.  Genitourinary: Tanner I.  Extremities: warm and well perfused.  Neurological: 2+ symmetrical brisk deep tendon reflexes bilaterally.

In summary: Cesar's previous laboratory tests are consistent with a partial growth hormone deficiency.  He has only grown one centimeter over the past five months.

Disposition: Plan is to start growth hormone as soon as it can be ordered (Protropin 0.6 milligrams SQ/day).  Diane Souza, RN, will provide instruction.  He is to return to endocrine clinic for follow up in three months.

Laboratory studies pending at this time include: IGF-1, IGF-1 BP3, bone age

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

Sincerely,


Leif Pavarotti, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Clotilde Montague, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Montague:

We had the pleasure of seeing Cesar in the Endocrine Program on 1/27/92 for  follow-up of short stature and  growth hormone deficiency.

History: Cesar is now 8 and 8/12 years old and has been taking Protropin 0.6 mg per day subcutaneously (0.15 mg/kg/week) since 11/11/92.  He has had no intercurrent illnesses and is on no other medications.

Review of systems:  No headaches, blurry vision, diplopia, palpitations, shortness of breath, abdominal pain, constipation, diarrhea, tremors, hair loss, or cold or heat intolerance.

Physical exam:  
Height: 112.4 cm        Weight: 29. kg          BP: 104/65              
Pulse: 96               R. testis: 2.0 x 1.1 cm L. testis: 1.9 x 1.2 cm 
Phallus length: 5.2 cm  Mid-shaft diam.: 1.4 cm 
General: Awake and alert,
Skin: Without lesions.
HEENT: Right fundus not well visualized.  Left fundus benign.  Decreased lateral gaze bilaterally.  
Neck: No thyromegaly.
Chest: Lungs clear.
Heart: S1, S2 regular rate and rhythm with a 2/6 systolic ejection murmur at the left sternal border.
Abdomen: Soft, no hepatosplenomegaly.
Extremities: Warm and well-perfused.
Neurological: Normal deep tendon reflex relaxation phase.

Laboratory studies:  10/28/91:  IGF 1 0.13 U/ml, IGF1 BP3 1.6 - both of which are below normal limits.  Bone age 7 years with a standard deviation of 10.8 months, with a chronologic age 8 years and 5 months.

In summary: Impression:  Cesar has grown 2 cm over the past 3 months.  This is an improvement.  We will continue his current growth hormone dose; however, if there is not further improvement in his growth rate, we will consider increasing the dose.

Disposition: Return to Endocrine Clinic in 3 months.

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

Sincerely,


Leif Pavarotti, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 05/11/92 for follow-up evaluation of growth hormone deficiency.

History: Cesar is now almost 9 years old.  He  has grown 3.4 cm in 3 months. He has no headaches, blurry vision, cold intolerance, fatigue, diarrhea, constipation, polyuria, polydipsia, nocturia or tremors.

Current medications: Protropin 0.6 mg every day (0.02 mg/kg/day)

Physical exam:  
Height: 115.8 cm        Weight: 29.8 kg         BP: 108/66              
Pulse: 76               Pubic hair Tanner: 1    R. testis: 2.2 x 1.3 cm 
L. testis: 2.2 x 1.2 cm Phallus length: 5.5 cm  Mid-shaft diam.: 1.8 cm 
Skin: No lesions. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact.  Oropharynx clear. Neck: No thyromegaly. Chest: Clear. Heart: Regular rate and rhythm, with a I/VI systolic murmur at the left upper sternal border.   Abdomen: Soft, no hepatosplenomegaly. Extremities: Warm and well perfused.  Neurological: Symmetrical deep tendon reflexes with normal relaxation phase.

Impression: Cesar's growth rate has improved on growth hormone.  His protropin has been increased to 0.75 mg every day (.025 mg/kg/day).

Disposition: Return to Endocrine Clinic in three months.

Laboratory studies pending at this time include: Thyroid function tests, IgF-1 and bone age. A head MRI has been scheduled for 06/16/92 to rule out intracranial pathology. Thank you for letting us share in the care of Cesar.

Sincerely,




Leif Pavarotti, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 9/14/92 for evaluation of  short stature secondary to growth hormone deficiency.

History: Cesar is a 9 and 3/12 year old with growth hormone deficiency. He denies heat or cold intolerance, polyuria, polydipsia, constipation,  diarrhea, fatigue, or headaches. His only medication is Protropin 0.75 mg sc QHS.

Physical exam:  
Height: 118.6 cm        Weight: 31.5 kg         Pubic hair: Tanner I    
R. testis: 2.3 x 1.2 cm L. testis: 2.3 x 1.2 cm Phallus length: 5 cm    
Mid-shaft diam.: 1.4 cm 
Skin: No lesions.   HEENT: Normal optic discs.   Neck: No thyromegaly.   Chest: Clear.   Heart: Regular rate and rhythm with a 2/6 systolic murmur at the left sternal border.   Abdomen: Soft, without hepatosplenomegaly.   Extremities: Warm and well-perfused.   Neurological: Normal deep tendon reflexes.

Laboratory studies:  May 11, 1992: T4 8.6 mcg/dL, Total T3 186 ng/dL, TBGI 0.96, TSH 3.70 mcu/dL, IGF-1 203 ng/mL (now normalized while on treatment).  Bone age 7 years old with a chronologic age of almost 9 years old.
July 7, 1992: MRI of the brain revealed small volume pituitary and thickened infundibulum with presumed ectopic posterior pituitary.

Impression: Cesar has gained 2.8 cm in the past four months and appears to have a normal growth velocity.

Disposition: His Protropin dose has been increased to 0.8 mg QD to give 0.025 mg/kg/day with his increased weight gain. He will return to endocrine clinic in three months.
Thank you for letting us share in the care of Cesar.

Sincerely,


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


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 12/3/92 for evaluation of growth hormone deficiency.

History: Cesar is now 9 and 6/12 years old. He is currently receiving Protropin 0.8 mg subcutaneouly q day.

Review of systems:  Negative for headaches, blurry vision, cold intolerance, palpitations, constipation, diarrhea, change in hair or skin texture, polydipsia, or polyuria.

Physical exam:  
Height: 120.4 cm        Weight: 32 kg           BP: 104/66              
Pulse: 74               R. testis: 2.4 x 1.2 cm L. testis: 2.4 x 1.2 cm 
Phallus length: 5 cm    Mid-shaft diam.: 2 cm   
Skin: Normal texture.   HEENT: Decreased lateral gaze bilaterally.  PERRL. Fundi not visualized.   Neck: No thyromegaly.  Chest: Clear.   Heart: Regular rate and rhythm with a 2/6 systolic murmur at the lower left sternal border.   Abdomen: Soft without hepatosplenomegaly.   Extremities: Well perfused.   Neurological: Normal deep tendon reflexes.

Impression: Cesar has grown 1.8 cm over the past 2 1/2 months and 10 cm over the past 13 months while receiving growth hormone treatment.  This is an excellent growth velocity.

Disposition: He will continue the same dose of Protropin of 0.025 mg/kg/day and return to the endocrine clinic in 3-4 months.
Thank you for letting us share in the care of Cesar.

Sincerely,


Leif Pavarotti, MD             Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 3/8/93 for follow-up of growth hormone deficiency.

History: Cesar is now 9 and 9/12 years old and receiving Protropin 0.8 mg q day. His pants have required lengthening and his shoe size has increased 1 1/2 sizes. He has a facial rash but no axillary odor. He denies cold intolerance, dry skin, constipation, fatigue, headaches, blurry vision, polyuria, or polydipsia. He is an A student.

Physical exam:  
Height: 122.3 cm        Weight: 33.2 kg         BP: 104/74              
Pulse: 88               Pubic hair: Tanner I    R. testis: 2.2 x 1.4 cm 
L. testis: 2.1 x 1.3 cm Phallus length: 6 cm    Mid-shaft diam.: 1.8 cm 
General: Alert.   Skin: Papules on cheeks.   HEENT: Pupils equal, round and reactive to light. Decreased lateral gaze bilaterally which is an old finding.   Neck: No thyromegaly.   Chest: Clear.   Heart: Regular rate and rhythm with a 2/6 systolic ejection murmur at the left lower sternal border.   Abdomen: Soft without hepatosplenomegaly or masses.   Extremities: Warm and well perfused.  Neurological: Normal deep tendon reflexes.

Impression: Cesar has grown 1.9 cm over the past three months. His Protropin dose will be increased to 0.835 mg q day to compensate for his increase in weight. He will return to endocrine clinic in three months.

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

Sincerely,


Leif Pavarotti, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief, Emeritus


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 6/24/93 for follow-up of growth hormone deficiency.

History: Cesar is a 10 and 1/12 year old with short stature secondary to growth hormone deficiency. Since his last visit, he has increased in clothing and shoe size and in weight. He has no axillary odor, headaches, blurry vision, polyuria, polydipsia, cold intolerance, constipation or dry skin.

Current medications: Protropin 0.835 mg q day.

Physical exam:  
Height: 124.2 cm        Weight: 35.8 kg         BP: 110/64              
Pulse: 70               Pubic hair: Tanner I    R. testis: 2.2 x 1.4 cm 
L. testis: 2.4 x 1.4 cm Phallus length: 6 cm    Mid-shaft diam.: 1.9 cm 
General: Alert.  Skin:  Normal texture, no rashes.   HEENT: PERRL, decreased lateral gaze bilaterally (old finding).  Neck: No thyromegaly.  Chest:  Clear.   Heart: Regular rate and rhythm without murmur.   Abdomen:  Soft without hepatosplenomegaly.   Extremities: Well perfused.   Neurological:  Normal DTRs.

Laboratory studies:  T4 8.2 mcg/dL, TT3 173 ng/dL, TSH 3.30 uU/mL, IG-1 364 ng/dL.  Bone age 9 and 0/12 years old.

Impression: Cesar has had a good growth velocity of 1.9 cm over the past 3 1/2 months. His Protropin dose has been increased to 0.9 mg/day because of his increase in weight. This will continue to give him 0.025 mg/kg/day. He has been encouraged to increase his physical activity.

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

Sincerely,


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


CONTENT:
Cavinder Brezny, M.D.          RE: Cesar Morris
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/29/83

Dear Dr. Brezny:

We had the pleasure of seeing Cesar in the Endocrine Program on 9/2/93 for follow-up of growth hormone deficiency.

History: Cesar is a 10 and 3/12 year old with short stature secondary to growth hormone deficiency.  He is currently receiving Protropin 0.9 mg QD.  His shoe size has increased over the past two months.  He is very active.  He denies headaches, blurry vision, axillary odor or signs of hypothyroidism.

Physical exam:  
Height: 125.9 cm        Weight: 38.3 kg         BP: 100/60              
Pulse: 76               R. testis: 2.3 x 1.6 cm L. testis: 2.3 x 1.5 cm 
Phallus length: 5.5 cm  Mid-shaft diam.: 2.0 cm 
General: Alert.  Skin: Normal. HEENT: PERRL, decreased lateral gaze bilaterally (old) Neck: No thyromegaly. Chest: Clear. Heart: Regular rate and rhythm without murmur. Abdomen: Without hepatosplenomegaly. Genitourinary: three long straight pubic hairs peri-scrotally. I Extremities: Well perfused.  Neurological: Normal DTR relaxation phase.

Laboratory studies:  June 24, 1993: T4 8.2 mcg/dL, TT3 173 ng/dL, TSH 3.30 uU/mL.  Bone age 9 years with chronological age of 10 1/12 years old.

Impression: Cesar's genitalia are prepubertal, and the few pubic hairs may reflect the onset of adrenarche.  He is having a good growth velocity having grown 1.7 cm over the past 2 1/2 months.  His dose of Protropin was increased to 0.95 mg to continue to give him 0.025 mg/kg/day.

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

Sincerely,


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


CONTENT:
Bleck DeNiro, M.D.          RE: Frederick Froissart
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/15/81

Dear Dr. DeNiro:

We had the pleasure of seeing Frederick in the Endocrine Program on 7/18/94 for hashimoto's thyroiditis.

History: Frederick is a 12 year old boy who was referred for evaluation of goiter and the possibility of Hashimoto's thyroiditis.  As you know, Frederick's goiter was noted on physical examination and is asymptomatic at present.  In particular, he has no lethargy, constipation and no heat or cold intolerance.   The thyroid functions that you performed on 6/6/94 revealed a total T4 of 6.2 mcg/dl (range 4.5 -12), TSH of 9.84 mcU/ml (range of 0.32-5).

Past medical history:  Notable for a full term pregnancy, forceps delivery with  birth weight of 6 pounds 11 ounces.   Normal growth and development.   No excessive weight gain; sinusitis and recurrent ear infections around 4-5 years of age requiring adenoidectomy and sinus biopsy.

Review of systems:  Unremarkable.   He has no rash, headaches or chest pain.   No constipation, polyuria or polydipsia.

