# BIGPATS_DOC_STORE

CONTENT:
Etta Swartzenegger, M.D.          RE: Lewis Curry
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/30/87

Dear Dr. Swartzenegger:

We had the pleasure of seeing Lewis in the Endocrine Program on 11/7/94 for hyperhydrosis and tall stature.

History: Lewis is a 7 year 6 month old boy who was referred for "heat intolerance" and "growth spurt".   He initially presented to his pediatrician in September 1994 complaining of intermittent diaphoretic spells occurring one to two times a week associated with palpitations and headache.   They last approximately 5-10 minutes and resolve spontaneously.   They are usually followed by fatigue, and began in late July. 

Lewis's parents state that he has undergone a significant growth spurt which began in the Spring of 1994.   He has recently required an increment in his shoe, shirt and pant size.  

Lewis is in second grade and is described as a B student.   He has excellent social skills and is considered a leader amongst his peers.  He is very active in athletics and plays hockey as well as baseball.  He is not described as an aggressive child and has no social problems.

Current medications: None.

Past medical history:  Notable for croup as an infant.  His mother's pregnancy with him was described as uneventful and he was born by vaginal delivery.   His father describes him as a picker eater and "likes what he likes".   He has had no hospitalizations, injuries or operations.

Review of systems:  Notable for new glasses acquired in November of 1994 for the diagnosis of astigmatism.   Cardio-Resp; notable for intermittent wheezing with activity.  GI; denies loose stools or abdominal pain.  Normal GU and neurologic review of systems.

Family history:  His mother was one of five siblings and had puberty at age 16.  His father is 1 of three siblings and had puberty at age 15.  Lewis has one sister age 14.   Lewis's mother's height is 5'8", father's height is 5'11".

Physical exam:  
Height: 132.5 cm        Weight: 32.4 kg         BP: 92/60               
Pulse: 80               U/L ratio:  1.01        Arm span: 137.5         
Pubic hair: Tanner I    R. testis: 2 x 1.1 cm   L. testis: 2 x 1 cm     
Phallus length: 6.4 cm  Mid-shaft diam.: 2.2 cm 
Bone age of 8 years done in September of 1994 at a chronologic age of 7 years 4 months.   
General: Healthy.  
Skin: No lesions or rashes.  
HEENT: Normal fundoscopic exam.  
Neck: No goiter.  
Chest: Clear.  
Heart: No murmurs, gallops or rubs.   
Abdomen: Positive bowel sounds, nontender, no hepatosplenomegaly.  
Genitourinary: As above.   
Neurological: Normal.

Laboratory studies:  September of 1994; free T4 of 1.1, TSH 6.04 and a total T3 of 155.   White count of 7.2 with a hemoglobin and hematocrit of 14.1/41.7 with an MCV of 84 and a urinalysis which was negative.

Labs results from this visit:  IGF-I 144 ng/mL, glucose 83 mg/dl, TBGI    1.01, T4 6.4 ug/dL, TT3 135 ng/dL, TSH 4.50 uU/mL, all normal.

Impression: Lewis exhibits intermittent spells of diaphoresis, headaches and palpitations.    Previous thyroid studies have effectively ruled out hyperthyroidism as an etiology.  We should,  however, rule out Pheochromocytoma, and screen for hypoglycemia. 

Lewis also displays tall stature.  In the setting of a mildly advanced bone age and prepubertal sexual development.  An IGF-1 level was obtained to screen for growth hormone excess.  We will reassess height and growth velocity in six months.  

Thirdly, history of subclinical hypothyroidism by September labs.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Herbert Prawius, M.D.
Fellow in Endocrinology


CONTENT:
Gleide Capulet, M.D.          RE: Daphne Monnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/22/85

Dear Dr. Capulet:

We had the pleasure of seeing Daphne in the Endocrine Program on 9/19/94 for hashimoto's thyroiditis.

History: As you know, Daphne is 9 and 1/12 years of age with a negative past medical history by mother's report.   Daphne was seen in clinic today with her parents who report that she has not had any symptoms of thyroid illness or any other illnesses.   They specifically deny any problems with heat or cold intolerance, weight gain or loss, skin changes, concentration problems or any change in bowel function.   In fact, it sounds as if Daphne has not noticed problems.

There is no history of radiation to Daphne's neck or having lived in an Iodine deficient area.   Serum tests that you ordered showed Daphne to have a TSH of 94.16, total T4  5.10, T uptake 30.20%, and free thyroxine index  1.5.  Also, Daphne was found to have an anti-microsomal thyroid antibodies of 13.9 U/mL  as well as anti-thyroglobulin antibodies at 4.7 U/mL, both significant values.

Current medications: Daphne receives no medications; there is no known history of drug allergies.

Past medical history:  Daphne was full term infant delivered at the Mount Auburn Hospital via vaginal delivery.  Growth and development were normal.   Her immunizations are up to date.   There have been no hospitalizations or operations.   Daphne suffered a wrist fracture approximately one year ago after having fallen off a jungle gym in a play ground.

Review of systems:  Negative apart from some mild constipation which is ongoing.

Family history:  Family history of thyroid problems with maternal grandmother having had a "small" thyroid for which no treatment was given.   An aunt of Daphne's father who had a goiter that was removed surgically. Paternal great grandmother had insulin dependent diabetes mellitus requiring insulin therapy.   There is no family history given of vitiligo, pernicious anemia, rheumatoid arthritis or any other auto immune diseases except for the above mentioned diabetes.

Physical exam:  
Height: 128.1 cm        Weight: 27.4 kg         BP: 90/60               
Pulse: 72               Pubic hair: Tanner I    
General: Well looking, well nourished.   Skin: Clear.  HEENT: Clear.  There is no lymphadenopathy.    Neck: Diffusely enlarged thyroid.   Chest: Clear.   Heart: Normal S1 and S2, no gallops or murmurs.    Abdomen: Soft nontender abdomen with no masses or organs palpable and bowel sounds are present.   Neurological: Cranial nerves are intact and the fundi is clear.   There is sharp disc margins seen on fundoscopic examinations.  DTR's were 2+ with slowed relaxation phase.    There is no proximal muscle weakness and muscle power is 5/5 throughout.

Impression: Daphne has Hashimoto's thyroiditis requiring thyroxine replacement therapy.  A prescription was given to Daphne's parents for Synthroid, at a dose of 0.05 mg (about 2 mcg/kg) daily.   Daphne will follow up in your office for thyroid function testing to evaluate the adequecy of this dose.  It was explained to Daphne's parents that with replacement therapy her thyroid function would return to normal but that the underlying immunological process will not be effected.  There are some cases of Hashimoto's thyroiditis which remit but the majority of cases do require life long therapy with thyroid hormone.

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

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology
  


Addendum: Timothy Flynn, M.D.
Endocrinology Fellow


CONTENT:
Gleide Capulet, M.D.          RE: Daphne Monnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/22/85

Dear Dr. Capulet:

We had the pleasure of seeing Daphne in the Endocrine Program on 12/12/94 for hashimoto's thyroiditis.

History: As you know, Daphne is a 9 and 1/4 year old girl who was diagnosed with Hashimoto's thyroiditis in September of 1994.   At that time she was begun on Synthroid replacement (2 mcg/kg/day) or 0.05 mg/day.   Her parents report that she has had no thyroid symptomatology since her last visit; specifically she has had no cold or heat intolerance, no difficulty concentrating, no constipation or diarrhea.   Her weight has been stable and she has had no change in the texture of her skin or hair.

Physical exam:  
Height: 130 cm          Weight: 27.8 kg         BP: 92/66               
Pulse: 72               Breast: Tanner I        Pubic hair: Tanner I    
General: She is comfortable, cooperative, friendly young girl.  
Skin: Without rash or lesion and of normal texture.  
HEENT: Reveals sharp discs.   
Neck: Reveals a palpable thyroid.   The isthmus is measured at 0.6 cm.  The left side of her thyroid is 2 cm and the right is 2.5 cm.   She has no palpable lymph nodes.   
Chest: Lungs are clear to auscultation bilaterally.   
Heart: Regular rate and rhythm with normal S1 and S2, no murmurs.   
Abdomen: Positive bowel sounds.   Soft and nontender, nondistended.  
Genitourinary: Normal female.    
Extremities: Well perfused.   
Neurological: Her deep tendon reflexes are 2+ with a slowed relaxation phase noted at her ankles.

Laboratory studies:  The laboratories that you obtained on 11/19/94 revealed a TSH of 8.94 (normal 0.3-5.3) and a T4 of 8.1 (normal 6.4-13.3).

Impression: Our impression is that Daphne is clinically well without symptoms of thyroid symptomatology on her replacement Thyroxine.   The lab values however, reveal that her replacement is not quite adequate with her TSH still being supranormal.

Disposition: We will increase Daphne's Synthroid dose to 75 mcg each day.   We ask you to recheck her T4 and TSH in approximately 4 weeks from today and have the results forwarded to us.   At that time any adjustments necessary can be made in her thyroid medication.  Otherwise, we will see her again in six months in our clinic.
Thank you for letting us share in the care of Daphne.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology
  


Addendum: Mark Palmert, M.D.
Senior Resident in Medicine


CONTENT:
Gleide Capulet, M.D.          RE: Daphne Monnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/22/85

Dear Dr. Capulet:

We had the pleasure of seeing Daphne in the Endocrine Program on 7/17/95 for Hashimoto's thyroiditis.

History: Daphne is now a 10-year old young lady being followed for Hashimoto's thyroiditis.  She has had no complaints since she was last seen in December of 1994.  Her energy level is good, her sleep is normal, and she has no signs or symptoms of hypo or hyperthyroidism.  The tests done after starting 75 micrograms per day of Synthroid were reportedly normal.

Current medications: Synthroid 0.075 mg. per day, with which she is reportedly compliant.

Physical exam:  
Height: 133.8 cm        Weight: 30.2 kg         
BP: 94/60               Pulse: 96               
She is a well developed, well nourished white female.  Skin is normal.  Neck shows a small thyroid with a rubbery consistency.  There are no significant lymph nodes.  The heart shows a normal sinus rhythm with no murmur.  Neurologic exam shows deep tendon reflexes that are 2+ and equal with no delay.  A TSH done subsequent to this visit showed a T4 of 7.97 and a TSH of 7.33.  The former is normal, the latter is slightly elevated.

Impression: She is clinically euthyroid and with excellent growth.  Since the TSH is very slightly elevated, we have recommended that she increase her dose to .088 mg. per day and have the thyroid functions retested in 6-8 weeks.  She is to follow up in six months with you and return here in 12 months.



Sincerely,




Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Gleide Capulet, M.D.          RE: Daphne Monnet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/22/85

Dear Dr. Capulet:

I saw Daphne in the Endocrine Program on 9/4/96 for follow-up of Hashimoto's thyroiditis.

History: Daphne is now 11 years old and was last seen here about 14 months ago.  In the interim she has been healthy.  Review of systems is negative for  symptoms of hypo- or hyperthyroidism.  She sleeps 9 1/2 hours per night and does not require naps.  Her energy is good, her appetite fair but unchanged.  She is entering 6th grade this year and will be a cheerleader.  Her mother notes that she had started to develop breasts within the last year and that she has grown rapidly during that time period.  Her mother was also giving her adult vitamins with calcium supplements because of her limited milk intake.

Current medications: Synthroid 0.088 mg daily (2.6 mcg/kg/d).  There are rare omissions.

Physical exam:
Height: 142.3 cm        Weight: 33.6 kg
BP: 104/51              Pulse: 77               
Breast: Tanner II       Pubic hair: Tanner I    
This is a slim, quiet, slightly pale young woman.  Skin exam is entirely normal.  The thyroid gland is enlarged and somewhat rubbery and granular to palpation with the left lobe greater than the right.  There are no significant lymph nodes present.  The lungs are clear.  The breasts are Tanner 2-3 with immature nipples.  The heart exam is normal.  The  abdomen is benign although with stool in the colon.  The genitalia are still prepubertal.  The extremities are normal.  Neurologic; deep tendon reflexes are 1+ and equal with no delay.

Laboratory studies:  Thyroid studies done in June include a T4 of 10.3 mcg/dl and a TSH of 3.61, both of which are normal.

Impression: Daphne is clinically and chemically euthyroid at this time.  She is in the early days of what appears to be a normal puberty.  Her growth curve shows an upswing consistent with a growth spurt.

Disposition: I have asked the mother to continue the Synthroid at the same dose.  She is to obtain thyroid studies in 6 months and fax them here for evaluation.  Finally, she will obtain thyroid function tests just prior to our next visit in a year from now.   

Thank you for letting us share in Daphne's care.



Sincerely,




Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Owen Brezny, M.D.          RE: Agatha Alva
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/13/94

Dear Dr. Brezny:

We had the pleasure of seeing Agatha in the Endocrine Program on 1/20/95 for follow-up of 21-hydroxylase deficiency.

History: Agatha is a 4 month old with virilizing congenital adrenal hyperplasia who recently had cystoscopy and is scheduled to have corrective surgery at one year of age.  Agatha has had a month of low grade fevers with occasional spikes to 102-103F.  Reportedly, a recent virus culture revealed E. coli bacteruria and Agatha is now treated wtih Bactrim.  She  has defervesed since onset of the Bactrim.  Agatha has taken "stress dose" glucocorticoids with the spikes when she appeared ill.

Current medications: Bactrim 1/2 tsp bid, hydrocortisone 2.5 mg tid, Florinef 0.05 mg bid, Nacl 16 mEq/day.