Family history:  Maternal grandmother with non-insulin dependent diabetes mellitus late onset and a maternal first cousin with insulin-dependent diabetes mellitus.  There are no family members with thyroid dysfunction.

Physical exam:  
Height: 157.1 cm        Weight: 47 kg           BP: 90/65               
Pulse: 65               U/L ratio:  0.72        Arm span: 165           
Pubic hair: Tanner III  R. testis: 4 x 2.1 cm   L. testis: 3.8 x 2 cm   
Phallus length: 8 cm    
General: Alert and pleasant.  
Skin: He has one cafe au lait spot and three small pigmented nevi on the back.  No erythema or bleeding from these.   
Neck: Goiter was firm and smooth and measured 4x4.5 cm.   There is no bruit.  There are palpable carotids bilaterally and a palpable prelaryngeal lymph node (frequently seen in Hashimoto's).   
The rest of his physical examination is unremarkable including a soft abdomen with no masses.

Impression: 12 year old boy with Hashimoto's thyroiditis with positive anti-thyroid microsomal antibody in the presence of a goiter.   He has compensated hypothyroidism eveidenced by an elevated TSH and a normal total T4.

Disposition: We recommend that Frederick start Synthroid 100 mg a day with follow-up in three months.   We would appreciate it if you would repeat a total T4 and TSH level before this appointment to evaluate the adequacy of his Synthroid dose.
Thank you for letting us share in the care of Frederick.

Sincerely,


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


Addendum: Senior Resident in Pediatrics


CONTENT:
Bleck DeNiro, M.D.          RE: Frederick Froissart
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/15/81

Dear Dr. DeNiro:

We had the pleasure of seeing Frederick in the Endocrine Program on 10/17/94 for .

History: I saw Frederick, age 12 years 11 months, in follow-up for compensated hypothyroidism treated with Synthroid 0.1 mg daily.

He feels well and has no complaints  He sleeps from 10:00 p.m. until 7:00 a.m. without disturbance and he does not have insomnia.  He has a huge appetite and normal bowel movements.

Physical exam:  
Height: 169.4 cm        Weight: 50 kg           BP: 106/54              
Pulse: 72               
General: He was a tall, slender youth who looked well.   Skin: Smooth and warm.  Neck: Thyroid gland was ~ 1.5 time the normal size and firm in consistency.  There were no palpable nodules.  The remainder of the exam was normal.

Laboratory studies:  Thyroid function tests obtained on October 6th were as follows:  serum thyroxine 9.5 5g/dL, T3 resin uptake 33%, and TSH 0.04 5U/mL, all within the normal range.

Impression: Frederick is having his adolescent growth spurt.  He is euthyroid.  He still has a small goiter but the clinical and biochemical evidence indicate that the current dose of Synthroid is perfectly adequate.

Disposition: I have recommended continuing Synthroid 0.01 mg daily.  I would appreciate the opportunity to see him again in 12 months.
Thank you for letting us share in the care of Frederick.

Sincerely,


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


CONTENT:
Gorby, M.D.          RE: Enrico Casement
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/13/74

Dear Dr. Gorby:

We had the pleasure of seeing Enrico in the Endocrine Program on 1/20/94 for follow up for diabetes mellitus.

History: Enrico is a 19 and 6/12 year old man with cystic fibrosis, diagnosed at birth and diabetes mellitus insulin dependent, diagnosed five years ago.   He is maintained on NPH 22 units at 7:00 am and 8 units between 5 and 7 pm, he is on Regular insulin, 4 units in the morning and 3 units in the evening.   He has three meals per day with one afternoon and one night snack.   He does not follow any calorie plan.   Interval history is negative for night hypoglycemic episodes.   He notes one hypoglycemic episode prior to dinner however, then he had only a small portion at lunch.  Blood sugar, half an hour pre-prandial in the morning is between 120 and 200. In the evening, prior to his meals, it is usually 141 to 241.   He has been having an upper respiratory tract infection for a few days and has not decreased his insulin dose.   His last eye check up was one year ago and he is due for one shortly.

Current medications: Medications:  Slo-bid 300 mg, Albuterol sulfate, Dicloxacillin, Bactrim, Pancrease and Humulin insulin, NPH and Regular.

Physical exam:  
Weight: 53.3 kg         BP: 120/80              Pulse: 70               
Height is 5'4".
General:   He is healthy looking.   He is coughing but is in no distress.
Skin:  Sites of injections are the triceps area, abdomen and thighs.   These are not red or swollen but slightly hypertrophied.  
HEENT:  Tonsils are erythematous but no follicles can be seen.   Tympanic membranes are shiny bilaterally.  Fundoscopy could not be done good.   
Neck:  Supple with no thyromegaly.   No lymph nodes were felt.   
Chest:  Clear with good air entry.   No crackles or wheezes.   
Heart:   Normal sounds with no murmur.
Abdomen:  Soft.   Positive bowel sounds.   No hepatosplenomegaly.
Extremities:   No ulcers.   Good strong pulses.   
Neurologic:   Grossly intact.

Impression: Insulin-dependent diabetes mellitus.


Laboratory studies pending at this time include: Hemoglobin A1C=10.0%..
Disposition: Increase his Regular insulin 2 to 3 units each in the morning and evening.   Will follow him up in four months.
Thank you for letting us share in the care of Enrico.

Sincerely,


Nilto Carter, MD             
Attending in Endocrinology   


Addendum: Zeina Jeha, M.D.
Medical Student


CONTENT:
Brett Bird, M.D.          RE: Enrico Casement
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/13/74

Dear Dr. Bird:

We had the pleasure of seeing Enrico in the Endocrine Program on 11/17/94 for .

History: I had the pleasure of seeing Enrico on 11/17/94.  As you know, this now 20 year old, male sign painter from New Bedford who has both CF and diabetes, has been doing quite well with respect to his CF.   I was pleased to see that he gained 2.3 kg in the past year and he is now fully grown.  His diabetes could be somewhat better controlled, however, with an insulin dose of 5 of Regular and 22 of NPH Humulin in the morning and 5 of Regular and 8 of NPH in the evening.  He is having some blurring of vision and he is frequently having blood sugars in the morning that exceed 150 to the 200 range and are similarly up in the afternoon.  He is not polyuric but he may have a bladder that has adapted to this urine volume.

Physical exam:  
Height: 165.1 cm        Weight: 55.6 kg         BP: 120/70              
Pulse: 80               
On physical exam he shows no evidence of retinopathy.  He has no testicular masses and I taught him testicular self examination.    Rhonchi bilaterally.  There is no hypertrophy in his injection sites and he does use 6 different sites.

Laboratory studies:  Blood gluocse 317 mg/dl, hemoglobin 9.5%, microalbumin 0.08 mg/gCr (normal).

Impression: I have told him that he needs to increase his NPH at night to 10-12 units or whatever it takes (without nocturnal reactions) to get his morning blood sugar under 120.  He also needs to be carrying glucose tablets in case he has reactions when his control gets better.   I did a urinary microalbumin and glycohemoglobin and blood glucose today.   I have urged him to get a flu vaccine at today's visit in the CF program.   I want to keep somewhat closer tabs on his diabetes so we will see him again in three months.

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

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology   


Problem list to date:

Transcribed by Sullivan_ma


CONTENT:
Brett Bird, M.D.          RE: Enrico Casement
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/13/74

Dear Dr. Bird:

We had the pleasure of seeing Enrico in the Endocrine Program on 6/1/95 for .

History: I  saw Enrico back on June 1, 1995 for evaluation of diabetes which complicates his cystic fibrosis.  I understand that he has begun on Pulmozyme therapy two weeks ago and it seems to be fine with him.  The last time I saw him in November his glycosylated hemoglobin was 9.5% and he showed no complications of diabetes and no evidence of microalbuminuria in his "spot" urine.  He is on 22 units NPH with 6 units of Regular each morning and 12 NPH and 6 of Regular pre-supper and tests his sugar bid with an Ames glucometer.  The sugars have been running as low as 84, but frequently above 140 in the AM and about 50-60 points lower on average in the evening.  He definitely notes an decrease in blood sugar the morning after some degree of exercise.  He has had no insulin reactions, polyuria, or nocturia.

Physical exam:  
Weight: 54.5 kg         BP: 110/60              
He is down 1kg from his weight back in November.
General: His injection sites (arms, legs, abdomen) look fine. 
HEENT: No evidence of retinopathy.

Impression: His blood sugar control does not look problematic, but on the other hand a slight increase in PM NPH may lower his fasting blood sugar to the 80-120 range and potentially reduce his glycohemoglobin another 1 1/2%.  I have suggested that he do the increase on days other then those when he has been or is about to be physically active in the evening and he will maintain the present dose on days when he is going to be active.  The only test ordered today is a glycosylated hemoglobin (which was a supberb 8.2%).

Disposition: His situation is so stable that unless you see any reason to intervene I would be content to see him again in 4-6 months.
Thank you for letting us share in the care of Enrico.

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Brett Bird, M.D.          RE: Enrico Casement
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/13/74

Dear Dr. Bird:

I saw Enrico in the Endocrine Program on 11/2/95 for CF and diabetes mellitus.

History: At 21-2/12 years of age, his CF program remains the same and we have adjusted his insulin treatments so that by the time of his last visit in August, we began to shift him to a three shot a day program with  6 of Regular, 22 of NPH in the morning, 6 of Regular at supper and 14 of NPH at bedtime.  This gives him 48 units a day or 0.86 u/kg/day.  He had one moderately significant insulin reaction midday several weeks after this dose was raised, but he has otherwise been fairly unremarkable with  respect to any difficulties.  His blood sugars are in a perfectly  acceptable range and the last glycohemoglobin in August was 8.3%.

On examination today, his 55.7 kg, and essentially the same as he was in August.  Blood pressure were 125/70 and he has no signs of retinopathy or thyromegaly.  I have redrawn a glycohemoglobin today (8.1%) and because everything is so stable, we would be content to see him again in 03/96.

Impression: I have urged Enrico to get flu vaccine from you today.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   


cc:  Lucie Yergeau  726 Church St  New Bedford , MA  02745


CONTENT:
Brett Bird, M.D.          RE: Enrico Casement
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/13/74

Dear Dr. Bird:

History: Enrico was back in follow-up for diabetes complicating cystic fibrosis on  08/15/96.  He has done well in terms of his diabetes management on 22 of NPH in the morning and 6 of regular, with 6 of regular at supper, and 14 of NPH at bed time--giving him 48 units/day total or .89 units/kg./day. 

He has recently had an upper respiratory infection and, in addition to his usual medications for cystic fibrosis--which includes Pulmazyme--he has been taking some Actifed, which probably raised his blood sugar a bit.  His blood sugars have been consistently in the higher range in the evening during the time of this recent infection.

Physical exam:
WT: 54.8 kg
BP: 122/68              Pulse: 119              
I note that he has gained .8 kg. since he was here in April, but not up to the 55.7 kg. weight he was at last November.  He states that he has his retinae checked annually and it was done six months ago. 

I saw no evidence of retinopathy.  His injection sites looked excellent.

Laboratory studies pending at this time include: CRU 105.8 MG/DL, HGB A1C     6.6 % (H) (good glycemic control).

Impression: I have asked him to obtain a urine micro-albumin screen today because he has had diabetes for just about ten years--at least he has been insulin-treated for that long, so his actual insulin impairment probably pre-dates that. 

I will see him again in about six months.  If you see him before then, do another glycohemoglobin.  Thanks for allowing me to share in his care.


Sincerely,






Nilto Carter, MD             
Associate in Endocrinology   

cc: Mr. Enrico Casement  726 Church St   New Bedford , MA  02745


CONTENT:
Etta Lear, M.D.          RE: Justin Bloch
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/16/83

Dear Dr. Lear:

We had the pleasure of seeing Justin in the Endocrine Program on 8/30/93 for evaluation of  cryptoorchidism.

History: As you know, Justin is a 10 year old who has the diagnosis of cryptoorchidism.  Justin had undescended testes bilaterally since birth. In 1985, he had a right orchidopexy and right inguinal hernioraphy. In 1986, he had a left orchidopexy and hernioraphy and right orchidectomy with testicular prosthesis replacement on the right. The parents come in with the question of possible hormonal replacement. He has been in relatively good health since the two operations. The parents do say that he has problems with constipation where he has 1-2 bowel movements a week. They have tried dietary changes without much success. He has not had any changes in his sexual development of late.

Family history:  Mom is 5'3" tall. Dad is 5'7" tall. They have a 5 year old girl and a 3 month old boy.

Physical exam:  
Height: 136.7 cm        Weight: 37.6 kg         L. testis: 2.5 x 1.2 cm 
Phallus length: 7 cm    Mid-shaft diam.: 1.5 cm 
General: Justin is a shy 10 year old male whose exam is within normal limits. He has no evidence of any pubic hair at all.

Impression: Currently, Justin is growing well. There is some question to whether or not he will develop normally from sexual standpoint. He might very well not go through puberty because of this history of undescended testicles. Right now, his left testicle is of decent size but it is still too early to tell. At this time we will check a bone age, malarian inhibiting factor, a testosterone, FSH, and LH level. He should follow-up with Dr. Blue in one year. We will have lab results in approximately 1-2 months time. We will let you know the results.

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

Sincerely,


Saurabh Simpson, MD               Lancelot Blue, MD             
                             Attending in Endocrinology   


Addendum: All results are still pending except for FSH 2.7 IU/L and LH 0.4 IU/L which are in the very early pubertal range.


CONTENT:
Daren Animal, M.D.          RE: Evelyn Howard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/28/83

Dear Dr. Animal:

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

History: Thank you very much for referring Evelyn, age 11 for assessment.  She has multiple medical problems including ocular cutaneous albinoism, pseudo obstruction with failure of feeding in childhood, ulcerative colitis diagnosed 1993 and all nutrition is currently through TPN.   Height and weight have always been below the 5th percentile.  Height velocity was adequate until approximately two years ago.   She has always maintained her weight for her height.   She has had no pubertal development to date.

Current medications: Carafate suspension, Titralac prn, Simetadine 1,000 mg daily, Ventolin prn, Pentasa 500 mg bid, Azmacort inhaler two puffs bid, Nasalcrom spray qid, Iron dextran 10 cc weekly with TPN, multi-vitamins and TPN.

Past medical history:  Tachy brady syndrome, steroid induced glaucoma 1993, three month usage of steroids only.   Asthma since age 5 and fundoplication surgery age 7.

Family history:  Two other sister, one with ocular albanism, one Ehlers Danlos syndrome, both have achieved mid parental height.   There is a positive family history of Turner's syndrome in the mother's family.

Physical exam:  
Height: 119.9 cm        Weight: 25.7 kg         BP: 90/60               
Pulse: 89               Breast: Tanner I        Pubic hair: Tanner I    
General: Well nourished.  Hickman catheter.   
Skin: Pigmentation was albino.   No stigmata of Turner's syndrome.  
Abdomen: Revealed G-tube.  
Genitourinary: Mild vaginal erythema.   
The remainder of the physical examination was normal.

Laboratory studies:  .

Impression: Pituitary function was tested in 1991 and was normal.   Bone age, measured several times in the past had always been slightly delayed.   Certainly a certain part of her growth retardation in early childhood was related to her medical illnesses and perhaps she has an element of functional hypopituitarism.

Evelyn's mother will be in touch in a few weeks.   At that point, consideration will be given to the usage of growth hormone.   We will be in touch further at that point.


Laboratory studies pending at this time include: The following studies were ordered; bone age, thyroid function tests, DHEAS, IgF-1, FSH, LH (patient was seen with Dr. Simpson who is concerned that Turner syndrome needs to be rule out).   Apparently a karyotype has been done in the past but we are awaiting her previous records to confirm this.
Thank you for letting us share in the care of Evelyn.

Sincerely,


Mitsuko Simpson, MD             
Chief Emeritus               


Addendum: Karen McCowan, M.D.

Problem list to date:

Transcribed by Fahey


CONTENT:
Daren Animal, M.D.          RE: Evelyn Howard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/28/83

Dear Dr. Animal:

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

History: Thank you very much for referring Evelyn back to the Endocrine Program (previously seen in 1990 and 1991) for assessment of her growth.

As you know, she has multiple medical problems including ocular cutaneous albinism, pseudo-obstruction with failure of feeding in childhood, ulcerative colitis diagnosed 1993.  All nutrition is currently through TPN.  Height and weight have always been below the 5th percentile.  Height velocity was adequate until approximately two years ago.  She has always maintained her weight  for her height.  She has had no pubertal development to date.

Current medications: Carafate suspension, Titralac prn, Simetadine 1,000 mg daily, Ventolin prn, Pentasa 500 mg bid, Azmacort inhaler two puffs bid, Nasalcrom spray qid, Iron dextran 10 cc weekly with TPN, multi-vitamins and TPN.

Past medical history:  Tachy-brady syndrome, steroid induced  glaucoma 1993, three month usage of steroids only.   Asthma since,  age 5 and fundoplication surgery age 7.

Family history:  Two other sister, one with ocular albanism, one Ehlers Danlos syndrome, both have achieved mid-parental height.   There is a positive family history of Turner's syndrome in the mother's family (2 cousins).

Physical exam:  
Height: 119.9 cm        Weight: 25.7 kg         BP: 90/60               
Pulse: 89               Breast: Tanner I        Pubic hair: Tanner I    
General: Well nourished.  Hickman catheter.  No stigmata of Turner's syndrome except short stature.
Skin: Pigmentation was albino.
Chest, heart and lungs not remarkable
Abdomen: Revealed G-tube.
Genitourinary: Mild vaginal erythema.
The remainder of the physical examination was normal.

Laboratory studies:  7/13/94 1344 - T4 8.9 mcg/dl, TBGI 0.90, T3 177 ng/dl, TSH 1.5 mU/L, IGF-1 267 ng/ml, LH <0.1 IU/L, FSH 2.2 IU/L, cortisol 1.4 mcg/dl and DHEAS <10 mcg/dl (cortisol and DHEAS low, pssibly secondary to the inhaled steroids).  Hand and wrist x-ray  revealed a bone age of 10 years which gives her a predicted adult height of 137 to 138.8cm (54" to 55"), the average height for patients with Turner's syndrome without growth hormone therapy.

Impression: Oculocutaneous albinism with significant intestinal dysfunction and history of ulcerative colitis with short stature and decreased growth velocity since age 7.5 years.  Preputertal at 11 2/12 years.  Currently receiving TPN.  Pituitary function was tested in 1991 and was normal.  Bone age, measured previously and again today, is slightly delayed for chronocological age but well above her height age and thus consistent with a genetic cause (as seen in Turner's syndrome) for her short stature.  The decrease in her growth velocity since her last visit to the Endocrine Program is probably related to a delay in the hormonal changes associated with adrenarche and gonadarche and possibly secondary to GI illnesses although not due to deficient calories as she is approximately 3.7 kg (16%) overweight for height.  The prepubertal levels of LH and FSH are as expected for her lack of pubertal changes and are not helpful in excluding primary hypogonadism such as associated with Turner's syndrome.  The latter is of interest because of her pattern of growth and development and the unusual family history.  The Division of Genetics here has no record of a karyotype being done.  If it has not been done elsewhere, it is indicated to exclude this syndrome as the cause of her growth pattern since, if she has this disorder, she would be a candidate for growth hormone therapy.

Disposition: I have contacted Mrs. Howard and requested blood for a karyotype.  When the results are available, a decision concerning treatment with growth hormone can be made.
Thank you for letting us share in the care of Evelyn.

Sincerely,


Mitsuko Simpson, MD             
Chief Emeritus               


Addendum: Karen McCowan, M.D.
Fellow in Endocrinology


CONTENT:
Milton Animal, M.D.          RE: Evelyn Howard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/28/83

Dear Dr. Animal:

We had the pleasure of seeing Evelyn in the Endocrine Program on 11/3/94 for short stature.

History: Evelyn is now 11 years and 6 months old.   Evelyn has a number of problems including oculo-cutaneous albinism, autonomic dysfunction, intestinal pseudo obstruction, inflammatory bowel disease, and is TPN dependent.   She had a J-tube placed at 8 years of life, but due to continued inability to gain weight and bleeding from the colon, a central venous line was placed.  She tolerated a small amount of foods orally, but is mostly on TPN.   Evelyn has developed glaucoma from steroid treatment from inflammatory bowel disease.   She was on intravenous steroids for two months from December of 1993 to February of 1994.   She is not on any steroids currently.   Evelyn's other medical problems include ADHD and she will be starting on Dexadrine, in the near future.   Evelyn also has a history of seizures, but has not been on any anti-convulsants for two years.   Evelyn is legally blind from her oculo-cutaneous albinism.  She also has submucosal cleft.   She has returned to the Endocrine Clinic for lack of growth despite good calorie intake.

Current medications: Multi-vitamins, Tagamet, Pentasa, Carafate suspension, Nasalcrom spray, Azmacort inhaler, iron dexadran 10 cc weekly with her TPN, Titralac prn, Ventolin prn and TPN.

Family history:  Evelyn has a 20 year old sister with Ehler-Danlos syndrome and a 23 year old sister with albinism.  Both sisters are 5'2" tall.   Mom had two spontaneous abortions, is 46 years old, 4'10" tall, has albinism, asthma and mitral valve prolapse and has three siblings.   Mom's 34 year old sister has albinism, eczema and is 5 feet tall and her 31 year brother has albinism and is 5'8" tall.  Mom also has a 43 year old sister who is 5 feet tall and has asthma.  This sister has two children who are normal.  Evelyn's maternal grandmother is 67 years old and has Lupus and intestinal malrotation.   Evelyn's maternal grandmother's brother has adult onset diabetes, and has a son, who has a daughter who died with Turner syndrome.   In addition, Evelyn's maternal grandmother has a sister who had a daughter who is now 32 years old and has Turner's syndrome.   Evelyn's father is 49 years old and 5'10" tall.   He has a brother who has multiple sclerosis and is 5'10" tall.  This brother has a daughter who also has Ehler- Danlos syndrome.  The father's side of the family is Syrian and the mother's side of the family is English, Irish and Swedish.

Physical exam:  
Breast: Tanner I        Pubic hair: Tanner I    
Height: 120.7 cm (below the delayed case, and 0.8 cm increase over the past three and a half months).  Weight 25.7 kg (just below the delayed case, and the same as at her last visit three and a half months ago).   
General: Small, somewhat immature female in no apparent distress.   
Skin: Soft.  
HEENT: Normocephalic, atraumatic.   Glasses are worn . 
Neck: No thyromegaly.  
Chest: Clear.  
Heart: Regular rate and rhythm. 
Abdomen: J-tube and CVL were in place.  There was no hepatomegaly. 
Genitourinary: Tanner stage I.  
Extremities: Grossly intact.

Laboratory studies:  A bone age was 10 years at a chronologic age of 11 years and 3 months.

Impression: Evelyn is quite short, with a decreased growth velocity, and has not undergone puberty.   She had blood drawn for chromosomes recently, which showed a normal 46 XX karyotype.   However, given the strong family history of Turner syndrome, and Evelyn's short stature and lack of puberty, I would like to rule out the possibility that Evelyn is a Turner Mosaic, a skin biopsy was performed.  A 3 mm punch biopsy was obtained and was sent for fibroblast culture for chromosome analysis.

Disposition: If the chromosomes on the skin biopsy are normal, I will consider performing an insulin tolerance test and an GnRH stimulation test.  Return to clinic in four months.
Thank you for letting us share in the care of Evelyn.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Milton Animal, M.D.          RE: Evelyn Howard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/28/83

Dear Dr. Animal:

We had the pleasure of seeing Evelyn in the Endocrine Program on 1/10/95 for short stature.

History: Evelyn is now 11 years and 8 months old.   As she has oculocutanoeous albanisim, automatic dysfunction, intestinal pseudo obstruction, inflammatory bowel disease, and is TP dependent.  She had a skin biopsy on her last visit, and the fibroblast did not grow so we were unable to determine if she is a 46 X/46 XX Mosiac.   She had a renal ultrasound today which showed normal prepubertal ovaries and uterus, and normal kidneys.   Mom is a little bit concerned as Evelyn has gained 5 pounds over teh last several months, and she growing changes in her TPN.

Physical exam:  
Height: 122.0 cm        Weight: 28 kg           BP: 100/60              
Pulse: 90               Breast: Tanner I        Pubic hair: Tanner I    
General: Small, well developed female.
Skin: Very pale.  
HEENT: Hair is almost white.   Oropharynx is normal.   
Chest: Clear.  
Heart: Regular rate and rhythm without a murmur.  
Abdomen: Several tubes and bandages in place.  
Genitourinary: Prepubertal female external genitalia.   
Neurological: Deep tendon reflexes are 1+ on teh right, lower extremity, and I was unable to ilicit them on the left.

Impression: Evelyn has grown 1.3 cm over the past 2-3 months.   Her ultrasound does not suggest that she has        ovaries but it is difficult to dtermine given the fact taht her ovaries and uterus are prepubertal.   Her most recent LH was less than 0.1 and FSH was 0.2 (both were performed about 5 months  ago).   Mom is unwilling to have Evelyn undergo another skin biopsy at this time, and we will obtain another skin fibroblast culture if Evelyn undergos any type of surgerical procedure, even minor, were we can obtain a piece of skin.  In the meantime, we will  hold off on this test.  We also discussed whether a GnRH stimulation test and growth hormone stimulation test are warranted at this point.   Evelyn had an IGF-1 in the normal range 5 months ago, and the LH and FSH as mentioned.   Both Mrs. Howard and myself are hesitant toodo any testing on Evelyn unless there is a potential clear reason and benefit.

Disposition: I will discuss with Dr. Crigler, his thoughts on whether we should go provocative testing.   In the meantime, we will continue to follow Evelyn.  Return to clinic in 6 months.
Thank you for letting us share in the care of Evelyn.