Physical exam:  
Height: 54 cm           Weight: 5.44 kg         Pulse: 110              
General: Comfortable, playful, smiling girl. Skin: A few acneiform facial lesions. Neck: No thyromegaly.  Abdomen: No hepatosplenomegaly. Genitourinary:  No discharge.   Extremities: No edema.

Impression: Agatha is doing well.  The etiology of her fevers remains unclear but she appears to be thriving despite them.

Disposition: No chagne in medication.  Return to clinic in six months.
Thank you for letting us share in the care of Agatha.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology


CONTENT:
Owen Brezny, M.D.          RE: Agatha Alva
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/13/94

Dear Dr. Brezny:

We had the pleasure of seeing Agatha in the Endocrine Program on 10/13/94 for follow-up of congenital adrenal hyperplasia.

History: Agatha was diagnosed with 21-hydroxylase deficiency by state screening  after presenting at birth with ambiguous genitalia (Newton-Wellesley Hospital).  Ultrasound demonstrated normal female internal anatomy, and chromosomes from amniocentesis showed 46XX.  She was initially treated with hydrocortisone 5 mg tid, but no salt-supplementation nor mineralocorticoid.  She was admitted to Children's Hospital at two weeks of age with a salt-loosing crisis (sodium <130, potassium >7), and subsequently discharged on Florinef 0.025 mg po qd.  A second salt-loosing  crisis lead to yet another hospitalization September 30th.  This time, she was treated with increased Florinef and addition of salt supplementation .  Agatha was discharged to home 10/11/94.  The Alvas arrive in Endocrine Clinic today with the intention of transferring her care to us.   Health since discharge has been good: appetite is strong, sleep is normal, energy is vigorous, skin color is good.  She feeds by bottle with Prosobee, 6 oz q 4 hours.

Current medications: hydrocortisone 5 mg/2.5 mg/2.5 mg po tid, Florinef 0.1 mg/0.05 mg po bid, sodium chloride 9 mEq po qid

Family history:   negative for congenial adrenal hyperplasia, precocious puberty, or hirsutism.  Mother's height 5'3", father's height 5'6".

Physical exam:  
Height: 48.6 cm         Weight: 3.59 kg         BP: 95/51               
Pulse: 117              
General: Well-appearing.  Skin: Good color.  HEENT: Head circumference 35.25 cm.  Chest:  Clear. Heart: Benign.  Abdomen: Without hepatosplenomegaly or masses.  G enitourinary: Hyperpigmented.  Ambiguous genitalia with subtotal labial fusion, small genitourinary sinus evident, clitoromegaly measuring 1.0 cm width.   Anus normally placed.
:

Laboratory studies:  Electrolytes:  sodium 141 mEq/L, potassium 6.0, chloride 106, bicarbonate 28, BUN 18, creatinine 0.2, glucose 84.

Impression: Agatha is a one month old girl with presumed 21-hydroxylase deficiency, s/p two salt-loosing crises, now doing very well on increased replacement therapy.  Excessive appetite and weight gain may reflect somewhat high glucocorticoid and/or mineralicorticoid dosage.  We would like to decrease hydrocortisone 2.5 mg po tid, a dose which should be quadrupled in the event of significant stress. In addition, we would like to decrease Florinef to 0.05 mg po bid, and salt to 5 mEq with each bottle (for a total of about 30 mEq/day).  Follow -up is recommended for one month.

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

Sincerely,


Gleide Crane, MD             Mitsuko Simpson, MD             
Fellow in Endocrinology      Chief Emeritus


CONTENT:
Owen Brezny, M.D.          RE: Agatha Alva
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/13/94

Dear Dr. Brezny:

We had the pleasure of seeing Agatha in the Endocrine Program on 11/21/94 for congenital adrenal hyperplasia.

History: Agatha is a 10 week old female with 21-hydroxylase deficiency who was recently seen at the Children's Hospital for evaluation of heart murmur.   Since her last admission (for rule out sepsis) she has been well although mother concerned about increased sleep (now sleeps through night).   She drinks 4-6 ounces of Nutramycin 4-5 times a day.   She has bowel movements twice a day.

Current medications: Hydrocortisone 2.5 mg tid, NaCl 4 cc 4-5 x day, Florinef 0.05 mg bid.

Physical exam:  
Height: 51.8 cm         Weight: 4.39 kg         Pulse: 150              
General: Comfortable, feeding well.
Skin: Good color.
HEENT: Mucous membranes moist, open fontanelle.
Neck: No thyromegaly. 
Chest: Clear.
Abdomen: No hepatomegaly.   
Genitourinary: Unchanged. 
Extremities: No edema.

Laboratory studies:  11/15:  Sodium 142 meq/L,        10/13/94:  17OHP 98 ng/dL, PRA 4.5 ng/L/hr.

Impression: Agatha has gained 1 pound over the last month.  She is feeding well and has adequate suppression of her androgens.   She should have her androgen levels and PRA rechecked in one month.

Disposition: Recheck DHEA, 17)HP, DHEAS, Testosterone, PRA.   Return to clinic in two months.
Thank you for letting us share in the care of Agatha.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Problem list to date:
21-HYDROXYLASE-DEFICIENCY                    11/08/94  
Transcribed by Fahey


CONTENT:
Owen Brezny, M.D.          RE: Agatha Alva
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/13/94

Dear Dr. Brezny:

We had the pleasure of seeing Agatha in the Endocrine Program on 4/14/95 for follow-up of 21-hydroxylase deficiency.

History: Agatha is a 7 month infant girl with classical, salt-losing 21-hydroxylase deficiency.  Since she was last seen she has had many febrile episodes.  The etiology remains unclear.  The fevers are between 100f and 100.3f, typically highest in the late afternoon.  There are no behavioral concerns.  All urine cultures are negative.  In addition to formula, she has processed food that includes salt in her three meals.

Current medications: Bactrim 1/2 tsp qhs, Hydrocortisone 2.5 mg tid, Florinef 0.05 mg bid, NaCl 15 mEq qd.

Physical exam:  
Height: 58.7 cm         Weight: 6.05 kg         Pulse: 120              
General:  alert and interactive girl.
Skin:  slightly mottled.
HEENT: mucous membranes moist.
Heart: regular rate and rhythm.
Abdomen:  no hepatomegaly.
Genitourinary:  no discharge.

Impression: Agatha is doing well.

Disposition: No change in therapy at this time.
Thank you for letting us share in the care of Agatha.

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Problem list to date:
21-HYDROXYLASE-DEFICIENCY                    11/08/94  
Transcribed by Sullivan_ma


CONTENT:
Owen Brezny, M.D.          RE: Agatha Alva
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/13/94

Dear Dr. Brezny:

I saw Agatha in the Endocrine Program on 10/9/95 for 21-hydroxylase deficiency.

History: Agatha is a 13 month old with 21-hydroxylase  deficiency who was recently, on August 7th, seen by Dr. Hendren who performed corrective surgery on her at that time.  Her course since that visit was unremarkable.  She has not had any of the recurrent fever episodes that she had prior to the surgery in the past year.  Her appetite is good and she sleeps through the night.  She is reported to crave salty foods including chips and pretzels.  She is in fact slightly lethargic in the morning.

Current medications: Hydrocortisone 2.5 mg. t.i.d.; Florinef 0.05 mg. b.i.d.; sodium chloride 10 mEq per day.

Physical exam:
Ht: 68.8 cm    Wt: 7.2 kg     BP: 80/55       Pubic hair: Tanner I    
Active, playful child.  Length 68.1 cm., weight 7.2 kg., blood pressure 80/55.  Pubic hair Tanner I, breasts Tanner I.  Skin; warm with diaper area rash.  HEENT reveals mucous membranes moist.  Neck no thyromegaly.  Chest clear.  GU well healed surgical incisions.

Impression: Agatha is doing well and growing just under the 5th percentile curve.  Her weight gain also seems to be appropriate.  She does seem to be a little bit lethargic by report in the morning and might benefit from a redistribution of her glucocorticoid dose.

Disposition: I have recommended to Agatha's mother to change the hydrocortisone dosing to 5 mg. every morning and 2.5 mg. at dinner.  Otherwise, no treatment is recommended.  I would like to see Agatha in six months for follow-up.



Sincerely,




Lancelot Blue, MD             
Attending in Endocrinology   


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


CONTENT:
Herman Pluto, M.D.          RE: Kiki Richards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/80

Dear Dr. Pluto:

     We had the pleasure of evaluating Kiki in the Renal Program on 11/2/94 for primary hyperoxaluria.

     Kiki has remained active and doing well in school.  There have been no renal symptoms

Current medications include:
     PREDNISOLONE 17.5 mg q.o.d.
     PYRIDOXINE HCL 800 mg q.o.d.
     IMURAN 75 mg q.o.d.
     CYCLOSPORINE 300 mg q.o.d.
     HYDROCHLOROTHIAZIDE  25 mg q.p.m., 37 mg q.a.m.
     MEQ  200 mg q.d.

Past medical history:
     Primary hyperoxaluria requiring a transplant for renal failure at age 2 months and a repeat transplant at age 12 years.  Prior ventricular septal defect with spontaneous closure at age 2 months.

Review of systems:
     No recent infections, dysuria, pain or hematuria.

Physical exam:
     BP 121/71   P 80  
     General: Attractive small statured 14 year old girl, comfortable at rest
     Skin: Intact, without evidence for rash or deposits
     HEENT: Within normal limits apart form the fundal changes of oxalosis which have been previously noted
     Neck: Supple, without lymph adenopathy
     Chest: Clinically clear
     Heart: Clinically clear, now without bruit
     Abdomen: Soft and non-distended and the kidney allograft was palpable size, approximately 11 cm no bruit
     Genitourinary: Tanner 3
     Extremities: No edema or rash
     Neurological: No focal signs and no tremor

Urinalysis:
     SPEC GR UA  1.016           PH UA       5          
     PROTEIN UA  trace           BLOOD UA               
     GLUCOSE UA  50              WBC/HPF     N     
     RBC/HPF     5+              CASTS       N   
     CRYSTALS    N
   
Laboratory studies at this time include:
          ALB         3.9    G/DL       ALKP        239     U/L (H)
          CO 2         27   MEQ/L (H)   CA          9.5   MG/DL    
          CR          1.2   MG/DL (H)   GLU         115   MG/DL    
          PHOS        3.5   MG/DL       TP          7.3   GM/DL    
          AST          26     U/L       BUN          33   MG/DL (H)
          NA          143  MMOL/L       K           4.6  MMOL/L (H)
          CL          104  MMOL/L       PLT         351   K/MM3    
          WBC       12.28   K/MM3       RBC        4.32   M/MM3    
          HGB        13.2    G/DL       HCT.       38.7       %    
          MCV        89.6      FL       MCH        30.6      PG    
          MCHC       34.1    G/DL       RDW        13.2       %    
          HDW        2.57    G/DL       PLT UNC     351   K/MM3    
          NEUT         81       % (H)   LYMPH         9       % (L)
          MONOS         7       %       BAND          3       %    
          CELLS C     100       ABS NEU   10.32   K/MM3    
          ABS LYM    1.11   K/MM3       ABS EOS     .00   K/MM3    
          MORPH    NORMAL       


     1)  Primary Hyperoxaluria in good control  2)  Renal Transplant  3)  Cadaver Donor Transplant  3)  Good function after 3 years 10 months

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Herman Pluto, M.D.          RE: Kiki Richards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/80

Dear Dr. Pluto:

     We had the pleasure of evaluating Kiki in the Renal Program on 3/30/95 for hyperoxaluria post transplant.

     Kiki returns asymptomatic since her past review with no intercurrent infections or change.

Current medications include:
     PREDNISOLONE 17.5 mg q.o.d.
     IMURAN 75 mg q.o.d.
     CYCLOSPORINE 300 mg q.d.
     PYRIDOXINE HCL 800 mg q.d.
     HYDROCHLOROTHIAZIDE 37 mg qam, 25 mg qpm

Past medical history:
     Primary hyperoxaluria number two transplant now 4 years and two months after a second cadaver transplant.

Review of systems:
     Asymptomatic without intercurrent problems.  Kiki is now however feeling her short stature somewhat more than on prior occasions.

Physical exam:
     BP 106/52   P 91   R 16    HT 140.2cm   WT 43.2kg
     General: attractive, small statured 14 year old with good proportions
     HEENT: clear
     Neck: supple, lymph nodes not palpable
     Chest: clinically clear
     Heart: regular rate and rhythm without bruit
     Abdomen: allograft 11cm, non-tender, no bruit
     Genitourinary: Tanner 3-4, axillary breast and pubic hair
     Extremities: no local lesions apart from an eczematoid area on the right metacarpal phalangeal joint and proximal interphalangeal joint on the index finger on the right hand
     Neurological: no localizing signs

Urinalysis:
     SPEC GR UA  1.016           PH UA       6.5        
     PROTEIN UA  N               BLOOD UA    trace      
     GLUCOSE UA  N               WBC/HPF     0-2        
     RBC/HPF     0-1             SQUAM EPI   rare  
     GRAN CAST   rare, fine

     Renal transplant number two; cadaver transplant number two four year and two months with sustained good function.  2) Primary hyperoxaluria in good control.  3) Slow growth and small stature secondary to prior renal disease and primary hyperoxaluria present.  4) Eczemamatoid area on right hand as previously described.  X-ray of the area to exclude oxalate deposition was performed and this shows no cutaneous oxalate deposition.  Bone age 14 years concordant with her chronological age.  5) Cyclosporine level detectable thus a readjustment of timing of dosage will be necessary and a recheck of level.  6) Discussion of potential growth hormone therapy - prior growth hormone therapy had been carried out at the end of the functioning time for her first cadaver transplant and a good growth spurt attained.  Present bone age suggests a limited potential for growth with this and a prior decrease in renal function, there is a larger risk to renal function and the review in the three months will be carried out and if the renal function is stable and no other problems occur a re-review for growth hormone therapy will be undertaken.