Sincerely,


Penelope Hagen, MD              
Attending in Endocrinology


CONTENT:
Milton Animal, M.D.          RE: Evelyn Howard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/28/83

Dear Dr. Animal:

I saw Evelyn in the Endocrine Program on 9/14/95 for short stature.

History: Evelyn is now 12 years and 4 months old.  She has a history of autonomic dysfunction and albinism, and is on total parenteral nutrition.  She has been doing quite well.  Her work-up for short stature has been negative, including a normal growth hormone stimulation test, and no evidence for Turner's syndrome on karyotype testing on a blood lymphocyte sample or on a skin biopsy.  On GNRH test in February, she had an LH that went from less than 0.1 to 1.3 and an FSH of 4.2 that increased to 13.2.  This suggests that her pituitary is functioning and producing  gonadotropins. She is complaining of hair on her legs especially under her knees, but not anywhere else.

Current medications: None.

Physical exam:
Ht: 123.4 cm            Wt: 29.2 cm
BP: 110/70              Pulse: 90               
Breast: Tanner I        Pubic hair: Tanner I    
General appearance:  A well-developed but short female. Skin: pale. HEENT: hair very light in color. Pupils equal, round and reactive to light. Oropharynx clear. Neck: no thyromegaly.  Chest: clear. Cardiac: regular rate and rhythm. Abdomen:  benign with tubes in place.  GU: prepubital. Extremities: she has hair on her knees and legs, which is soft.

Laboratory studies:  Bone age is 10 years at a chronological age of 12 years and 4 months

Impression: We have no explanation for Evelyn's short stature.  Her  hormone work-up has been negative to this point.  She also has delayed puberty.  Her bone age is still read at 10 years, which it was a year ago, and is now delayed.  This suggests that she has not developed much over the past year in terms of bone development.  She appears to not have enough estrogenn to be advancing her bone age.  It is possible that she may have some gonadal failure, and that we tested too early in her progression of puberty.  However, she had an ultrasound that  showed she had normal prepubertal ovaries.  We clearly do nnot have a good explanation for what is going on with Evelyn, but she does not appear to be GH deficient.  We will have to watch her, and may have to retst her gonadal axis in the future, if she does not progress in her development.

Disposition: We plan to follow Evelyn every six months, and repeat a GNRH stimulation test in several years if she still has not gone into puberty.



Sincerely,




Penelope Hagen, MD              
Attending in Endocrinology   


cc:  Margaret Bauman, M.D. Youville Hospital Cambridge Street
     Cambridge, MA 02139

     Michael McKenzie, M.D. Pediatric Associates of Wellesley
     134 South Avenue Weston, MA 02193

     Russell Howard  14 Pembroke St  Medford , MA  02155

     Clifford Lo, M.D. Division of Nutrition Children's Hospital
     Boston, MA 02115


CONTENT:
Milton Animal, M.D.          RE: Evelyn Howard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/28/83

Dear Dr. Animal:

I saw Evelyn in the Endocrine Program on 3/28/96 for short stature and delayed puberty.

History: Evelyn is now 12 years and 11 months old.  She recently had surgery to change her G-tube, and due to complications, ended up staying in the hospital for about 10 days.  She developed a chemical peritonitis and was treated intravenously and with antibiotics.  She is doing much better now.  She continues on her total parenteral nutrition, so she did not lose weight during this illness.

Current medications: None.

Physical exam:
HT: 125.5 cm    WT: 30.2 kg     BP: 95/65       Pulse: 90              
Breast: Tanner I        Pubic hair: Tanner I    
General appearance:  Well developed, small, in no apparent distress.  Skin:  Pale.  HEENT: Normocephalic/atraumatic, very blonde hair, pupils equal, round and reactive to light.  Neck: No thyromegaly.  Lungs: Clear.  Breasts: Tanner I.  Heart: Regular rate and rhythm without a murmur.  Abdomen: G-tube in place.  GU: Tanner Stage I pubic hair, prepubertal, red and shiny vaginal mucosa.

Impression: Evelyn is growing slowly, and is not going into puberty.  Her bone age on two occasions now has been approximately 10, once was 6 months ago, the other was almost 2 years ago.  He has had extensive studies, as outlined in my previous letter, and we have found no etiology to her delayed puberty and her short stature.

Disposition: We will continue to follow Evelyn, and plan to repeat her bone age in 6 months.  If she has not started with breast development by the time she is 14 to 15 years, we will repeat her GnRH stimulation test, and consider estrogen therapy.  Return to clinic in 6 months.


Sincerely,




Penelope Hagen, MD              
Attending in Endocrinology   

cc: Margaret Bauman, M.D. Youville Hospital Cambridge Street 
    Cambridge, MA 02139
    Clifford Lo, M.D. Division of Nutrition Children's HospitalBoston, MA 02115
    Michael Mckenzie, M.D. Pediatric Associates of Wellesley 134 South Avenue
    Weston, MA 02193
    Mr. & Mrs. Russell Howard  14 Pembroke St  Medford , MA  02155


CONTENT:
Antonio Meisner, M.D.          RE: Evelyn Howard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/28/83

Dear Dr. Meisner:

I saw Evelyn in the Endocrine Program on 1/2/97 for short stature and delayed puberty.

History: Evelyn is now 13 years and 8 months old.  She was recently found to have osteopenia, documented on a bone density study done at Newton Wellesley Hospital.  Evelyn has asthma and was on inhaled steroids several years ago, but developed glaucoma.  She was then switched to Azmacort, which when she took it 3 times a day exacerbated her glaucoma.  Over the past several years, she has been on Azmacort twice a day and has had no problems with glaucoma.  She is in a wheelchair at school for a while during the day, but does not use a wheelchair at home.  She does walk around, but her stamina continues to be low.

Current medications: Azmacort inhaler BID.  Reglan 7.5 mg Q8H IV.  Pepcid 20 mg Q8H IV.  Mineral oil laxatives.  Neo-Calglucon 20 cc QD.  22.5 mEq of calcium in her PN.

Physical exam:
Height: 128.8 cm        Weight: 32.6 kg
BP: 131/55              Pulse: 106              
Breast: Tanner II       Pubic hair: Tanner II   
Evelyn's physical exam is notable for a left breast bud, with no breast tissue palpable on the right.  In addition, she has some pubic hair on her labia majora.

Laboratory studies: 
CRU        19.2   MG/DL       MG          2.2   MG/DL    
ALKP        258     U/L (H)   CAU        10.6   MG/DL    
ALB         3.7    G/DL       PHOS        3.8   MG/DL    

Impression: Evelyn may be in early puberty given that she has a left breast bud.  This is good news, and we will follow.

Regarding her osteopenia, the bone density is a little difficult to evaluate, since the standards used are usually age-based, and not Tanner stage based.  Evelyn's bone density should be compared to a child with her bone age.  We do not have the standards used to determine her bone density, and thus cannot comment on it.  However, it would not be suprising if she were osteopenic, and her osteopenia may be related to her inhaled steroids and her decrease in activity.  In assessing whether she has a metabolic bone disease, we noted that her urine calcium to creatinine ratio is elevated at 0.55, which may be due to the fairly large amount of calcium she is taking.  We don't feel that she is likely to be vitamin D deficient.

Disposition: We will discuss the amount of calcium Evelyn is getting with Nutrition Support.  We will await her calcium, 1,25-dihydroxy vitamin D and 25-hydroxy vitamin D levels to full assess whether she has a metabolic bone disease.  We would like to see Evelyn back in our clinic in 6 months.


Sincerely,



Penelope Hagen, MD              
Attending in Endocrinology   

cc:  Alejandro Flores, M.D.  40 Second Street  Waltham, MA 02154

     Robert Sundel, M.D.  Allergy and Immunology  Children's Hospital  300 Longwood Ave.  Boston, MA 02115

     Clifford Lo, M.D.    Division of Gastroenterology & Nutrition   Children's Hospital 

     Russell Howard   14 Pembroke St   Medford , MA  02155


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 12/27/93 for diabetes mellitus.

History: Marlon is a 17 and 9/12 year old boy with diabetes mellitus since September 1991.    He has had a recent bout of an upper respiratory infection and also gastroenteritis, but is currently doing well.   He is doing well in school,  is a junior in high school, and plays several sports.

His current dose of insulin is 4 units of Regular and 19 units of NPH in the morning with 3 units of Regular and 10 units of NPH in the afternoon for a total of 36 units daily or 0.53 U/kg/day.   

He has had no hypoglycemic reactions since his last visit, and is on an exchange diet.

Review of systems:  Review of his log book today revealed most of his pre-breakfast sugars were between 80 and 180 mg/dL.   He had very few pre-lunch values measured but these were occasionally low between 60 and 90.   Pre-supper and pre-bedtime were similar to the morning values.

Physical exam:  
Height: 176.1 cm        Weight: 67.9 kg         BP: 90/60               
Pulse: 60               Pubic hair: Tanner VI   
General physical examination was entirely normal.

Laboratory studies:  Glycosylated hemoglobin of 7.4%.

Impression: Marlon is an almost 18 year old young man with diabetes mellitus who appears to be still in the honeymoon period and in good glycemic control on his current regimen.   Given his mild hypoglycemia in the morning, before lunch, we have asked him to obtain additional blood sugar checks at this time.    In the meantime, we will cut his morning Regular insulin dose to 2 units and continue his morning NPH insulin dose at 19 units.  He will call us back in a few weeks to tell us the results of this maneuver.

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

Sincerely,


Antonio Capulet, MD             Kendell Simpson, MD             
Fellow in Endocrinology      Clinical Director


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 8/8/94 for diabetes mellitus.

History: Marlon is an 18 and 4/12 year old young man with diabetes mellitus who has been in excellent health since his last visit.   He denies any symptoms of significant hypoglycemia, nor has he had any hyperglycemic episodes since his last visit.  He saw the ophthalmologist in July and was given a clean bill of health.   He monitors his blood sugars with  One Touch II meter, both before breakfast and before supper.   Today, review of his log book revealed that most of the pre-breakfast sugars were between 80 and 180 mg/dL, but the pre-supper sugars were a bit higher between 100 and 240 mg/dL.  No monitoring was done at lunch or at bedtime.   He has decreased his activity level since the last visit.   His diet is approximately 3,200 calories (ADA exchange meal plan).  

Current insulin dose is 2 units of Regular and 19 units of NPH in the morning and 3 units of Regular with 10 units of NPH in the afternoon for a total of 34 units daily or 0.5 units/kg/day.

Physical exam:  
Height: 175.2 cm        Weight: 68.8 kg         BP: 90/60               
Pulse: 72               Breast: Tanner I        Pubic hair: Tanner VI   
General: He is an alert, pleasant boy in no acute distress.  
Skin: Benign.  
HEENT: Extraocular movements and pupillary reflexes were normal.   Oropharynx was benign.  
Neck: Supple.   
Chest: Clear.  
Heart: No murmur noted. 
Abdomen: Soft.  
Genitourinary: Normal Tanner V male.  
Extremities: Mild lipo-hypertrophy was noted in the right leg.  
Neurological: Deep tendon reflexes are symmetrical.

Laboratory studies:  Glycosylated hemoglobin 9.9%.

Impression: Marlon is an 18 and 4/12 year old young man with diabetes mellitus who is currently doing well.   However, given his glycosylated hemoglobin which is higher than previous visits, I suspect that he may be coming out of the honeymoon period.   I have asked that he obtain additional blood sugars, both at lunch and at bedtime and give me a call back in a week so that I can adjust his insulin dose if need be at that time.   We have also discussed at length the importance of avoiding ethanol.  In diabetic patients, it can lead to severe hypoglycemia.   

Finally, as I will be leaving the state in a few weeks to take a new job in Michigan, I have suggested that the Binghams consider follow up with Dr. John Capotorto at the Joslin.   He is a fellow there and I know him very well and certainly he would be a wonderful resource for the Binghams.   However, I explained that referral patterns are often set by insurance companies and I have asked the family to contact you regarding the appropriate follow up provider for Marlon.

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

Sincerely,


Antonio Capulet, MD             Maureen Shields, MD             
                             Attending in Endocrinology


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 9/27/91 for evaluation of diabetes.

History: Marlon is a 15 and 1/2 year old boy who was recently diagnosed with diabetes.  He was admitted to Children's from 9/6/91-9/13/91 for teaching related to his diabetes.  He presented to the clinic today with a history of upper respiratory tract infections, mild cough, fever and some wheezing for the last day or two.  His diabetes control has been quite good.  His medicines include insulin 14 of NPH in the morning with 7 units of Regular 5 units of NPH in the evening with 4 units of Regular.  He had no hypoglycemic reactions and follows approximately 3000 calorie day diet.  He exercises quite frequently and will take an extra snack prior to exercise.  Monitoring has been going extremely well with the pre-breakfast, pre-lunch, pre-dinner and pre-bedtime sugars being in quite good range.

Physical exam:  
Height: 169.2 cm        Weight: 54.6 kg         BP: 90/50               
Pulse: 100              Breast Tanner: 2        Pubic hair Tanner: 4    
General: Alert, pleasant white male with mild respiratory distress.
Skin: 
HEENT: Benign.
Neck: Thyroid gland was not palpable.
Chest: Revealed bilateral defused wheezes with mild to moderate obstruction to forced ? maneuvers. 
Heart: Without murmur.
Abdomen: Soft.
Genitorurinary: Normal.

In summary: It is our impression Marlon's diabetes management was going extremely well and infact he had been using the sliding scale sick day dosing without much difficulty.  However, given the fact that he was wheezing we began him on a Beta 2 Agonist (Ventilin inhaler) after a nebulizer in the office cleared his wheezing.  As I explained to him this is likely to make his sugars much higher ?followed sick day dosing for the next few days.  I have just spoken to him on the phone and he is doing extremely well.  In terms of his diabetes management, we have nothing further to add and would like to see him back in one months time.

Disposition: 

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

Sincerely,


Antonio Capulet, MD                      Etta Kramer, MD


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 9/27/91 for evaluation of diabetes.

History: Marlon is a 15 and 1/2 year old boy who was recently diagnosed with diabetes.  He was admitted to Children's from 9/6/91-9/13/91 for teaching related to his diabetes.  He presented to the clinic today with a history of upper respiratory tract infection, mild cough, fever and some wheezing for the last day or two.  His diabetes control has been quite good.  His medicines include insulin 14 units of NPH in the morning with 7 units of Regular and 5 units of NPH in the evening with 4 units of Regular.  He has had no hypoglycemic reactions and follows a 3000 calorie/day diet.  He exercises quite frequently and will take an extra snack prior to doing so.  Monitoring has been going extremely well with the pre-breakfast, pre-lunch, pre-dinner and pre-bedtime sugars being in quite good range.

Physical exam:  
Height: 169.2 cm        Weight: 54.6 kg         BP: 90/50               
Pulse: 100              Breast Tanner: 2        Pubic hair Tanner: 4    
General: Alert, pleasant white male with mild respiratory distress.
Skin: 
HEENT: Benign.
Neck: Thyroid gland was not palpable.
Chest: Bilateral diffuse wheezes with mild to moderate obstruction to forced expiratory maneuvers. 
Heart: Without murmur.
Abdomen: Soft.
Genitorurinary: Normal.

In summary: It is our impression Marlon's diabetes management was going extremely well and in fact he had been using the sliding scale sick day dosing without much difficulty.  However, given the fact that he was wheezing we began him on a Beta 2 Agonist (Ventolin inhaler) after a nebulizer in the office cleared his wheezing.  As I explained to him this is likely to make his sugars  higher, and he will follow sick day dosing for the next few days.  I have just spoken to him on the phone and he is doing fine.  In terms of his diabetes management, we   we would like to see him back in one months time.  We have instructed the family to follow-up with you in regard to the wheezing.

Disposition: 

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

Sincerely,


Antonio Capulet, MD                      Etta Kramer, MD


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 02/28/92 for  follow-up of diabetes mellitus.

History: Marlon is a 15 and 10/12 year old boy with diabetes, diagnosed in 9/91.  He has been doing extremely well, and has essentially no problems since his last visit. He has been involved in athletics, and is doing well in school.  He has several supportive friends who are aware of his diagnosis.  Current insulin dose: 12-14 units NPH (depending on afternoon activity) in the morning with 5 units of regular, and 5 units of NPH with 3 units of regular in the evening for a total of 25-27 units/day (0.40 units/kg/day).  The injections are given 10-15 minutes before meals, and are usually in the upper or lower extremity. He has had occasional hypoglycemic reactions after playing sports, as he often feels a bit sweaty and tired. However, he recognizes the onset and treats them appropriately with Lifesavers or soda.  His diet is a 3,200 cal/day ADA exchange diet and he seems to feel this is an appropriate amount of food.  He exercises daily and as mentioned, adjusts his insulin.   Blood sugars are monitored with  One Touch 2 meter with good technique and they are recorded in log book. His pre-breakfast and pre-dinnr sugars are mostly in the 110-120 range.

Physical exam:  
Height: 171.8 cm        Weight: 62.1 kg         Breast Tanner: 2        
Pubic hair Tanner: 5    
General: Height increase of 1 cm in the last 3 months. Ideal body weight for stature is approximately 61 kg.  Healthy appearing male in no acute distress.
Genitourinary: Tanner genitals: 5
HEENT: Benign
Neck: Thyroid not palpable.
Lungs: Clear.
Heart: Without murmur.
Abdomen: Soft, non-tender without hepatosplenomegaly
Neurological: including deep tendon reflexes was normal.

Laboratory studies:  Glycosylated hemoglobin on the day of his visit was 7.1%.

Impression: Marlon is a 15 and 10/12 year old boy with diabetes mellitus now for 5 months who is doing well on his current regimen.  His glycosylated hemoglobin on the day of his visit was 7.1% which is within normal range, making it certain that much of his good control may relate to his honeymoon phase and endogenous insulin secretion.  We have not changed the current insulin dose at this time and have stressed to the parents the importance about watching for him coming out of the honeymoon period.

Disposition: We would like to see Marlon back in Clinic in three months.

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

Sincerely,


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


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 6/5/92 for evaluation of diabetes mellitus .

History: Marlon is a 16 and 2/12 year old boy with diabetes mellitus for nine months. He has had no recent medical problems, and is the ninth grade and does well in school.  The major issue at this point is financial. The father is recently unemployed and the mother is attempting to pay several old medical bills related to Marlon's diabetes. His insulin management has been quite good, on current insulin doses of 14 units of NPH in the morning with 5 units of regular, and 5 units of NPH in the evening with 3 units of regular. Total is 27 units daily, or 0.42 units/kg daily. The injections are given in the upper and lower extremities and occasionally in the abdomen.

Review of systems:  Was benign. He has had no severe reactions, and those he has had have involved fatigue, shakiness, and sweatiness. They are usually related to exercise without an adequate snack. Diet is 3200 calories on the exchange program and it seems to be adequate. He exercises daily, and plays several different sports. Blood sugar monitoring is with Chem Strips and these are recorded in a log book. He monitors before breakfast and before dinner; breakfast sugars have been in the 100-150 range, and pre-dinner in the 80-160 range with an occasional 60-70 seen.

Physical exam:  
Height: 173.8 cm        Weight: 64.2 kg         Pubic hair: Tanner V    
General: Marlon is an ideal body weight for his height.  He is an alert boy in no acute distress. He had right sided gynocomastia.  The rest of the general physical exam was normal.

Impression: Marlon is a 16 and 2/12 year old boy with diabetes for nine months with very good control clearly in the honeymoon period. Glycosylated hemoglobin was 6.5% and his random blood sugar was 146 mg/dL, confirming our impression. The family met with Alan Gooodman (social worker) to arrange for monetary assistance. We have elected to continue his current insulin dose, and suggested that he delay his evening insulin dose on the days when he plays a late ball game. On these days he will need a second snack prior to the ball game.

Disposition: We would like to see him back in three months.
Thank you for letting us share in the care of Marlon.

Sincerely,


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


Problem list to date:
INSULIN-DEPENDENT-DM         Start: 02/28/92  End:          Invalid: 

Transcribed by Cassells


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

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

History: Marlon is a 16 and 2/12 year old boy with diabetes mellitus, diagnosed in September, 1991.  He has had no recent medical problems, is in the ninth grade and does well in school.  A major issue for the family at this time is financial. The father is recently unemployed and the mother is attempting to pay several old medical bills related to Marlon's diabetes. His insulin management has been quite good, on current insulin doses of 14 units of NPH in the morning with 5 units of regular, and 5 units of NPH in the evening with 3 units of regular; total daily, dose=0.42 units/kg . The injections are given in the upper and lower extremities and occasionally in the abdomen.

Review of systems:  Benign. He has had no severe reactions, and those he has had have involved fatigue, shakiness, and sweatiness. They are usually related to exercise without an adequate snack. Diet is 3200 calories on the exchange program and it seems to be adequate. He exercises daily, and plays several different sports. Blood sugar monitoring is with Chem Strips and these are recorded in a log book. He monitors before breakfast and before dinner; breakfast sugars have been in the 100-150 range, and pre-dinner in the 80-160 range with an occasional 60-70 seen.

Physical exam:  
Height: 173.8 cm        Weight: 64.2 kg         Pubic hair: Tanner V    
General: Marlon is an ideal body weight for his height.  He is an alert boy in no acute distress. He had right sided gynocomastia.  The rest of the general physical exam was normal.

Impression: Marlon is a 16 and 2/12 year old boy with diabetes for nine months with very good control clearly in the honeymoon period. Glycosylated hemoglobin was 6.5% and his random blood sugar was 146 mg/dL, confirming our impression. The family met with Ellen Gooodman (social worker) to arrange for monetary assistance. We have elected to continue his current insulin dose, and suggested that he delay his evening insulin dose on the days when he plays a late ball game. On these days he will need a second snack prior to the ball game.

Disposition: We would like to see him back in three months.
Thank you for letting us share in the care of Marlon.

Sincerely,


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


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 9/22/92 for follow-up of diabetes mellitus.

History: Marlon is a 16 and 6/12 year old boy with diabetes mellitus for a year, who has had no medical problems since his last visit. He is in the 10th grade and doing well, and has supportive friends. His current insulin dose is 14 NPH and 5 units of regular in the morning with 5 units of NPH and 3 units of regular in the afternoon for a total of 27 units daily or 0.42 units/kg/day. He has had no hypoglycemic reactions since his last visit, and his review of systems today was benign. His current diet is 3000 calories on the exchange program. He exercises daily and monitors his blood sugars with a One Touch II meter. Typical pre-breakfast sugars are in the 100-170 mg/dL range, with a similar range pre-supper.

Physical exam:  
Height: 173.6 cm        Weight: 64.9 kg         BP: 110/70              
Pulse: 60               Breast: Tanner I        Pubic hair: Tanner VI   
The general physical examination was unremarkable.

Impression: Marlon is a 16 and 5/12 year old boy with diabetes mellitus in the honeymoon period, doing well on his current insulin regimen. Glycosylated hemoglobin today was normal at 7.2%, confirming our impression of his honeymoon status. We would like to see him back in three months.

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

Sincerely,


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


Problem list to date:
INSULIN-DEPENDENT-DM         Start: 02/28/92  End:          Invalid: 

Transcribed by Cassells


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 1/5/93 for follow-up of diabetes mellitus.

History: Marlon is a 16 and 9/12 year old boy with diabetes mellitus, diagnosed in  September, 1991. He has had no recent medical issues, and is currently in the 10th grade and doing well. 

His current insulin dose is 14 units of NPH and 5 units of regular in the morning, with 5 units of NPH and 3 units of regular in the afternoon, for a total of 0.47 units/kg/day.  

He has had no hypoglycemic reactions since his last visit, and follows a 3200 calorie per day ADA diet. He exercises daily (basketball), and we have adjusted his diet as follows: on the day of basketball games, he will take an extra snack at 5 p.m. rather than taking his insulin and meal at that time. When the game is finished, he will then take his insulin and eat his evening meal at 7:45 p.m.   This seems to work quite well. His blood sugars are monitored with a One Touch II Meter and review today revealed most blood sugars in the 80-180 mg/dL range.

Physical exam:  
Height: 174.6 cm        Weight: 65.8 kg         BP: 100/60              
Pulse: 68               
Marlon's general physical examination was normal.

Impression: Marlon is a 16 and 9/12 year old boy with diabetes mellitus who still, by definition, is in the honeymoon period. However, the current pattern of his blood sugars suggest that he may be coming out of the honeymoon in the next few months. We have discussed this with the parents and have made no changes in his current insulin dose. His glycosylated hemoglobin today was 7.7%. We would like to see him back in three months.

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

Sincerely,


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


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 4/20/93 for follow-up of diabetes mellitus.

History: Marlon is a 17 year old boy with diabetes mellitus diagnosed in September of 1991. His general health has been excellent since his last visit. He is currently in the 10th grade and doing well. His current insulin dose is 14 units NPH with 5 units of Regular in the morning, 5 units NPH and 3 units Regular in the afternoon for a total of 27 units daily or 0.41 unit/kg/day.

Review of systems:  He has had  very rare mild hypoglycemic reactions. He is on a 3200 calorie meal plan, and exercises daily. The blood sugars are monitored with a One Touch II meter. Review of his records today revealed pre-breakfast and pre-dinner sugars in the 80-180 mg/dL range.

Physical exam:  
BP: 100/60              Pulse: 92               Pubic hair: Tanner VI   
The entire general physical examination was unremarkable aside from a few areas of vitiligo.

Laboratory studies:  Glycosylated hemoglobin 7.8%, random glucose 201 mg/dL.

Impression: Marlon is a 17 year old boy with diabetes mellitus in the honeymoon period , doing well on his current regimen. We have elected to continue his current dose and see him back in three months.