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Pluto, M.D.          RE: Kiki Richards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/80

Dear Dr. Pluto:

     We had the pleasure of evaluating Kiki in the Renal Program on 12/13/95 for renal transplant for ESRD secondary to hyperoxaluria.
     

Kiki has now a functioning renal transplant (second cadaver allograft)        for end stage renal failure secondary to hyperoxaluria.  She has had some  adolescent rebellion and has been a  little less compliant with her medications over the past one to two  months and over the past one week had shown potentially a lower urine  output.

Her current medications include:


Past medical history:
     

Past medical history:  Well known for oxalosis/hyperoxaluria.

Review of systems:
     


Review of systems:  Asymptomatic.

Kiki's physical exam was notable for:
     BP 121/68   P 86   R 16   T    HT 142.2cm   WT 47.5kg
     
     
     Physical exam:  A well hydrated well covered teenager.  HEENT: normal  limits.  Ocular fundi show oxalate deposits as on previous occasions - unchanged.  Neck: supple. Lymph nodes: not palpable.  Chest: clinically  clear.  Heart rate and rhythm regular.  Abdomen: nontender.  Scars from  prior renal transplants. Genitourinary: adolescent female Tanner stage  IV-V.  Extremities: no edema or purpura.  Skin: intact.  Neurological  examination: no focalizing signs.
A urinalysis revealed:
     SPEC GR UA  1.016           WBC/HPF                
     PH UA       6.5             SQUAM EPI              
     WBC ENZ UA                  RBC CAST    0-1        
     BLOOD UA    negat           WBC CAST    0-2        
     PROTEIN UA  negat           GRAN CAST              
     GLUCOSE UA  negat           WAXY CAST              
     RBC/HPF                     BACTERIA    negat 

Laboratory studies at this time include:
          ALKP        186     U/L (H)   MCV        85.9      FL    
          K           5.0  MMOL/L (H)   MCH        30.6      PG    
          ALB         3.9    G/DL       MCHC       35.6    G/DL    
          CA          9.3   MG/DL       RDW        13.0       %    
          MG          1.7   MG/DL       HDW        2.74    G/DL    
          CO 2         22   MEQ/L       PLT UNC     313   K/MM3    
          CR          1.2   MG/DL (H)   NEUT AB    7.33   K/MM3    
          PHOS        2.7   MG/DL       LYMPH A     .77   K/MM3    
          TP          7.4   GM/DL       EOS ABS     .04   K/MM3    
          BUN          26   MG/DL (H)   NEUT-A     86.5       % (H)
          NA          142  MMOL/L       LYMPH-A     9.1       % (L)
          CL          110  MMOL/L       MONO-A      2.3       %    
          WBC        8.47   K/MM3       EOS-A        .5       %    
          RBC        4.68   M/MM3       BASO-A       .6       %    
          HGB        14.3    G/DL       ATYP LY     1.1       %    
          HCT.       40.2       %       NF-2002  ABSENT    

     
Assessment:  Renal transplant with continuing renal function.  There has  been a mild increase in serum creatinine possibly associated with the  compliance with medications and hydration.  A mild increase in  cyclosporine dose would be justifiable since her trough levels have been  extremely low when measured and an increase to 125 mg t.i.d. was instituted at  this time.   

We discussed and emphasized compliance and will have chemistries  repeated once monthly for three months and she will be reviewed then if  stable.   

An ultrasound at this stage showed an 11.8 cm kidney in the left iliac  fossa with resistive indices ranging between 0.69 to 0.81 in a small  portion of the mid pole only.  No hydronephrosis or stones present and  the bladder was not taken.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Herman Pluto, M.D.          RE: Kiki Richards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/80

Dear Dr. Pluto:

     We had the pleasure of evaluating Kiki in the Renal Program on 2/21/96 for renal transplant/hyperoxaluria.
     
She has done well since her last visit and is more compliant with  medications although still finding difficulty with the pyroxidine and  magnesium oxalate regime for her hyperoxaluria.

Her current medications include:
     CYA 125 mgm t.i.d.
     HYDROCHLOROTHIAZIDE 37.5 mg q a.m. 25 mgm q p.m.
     PREDNISONE 5 mgm q.o.d.
     IMURAN 75 mgm q.d.
     VIT B6 (Pyridoxine) 200 mgm q.i.d.
     MAGONATE (magnesium gluconote) 500 mgm q.i.d.

Past medical history:
     Her past medical history well known for hyperoxaluria with the need for  renal transplant secondary to end stage renal failure. There have been no intercurrent illnesses.

Kiki's physical exam was notable for:
     BP 109/45   P 67   R    T    HT 142.2cm   WT 46.7kg
     A happy, alert, well hydrated adolescent girl.  Head,  eyes, ears, nose and throat within normal limits.  Fundi show oxalate deposits as previously without extension or improvement.  
     Neck: supple.  
     Lymph nodes: not palpable.  
     Chest: clinically clear.  
     Heart: regular rate and rhythm without bruit.  
     Abdomen: nontender, kidney easily  palpable 10.5 to 11 cm in size and without bruit.  
     Genitourinary:  Tanner stage IV-V.  
     Extremities: no localizing signs or rash.  
     Skin:  intact. 
     Neurological: no focalizing signs.
A urinalysis revealed:
     SPEC GR UA  1.016           WBC/HPF     0-2        
     PH UA       6               SQUAM EPI   occ.       
     WBC ENZ UA  neg             RBC CAST    0          
     BLOOD UA    neg             WBC CAST    0          
     PROTEIN UA  neg             GRAN CAST   0          
     GLUCOSE UA  neg             WAXY CAST   0          
     RBC/HPF     0-1             BACTERIA    neg   
     CASTS rare fine

Laboratory studies at this time include:
          K           4.7  MMOL/L (H)   RDW        13.7       %    
          CR          1.0   MG/DL       HDW        2.78    G/DL    
          BUN          23   MG/DL (H)   PLT UNC     341   K/MM3    
          NA          142  MMOL/L       NEUT AB    3.61   K/MM3    
          CL          110  MMOL/L       LYMPH A    2.58   K/MM3    
          CO 2         27   MEQ/L       EOS ABS     .62   K/MM3 (H)
          WBC        7.52   K/MM3       NEUT-A     48.1       %    
          RBC        4.32   M/MM3       LYMPH-A    34.4       %    
          HGB        12.5    G/DL       MONO-A      4.7       %    
          HCT.       35.9       % (L)   EOS-A       8.3       % (H)
          MCV        83.2      FL       BASO-A      1.4       %    
          MCH        28.9      PG       ATYP LY     3.2       %    
          MCHC       34.8    G/DL       LEFT SH  ABSENT    

     Kiki has a renal transplant with stable clinical function and with no  signs for activity of the hyperoxaluria.  The present urinalysis is in  good range although the specific gravity is higher than I would like.  She has been encouraged to increase her fluid intake.   

A discussion with Kiki reveals that her adolescent social life makes  some difference in ability to keep strictly to her medicational regime  and changes were made to simplify the regime to a twice daily dosage  regime.  Cyclosporine will be changed to 200 mg am, 175 mg p.m.,  prednisone will continue at 5 mg every other day (on odd days).   Pyridoxine 400 mg will be changed to twice daily to assist in dose simplification and  magnesium will be changed to 750 mg in the morning, 500 mg in the  afternoon, and 750 mg at suppertime or early evening.  Kiki will have a one monthly blood review.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Herman Pluto, M.D.          RE: Kiki Richards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/80

Dear Dr. Pluto:

We had the pleasure of seeing Kiki in the Renal Program on 8/7/96 for follow up renal transplant.
This teenage girl returns for review follow up of her second  renal transplant and control of her underlying oxalosis.  Past medical history is well known for the oxalosis and transplant, and for hold up in growth rate secondary to her prior renal failure and bone disease.   Review of systems shows no recent symptomatology.  Compliance with full  medications regimen is not total and needs to be rediscussed.

Her current medications include:
     IMURAN 75 mg q.p.m.
     PREDNISONE 10 mg q.p.m.
     HYDROCHLOROTHIAZIDE 37.5 mg q.a.m.
     HYDROCHLOROTHIAZIDE 25 mg q.p.m.
     VITAMIN B6 800 mg q.d.
     MAGANATE 500 mg q.i.d
     CYA 100 mg t.i.d.

Kiki's physical exam was notable for:
     BP 99/56   P 80   R 18   T    HT 142.6cm   WT 47.6kg
      General appearance is that of an attractive, happy  teenager who is well hydrated.  Head, eyes, ears, nose and throat is  within normal limits.  Fundi show oxalate deposits in the retina which  are unchanged.  The neck was supple, no lymph nodes not palpable.  Chest  is clinically clear.  Heart has regular rate and rhythm without bruit.   Abdomen is nontender, and there is minimal bruit audible over the  transplant site.  GU is deferred.  Extremities show no edema.  Skin is  intact.  Neurological exam was intact.
A urinalysis revealed:
     SPEC GR UA  1.009           WBC/HPF     0-2        
     WBC ENZ UA  neg             RBC/HPF     nil        
     PH UA       7               WBC CAST    nil        
     PROTEIN UA  neg             RBC CAST    nil        
     BLOOD UA    neg             GRAN CAST   nil        
     GLUCOSE UA  neg             WAXY CAST   nil   
     BACTERIA    neg             SQUAM EPI   occ   

Laboratory studies at this time include:
          AST          22     U/L       HCT.       42.9       %    
          ALKP        194     U/L (H)   MCV        83.7      FL    
          K           4.3  MMOL/L       MCH        29.5      PG    
          ALB         4.2    G/DL       MCHC       35.2    G/DL    
          CA          9.4   MG/DL       RDW        13.9       %    
          CR          1.3   MG/DL (H)   HDW        2.48    G/DL    
          PHOS        4.6   MG/DL (H)   MPV         8.6      FL    
          TP          7.9   GM/DL       PLT UNC     350   K/MM3    
          ALT          10     U/L       NEUT         83       % (H)
          BUN          35   MG/DL (H)   LYMPH        11       % (L)
          NA          137  MMOL/L       MONOS         1       %    
          CL          103  MMOL/L       EOS           1       %    
          CO 2         23   MEQ/L       ATYP LY       2       %    
          WBC       11.45   K/MM3       BAND          1       %    
          RBC        5.12   M/MM3 (H)   METAMYE       1       %    
          HGB        15.1    G/DL       

This teenage girl has done well with long term treatment of oxalosis and transplant, but shows some of the features of adolescent  changes in her home situation with less than total compliance with a  complex medical regimen.   

We had a long discussion of each medication, its indication, side  effects and the need for full cooperation and this appears to be  satisfactory response.  We will review the oxalate excretion together  with that of her sisters, who have a milder form of the disease in the  next month and have her chemistries repeated in 2 months with a return  review here in 
4 months, to be sure that compliance is occurring, and  that we can keep her under full control.

Thank you for the opportunity to participate in Kiki's care. We would be happy to discuss or review Kiki should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Herman Pluto, M.D.          RE: Kiki Richards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/29/80

Dear Dr. Pluto:

We had the pleasure of seeing Kiki in the Renal Program on 11/6/96 for follow up of renal transplant #2 for hyperoxaluria.
Kiki continues to do well in follow up after her second renal  transplant for primary hyperoxaluria.  She appears to be more compliant with her medications for both immunusuppression and oxalosis at this time.  

Her past medical history is well known for hyperoxaluria and the need for  transplantation. 

Review of systems shows an interval period of asymptomatic control.

Her current medications include:
     IMURAN 75 mg q.h.s.
     PREDNISONE 10 mg q.a.m.
     HYDROCHLOROTHIAZIDE 25 mg q.a.m.
     HYDROCHLOROTHIAZIDE 37.5 mg q.p.m.
     CYA 100 mg q.i.d.
     VITAMIN B6 200 mg q.i.d.
     MAGONATE 500 mg q.d.

Kiki's physical exam was notable for:
     BP 102/49   P 78   R    T    HT 143cm   WT 49kg
     General appearance: A happy, well hydrated teenager.   
     HEENT: within normal limits.  
     Eyes show no  corneal or conjunctival deposits but retinal changes consistent with  hyperoxaluria. 
     Neck: supple, lymph nodes not palpable.  
     Chest: clear.   
     Heart: regular rate and rhythm without bruit.  
     Abdomen: prior operative  scars, no local tenderness, mass or viscous palpable.  Genitourinary:  deferred.  
     Extremities: no edema.  
     Skin: intact.  
     Neurological: no  focalizing signs.
A urinalysis revealed:
     SPEC GR UA  1.018           GLUCOSE UA  neg        
     WBC ENZ UA  neg             BACTERIA    neg        
     PH UA       6               WBC/HPF     0-1        
     PROTEIN UA  neg             RBC/HPF     1-2        
     BLOOD UA    neg             SQUAM EPI   few   
CASTS: rare hyaline

Laboratory studies at this time include:
          K           3.7  MMOL/L       HDW        2.50    G/DL    
          CA          9.4   MG/DL       MPV         8.7      FL    
          CR          1.1   MG/DL (H)   PLT UNC     378   K/MM3    
          PHOS        4.0   MG/DL       NEUT AB    7.27   K/MM3    
          BUN          34   MG/DL (H)   LYMPH A    3.39   K/MM3    
          WBC       11.83   K/MM3       EOS ABS     .35   K/MM3    
          RBC        4.34   M/MM3       NEUT-A     61.5       %    
          HGB        12.8    G/DL       LYMPH-A    28.7       %    
          HCT.       36.5       %       MONO-A      4.0       %    
          MCV        84.0      FL       EOS-A       3.0       %    
          MCH        29.5      PG       BASO-A      1.1       %    
          MCHC       35.1    G/DL       ATYP LY     1.8       %    
          RDW        13.9       %       LEFT SH  ABSENT    

My assessment is that Kiki is doing better and settling into her adolescence well.  She is more compliant with her medications and her  chemistries and urinalysis are both in good range.   