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

Sincerely,


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


CONTENT:
Gleide Capulet, M.D.          RE: Marlon Bingham
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/08/76

Dear Dr. Capulet:

We had the pleasure of seeing Marlon in the Endocrine Program on 8/24/93 for follow-up of diabetes mellitus.

History: Marlon is a 17 and 4/12 year old boy with diabetes mellitus diagnosed in September of 1991. His general health has been good since his last visit and he is actively involved in athletics. 

His current insulin dose is 5 units of Regular in the morning with 14 units of NPH and 3 units of Regular in the afternoon with 5 units of NPH for a total of 27 units daily or 0.40 units/kg/day. 

Injections are given in the upper and lower extremities as well as the abdomen and are rotated appropriately. He has had no hypoglycemic reactions since his last visit and follows a 3200 meal plan. Blood sugars are monitored twice daily with a One Touch II meter, most of the blood sugars are between 80 and 180 mg/dL. However, it was obvious that the pre-breakfast sugars have been a bit elevated compared to previous visits.

Physical exam:  
Height: 175.3 cm        Weight: 67 kg           BP: 90/60               
Pulse: 60               Pubic hair: Tanner VI   
General physical examination was entirely normal.

Laboratory studies:  Glycosylated hemoglobin 7.7%.

Impression: Marlon is a 17 and 4/12 year old boy with diabetes mellitus, clearly still in the honeymoon period. With a slight increase in his blood sugars in the morning pre-breakfast, we have increased his evening NPH to 6 units daily. We would like to see him back in four months.

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

Sincerely,


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


CONTENT:
Nilberto Meisner, M.D.          RE: Elisha Wynn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/15/83

Dear Dr. Meisner:

We had the pleasure of seeing Elisha in the Endocrine Program on 12/15/94 for hypothyroidism.

History: Elisha is an 11 and 8/12 year old who was first noted to have thyroid gland enlargement approximately two years ago.   At that time she was asymptomatic with normal thyroid hormone levels, a TSH of 5.6 mcU/ml, and negative anti-microsomal antibodies.   Follow up in May 1993 revealed a diffuse increase in thyroid gland enlargement.   At that time,  she had dry skin and fatigue.   Laboratory studies included a low T4 of 4.4 mcg/dL and elevated TSH of 140 mcU/mL, positive anti-microsomal antibodies of 1:6,400, and negative anti-thyroglobulin antibodies.   She was treated with Levothyroxine 50 mcg daily and has required increased doses over time.  The last increase was to 88 mcg on June 30, 1994 for a borderline elevated TSH of 5.0 mcU/mL.

Current medications: Levothyroid 88 mcg po q day.

Past medical history:  She was the 5 pound 3 ounce product of an 8 month gestation with pregnancy complicated by vaginal bleeding treated with bed rest.   She was delivered vaginally without complications.   Growth and development; she walked at 11 months.  Illnesses; febrile seizures twice.   Hospitalizations; hospitalized for the first febrile seizure at approximately one year.   Injuries and operations; none.

Review of systems:  Skin; no dryness or diaphoresis.   HEENT; status post severe headaches but none in the past 6 months.   Cardio-Resp; over the past few weeks she has noticed her heart racing in school.  GI; no constipation.   Intermittent diarrhea present for one month.  GU; no polyuria or polydipsia.   Neurologic; occasional tremulousness.

Family history:  Thyroid disease in the maternal grandmother, possibly hypothyroidism but no longer requiring medications.   There is a family history of cystic fibrosis in two paternal siblings, cancer on both sides and heart disease on he maternal side.   Maternal height 5'2", paternal 5'9".

Physical exam:  
Height: 142.4 cm        Weight: 44 kg           BP: 102/58              
Pulse: 80               
General: Alert.
Skin: Normal texture.    
HEENT: Pupils equal, round, reactive to light.   Extraocular movements intact.  
Neck: Thyroid gland diffusely enlarged without nodularity.   Length approximately 3.5 cm bilaterally.   
Chest: Clear.  
Heart: Regular rate and rhythm without murmur.   
Abdomen: Soft without hepatosplenomegaly.   
Genitourinary: Pubic hair scant, Tanner II.    
Extremities: Well perfused.   
Neurological: Normal ankle deep tendon reflex, relaxation phase.  No fine tremors.

Prior Labs:  11/10/94: T4 9.7 mcg/dL (normal 4.2-11.8), T3 uptake 27% (normal 25-35), free T4 2.60 (normal 1.10-4.50), TSH 0.09 (normal 0.35-5.50).

Impression: Elisha's T4 level is within normal limits.  However, her suppressed TSH implies subclinical hyperthyroidism and therefore, excessive thyroid hormone replacement.  This is consistent with her symptoms of diarrhea and a racing heart.

Disposition: I have decreased her Levothyroid dose to 75 mcg q day.   She should have thyroid function tests checked at HCHP in two months.   If these are within normal limits, please recheck them in 6 months prior to her next visit.
Thank you for letting us share in the care of Elisha.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Nilberto Meisner, M.D.          RE: Elisha Wynn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/15/83

Dear Dr. Meisner:

We had the pleasure of seeing Elisha in the Endocrine Program on 6/29/95 for acquired hypothyroidism.

History: Elisha is a 12 and 2/12 year old with Hashimoto's thyroiditits.  She has a good energy level, and denies heat or cold intolerance, dry skin (except for her feet), diaphoresis, hair loss, constipation, or tachycardia.  She had severe diarrhea felt secondary to a parasitic infection or lactose intolerance, which has cleared after 8 days of medication and 3 weeks of a lactose-free diet.  Today, she has some mild lower abdominal pain without dysuria.

Current medications: Synthroid 75 mcg po QD.  She misses ~1 pill per week, and then takes 2 the next day.

Physical exam:  
Height: 146.1 cm        Weight: 47.2 kg         BP: 120/70              
Pulse: 70               U/L ratio:  0.9         Arm span: 146.6         
Breast: Tanner I        Pubic hair: Tanner I    
General: alert. 
Skin: normal texture.
HEENT: PERRL, EOMI.
Neck: firm diffusely enlarged thyroid, each lobe ~3 cm in length, without nodularity.
Chest: clear. 
Heart: RRR, no murmurs.
Abdomen: soft, no hepatosplenomegaly.
Extremities: well-perfused. 
Neurological: normal patellar DTR's.

Additional studies:  HCHP 5/2/95:  T4 6.8, T3U 29%, FT4 2.0, TSH 3.8.

Impression: Clinically and biochemically euthyroid with decrease in thyroid gland size.

Disposition: Please obtain thyroid function tests at HCHP in late October or early November, 1995 (6 months after the previous tests), along with a bone age.  Please send a copy of the bone age for our review.  Follow up in endocrine clinic 11/95.
Thank you for letting us share in the care of Elisha.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology   


Problem list to date:
HYPOTHYROIDISM                               01/13/95  
ACQUIRED-HYPOTHYROIDISM                      01/13/95  
HASHIMOTO'S-THYROIDITIS                      01/13/95  
Transcribed by Cohen_l


CONTENT:
Bleck Pavarotti, M.D.          RE: Elisha Wynn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/15/83

Dear Dr. Pavarotti:

I saw Elisha in the Endocrine Program on 11/2/95 for hypothyroidism.

History: Elisha is a 12-6/12 year old with acquired hypothyroidism.  Since her last visit, she was hospitalized for infectious mononucleosis in August 1995 and treated with IV fluids and steroids.  She now has a good energy level, although she sometimes feels fatigued around 2:00-3:00 p.m.  She denies dry skin, diaphoresis, shortness of breath, tremors, constipation or diarrhea.  She sometimes feels her heart is racing occasionally for a short duration, but has had no feelings of irregular heart beats.

Current medications: Synthroid 0.075 mg. PO q.day.
Physical exam:
HT: 148.3 cm    WT: 49.4 cm    Arm span: 151 cm    U/L ratio:  0.88
BP: 112/58              Pulse: 92               Breast: Tanner IV       
Pubic hair: Tanner IV   

General appearance: alert.  Skin: normal texture.  HEENT: PERRL, EOMI.  Neck: firm thyroid gland enlarged around 4 cm. in length without nodularity.  Chest: clear.  COR: regular rate and rhythm without murmur.  Abdomen: soft without hepatosplenomegaly.  Back: mild scoliosis.  Extremities:  well-perfused.  Neurological: normal patellar deep tendon reflexes.

Laboratory studies:  10/23/95 at Winthrop Community Health Center:  Free T4 1.25 ng/dl, TSH 3.10 uIU/ml, bone age 13.25 years.

Impression: Elisha has had a normal growth velocity of 2.2 cm. over the past 4 months and is clinically and biochemically euthyroid.

Disposition: No adjustment of the Synthroid dose is necessary.  It would be useful for me to review the bone age if you can send it.  If HCHP requires that Elisha have her thyroid function tests performed at your center rather than at Children's Hospital, please obtain a T4 rather than a free T4, as well as the TSH.  Return to Endocrine Clinic in 6 months.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Bleck Pavarotti, M.D.          RE: Elisha Wynn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/15/83

Dear Dr. Pavarotti:

I saw Elisha in the Endocrine Program on 11/2/95 for hypothyroidism.

History: Elisha is a 12-6/12 year old with acquired hypothyroidism.  Since her last visit, she was hospitalized for infectious mononucleosis in August 1995 and treated with IV fluids and steroids.  She now has a good energy level, although she sometimes feels fatigued around 2:00-3:00 p.m.  She denies dry skin, diaphoresis, shortness of breath, tremors, constipation or diarrhea.  She sometimes feels her heart is racing occasionally for a short duration, but has had no feelings of irregular heart beats.

Current medications: Synthroid 0.075 mg. PO q.day.

Physical exam:
HT: 148.3 cm    WT: 49.4 kg    Arm span: 151 cm    U/L ratio:  0.88
BP: 112/58              Pulse: 92               Breast: Tanner IV       
Pubic hair: Tanner IV   
General appearance: alert.  Skin: normal texture.  HEENT: PERRL, EOMI.  Neck: firm thyroid gland enlarged around 4 cm. in length without nodularity.  Chest: clear.  COR: regular rate and rhythm without murmur.  Abdomen: soft without hepatosplenomegaly.  Back: mild scoliosis.  Extremities:  well-perfused.  Neurological: normal patellar deep tendon reflexes.

Laboratory studies:  10/23/95 at Winthrop Community Health Center:  Free T4 1.25 ng/dl, TSH 3.10 uIU/ml, bone age 13.25 years.

Impression: Elisha has had a normal growth velocity of 2.2 cm. over the past 4 months and is clinically and biochemically euthyroid.

Disposition: No adjustment of the Synthroid dose is necessary.  It would be useful for me to review the bone age if you can send it.  If HCHP requires that Elisha have her thyroid function tests performed at your center rather than at Children's Hospital, please obtain a T4 rather than a free T4, as well as the TSH.  Return to Endocrine Clinic in 6 months.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc:  Mr. and Mrs. Wynn  48 Francis Street Revere, MA  02151


CONTENT:
Bleck Pavarotti, M.D.          RE: Elisha Wynn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/15/83

Dear Dr. Pavarotti:

I saw Elisha in the Endocrine Program on 5/23/96 for follow-up of acquired hypothyroidism.

History: Elisha is now 13 and 1/12 years old.  Since her last visit, she broke her back 12/27/96 and was hospitalized for two to three weeks.  She missed five days of Synthroid during the hospitalization.   She forgets to take her pill about 5 times per month, but does take two the next day.  She complains of increased fatigue and mildly dry skin which is unchanged.  She denies other signs of hypothyroidism, such as cold intolerance, constipation or coarse hair.  She also denies signs of excessive thyroid hormone replacement such as heat intolerance, palpitations, or diarrhea.  Her menarche was 12/25/95, and she has had monthly periods with a duration of seven days.

Current medications: Synthroid 0.075 mg PO q.day.

Physical exam:
HT: 150.0 cm    WT: 49.3 kg   Arm span: 156 cm    U/L ratio:  0.89
BP: 98/64         Pulse: 72      Breast: Tanner IV       Pubic hair: Tanner IV   
General appearance:  alert and conversant.  Skin:   normal texture.  HEENT:  PERRL, EOMI.  Neck:  enlarged thyroid gland  without nodularity, length of lobes approximately 3.5 cm.  Lungs:   clear.  Heart:  regular rate and rhythm without murmur.  Abdomen:  soft,  without hepatosplenomegaly or masses.  Extremities: well-perfused.   Neurologic:  normal ankle deep tendon reflexes relaxation phase.

Impression: Elisha is essentially clinically euthyroid.  Her mother forgot to schedule this visit, and therefore, she did not have time to have her thyroid function tests done prior to coming to Children's Hospital.  Therefore,  her mother plans to take her to see you in one day.  I would appreciate if you could send me the results.

Disposition: Thyroid function tests.  Return to Endocrine Clinic in six months if thyroid function tests are within normal limits.