I would suggest we perform an elective 24 hour oxalate excretion and creatinine clearance in the next school break.  I re-emphasized to Kiki in discussion the need for constant immunosuppression and continuing need for compliance with treatment for her oxalosis.  We will  review her physically in four months with a follow up blood testing in  three months.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Stanwood Crane, M.D.          RE: Ernst Jordan
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/13/87

Dear Dr. Crane:

     We had the pleasure of seeing Ernst in the Renal Program on 11/10/94 for hematuria.

     This 7 year old has had asymptomatic microscopic hematuria detected over 2 years.  He has otherwise been well without gross hematuria, rash, arthritis or GI complaints.

Family history:
     Father has renal glycosuria and at this exam shows also microscopic hematuria with casts of fine granular, hyaline and occasional course granular cast.  There is no proteinuria in the father's urine nor in Ernst's urine.

Physical exam:
     BP 106/68   P 86   R 20    HT 125.1cm   WT 24.4kg
     General: Well hydrated, well covered 6 year old
     Skin: Intact, without rash, telangiectasia or other lesions
     HEENT: Within normal limits, without any evidence for lymph nodes
     Neck: Supple
     Chest: Clinically clear
     Heart: Clinically clear
     Abdomen: No masses or tenderness
     Genitourinary: Normal male
     Extremities: No lesions

Urinalysis:
     SPEC GR UA  1.020           PH UA       5          
     PROTEIN UA  N               BLOOD UA    3+         
     GLUCOSE UA  N               WBC/HPF     occ        
     RBC/HPF     clump           RBC CAST    5          
     GRAN CAST   fine            SQUAM EPI   occ   

     Urinalysis remains positive with prior positive urinalyses at Tuft's New England Medical Center.  

1)  Benign familial hematuria with potential for thin basement membrane disease or IgA familial nephropathy  2)  Absence of proteinuria.

Diagnostic studies include review father's urinalysis.  This shows a 1+ dip positive urine for blood with occasional small clumps of red cells and with 1 coarse granular cast, 2 fine granular casts and occasional hyaline casts on examination of a full cover slip.  Urinalysis on the sister through Dr. Crane's office has been reportedly normal according to the father.  

No testing was done at this time but at the time of his next blood drawing it would be reasonable to document a C3 and IgA level.

Follow-up with Dr. Crane in 12 months with urinalysis to exclude development of proteinuria and or hypertension and return here in 2 years or if there was development of proteinuria or hypertension.

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Bleck DeNiro, M.D.          RE: Lori Loubet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/20/87

Dear Dr. DeNiro:

We had the pleasure of seeing Lori in the Endocrine Program on 11/28/94 for premature adrenarche.

History: The patient is a 7 and 2/12 year old Hispanic female who was noted in September to have a growth of axillary and pubic hair on routine exam by her local physician.   Mother states that this was present for approximately 6 months, and she has also noted for 6 months increased body odor and need for deodorant.   There is no breast development, vaginal discharge or vaginal bleeding.   Mother denies that the patient has any change in bowel habits.   There is no nausea or vomiting, no change in activity level or change in the level of aggression.  No visual changes.   The mom does report that the patient complains of headaches.   The patient has had good growth and was always larger than her peers.

Current medications: None.  

Allergies:  None.

Past medical history:  Mother is gravida 6, para 4 with 2 early spontaneous abortions.   The patient was delivered by a vaginal delivery at term and she was 7 pounds 10 ounces and 20 inches long.   Nutritionally she has always been a big eater.  No history of infectious disease other than chicken pox.   Immunologically she is up to date.   She has had no hospitalizations, injuries or operations.

Review of systems:  Noncontributory except for history of headaches.

Family history:  Positive for asthma in the father.   Positive for adult onset diabetes in maternal grandmother and insulin dependent diabetes in a paternal uncle.   There is no history of precocious puberty, hirsutism, adrenal, thyroid or kidney disease.  Mother's height is 5'2", father's height is 5'4".   The patient's projected height is 5'1".

Physical exam:  
Height: 129.3 cm        Weight: 44.0 kg         BP: 102/58              
Pulse: 72               Breast: Tanner I        
General: She is an obese, Hispanic female in no apparent distress.   
Skin: There are no cafe-au-lait patches.   There are two hypopigmented lesions on the back which mother says may be due to her history of chicken pox.   
HEENT: Pupils equal, round and reactive to light and accommodation.  Fundi were benign with crisp disc margins.    There was acanthosis nigricans noted on the posterior aspect of the neck.  
Neck: There is no thyromegaly or noted adenopathy.   
Axillary:  Exam showed coarse hair bilaterally.    
Breasts:  No breast tissue was noted bilaterally.  
Lungs: Clear to auscultation and percussion.  
Heart: Regular rate and rhythm without murmur.  
Abdomen: Flat, soft and nontender.   No hepatosplenomegaly.  
Genitourinary: There is no clitoromegaly.   She has Tanner stage II-III pubic hair.  Vaginal mucosa is red with no signs of estrogenization.    
Extremities: No clubbing, cyanosis or edema.   2+ deep tendon reflexes bilaterally in the lower extremities with no deep tendon reflex lag.   
Bone age was reported as 8 and 10/12.

Laboratory studies:  glucose 98  mg/dL, 17OHP <10 ng/dL,DS  55 ug/dL, LH  <0.10 IU/L, FSH 0.20    IU/L,   IRI 70.1  uU/mL

Impression: Premature adrenarche without signs of estrogen effect thus far may be early central precocity, late onset CAH, or benign premature adrenarche.   Secondary diagnosis of obesity and acanthosis nigricans.   Studies ordered today included an FSH, LH, DHEA-S and a 17 hydroxy progesterone.   Also, becausethe obesity and acanthosis we ordered a serum insulin and glucose.

Disposition: We asked for the bone age films to be sent to us for review.  Thse labs are normal for age except the signficiant hyperinsulinism.  Otherwise, it appears that the patient has premature adrenarche.   This can be followed if all the testing is normal.    We do suggest that the patient get some dietary counselling as her obesity and acanthosis at this time is a strong predictor of future problems with obesity and risk factor for diabetes.  As well, this picture may predispose her to PCO in the future.  We would like to see her back in three months.
Thank you for letting us share in the care of Lori.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology
  


Addendum: Daniel Schust, M.D.
Resident in Pediatrics


CONTENT:
Bleck DeNiro, M.D.          RE: Lori Loubet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/20/87

Dear Dr. DeNiro:

We had the pleasure of seeing Lori in the Endocrine Program on 03/06/95 for premature adrenarche.

History: She was last seen in November,1994 for premature adrenarche.  She is now 7 5/12 and her mother notes no change in hair or breast development in the interim.  There also has been no vaginal discharge.  She continues to use  a deodorant, as she has since age 6.  Her 9 3/12 yr. old sister recently had onset of menses.  Mother notes that a maternal aunt may also have had early development.  Relative to Lori's weight, her mother comments that she has "always been eating and drinking" since she was very small.  As mother is in school, Lori eats breakfast and lunch at school and then her grandmother keeps her in the afternoon; thus control of diet is rather difficult.  Of note Lori has wet the bed for the last three nights.  This is a new symptom.

Physical exam:  
Height: 131.6 cm        Weight: 46.4 kg         BP: 100/62              
Breast: Tanner I        Pubic hair: Tanner III  
General: chubby girl 
Skin:   some acanthosis nigricans
HEENT: eye exam normal
Neck: thyroid is just palpable
Abdomen:  obese without mass or hepatosplenomegaly
Genitourinary: pubic hair Tanner 3; no significant change since I last examined her.  The vaginal mucosa is red.
Extremities:   normal
Neurological:  normal

Laboratory studies:  No studies ordered today.

Impression: 1.   Lori has early adrenarche with a family history of early puberty in her sister.  The evaluation done in November was unrevealing.

2.   Lori is obese with hyperinsulinism and acanthosis, indicating insulin resistance.  She needs nutritional evaluation and input in order to help her at least maintain her weight while she grows.  Her mother is to call your office to arrange that.  

3.   Recent nocturnal enuresis.  I doubt that she has diabetes as there has been no weight loss and the thirst is a chronic complaint and not a new one.  In addition the patient is unable to void here.  I sent a reactive strip home with mom to check for urine glucose and she is to call me if it is positive.

Disposition: I'd like Lori to return to the clinic in four months.  As transportation is difficult for this patient, I have sent a letter with mom to see if she can arrange that through Department of Social Services.
Thank you for letting us share in the care of Lori.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Bleck DeNiro, M.D.          RE: Lori Loubet
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/20/87

Dear Dr. DeNiro:

I had the pleasure of seeing Lori in follow-up on 11/08/95 for premature adrenarche and acanthosis nigricans.  

Lori is now 8 and 1/12 years old and the newest news is that she is receiving a learning evaluation at school.  According to her mother, on a recent physical at your office, she was told that she had "gained too much."  Mother says she cannot control her eating.  She was seen three times by nutritionists with no results.  Her mother notes a weight of 108 pounds in September of 1995.  She also notes that for the last two months, there has been no nocturnal enuresis.  She notes frequent crying, "for any reason."  She is fighting frequent with the other children in the  family and is quite verbal.  She stays physically active.  They see no pubertal changes occurring.

Current medications: None.

Physical exam:
HT: 135.6 cm    WT: 50.7 kg      Breast: Tanner I     Pubic hair: Tanner III  
She is an overweight, quite youngster.  There is significant acanthosis nigricans on the neck.  The breasts are fatty with no glandular tissue.  The abdomen is obese but otherwise appears normal.  The genitalia shows sparse, long curly hair on the labia and mons.   

No studies were ordered today.

Impression: Lori has grown 4 cm and 4.3 kg in eight months.  This shows normal linear growth and a continued steady weight gain, and she continues to have premature adrenarche, but no signs of true puberty yet.  Suggested that they continue their efforts at weight control and encouraged the mental health consult to support that.  She is to return to clinic in six months for follow-up of the early development.   

Thank you for letting us share in Lori's care.



Sincerely,




Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Sookdei Beaker, M.D.          RE: Conan Richter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/21/81

Dear Dr. Beaker:

We had the pleasure of seeing Conan in the Endocrine Program on 1/10/95 for .

History: I saw Conan, age 13 years 2.5 months, for follow up of insulin dependent diabetes mellitus diagnosed nearly 5 years ago.

He is currently on Pure Pork insulin, 14.5 Regular and 14.5 NPH before breakfast, 9.5 Regular before supper and 12 NPH at bedtime (approximately 50 units or 1.1 U/kg/day).   

He does well in school and reports no significant problems related to his diabetes control.  The question has come up whether it would be desirable to switch from Pork to Human insulin.

Physical exam:  
Height: 153.9 cm        Weight: 45.3 kg         BP: 121/66              
Pulse: 84               
He looks well and has good color and hydration.   The physical exam was unremarkable except to note minimal lipohypertrophy at the injection sites in the upper extremity.  

Urine had 2+ glucose, negative ketones and protein; plasma glucose in the mid afternoon was 277 mg/dL, hemoglobin A1 was 7.6% (normal 5.2-7.8%).

Impression: Conan is growing and gaining weight normally.   His diabetes is extremely well controlled.   I have switched from Pork to Human insulin at the patient's and family's request.   I explained the expected differences in action; namely, a more rapid onset of action of the NPH insulin with an earlier peak and probably a shorter total duration of action.   I have modified his insulin doses so that he will now receive 10 Regular and 18 NPH in the morning, 9 Regular before supper and 11 NPH at bedtime.   Because Conan does not typically have a mid-morning snack, it would seem prudent to lower the morning dose of Regular insulin.

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

Sincerely,


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


CONTENT:
Sookdei Beaker, M.D.          RE: Conan Richter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/21/81

Dear Dr. Beaker:

History: I saw Conan, age 13 years 6 months, for follow up of insulin dependent diabetes mellitus.   

He has continued to use Pure Pork insulin, 5.5 Regular and 17.5 NPH before breakfast, 12.5 Regular before supper, 13.5 NPH at approximately 10 pm.  His average daily dose is 59 units or 1.22 U/kg.  

Although we had discussed the possibility of switching to Human insulin after the last visit, his parents decided to wait until the summer when he can be more closely supervised.

There have been no problems with severe hypoglycemia and he reports no diabetes-related symptoms.  He continues to follow a structured meal plan and pays careful attention to his food intake.   

Blood glucose monitoring is done 4-5 times daily.

Physical exam:  
Height: 154.9 cm        Weight: 48.5 kg         BP: 115/61              
Pulse: 68               
Physical exam was entirely unremarkable except that he did have mild lipohypertrophy at the injection sites on the anterior abdominal wall.  

Urine had trace glucose, negative ketones and trace protein; random plasma glucose in the mid afternoon was 277 mg/dL, hemoglobin A1 was 8.2% (normal 5.2-7.8%).  Urine microalbumin was 7 mg/g Cr, a normal value.

Impression: Conan is growing and gaining weight normally.   He is in early puberty.   His diabetes is exceptionally well controlled.  I have pointed out the need to rotate his injection sites to avoid the areas of hypertrophy.   Conan has had diabetes for five years and is in early puberty; therefore, he should begin to have annual screening examinations to rule out diabetic retinopathy.  He has no evidence of nephropathy.

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


Sincerely,





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


CONTENT:
Sookdei Beaker, M.D.          RE: Conan Richter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/21/81

Dear Dr. Beaker:

We had the pleasure of seeing Conan in the Endocrine Program on 6/20/95 for .

History: I saw Conan, age 13 years  8 months, for follow up of insulin dependent diabetes mellitus diagnosed 5  years ago. 

He is currently on Pure Pork insulin, 15.5 Regular and 17.5 NPH before breakfast, 12.5 Regular before supper, 15.5 NPH at bedtime (average daily dose 59 units or 1.2 u/kg).  

General health has been good until he developed an upper respiratory infection and a bronchial cough the day before this visit.  He has done very well in school.  Social life is excellent.  He reports no diabetes-related symptoms and there have been no symptoms of severe hypoglycemia.

Physical exam:  
Height: 156.8 cm        Weight: 48.8 kg         BP: 136/71              
Pulse: 90               
General:  He appeared healthy, well developed, well nourished.  He had a dry cough.  Physical exam was unremarkable.

Laboratory studies:  Urine had trace glucose, negative ketones and protein; plasma glucose 121 mg/dL in mid-afternoon, hemoglobin A1 8% (normal 5.2-7.8%).

Impression: Diabetes is well controlled.  After extensive discussion, we decided not to change from Pork to Human insulin because his diabetes is so well controlled.  I advised him to reduce his dose of insulin when he increases his level of physical activity at camp.

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

Sincerely,


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


CONTENT:
Mitsuko Benise, M.D.          RE: Conan Richter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/21/81

Dear Dr. Benise:

We had the pleasure of seeing Conan, age 13 years 11 months, for insulin dependent diabetes. 

He has continued to use pure pork insulin: 14 units Regular and 16.5 units NPH before breakfast, 12.5 units Regular before supper and 12 units NPH prior to bedtime.  His average daily dose is 55 units or1.1 units per kg per day.   

He reports two recent events that have caused him to have overall higher blood sugars.  The first is that he broke his collarbone while playing touch football on 9-20-95 and as a result has had decreased activity more recently.  Prior to the summer we had decreased his insulin slightly anticipating greater activity during the summer and lower blood sugars in the spring. 

Overall, his prelunch and dinner blood sugars have been slightly high in the 200s mg/dL.  In addition, he has occasionally adjusted his insulin by half units depending on his activity level and his appetite.   

There have been no problems with severe hypoglycemia.  He reports no  diabetes-related symptoms.  He continues to follow a structured meal plan of three meals a day with snacks being optional based on his blood sugar and activity levels. 

Blood glucose monitoring is done five times a day.

Current medications: None.

Physical exam:
HT: 158.3 cm            WT: 44.8 kg
BP: 110/70              Pulse: 70               
His physical exam is unremarkable except that he is wearing a sling for his collarbone fracture.  He is currently Tanner stage III.  He had no atrophy or hypertrophy of his injection sites.

Laboratory studies: Serum total cholesterol 144 mg/dL; total glycosylated hemoglobin 7.9% (normal 5.2-7.8).

Impression: Conan has had recent increased blood sugar secondary to decreased activity following his collarbone injury.  We recommend changing his insulin in the morning to 15 units Regular, 18 units NPH with a goal of decreasing his prelunch and predinner sugars.  We also recommend increasing his dinner to 13 units or Regular while maintaining his bedtime dose at 12 units of NPH.  

The overall goal for his blood sugar should be in the range of 70-120.  We discussed with the family that rather than using a half unit of Regular to adjust for his blood sugars and activities, that he should use one unit of extra for every 50 mg/dL  glucose above the goal.  We have also discussed with the family that he will adjust his insulin through the scale as his activity level increases with his recovery.


Sincerely,






Michelle Weinberg, MD             Bernardo Bird, MD         
Resident in Endocrinology         Clinical Director of Endocrinology
                                  Associate Professor of Pediatrics, HMS


CONTENT:
Sookdei Beaker, M.D.          RE: Conan Richter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/21/81

Dear Dr. Beaker:

I saw Conan, age 14 years 3 months, for follow-up of insulin dependent diabetes mellitus diagnosed nearly six years ago.   

Medications:  Pure pork insulin 19 regular plus 20.5 NPH before breakfast, 13.5 regular before supper, and 12 NPH at bedtime (average daily dose 65 units or 1.26 u/kg/day). 

He reported no diabetes-related symptoms.  He is currently well.  He has had two episodes of hypoglycemia in which he became confused and required his mother's assistance.  He had been ill, appetite was diminished, but he took his usual insulin dose. 

He is moderately active; he has a good appetite with three meals and two or three snacks daily.  He monitors glucose levels approximately four times daily and keeps a complete record.

Current medications: None.

Physical exam:
HT: 160 cm              WT: 51.5 kg
BP: 110/68              Pulse: 70               
He was a healthy appearing youth.  The physical examination was entirely normal except for two findings:  he has mild gynecomastia and mild lipohypertrophy on the anterior abdominal wall.

Laboratory studies: Urine had 0.5% glucose, negative ketones and protein; plasma glucose at 12 p.m. 202 mg/dL; HbA1c 6.5 (normal 4-6)%.

Impression: He is growing and gaining weight normally.  He has mild pubertal gynecomastia.  From the history, it appears that he also has decreased hypoglycemia awareness.

Disposition: I reviewed his insulin doses and made recommendations for appropriate adjustments.  I also explained the use of sliding scales to achieve target glucose levels and emphasized the importance of avoiding hypoglycemia in 
order to recover normal hypoglycemia symptoms awareness.  I also encouraged him to measure blood glucose levels at approximately 2:00 to 3:00 a.m. at least once weekly to detect asymptomatic nocturnal hypoglycemia.


Sincerely,







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


CONTENT:
Mitsuko Benise, M.D.          RE: Conan Richter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/21/81

Dear Dr. Benise:

I saw Conan, age 14 years 7 months, for follow-up of insulin-dependent diabetes mellitus diagnosed just over 6 years ago. 

He has enjoyed good health and reported no diabetes-related symptoms.  There have been no episodes of severe hypoglycemia, and he is now better able to recognize symptoms of hypoglycemia.  He reported no problems with nocturnal hypoglycemia. 

Insulin dose:  Lilly pure pork insulin 22 Regular and 23 NPH before breakfast, 19 Regular before supper, 12 NPH at approximately 10 p.m.  Average daily dose 76 units or 1.37 u/kg. 

He has a voracious appetite and has 3 meals and 2 snacks daily.  He is physically active almost every day. 

Blood glucose monitoring is done 4-5x daily.

Physical exam:
HT: 163.6 cm            WT: 55.6 kg
BP: 114/82              Pulse: 91                    
Breast: Tanner III      Pubic hair: Tanner V    
He looked well, had good color and hydration.  He had hair on his upper lip.  Thyroid gland was not palpable.  He had a grade II/VI systolic ejection murmur.  Deep tendon reflexes were 2+ and symmetric.  Vibration sensation was intact.  He had mild hypertrophy at the injection sites on the anterior abdominal wall.   He had moderate bilateral gynecomastia.

Laboratory studies: Urine had 3+ glucose, and negative ketones and protein.  Random plasma glucose 275 mg/dl, non-fasting cholesterol 130, HDL 43, LDL 38, triglycerides 246 mg/dl; hemoglobin A1c 7% (normal 4-6%); spot urine microalbumin/creatinine ratio 47 mg/g (normal <20).

Impression: Conan has continued to grow and gain weight normally.  Diabetes is very well controlled and there have been no problems with severe hypoglycemia.  He has no complications of diabetes.  I did not change his insulin dose at this time.

Sincerely,




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


CONTENT:
Mitsuko Benise, M.D.          RE: Conan Richter
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/21/81

Dear Dr. Benise:

I saw Conan, age nearly 15 years, for follow-up of insulin-dependent diabetes mellitus diagnosed 6-1/2 years ago. 

Insulin dose:  pure pork 20 R and 25 NPH before breakfast, 19 R before supper, 14 NPH at 10pm (1.26 U/kg/day). 

He has enjoyed good health and currently has no diabetes-related symptoms.  He recently entered high school and is coping well in honor's courses.  

He has three meals and two snacks daily.  He does weight lifting three times a week in preparation for winter track. 

He has had one episodes of moderately severe hypoglycemia in which he became confused and incoherent and felt better after his father made him eat.  He was unaware that his symptoms were due to hypoglycemia.  In general, he does have hypoglycemia awareness manifested as lack of energy and inability to think properly.  There have been no seizures or loss of consciousness.   

He monitors glucose levels 3-4 times daily and does adjust his doses of Regular insulin according to a sliding scale, with one additional unit of Regular insulin for every 50 mg/dl of blood glucose above 200 mg/dl.

Physical exam:
HT: 166.1 cm            WT: 61.7 kg
BP: 130/65              Pulse: 70               Breast: Tanner II       
He is a healthy appearing adolescent with normal color and hydration.  His thyroid gland was palpable but not enlarged.  Cardiac exam was normal.  Physical exam revealed minimal facial acne.  Slight lipohypertrophy at the injection sites on the anterior abdominal wall.  The remainder of the exam was normal.

Laboratory studies: Plasma glucose 94 mg/dL, HGBA1c 7.1 % (4-6); urine microalbumin 2  mg/g Cr, normal.

Impression: He is growing and gaining weight normally.  His diabetes control is excellent.  He has no biochemical evidence of diabetic nephropathy.  We reviewed the prevention and treatment of hypoglycemia and I encouraged him to respond immediately to the earliest symptoms of hypoglycemia to avert more severe hypoglycemia.  No adjustments in his insulin dose are necessary at the present time.


Sincerely,






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

cc: Conan Richter   664 Pike Avenue   Attleboro, MA  02703


CONTENT:
Cavinder Hammer, M.D.          RE: Georges Haber
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/30/82

Dear Dr. Hammer:

We had the pleasure of seeing Georges in the Endocrine Program on 11/17/94 for hypothyroidism.

History: This is the first visit for this 12 year 8 month old girl for evaluation of hypothyroidism.   

She complains of fatigue of approximately one and a half years duration and falling asleep in school.   She describes increased moodiness and decreased concentration.   She received A's and B's in school last year and is now getting C's and D's.  She has noticed an increase in the size of her thyroid gland over the past year and complains of sore throat and "getting food stuck in her throat."   She denies any shortness of breath or raspiness in her voice.   She feels cold all the time and even in the summer, she was wearing long pants and sweaters.  Over the last year, she has had excessive weight gain and some swelling in her fingers.   She has always had a poor appetite but over the past few years it has gotten worse.   She has chronic dry skin and she denies any change in her bowels.    

She had menarche in May of 1993.  She usually gets her periods between the 15th and 19th of the month and they last 5 to 7 days.   She denies any premenstrual symptoms.  Her last menstrual period was October 15, 1994.   She started using deodorant before 1993.

Current medications: None.

Past medical history:  She was the 2 pound 1 ounce product of a 28 week gestation with pregnancy complicated by placenta previa.   Postnatally, she required respiratory support for one day and supplemental oxygen for a few days.   She has had normal growth and development.  Nutrition; she has lactose intolerance.    Immunizations, up to date.   She was treated for a left leg fracture after being hit by a car.

Review of systems:  As above.

Family history:  Significant for hypothyroidism in the maternal grandmother diagnosed in her twenties and a maternal aunt diagnosed at 24 years of age; diabetes mellitus in the maternal aunt. There is also a family history of hypertension, COPD, and alcoholism.  The patient has a 14 year old brother who is 6'1" and is alive and well.  Her mother underwent menarche at age 11.  Mother's height is 5'2.5" tall. Father's height is 6'1" tall.

Physical exam:  
Height: 158.3 cm        Weight: 53.5 kg         BP: 108/64              
Pulse: 84               U/L ratio:  0.93        Arm span: 162           
Breast: Tanner V        Pubic hair: Tanner V    
General:  Well-appearing.  
Skin: Dry, no rashes.   
HEENT: Pupils equal, round and reactive to light and accommodation.   Extraocular movements intact.  Fundi with sharp discs bilaterally.   
Neck: Diffuse thyromegaly,  no nodularity, no bruits.  The thyroid measures approximately 8x5 cm.   Shotty cervical lymphadenopathy bilaterally.  
Heart: Within normal limits without murmurs. 
Abdomen: Benign without hepatosplenomegaly.   
Genitourinary: Tanner V pubic hair.   
Extremities: Within normal limits.   
Neurological: Reflexes are 2+ with slight delayed relaxation phase.

Laboratory studies:  TBGI 0.94, T4 5.5 ug/dL, TT3 141 ng/dL, TSH 7.20 uU/mL, anti-thyroglobulin antibodies 8.8 U/ml (normal 0.0-0.3), thyroid peroxidase antibodies pending.

Impression: Consistent with primary hypothyroidism most likely secondary to Hashimoto's thyroiditis.