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


Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   

cc: Michael  Millis, M.D.   Orthopedic Clinic  Children's Hospital
    Richard and Elisha Wynn  48 Francis Street  Revere, MA  02151


CONTENT:
Bleck Pavarotti, M.D.          RE: Elisha Wynn
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/15/83

Dear Dr. Pavarotti:

We saw Elisha in the Endocrine Program on 12/12/96 for acquired hypothyroidism.

History: Elisha is now 13-8/12 years old.  She continues to complain that she is tired and sleeps from 8:30-9 p.m. to 7 a.m.  She denies constipation, but has had some loose stools over the past few days and intermittently over the past few weeks.  She denies changes in her skin or hair texture, palpitations, or heat intolerance (although she does report occasional "hot flashes".  She had strep. pharyngitis treated with an antibiotic that she has been off for three weeks.

Current medications: Synthroid 75 mcg PO q.d.

Physical exam:
Height: 152.4 cm        Weight: 55.4 kg
BP: 115/56              Pulse: 88               
Breast: Tanner V        Pubic hair: Tanner IV   
General appearance: healthy appearing.  Skin: normal texture.  HEENT: PERRL, EOMI.  Neck: symmetrically enlarged homogenous thyroid gland with length of lobes approximately 2.5 cm.  Lungs: clear.  Heart: regular rate and rhythm, without murmur.  Abdomen: soft, without hepatosplenomegaly.  Extremities: warm and well perfused.  Neurological: normal ankle deep tendon reflexes.

Laboratory studies:  Thyroid function tests at Winthrop Hospital 12/05/96: T4 8.7 mcg/dl, TSH 0.94 uIu/ml.

Impression: Other than some diarrhea which is probably due to an intercurrent illness, Elisha is clinically euthyroid.  She is biochemically euthyroid as well.

Disposition: I would like to see Elisha back in Endocrine Clinic in six months.  Could you please obtain repeat thyroid function tests in the week prior to this visit.  

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



Sincerely,




Sabie Hammer, MD             Leif Pavarotti, MD             
Fellow in Endocrinology      Attending in Endocrinology 
      


cc:  Mr. and Mrs. Wynn   48 Francis Street   Revere, MA  02151


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 1/13/94 for panhypopituitarism.

History: Ivan is an 8 and 10/12 year old, status post resection of a pilocytic astrocytoma in March of 1992.   Prior to the resection, he had growth hormone deficiency but he has been growing well off growth hormone treatment.  He has hypothyroidism treated with Synthroid 50 mcg q day, precocious puberty treated with Depot Lupron 7.5 mg q 28 days, and diabetes insipidus treated with DDAVP, two puffs every one to one and a half days.   His urinary breakthrough alternates between a full breakthrough and a partial one.   He continues to gain weight without any excessive appetite.   He has a decreased energy level requiring a two to three hour nap in the afternoon.   He complains of intermittent dizziness and is favoring his right leg.   An MRI showed a mild increase in tumor size and he has had some visual loss, therefore, he will be starting chemotherapy.

Physical exam:  
Height: 129.4 cm        Weight: 40.4 kg         BP: 82/30               
Pulse: 112              Pubic hair: Tanner I    R. testis: 3 x 1.8 cm   
L. testis: 2.8 x 1.6 cm Phallus length: 8 cm    Mid-shaft diam.: 2.2 cm 
General: Alert.  Skin: Normal texture.  HEENT: Pupils equal, round and reactive to light.   Extraocular movements are intact.  Fundi are not visualized.     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 patellar deep tendon reflexes.

Impression: Ivan's persistent fatigue and decreased water excretion may be due to adrenal insufficiency.  We  raised his Hydrocortisone dose 5 mg-2.5 mg-2.5 mg   He continues to grow adequately off growth hormone treatment and therefore, we will not consider restarting it at this time, especially in with the tumor regrowth.   This growth may be due to elevated insulin levels or other growth factors.   His weight gain continues to be of concern.   This has been seen in patients with central lesions and may or may not be related to a deficiency of CRH.   He is clinically and biochemically euthyroid.  There has been no progression of puberty and his gonadotropin levels are suppressed.

Disposition: For sugery and fevers, he should receive stress doses of steroids of at least 10 mg tid.

Laboratory studies pending at this time include: Sodium 143 mEq/L, osmolarity  283, T4 7.1 mcg/dL, TSH 0.4 IU/mL, IGF-1 32 ng/mL (low), LH 0.4 IU/L, FSH 0.5 IU/L, ACTH and baseline at 30 and 6 0 minutes Cortisol level after ACTH stimulation were all <1 mcg/dL.
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:
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 10/13/94 for suprasellar glioma.

History: Ivan is now 9 and 7/12 years old.  He continues to have a low energy level and sleeps a lot, but less during school than before.   He denies cold or heat intolerance, dry skin, diaphoresis, tremors, constipation or diarrhea, axillary odor or increased pubertal development.    He is status post chemotherapy treatment.  He has a voracious appetite but then eats very little.

Current medications: DDAVP two puffs q18-24 hours prn urinary breakthrough, Synthroid 50 mcg qd, Depot Lupron 7.5 mg IM q28 days, Cortef 5 mg qam, Ventolin multi-dose inhaler prn.

Physical exam:  
Height: 132.3 cm        Weight: 42.9 kg         BP: 105/70              
Pulse: 108              U/L ratio:  0.97        Arm span: 130           
Pubic hair: Tanner I    R. testis: 3 x 1.7 cm   L. testis: 2.7 x 1.6 cm 
Phallus length: 9 cm    Mid-shaft diam.: 2.6 cm 
General: Alert, happier than in past. Skin: Dry.  HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Neck: No thyromegaly.   Chest: Clear. Heart: Regular rate and rhythm without murmur. Abdomen: Soft without hepatosplenomegaly. Extremities: Well perfused. Neurological: Normal ankle deep tendon reflex, relaxation phase.

Laboratory studies: OSMO 289 MOSMKG; NA 140 MMOL/L; T4 7.5 ug/dL Bone age: 9.5 years

Impression: Ivan has panhypopituitarism.  His diabetes insipidus in in good control under the current management. He continues to grow in height despite his growth hormone deficiency, but there has been a slight decrease in this growth rate. His growth is probably due to insulin or insulin-like factors secondary to obesity. This obesity is often seen after treatment of brain tumors and is of unclear etiology. His central hypothyroidism is clinically and biochemically under good control, with no signs of hypothyroidism other than dry skin.   By testing, he had adrenal insufficiency, but it is unclear whether this is due to suppression of the adrenal gland by exogenous steroid or central CRH or ACTH deficiency.  He is on a low dose of Hydrocortisone of 3.8 mg/m2 per day from which we may want to consider weaning him in the future.  I suggest that we give this as 2.5 mg bid rather than the current 5 mg qam.

Finally, Ivan had precocious puberty treated with Depot Lupron.  Given that his bone age is not advancing and that he has several other hormonal deficiencies, it is likely that he has gonadotrophin deficiency at this time. 

Disposition: Ee will discontinue his Depot Lupron treatment and repeat a GnRH stimulation test in one to two months.  Return to Endocrine clinic in four months. Thank you for letting me share in the care of Ivan.

Sincerely,



Leif Pavarotti, MD             
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 1/20/95 for panhypopituitarism.

History: Ivan is a 9 and 10/12 year old with a suprasellar glioma.   He continues to have the same energy level but has been in a good mood with less mood swings.   He complains of some cold intolerance, but no constipation, diarrhea, or hair loss.   He has some mild shakiness which may be due to some poor coordination due to his decreased peripheral vision.   His DDAVP lasts 24 hours.   He had a trial off Depot Lupron, but his GnRH stimulation test showed pubertal levels of testosterone and therefore, Depot Lupron was restarted 1/11/95.   There has been no development of axillary odor or advancement in puberty.

Current medications: DDAVP one puff each nostril in the morning, Synthroid 50 mcg q day, Cortef 5 mg qam, Depot Lupron 7.5 mg IM q 28 days.

Physical exam:  
Height: 132.9 cm        Weight: 41.9 kg         BP: 96/72               
Pulse: 108              Arm span: 131           Pubic hair: Tanner I    
R. testis: 3.0 x 1.8 cm L. testis: 2.8 x 1.7 cm Phallus length: 9.0 cm  
Mid-shaft diam.: 2.3 cm 
General: Alert, cooperative, good mood. 
Skin: Dry.
HEENT: Pupils equal, round, reactive to light.  Extraocular movements intact.  Right tympanic membrane within normal limits.   Left ear canal occluded with cerumen.   
Neck: No thyromegaly. 
Chest: Clear. No axillary hair.   
Heart: Regular rate and rhythm without murmur.  
Abdomen: Soft.   
Extremities: Well perfused.  
Neurological: Normal ankle deep tendon reflex relaxation phase.

Laboratory studies:  Prior Labs:  10/13/94:  Sodium 140 mmoL, osms 289, bone age 9.5 years.   12/19/94:  T4 6.0 mcg/dL, TSH 3.2 mcU/mL, GnRH stimulation test basal testosterone 149 ng/dL which rose to 178 ng/dL after stimulation.

Impression: Ivan has only grown 0.6 cm in the past three months.  This decreasing growth rate in this growth hormone deficient patient may be due to his decreased weight velocity and therefore less of a drive by insulin or some other growth factor.   His pubertal development is stable and his diabetes insipidus and hypothyroidism appear in good control.   He continues to have the question of Cortisol deficiency but has been maintained on very low dose replacement.  In times of stress, he should receive 12.5 mg of Hydrocortisone tid.

Disposition: He needs a repeat GnRH stimulation test prior to the third dose after restarting Depot Lupron to assess suppression.   Return to clinic in three to four months.
Thank you for letting us share in the care of Ivan.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology   


Addendum: There has been some confusion regarding the interval between Ivan's Depot Lupron injections - it needs to be exactly 28 days and not be increased.


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

Dear Dr. Sanders:

I saw Ivan in the Endocrine Program on 1/29/96 for panhypopituitarism status post astrocytoma treatment.

History: Ivan is now 10 and 11/12 years old.  He was last seen 1/20/95 and since that time, he has completed an individualized protocol of CCNU 100 mg/m2 q 6 weeks for recurrent growth of the astrocytoma.  He had been doing well since the start of the school year.  However, about 2 months ago, his temperament changed and he has become very stubborn.  He has also had a weight loss over at least the past 2-3 months which has not been attempted.  His mother feels he has the same dietary intake. His hair has become smoother with red highlights.  He has very dry and coarse skin and complains of cold intolerance outdoors.  He denies constipation, and if anything, has loose stools.

Current medications: Synthroid 50 mcg PO q day., Solu-Cortef po 5 mg at 7:30 a.m., 2.5. mg at 4 p.m., 2.5 mg at 8-9 p.m. DDAVP 2 puffs (20 mcg) about every 24 hours, Depot Lupron 7.5 mg IM q 28 days (last shot 1 week ago).

Physical exam:
HT: 134.1 cm    WT: 34.9 kg    Arm span: 129.5 cm    U/L ratio:  1.1
BP: 90/62               Pulse: 84               Pubic hair: Tanner I    
R. testis: 2.4 x 1.4 cm L. testis: 2.2 x 1.3 cm Phallus length: 8.5 cm  
Mid-shaft diam.: 2.2 cm 
General appearance: alert.  Skin: dull and dry, pallor.  HEENT: not examined because of non-compliance.  Neck: no thyromegaly.  Lungs: clear.  Heart: regular rate and rhythm without murmur.  Abdomen: soft without hepatosplenomegaly or masses.   Extremities: well perfused.  Neurological: normal patellar deep tendon  reflexes.

Laboratory studies:  Na 141 mmol/l, K 3.6 mmol/l, Cl 108 mmol/l, CO2 23 meq/l, Creat 0.8 mg/dl, osm 283 mosmkg, AST 23 u/l, alk phos 119 u/l, bili total 0.8 mg/dl and direct 0.2 mg/dl.  WBC 2.87 (36 lymphs, 5 monos, 1 eos, 9 bands), hgb 6.8, hct 22.4%, plt 91k.  T4 8.9 ug/dl, TBGI 0.86, TSH 0.10 uU/ml, LH 0.10 IU/L, FSH 0.40 IU/L, testosterone <10 ng/dl, prolactin 6.0 ng/ml.  Bone age: 10 years

Impression: Ivan has had no advancement in puberty on the Depot Lupron.  He has shown a poor growth rate of only 1.2 cm over the past 12 months.  This is presumably secondary to his growth hormone deficiency.  He had had a normal growth rate off growth hormone treatment, which was probably due to his obesity.  Since losing weight (6 kg over the past 12 months), this growth rate has declined.  This may be due to the lack of drive from insulin or other growth factors connected to the obesity, or because of poor nutritional intake.  He remains on a dose of Solu-Cortef of 8.7 mg/m2/d (BSA 1.15 m2).  In times of stress (e.g., fever >101, surgery), he should receive hydrocortisone 15 mg PO or IV q 8h.