Disposition: Georges was started on Levoxine  0.075 mg a day.   She will follow up in four to six weeks time.
Thank you for letting us share in the care of Georges.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology   


Addendum: Jennifer Braimon, M.D.
Fellow in Endocrinology


CONTENT:
Cavinder Hammer, M.D.          RE: Georges Haber
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/30/82

Dear Dr. Hammer:

We had the pleasure of seeing Georges in the Endocrine Program on 2/17/95 for hypothyroidism.

History: Georges is a 12 and 10/12 year old with acquired hypothyroidism.  Since receiving thyroid hormone replacement, she has a better disposition and energy level and has improved her school performance to "B's".  She continues to feel like food is "stuck" in her throat and complains of tenderness over the thyroid.  She denies dry skin, diaphoresis, constipation and diarrhea.  She has had some hair loss, but no bald patches.  Her menstrual periods are of irregular intervals and last seven days.

Current medications: Levoxine 75 mcg/QD (missed three days about 1 month ago)

Physical exam:  
Height: 158.7 cm        Weight: 54 kg           BP: 120/74              
Pulse: 72               Breast: Tanner V        Pubic hair: Tanner V    
General:   Alert
Skin:   Normal texture.
HEENT:   Pupils equal, round, and reactive to light, extraocular movements intact.
Neck:   Decreased size of thyroid gland, about 4 cm in length, firm with questionable mild tenderness.
Chest:   Clear.
Heart: Regular rate & rhythm without murmur.
Abdomen:  Soft without hepatosplenomegaly. 
Extremities:   Well-perfused.
Neurological:   Mild delay in ankle deep tendon reflex relaxation phase, probably within normal limits.  Mild fine hand tremor.

Laboratory studies:  T4 8.3 mcg/dL, TSH 1.80 uU/mL

Impression: Georges is biochemically euthyroid.

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

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology   


Problem list to date:
THYROID-DISEASE                              03/23/95  
HYPOTHYROIDISM                               03/23/95  
ACQUIRED-HYPOTHYROIDISM                      03/23/95  
HASHIMOTO'S-THYROIDITIS                      12/15/94  
PRIMARY-HYPOTHYROIDISM                       12/15/94  
Transcribed by Cohen_l


CONTENT:
Cavinder Hammer, M.D.          RE: Georges Haber
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/30/82

Dear Dr. Hammer:

We had the pleasure of seeing Georges in the Endocrine Program on 5/18/95 for aquired hypothyroidism.

History: Georges is a 13 and 1/12 year old with Hashimoto's thyroiditis.  She has a good energy level, and her school performance is back to her norm.  She and her mother have noted a decrease in her thyroid size, and she no longer feels like food is getting "stuck" in her throat.  She denies, dry skin, hair loss, constipation or diarrhea.  She has regular menses monthly, with a 5-7 day duration.

Current medications: Levoxyl 75 mcg po QD.  She has missed one dose since the last visit (5/17/95).

Physical exam:  
Height: 158.9 cm        Weight: 55 kg           BP: 110/70              
Pulse: 84               Breast: Tanner V        Pubic hair: Tanner V    
General: alert. 
Skin: normal texture.
HEENT: PERRL, EOMI.
Neck: decreased thyroid gland size ~2.5 cm in length, nontender. 
Chest: clear.
Heart: RRR, no murmurs.
Abdomen: soft, no hepatosplenomegaly.
Extremities: well-perfused. 
Neurological: normal ankle DTR relaxation phase.

Impression: Georges is clinically euthyroid.  If she misses a dose of Levoxyl, she should take two pills the next day.


Laboratory studies pending at this time include: T4, TSH.
Disposition: Return to endocrine clinic in 4 months.
Thank you for letting us share in the care of Georges.

Sincerely,


Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Cavinder Hammer, M.D.          RE: Georges Haber
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/30/82

Dear Dr. Hammer:

I saw Georges in the Endocrine Program on 9/21/95 for acquired hypothyroidism.

History: Georges is now 13-6/12 years old.  She has no signs or symptoms of hyper or hypothyroidism.  She missed one week of thyroid hormone replacement while she was in South Carolina about 1-1/2 months ago.  Otherwise, she occasionally misses her medication and takes two pills the next day.  There is a question of lactose intolerance.

Current medications: Levoxyl 75 mcg PO q.d.

Physical exam:
HT: 159.2 cm            WT: 52.4 kg
BP: 118/80              Pulse: 80                     
Breast: Tanner IV       Pubic hair: Tanner IV   
General appearance: alert. Skin: normal texture.  HEENT: pupils equal, round and reactive to light, extraocular movements intact.  Neck: thyroid gland enlarged about 2x normal, nontender without nodules.  Chest: clear.  Cor: regular rate and rhythm without murmur. Abdomen: soft without hepatosplenomegaly.  Extremities: well perfused. Neuro: normal ankle deep tendon reflexes.

Laboratory studies:  T4 8.1 ug/dL, TSH 2.00 uU/mL.

5/18/95, T4 8.5 ug/dl, TSH 1.9 uU/ml.

Impression: Georges is clinically and biochemically euthyroid.

Disposition: Return to Endocrine clinic in six months.


Sincerely,





Leif Pavarotti, MD             
Attending in Endocrinology


CONTENT:
Gaston Frog, M.D.          RE: Vivien Barthes
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/01/84

Dear Dr. Frog:

We had the pleasure of seeing Vivien in the Endocrine Program on 12/8/94 for short stature.

History: This 10 and 11/12 month old Spanish speaking female is here for evaluation of short stature.   At approximately 9 years of age, the patient's mother noted that she was slightly shorter than the other children in school.   

The patient and her mother are originally from Puerto Rico and came to the United States in approximately September of 1994.   Mother fled to the United States secondary to domestic violence towards the mother.  She denies any physical or emotional abuse of the children.   Mother has some social supports in the United States.   

While in Puerto Rico, the patient was followed routinely by a physician.  We don't have those charts available at this time.

Current medications: None currently.

Past medical history:  The patient is the product of an 8 and a half month gestation status post elective repeat C-section.   There were no problems with the pregnancy or delivery.   Birth weight and height was 6.5 pounds and 22 inches.   The patient was bottle fed as a child and had recurrent strep infections, none recently.   Her immunizations are up to date.   She has never been hospitalized.   Mother describes a fall in January of 1994 in Puerto Rico where the patient was running around the house with the other children and fell on her face and had a hairline basal cell fracture.   There are no problems since then.   The patient has never had any operations.

The patient suffers from asthma but she has never been hospitalized.   Usually has exacerbations with URI's.   She has only been in the emergency room in Puerto Rico, never in the United States.   In addition, the patient has a history of migraines.   The mother describes over the past year, only while in Puerto Rico, she had frontal headaches every three weeks associated with nausea and photophobia.   These usually were relieved with Tylenol and warm compresses.   The pain was described as continuous, not stabbing.   In the United States the patient has only had one mild headache that resolved post Tylenol.

Review of systems:  The patient denies any skin abnormalities.  HEENT; the patient describes some blurry vision at a distance.   She denies any diarrhea or nausea.   In general she is a slow eater but likes most foods.   GU; the patient's mother describes one incidence of a yellow vaginal discharge in March of 1994 otherwise, no recurrence of this.   The patient denies any evidence of puberty.  She denies pubic or axillary hair.   Neurologically, the patient is doing well.   She is in the 5th grade in a Spanish speaking school getting B's and C's.

Family history:  The patient's mother is 32 years old.  There are two maternal aunts and three maternal uncles.   One aunt has migraines.   Maternal grandmother is 61 and she has diabetes.   She is approximately 5'3" tall.   Maternal grandfather died of lung cancer, he was approximately 5'4" tall.   The patient's father is 34 years of age.   There is one paternal aunt who is approximately 5'10" and a paternal uncle has AIDS.   Paternal grandmother has vague psych history, hypertension and coronary disease.   Mother describes the paternal grandfather dying of asthma.   The patient has a 14 year old brother and a 12 year old brother.   The 14 year old brother has rheumatic fever and both of her siblings are short for their age.   There is a family history of hypothyroidism.   Mother had menarche at 13 years of age.   Mother's height by history is 5'3" and father's height by mother's history is 5'9".

Physical exam:  
Height: 125.1 cm        Weight: 23 kg           BP: 123/58              
Pulse: 103              U/L ratio:  0.92        Arm span: 128           
Breast: Tanner I        Pubic hair: Tanner I    
General: The patient appears well without evidence of dysmorphic features.  
Skin: No evidence of ecchymosis.   There is no pubic or axillary hair.  
HEENT: Pupils are equal, round, reactive to light and accommodation.   Extraocular movements are intact.  Optic discs are full bilaterally.  
Neck: There is no thyromegaly.   The patient has shotty right anterior cervical tender lymphadenopathy.   
Chest: Clear even on deep inspiration.   
Heart: Significant for tachycardia, no murmurs.   
Abdomen: Benign.   
Genitourinary: Normal female without any discharge evident.   
Extremities: No clubbing, cyanosis or edema.   
Neurological: Reflexes were 2+ bilaterally and she had good muscle tone.  
Bone age obtained today, though a poor film was between 7.5-8 years of age.

Impression: This 10 and 11/12 year old Hispanic girl with a family history significant for short stature who comes from a family with evidence of domestic violence is here for evaluation of short stature.  Of note, comparing height and weight data from approximately three months ago, the patient has gained 1 inch in height and approximately 1 kg in weight.

Our impression is most likely combination of genetic short stature and question of blunted growth secondary to psycho-social stressors.   There may be evidence of rapid catch up growth though this must be confirmed by repeat visit.   Turner syndrome is unlikely.

Disposition: The patient will follow up in three months time.   We arranged social worker follow up at Children's Hospital for next week.   If there is still evidence of blunted growth will consider chromosomal analysis or karyotyping for Turner syndrome.
Thank you for letting us share in the care of Vivien.

Sincerely,


Mitsuko Simpson, MD             
Chief Emeritus               


Addendum: Jennifer Braimon, M.D.

Problem list to date:

Transcribed by Fahey


CONTENT:
Gaston Frog, M.D.          RE: Vivien Barthes
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/01/84

Dear Dr. Frog:

We had the pleasure of seeing Vivien in the Endocrine Program on 12/8/94 for short stature.

History: This 10 and 11/12 month old Spanish speaking female is here for evaluation of short stature.   At approximately 9 years of age, the patient's mother noted that she was slightly shorter than the other children in school.

The patient and her mother are originally from Puerto Rico and came to the United States in approximately September of 1994.   Mother fled to the United States secondary to domestic violence towards the mother.  She denies any physical or emotional abuse of the children.   Mother has some social supports in the United States.  While in Puerto Rico, the patient was followed routinely by a physician.  We don't have those charts available at this time.

Current medications: none currently

Past medical history:  The patient is the product of an 8.5 month gestation status post elective repeat C-section.   There were no problems with the pregnancy or delivery.   Birth weight and height was 6.5 pounds and 22 inches.   The patient was bottle fed as a child and had recurrent strep infections, none recently.   Her immunizations are up to date.   She has never been hospitalized.  Mother describes a fall in January of 1994 in Puerto Rico where the patient was running around the house with the other children and fell on her face and had a hairline fracture of the base of the skull.  There are no problems since then.  The patient has never had any operations.  The patient suffers from asthma but she has never been hospitalized.  Usually has exacerbations with URI's.   She has only been in the emergency room in Puerto Rico, never in the United States.  In addition, the patient has a history of migraines.  The mother describes over the past year, only while in Puerto Rico, she had frontal headaches every three weeks associated with nausea and photophobia.  These usually were relieved with Tylenol and warm compresses.  The pain was described as continuous, not stabbing.  In the United States the patient has only had one mild headache that resolved post Tylenol.

Review of systems:  The patient denies any skin abnormalities. HEENT-the patient describes some blurry vision at a distance.  She denies any diarrhea or nausea.  In general, she is a slow eater but likes most foods.  GU-the patient's mother describes one incidence of a yellow vaginal discharge in March of 1994 without recurrence.  The patient denies any evidence of puberty.  Neurologically, the patient is doing well.  She is in the 5th grade in a Spanish speaking school getting B's and C's.

Family history:  The patient's mother is 32 years old.  There are two maternal aunts and three maternal uncles.  One aunt has migraines.  Maternal grandmother is 61 and she has diabetes.  She is approximately 5'3" tall.  Maternal grandfather died of lung cancer, he was approximately 5'4" tall.  The patient's father is 34 years of age.  There is one paternal aunt who is approximately 5'10" and a paternal uncle has AIDS.  Paternal grandmother has vague psych history, hypertension and coronary disease.  Mother describes the paternal grandfather dying of asthma.  The patient has a 14 year old brother and a 12 year old brother.  The 14 year old brother has rheumatic fever and both of her siblings are short for their age.  There is a family history of hypothyroidism.  Mother had menarche at 13 years of age.  Mother's height by history is 5'3" and father's height by mother's history is 5'9".

Physical exam:  
Height: 125.1 cm        Weight: 23 kg           BP: 123/58              
Pulse: 103              Arm span: 128           Breast: Tanner I        
Pubic hair: Tanner I    
Height: 125.1 cm        Weight: 23 kg           BP: 123/58
Pulse: 103              U/L ratio:  0.92        Arm span: 128
Breast: Tanner I        Pubic hair: Tanner I
General: The patient appears well without evidence of dysmorphic features.
Skin: No evidence of ecchymosis.
HEENT: Pupils are equal, round, reactive to light and accommodation.  Extraocular movements are intact.  Optic discs are full bilaterally.
Neck: There is no thyromegaly.  The patient has shotty right anterior cervical tender lymphadenopathy.
Chest: Clear even on deep inspiration.
Heart: Significant for tachycardia, no murmurs.
Abdomen: Benign.
Genitourinary: Normal female without any discharge evident.
Extremities: No clubbing, cyanosis or edema.
Neurological: Reflexes were 2+ bilaterally and she had good muscle tone.

Laboratory studies:  12/8/94 X-ray hand and wrist - bone age between 7.5-8 years of age giving a predicted adult height of 155.6 to 158.8 cm.

Impression: Short stature, familial with possibly a psychosocial decrease in growth velocity more recently associated with a history of domestic violence in the home.  Of note, comparing height and weight data from approximately three months ago, the patient has gained 1 inch in height and approximately 1 kg in weight.

Disposition: Return visit three months to follow progress in growth and development.  Social worker follow up at Children's Hospital for next week.
Thank you for letting us share in the care of Vivien.

Sincerely,


Mitsuko Simpson, MD             
Chief Emeritus               


Addendum: Jennifer Braimon, M.D.
Fellow in Endocrinology

Problem list to date:
FAMILIAL-SHORT-STATURE                       01/03/95  
Transcribed by Sullivan_ma


CONTENT:
Frog, M.D.          RE: Robert Guiscard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/24/93

Dear Dr. Frog:

     We had the pleasure of evaluating Robert in the Renal Program on 11/17/94 for past refluxing megaureter (grade 5 reflux bilaterally), IVP reflux nephropathy.

     Good growth.

     No febrile episodes, dysuria have been noted.

Past medical history:
     Vesicoureteric reflux in the nursery noted with infection and reimplantation undertaken at age 5.5 months.

Review of systems:
     Normal limits.

Physical exam:
     BP 95/60    HT 81.7cm   WT 12kg
     Within normal limits, active, mobile

Urinalysis:
     SPEC GR UA  1.016           PH UA       6          
     PROTEIN UA  N               BLOOD UA    N          
     GLUCOSE UA  N               WBC/HPF     0-1        
     RBC/HPF     0-1             SQUAM EPI   rare  
     GRAN CAST   occ, fine
     Urinalysis shows no evidence for infection.

1)  Excellent result to early reimplantations  2)  Excellent normal growth

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Frog, M.D.          RE: Robert Guiscard
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/24/93

Dear Dr. Frog:

     We had the pleasure of evaluating Robert in the Renal Program on 4/3/96 for review anatomy after ureteric reimplantation.
     This now almost 3-year old boy returns for follow up of renal growth and  anatomy after a ureteral reimplantation performed in very early life.  He  has remained asymptomatic and doing well and at this state has had no  excessive febrile illnesses or recurrence of urinary tract infection.

His current medications include:


Past medical history:
     His past medical history includes hydronephrosis secondary to massive reflux found during the neonatal period.  Reimplantation of the ureters was performed at approximately 5-1/2 months of age.  Robert has been growing normally and there has been gradual growth of the left kidney with stabilization with adequate growth to the right kidney by ultrasound review.  His present  ultrasound at Children's Hospital today shows a right kidney 6.2 cm.,  normal in appearance with reasonable corticomedullary differentiation,  but no growth, from a one year ago film taken at Emerson Hospital - left kidney showing 7 cm. kidney with slightly full pelvis on exam.   This has grown from 6.5 cm. only over the last 12 months representing a  slightly lower than normal growth rate, but in the presence of kidneys  which were enlarged by the dilatation at birth.

Robert's physical exam was notable for:
     BP 90/55   P 110   R 18   T    HT 92.5cm   WT 13.7kg
     Well hydrated, well covered active almost 3-year old.  
     HEENT:  Normal.  
     Neck: supple.  
     Lymph nodes: nonpalpable.  
     Chest:  clinically clear.  
     Heart:  rhythm regular. 
     Abdomen:  No mass or viscus palpable and no areas of tenderness.  
     Genitourinary:  Circumcised with testes descended into the scrotum.  
     Extremities:  No edema or rash.   
     Skin: intact.  
     Urological:  No focalizing signs.
A urinalysis revealed:
     SPEC GR UA  1.018           WBC/HPF     0-2        
     PH UA       6               SQUAM EPI   occ.       
     WBC ENZ UA  neg             RBC CAST    nil        
     BLOOD UA    neg             WBC CAST    nil        
     PROTEIN UA  neg             GRAN CAST   nil        
     GLUCOSE UA  neg             WAXY CAST   nil        
     RBC/HPF     rare            BACTERIA    neg   

Laboratory studies at this time include:


     Robert shows normal somatic growth with slightly lower renal growth following early life ureteric reimplantations for massive reflux.  Robert is doing well  and is protected by his renal growth and better drainage without the  need for continuing antibiotics suppression.  I would suggest follow up in two years in our program with repeat ultrasound at that time and with  a one year follow up for blood pressure and urinalysis through Dr. Frog in the interim.

     Thank you for the opportunity to participate in Robert's care.  We would like to review him in 2 years.  In the interim, we would be happy to discuss or review Robert should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Getro Brezny, M.D.          RE: Josephine Pliny
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/92

Dear Dr. Brezny:

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

History: I saw Josephine per your referral today.   As you know, this 26 month old female was the product of an entirely normal pregnancy with a three hour labor and delivery at Lowell General Hospital.   Normal spontaneous vertex delivery.   Birth weight was 7 pounds 4 ounces.   There is essentially nothing in the prenatal history.   Mom was the product of a DES exposed pregnancy.  

Mom states that breast development was noted at three months of age and that it appears to be somewhat more than it was then but she feels that the development has been consistent for the past year.   She states that there has not been any appreciable rapid increase in growth.   There is no mucous from her vulva and no apocrine and no pubic or axillary hair.  She has had no history of headaches.

Family history:  Mom had menarche at age 10.   She is 64 inches.  Dad is 73 inches.

Physical exam:  
Height: 89.1 cm         Weight: 11.8 kg         BP: 100/40              
Pulse: 96               
She is an entirely well appearing 26 month old.  Eye, ear, nose and throat exam is unremarkable.   There is no thyromegaly.  No cafe au lait spots.  Normal cardiac exam.  Normal female pulses.  She has Tanner stage III breasts.  Left side is 3.5 cm, right is 3.0 cm.   The areola is of normal size and there is expressible fluid nor has there ever been.   Abdominal exam is unremarkable.  Her vulva shows unestrogenized mucosa and normal external female genitalia.  The remainder of the exam is normal.

Laboratory studies:  TSH 3.20 uU/mL (normal).  Bone age is 2 years (chronologic age 2 2/12 years).

Impression: Probable precocious thelarche due to normal activation of the hypothalamic-pituitary-gonadal axis in the first year of life which has  resulted in the release of transient estradiol.   I have ordered a bone age and an estradiol level and a TSH.   If these are normal then no additional tests need to be done unless there is further growth of her breasts or any signs of pubertal activation.

Disposition: I will see her again in six months.
Thank you for letting us share in the care of Josephine.

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Getro Brezny, M.D.          RE: Josephine Pliny
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/92

Dear Dr. Brezny:

I saw Josephine for follow up on 1/25/96 for assessment of precocious thelarche for which I had initally seen her approximately a year ago.  She is now 3 and 2/12 and is doing entirely beautifully and not showing any acceleration in growth velocity nor progression of breast development nor any estrogenic signs.  If anything, the breasts have seemed to have gotten smaller as she has grown.

Current medications: None.

Physical exam:
HT: 93.1 cm    WT: 13.4 kg      BP: 94/51          Pulse: 93               
Breast: Tanner II       Pubic hair: Tanner I    
She has no signs of pubic development elsewhere.  Her genitals are normal for her age not showing any estrogenization in terms of coloring of the vaginal mucosa or mucous  change.

Impression: Based on the above findings, I feel that her condition is, as discussed  previously, transient precocious thelarche and not precocious puberty.  I did not do any additional studies at this point and feel that in the context of normal growth velocity and absence of ongoing findings I needn't see her again unless you find significant change.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Hammer, M.D.          RE: Moe Miro
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/24/92

Dear Dr. O'Hammer:

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

History: This 2 and 11/12 year old Puerto Rican male with a history of asthma, status post multiple hospitalizations is referred to us for evaluation of abnormal thyroid function tests.   TFT's drawn November 11, 1994 revealed a T3 uptake of 29% (normal 30-43%), a total Thyroxine of 11.8 (normal 5.5-11.5) and normal thyroid stimulating hormone level of 1.4, a CBC drawn the same day was only notable for a mildly elevated platelet count of 547,000.   

It is not clear why the thyroid function tests were checked, presumably because of short stature.   The patient's mother is not concerned about the patient's growth.  She is concerned that he is speaking very little and is difficult to understand.   She believes he is otherwise normal.  He has normal strength and normal activity level.   He is a good eater and has no GI symptoms.   He has no difficulty sleeping, no heat intolerance, no increased restlessness.   He has been hospitalized approximately 9-10 times for asthma, most recently a year and a half ago.   He is currently on no medications and has never been on steroids as an outpatient for his asthma.

Past medical history:  He is the product of a term, uncomplicated pregnancy and normal spontaneous vaginal delivery.

Review of systems:  Noncontributory.

Family history:  His mother is 5'4", father is 5'6" and they are both healthy.   The patient has four brothers ages 5, 4, 1 and a half and 2 months.   Two of those brothers have had problems with asthma.   No other medical problems known in the family.   There is no family history of thyroid or other endocrine disease.

Physical exam:  
Height: 88.9 cm         Weight: 13.2 kg         BP: 90/58               
Pulse: 98               
General: He appears well.  
Skin: Unremarkable.  
Neck: Notable for normal thyroid exam and no enlargement and no nodules.  
Chest: Clear with no wheezes.   
Heart: Regular rate and rhythm with no murmurs.  
Abdomen: Soft and nontender, there is no masses.   
Extremities: Unremarkable.   His reflexes are 2+ with normal relaxation phase.  He has no tremor.

Impression: His height is less than 5th percentile and his weight is approximately 20th percentile.   There is no evidence of thyroid disease by exam and his TSH is normal.   His T4 is mildly elevated however, this is in the face of a low T3 uptake which would be consistent with an increased TBG.   There is no evidence of GI disease/malabsorption to account for his short stature.  His short stature may quite possibly be due to history of asthma with multiple hospitalizations.   To further evaluate his short stature we have ordered an ESR and IGF-1 today and in addition we will repeat the TSH.   He will return to clinic in 6 months for follow up to assess his growth.


Laboratory studies pending at this time include: ESR          11   MM/HR       IGF-I        40   ng/mL    
TSH         .80   uU/mL       

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

Sincerely,


Lancelot Blue, MD             
Attending in Endocrinology   


Addendum: Lisa Porter, M.D.
His IGF-1 is low.  If his height velocity remains low, we would recommend proceeding to formal growth hormone testing in 6 months.


CONTENT:
Gleide McPherson, M.D.          RE: Alexander Collier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/05/82

Dear Dr. McPherson:

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

History: On 12/15/94, we had the pleasure of seeing Alexander, a 12 and 1/12 year old boy with known hypothyroidism and Down syndrome.  The hypothyroidism was found incidentally on lab values in August of 1993, a T4 of 6.0 and a TSH of 8.93.   He was asymptomatic at the time with no cold intolerance, no goiter and only the slight possibility of dry skin in the winter.  He was placed on Synthroid 50 mcg a day.   There were no symptomatic changes after beginning the medication, no evidence of hyperactivity, however, his growth rate has increased impressively over the last year.  He has grown 8.9 cm in the last year and 6.2 kg in weight.   His most recent thyroid function tests in April of 1994 showed a T4 of 8.6 and a TSH of 3.2.  He moved here from Michigan in June of 1994 and this is his first referral to an Endocrine Clinic.   

Alexander's activity has been excellent.   He is athletic, playing basketball, soccer, baseball and skiing.   His diet is very good and well rounded.  He enjoys salads and snacks often.   Two to three months ago he began noticing pubic hair with negative axillary hair, negative apocrine odor and some penile and testicular growth.

Current medications: Synthroid 0.05 mg per day.

Past medical history:  Relatively uneventful with a pregnancy of 37 weeks and a C-section and delivery weight of 6 pounds 3 ounces and 19 cm in length.   He has had multiple incidents of otitis media and many tube placements.   He is currently scheduled to have a tube placement in the near future.   He has had one echocardiogram which was normal at the age of 1.

Family history:  Unremarkable with no history of diabetes, thyroid problems or Down's.

Physical exam:  
Height: 140.6 cm        Weight: 33.2 kg         BP: 100/60              
Pulse: 72               U/L ratio:  0.95        Arm span: 140           
Pubic hair: Tanner II   R. testis: 2.8 x 1.8 cm L. testis: 3.0 x 2.0 cm 
Phallus length: 7 cm    Mid-shaft diam.: 2.7 cm 
General: He was healthy in no apparent distress.   He was very cheerful and very active.   There were no visible lesions on his skin.   There was some mild chafing at the elbows.   
HEENT: Entirely normal with no lymphadenopathy and no palpable thyroid.   
Chest: His lung exam had some mild bilateral crackles but was otherwise clear.  Heart: Regular rate and rhythm.  Normal S1 and S2 with no extra sounds.   
Abdomen: Soft and nontender.   
Extremities: He had strong radial pulses and 2+ deep tendon reflexes with no delayed reflexes in all limbs.

Laboratory studies:  T4 9.0 ug/dL, TBGI 1.10, TSH 2.30 uU/mL

Impression: In summary, this is a charming 12 and 1/12 year old boy with well managed acquired hypothyroidism and Down syndrome.   He is currently doing very well on Synthroid at 0.05 mg per day.   His TSH levels from 8 months ago were normal however, he should have thyroid tests every six months while he grows for adjustment of his Synthroid dosages.