Disposition: We will continue to carefully follow Ivan.  At this time, he is not a candidate for growth hormone treatment given the nature of his tumor.  We would like to hold off in letting him advance through puberty with the hope that he continues to grow to some extent.   I would suggest he see a nutritionist to ensure that his weight loss is not due to inadequate caloric intake.  I would like to see him back in Endocrine clinic in 4 months.



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc:  Scott Pomeroy, M.D. Neurology, Enders 3 Children's Hospital

     R. Michael Scott, M.D. Department of Neurosurgery Bader 3

     Douglas Taylor, M.D. Dana Farber Cancer Institute

     Luisa Mayer, M.D. Opthalmology  

     Frank and Alice Wrigley  7 Hickory Hill Road 
     Great Barrington, MA  01230


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

Dear Dr. Plutarch:

I saw Ivan in the Endocrine Program on 11/14/96 for panhypopituitarism status post treatment of a hypothalamic astrocytoma.

History: Ivan is now 11-10/12 years old.  By his mother's report, his tumor appears to be stable, although there was a new spot on his visual field testing one month ago.  He was scheduled for repeat visual fields on the day of this visit.  The plan was that if the visual field still showed this spot or a worsening, he would have an MRI.  He has had some dry skin and occasional diarrhea, but denies headaches or constipation.  He has an improved energy level.

Current medications: Synthroid 0.05 mg PO q.day, Cortef 5/2.5/2.5 mg. (7.7 mg/m2/day), DDAVP 2 puffs (20 mcg) intranasally approximately q.day, depot Lupron 7.5 mg. IM q.28 days.

Family history:  Mother is 5'6", father is 5'4", 17 year old brother is 5'6".

Physical exam:
HT: 136 cm    WT: 41.7 kg    Arm span: 130 cm    U/L ratio:  1.03
BP: 113/59              Pulse: 98               Pubic hair: Tanner I    
R. testis: 2.6 x 1.3 cm L. testis: 2.5 x 1.3 cm Phallus length: 7 cm    
Mid-shaft diam.: 2.5 cm 
General appearance:  alert.  Skin:  normal texture.  HEENT:  PERRL, EOMI.  Neck:  no thyromegaly.  Lymph nodes:  no adenopathy.  Lungs:  clear.  Heart:  regular rate and rhythm without murmur.  Abdomen: soft without hepatosplenomegaly or masses.  Extremities: warm and well perfused.  Neurological:  normal patellar deep tendon reflexes.

Laboratory studies:  Na 141 mmol/L, osm 297, T4 6.3 5g/dL, TBGI 0.76, TSH 0.54 5U/mL, prolactin 7.70 ng/mL.  Bone age ordered but no report of having been done.

Impression: Ivan has only grown 2.1 cm. over the past 10.5 months which is a poor growth velocity.  At the same time, he has had an excessive weight gain of 6.8 kg.  He has been off recombinant human growth hormone therapy for several years because of his tumor recurrence.  Without growth hormone therapy, his final height will be quite low, and we need to make a decision at some point as to whether we should restart growth hormone therapy.  This is less of a problem while he is not going through puberty.  However, by age 14 years or so, he will need to be taken off the depot Lupron and then we will need to make sure that he has adequate testosterone levels to ensure good bone mineralization.  Some of his poor growth may be due to his lowish thyroid hormone levels, and I increased his dose of Synthroid to 0.0625 mg po q.day.  He should have thyroid function tests checked locally in 6-8 weeks.

Since Ivan's diabetes insipidus is well controlled on his intranasal DDAVP, he does not want to switch to oral DDAVP.  He is on low dose steroids, but he has a good energy level.  It should be remembered that in times of significant stress (e.g., temperature of greater than 101 or surgery), he needs stress dose steroid coverage with hydrocortisone15 mg. po or IV q.6 hours.

Disposition: Since Ivan's growth rate is decreasing, and he is now at an age where boys are expected to be going  through puberty, it is very important that I see him on a more regular basis.  I would like to see him back in Endocrine Clinic in 4 months.

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



Sincerely,




Leif Pavarotti, MD             
Attending in Endocrinology   


cc:
Douglas Taylor, M.D.  Dana Farber Cancer Institute  44 Binney Street  Boston, MA 02115

Scott Pomeroy, M.D.  Neurology  Enders 3  Children's Hospital  300 Longwood Avenue  Boston, MA 02115

R. Michael Scott, M.D.  Department of Neurosurgery  Bader 3  Children's Hospital  300 Longwood Avenue  Boston, MA 02115

Luisa Mayer, Ph.D.  Opthalmology  Children's Hospital  300 Longwood Avenue  Boston, MA 02115

Alice Wrigley   7 Hickory Hill Road   Great Barrington, MA  01230


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 10/10/91 for evaluation of .

History: I saw your patient Ivan Wrigley on October 10, 1991 for follow up.  Ivan is now a 6 7/12 year old boy with diencephalic syndrome.  After receiving irradiation, he developed precocious puberty and was treated with Luprone.  Subsequently, he developed a growth hormone deficiency and is currently receiving Protropin for growth hormone deficiency.  Report no problem about giving the shots.  Ivan appears to do quite well.  Review of systems is unremarkable.

Physical exam:  
Height: 116.5 cm        Weight: 19.9 kg         R. testis: 2.4 x 1.4 cm 
L. testis: 2.4 x 1.3 cm Phallus length: 7.6 cm  Mid-shaft diam.: 2.1 cm 
On physical exam, his height is 116.5 cm, weight is 19.9 kg.  Both are following the previous percentile.  There is no pubic hair or axillary hair seen.  The penile length is 7.6 cm and mid-shaft diameter 2.1 cm.  The left testicle measures 2.5 X 1.3 cm and the right side 2.4 X 1.4 cm.

In summary: My impression is that Ivan is doing well on his therapy now.  I would like to continue him on the same amount of Luprolide, 7.5 mg intermuscularly once a month.  However, an MRI scan indicated that the tumor grew somewhat.  Therefore, I have suggested to discontinue Protropin therapy at the present time.  I plan to see Ivan back in clinic in six months for another follow up.

Thank you for letting us share the care of your patient.  If you have any concerns, please contact me.

Disposition: 

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

Sincerely,


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


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 2/27/92 for  Leif Pavarotti.

History: Ivan is now a 6 and 11/12 year old boy with Diencephalic Syndrome. After receiving radiation he developed precocious puberty and has been treated with depolupron. Subsequently he developed growth hormone definciency and was treated with  Protropin until 10/19/91 when an MRI showed a slight increase in tumor size. However, a second opinion at Memorial Sloane Kettering felt that that may be blood accumulation rather than tumor.

Current medications: Depolupron 7.5 mg Im 2-4 weeks Intal Alupent

Past medical history:  Eent He was losing visual acuity in his right eye. Always has a complaint of headache but this goes away when he gets his own way and has not increased. Cardiorespitory: no shortness of breath or palpitations GI no abdominal pain diareahha or constipation. GU: no polyuria occasional noctounal enuresis 2-3 times per week. Neurologic: no cold or heat intolerance or tremors.

Physical exam:  
Height: 117 cm          Weight: 21.8 kg         BP: 94/54               
Pulse: 108              Pubic hair Tanner: 1    R. testis: 3 x 1.6 cm   
L. testis: 3.2 x 1.7 cm Phallus length: 7.5 cm  Mid-shaft diam.: 2.5 cm 
General: 
Skin: no lesions
HEENT: sharp optic disk, pupils equal round and reactive to light, extracular movements in tact
Neck: no thyroidmegalamy
Chest: lungs clear
Heart: core RRR without murmer
Abdomen: soft, no hepatosplenomegaly
Genitourinary: 
Extremities:warm and well profused 
Neurological:normal relaxation phase of deteded reflexes

Laboratory studies:  10/11/91 LH0 .13 Iu/l, FSH 0.4iu/l, Testosterone<10 ng/dl, TBGI 0.92, T46.2 mg/dl, TT3115 ng/dl, TSH 1/30uU/ml, Bone age approximately 5 years old. Chronologic age 6 7/12 years old.

In summary: Ivan's pubital status is stable GNRH analogue His height has only increased .5 cm over the last three months off growth hormone. We feel that growth hormone treatement should be continued to be held until the issue about his tumor growth is clarified.

Disposition: Return to Endocrine clinic in six months.

Laboratory studies pending at this time include: TFTs, TSH, LH, FSH, Testosterone.

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 2/27/92 for  Leif Pavarotti.

History: Ivan is now a 6 and 11/12 year old boy with Diencephalic Syndrome. After receiving radiation he developed precocious puberty and has been treated with depolupron. Subsequently he developed growth hormone definciency and was treated with  Protropin until 10/19/91 when an MRI showed a slight increase in tumor size. However, a second opinion at Memorial Sloane Kettering felt that that may be blood accumulation rather than tumor.

Current medications: Depolupron 7.5 mg Im 2-4 weeks, Intal, Alupent

Past medical history: He was losing visual acuity in his right eye. Always has a complaint of headache but this goes away when he gets his own way and has not increased. Cardiorespitory: no shortness of breath or palpitations GI no abdominal pain diareahha or constipation. GU: no polyuria occasional noctounal enuresis 2-3 times per week. Neurologic: no cold or heat intolerance or tremors.

Physical exam:  
Height: 117 cm          Weight: 21.8 kg         BP: 94/54               
Pulse: 108              Pubic hair Tanner: 1    R. testis: 3 x 1.6 cm   
L. testis: 3.2 x 1.7 cm Phallus length: 7.5 cm  Mid-shaft diam.: 2.5 cm 
General: 
Skin: no lesions
HEENT: sharp optic disk, pupils equal round and reactive to light, extracular movements in tact
Neck: no thyroidmegalamy
Chest: lungs clear
Heart: core RRR without murmer
Abdomen: soft, no hepatosplenomegaly
Genitourinary: 
Extremities:warm and well profused 
Neurological:normal relaxation phase of deeded reflexes

Laboratory studies:  10/11/91 LH0 .13 iu/l, FSH 0.4iu/l, Testosterone<10 ng/dl, TBGI 0.92, T46.2 mg/dl, TT3115 ng/dl, TSH 1/30uU/ml, Bone age approximately 5 years old. Chronologic age 6 7/12 years old.

In summary: Ivan's pubital status is stable GNRH analogue. His height has only increased .5 cm over the last three months off growth hormone. We feel that growth hormone treatement should be continued to be held until the issue about his tumor growth is clarified.

Disposition: Return to Endocrine clinic in six months.

Laboratory studies pending at this time include: TFTs, TSH, LH, FSH, Testosterone.

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 2/27/92 for  diencephalic syndrome.

History: Ivan is now an almost 7 year old boy with a hypothalamic glioma.  After receiving radiation, he developed precocious puberty and has been treated with depot Lupron.  Subsequently he developed growth hormone deficiency and was treated with Protropin until 10/19/91 when an MRI showed a slight increase in tumor size.  However, a second opinion at Memorial Sloane-Kettering felt that this may be blood accumulation rather than tumor.

Current medications: Depot Lupron 7.5 mg IM q 4 weeks, Intal, and Alupent.

Past medical history:  He is losing visual acuity in his right eye.  He always complains of headaches, but they goes away when he gets his own way and have not increased in frequency or intensity.  Cardiorespiratory: No shortness of breath or palpitations.  GI: no abdominal pain, diarrhea or constipation.  GU: no polyuria, occasional nocturnal enuresis 2-3 times per week.  Neurologic: no cold or heat intolerance or tremors.

Physical exam:  
Weight: 21.8 kg         BP: 95/54               Pulse: 108              
Breast Tanner: 1        R. testis: 3 x 1.6 cm   L. testis: 3.2 x 1.7 cm 
Phallus length: 7.5 cm  Mid-shaft diam.: 2.5 cm 
General: Alert and active.
Skin: No lesions.
HEENT: Sharp optic discs, pupils equal round and reactive to light, extraocular movements intact.
Neck: No thyromegaly.
Chest: Lungs clear.
Heart: Regular rate and rhythm without murmur.
Abdomen: Soft, no hepatosplenomegaly. 
Extremities: Warm and well-perfused.
Neurological: Normal relaxation phase of deep tendon reflexes.

Laboratory studies:  10/11/91: LH 0.13 IU/L, FSH 0.4 IU/L, testosterone <10 ng/dl, TBGI 0.92, T4 6.2 mg/dl, TT3 115 ng/dl, TSH 1.30 uU/ml, bone age approximately 5 years old with chronologic age of 6 7/12 years old.

2/27/92: T4 6.2 ng/dl, TT3 122 ng/dl, TSH 2.20, TBGI 0.94, LH 0.10 IU/L, FSH 0.4 IU/L.

In summary: Ivan's pubertal status is stable on GnRH analogue.  His height has only increased 0.5 cm over the last three months off growth hormone.  We feel that growth hormone treatment should be held until the issue about his tumor growth is clarified.


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

Sincerely,


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