Disposition: We will see him again in one year barring any developments.
Thank you for letting us share in the care of Alexander.

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology   


Addendum: Paul Chung
Harvard Medical Student


CONTENT:
Gleide McPherson, M.D.          RE: Alexander Collier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/05/82

Dear Dr. McPherson:

I saw Alexander back for follow up of acquired hypothyroidism in the context of Down's syndrome on 1/25/96 at which time Alexander is 13 and 2/12 years.  He has had a most remarkable growth spurt over the past year, having accumulated over 5" and 33 lb.  He looks excellent and is doing well both in his school and his after school sports program.  He has no signs or symptoms suggestive of hypothyroidism.

Current medications: None.

Physical exam:
Height: 152.3 cm    Weight: 48.3 kg
BP: 116/64          Pulse: 84               Breast: Tanner I        
Pubic hair: Tanner III  R. testis: 3.6 x 2.1 cm L. testis: 3.6 x 2.1 cm 
Phallus length: 9 cm    Mid-shaft diam.: 2.2 cm 
He looks much more physically mature than he did on previous evaluation and had some drying of his skin but not appreciably different from previously.

Laboratory studies:  His laboratory tests in June suggest that he may be somewhat undertreated with only 0.05 mg of L-thyroxine daily as his T4 was 5.0 mcg/dl and his TSH 7.3  mcu/ml (slightly elevated).

Impression: I have redrawn thyroid function tests  (T4 7.6 ug/dL, TSH 3.10 uU/mL, TBGI 1.05) and increased him to 0.075 mg a day of L-thyroxine and instructed him to have thyroid function tests done in 4-6 weeks.  If these are fine, to repeat them in approximately six months.  The latter can certainly be done in your office at the time of his visit with you and I would be glad to see him again in one year. 

Thanks for allowing me to share in his care.



Sincerely,




Nilto Carter, MD             
Associate in Endocrinology   


cc: Mr. & Mrs. Richard Collier  24 Chicory Rd  Westford , MA  01886


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, January 3, 1995.  He has chronic renal failure secondary to multicystic dysplastic kidneys.  
     Raymond appears very well on review.  He is here for follow up for admission for cardiac repair and gastrostomy insertion.

Current medications include:
     LASIX 6 mg b.i.d.
     EPOGEN 500 units b.i.w.
     POLYVISOL 1 cc q.d.
     DHT 5 cc q.d.
     FERINSOL 15 mg b.i.d.
     CAPTOPRIL 3 mg t.i.d.
     ZANTAC 10 mg b.i.d.
     CARAFATE 75 mg q.i.d.
     SODIUM BICARBONATE 2 mEq q.i.d.

Physical exam:
     BP 40/    R 24     HT 61cm   WT 6.925kg   HC 41cm
     General: bright and alert.
     HEENT: normal. 
     Neck: supple with no masses, lymph nodes not palpable.
     Chest: clear with bilateral session.
     Heart: two heart sounds.
     Abdomen: soft non-tender.  
     Genitourinary: testes down
     Extremities: no edema
     Neurological: 
     Developmental:  Fine motor, passes object from hand to hand, brings objects to
                              the midline and to the mouth.  He smiles, gurgles, and plays
                              with hands.  
                              Gross motor not rolling and unable to sit up.  Good head control
                              with anticipation.
Urinalysis:
     SPEC GR UA  1.010           WBC ENZ UA  0          
     PH UA       5               PROTEIN UA  2+         
     BLOOD UA    trace           GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     3-4        
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    0     


Laboratory studies at this time include:
          ALKP        212     U/L       CO 2         23   MEQ/L    
          CA         10.7   MG/DL (H)   CR          2.2   MG/DL (H)
          GLU          89   MG/DL       PHOS        5.1   MG/DL    
          BUN          33   MG/DL (H)   NA          142  MMOL/L    
          K           5.8  MMOL/L (H)   CL          106  MMOL/L    
          WBC       15.33   K/MM3       RBC        4.52   M/MM3    
          HGB        12.7    G/DL       HCT.       40.4       %    
          MCV        89.4      FL       MCH        28.2      PG    
          MCHC       31.5    G/DL       RDW        17.1       % (H)
          HDW        2.92    G/DL       PLT UNC     530   K/MM3 (H)


     Raymond appears to be doing well since last reviewed.  He is to be reviewed by Dr. Lund and will have a barium swallow today and he will also see the genetics group.  We will not suggest any changes in his medications.

     We have asked Raymond to return in one month.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, March 7, 1995.  He has chronic renal failure secondary to dysplastic kidneys. 
     Raymond has done well since his last visit with us.  His growth remains along his growth curve.  He had an upper endoscopy which revealed good healing of his esophageal tear.

Current medications include:
     EPOGEN 500 units b.i.w.
     LASIX 7 mg b.i.d.
     POLYVISOL 1 cc q.d.
     DHT 1 mg q.d.
     FERINSOL 15 mg b.i.d.
     CAPTOPRIL 3 mg t.i.d.
     ZANTAC (15 mg) 1 ml b.i.d.
     CARAFATE 75 mg q.i.d.
     SODIUM BICARBONATE 2 mEq q.i.d.
     VENTOLIN  2 t.i.d. 
     MYLICON .6 ml with each feed 
     INTAL 20 mg t.i.d.

Physical exam:
     BP 76/25   P 137    HT 64.5cm   WT 7.28kg   HC 42cm

     General: no acute distress
     HEENT: moist mucous membranes without exudate or masses
     Chest: clear 
     Heart: regular rate and rhythm with 3/6 systolic murmur heard throughout the entire precordium
     Abdomen: soft, non-tender, non-distended
     Extremities: warm and well perfused

Urinalysis:
     SPEC GR UA  1.008           WBC ENZ UA  N          
     PH UA       6.0             PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          ALB         3.7    G/DL       CO 2         21   MEQ/L    
          CR          3.1   MG/DL (H)   GLU          84   MG/DL    
          BUN          66   MG/DL (C)   NA          145  MMOL/L    
          K           5.0  MMOL/L (H)   CL          109  MMOL/L    
          PLT         359   K/MM3       WBC       13.19   K/MM3    
          RBC        4.52   M/MM3       HGB        12.8    G/DL    
          HCT.       39.3       %       MCV        87.0      FL    
          MCH        28.3      PG       MCHC       32.6    G/DL    
          RDW        17.4       % (H)   HDW        2.73    G/DL    
          PLT UNC     359   K/MM3       NEUT         29       %    
          LYMPH        65       %       EOS           6       %    
          CELLS C     100               ABS NEU    3.83   K/MM3    
          ABS LYM    8.57   K/MM3       ABS EOS     .79   K/MM3 (H)
          ANISO        1+               MICRO        1+

     Raymond has done well since his last visit with us.  We will change him over to Isomil formula at his mother's request.  We will increase his sodium bicarbonate to 3 mEg q.i.d to optimize his acid base status.  The increase in his BUN is much greater than the increase in his creatinine and may reflect volume status.

     We have asked Raymond to return in one month.

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

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, April 4, 1995.  He has chronic renal failure secondary to dysplastic kidneys. 
     Raymond has done well since his last visit with us.  In Cardiology follow up at UMass Worcester has noted that his cardiac status is stable.  Raymond will be allowed to outgrow his dose of Lasix.  Parents have noted a better fluid balance status since starting an increased dose of Bicitra.

Current medications include:
     EPOGEN 500 units b.i.w.
     LASIX 7 mg b.i.d.
     POLYVISOL 1 cc q.d.
     DHT 1 mg q.d.
     FERINSOL 15 mg b.i.d.
     CAPTOPRIL 3 mg t.i.d.
     ZANTAC (15 mg) 1 ml b.i.d.
     CARAFATE 75 mg q.i.d.
     BICITRA 3 mEq q.i.d.
     VENTOLIN  2 t.i.d. 
     MYLICON .6 ml with each feed 
     INTAL 20 mg t.i.d.

Physical exam:
     BP 84/39   P 137      HT 67cm   WT 7.75kg   HC 42.5cm
     General: no acute distress.
     HEENT: moist mucous membranes without exudate or masses.
     Chest: clear. 
     Heart: regular rate and rhythm with 3/6 systolic murmur significant of regurgitation heard best at the left apex but also at the left sternal border, it is non-radiating.
     Abdomen: liver is 2 cm below the right costal margin and non pulsatile and spleen is not palpable.  G-tube sites clean and dry.
     Extremities: warm and well perfused with good pulses.
     Neurological: Raymond rolls over from front to back and back to front and is able to push his chest up off the bed and is able to sit propped sometimes on a soft couch.
Urinalysis:
     SPEC GR UA  1.005           WBC ENZ UA  N          
     PH UA       9               PROTEIN UA  N          
     BLOOD UA    N               GLUCOSE UA  N     mg/dl
     WBC/HPF     N               RBC/HPF     N          
     WBC CAST    N               RBC CAST    N          
     GRAN CAST   N               WAXY CAST   N          
     SQUAM EPI   N               BACTERIA    N     


Laboratory studies at this time include:
          ALB         3.8    G/DL       CO 2         26   MEQ/L (H)
          CA         10.5   MG/DL       CR          2.8   MG/DL (H)
          GLU          73   MG/DL       PHOS        5.7   MG/DL    
          BUN          45   MG/DL (H)   NA          148  MMOL/L    
          K           5.4  MMOL/L (H)   CL          107  MMOL/L    
          PLT         400   K/MM3       WBC       14.08   K/MM3    
          RBC        4.64   M/MM3       HGB        13.8    G/DL    
          HCT.       40.9       %       MCV        88.2      FL    
          MCH        29.7      PG       MCHC       33.7    G/DL    
          RDW        15.6       % (H)   HDW        3.05    G/DL    
          PLT UNC     400   K/MM3       NEUT         29       %    
          LYMPH        61       %       MONOS         3       %    
          EOS           7       % (H)   CELLS C     100    
          ABS NEU    4.08   K/MM3       ABS LYM    8.59   K/MM3    
          ABS EOS     .99   K/MM3 (H)   HYPO         1+    


     Raymond has been very stable since his last visit with us.  He is to have a family meeting today to discuss the options for long term renal replacement therapy.

     We have asked Raymond to return in one month.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, June 13, 1995.  He has chronic renal failure secondary to dysplastic kidneys.  
     Raymond is doing well.  He is just recovering from an ear infection.  He will have bloods done today as work up towards a transplant.

His current medications include:
     EPOGEN 500 units b.i.w.
     LASIX 7 mg b.i.d.
     POLYVISOL 1 cc q.d.
     DHT 1 mg q.d.
     FERINSOL 30 mg q.d.
     CAPTOPRIL 3 mg t.i.d.
     ZANTAC (15 mg) 1 ml b.i.d.
     BICITRA 3 mEq q.i.d.
     INTAL 20 mg t.i.d.with VENTOLIN 2 t.i.d. 
     CEFZIL 62.5 mg b.i.d.

Raymond's physical exam was notable for:
     BP 70/   P 100   R 20     HT 70.6cm   WT 9.19kg   HC 43.5cm
     General: bright and cheerful.
     HEENT: right ear drum injected. 
     Neck: supple, lymph nodes not palpable.
     Chest: clear.
     Heart: grade 2 and 4 systolic murmur.
     Abdomen: soft non-tender with a feeding tube.
     Genitourinary: Testes down normal genitalia
     Extremities: no edema.
     Neurological: sitting and stands with support.
A urinalysis revealed:
     SPEC GR UA  1.003           RBC/HPF     2          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       8               RBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   +          
     BLOOD UA    trace           WAXY CAST   N          
     GLUCOSE UA  trace mg/dl     SQUAM EPI   N          
     WBC/HPF     1               BACTERIA    N     
     hyaline casts

Laboratory studies at this time include:
          ALB         4.0    G/DL       ALKP        316     U/L    
          CO 2         22   MEQ/L       CR          2.9   MG/DL (H)
          GLU          65   MG/DL       PHOS        5.9   MG/DL    
          TP          6.5   GM/DL       AST          61     U/L (H)
          ALT          39     U/L (H)   BUN          58   MG/DL (C)
          NA          141  MMOL/L       K           5.2  MMOL/L (H)
          CL          105  MMOL/L       BILI TO     1.0   MG/DL    
          BILI DI     0.1   MG/DL       WBC       14.09   K/MM3    
          RBC        4.59   M/MM3       HGB        13.5    G/DL    
          HCT.       41.5       %       MCV        90.5      FL (H)
          MCH        29.4      PG       MCHC       32.5    G/DL    
          RDW        16.0       % (H)   HDW        2.63    G/DL    
          PLT UNC     442   K/MM3 (H)   NEUT AB    3.60   K/MM3    
          LYMPH A    8.47   K/MM3       EOS ABS     .72   K/MM3 (H)
          NEUT-A     25.5       %       LYMPH-A    60.1       %    
          MONO-A      4.5       %       EOS-A       5.1       %    
          BASO-A      2.0       %       ATYP LY     2.7       %    
          ANISO-A       +       


     Raymond is doing well.

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

               Sincerely,


               Gleide Blue, MD
               Attending, Pediatric Nephrology


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, August 15, 1995.  He has chronic renal failure secondary to dysplastic kidneys.  
     Raymond has been doing fairly well since his last visit two months ago.  He recently saw Dr. Pollack the cardiologist who recommended discontinuing the Lasix.  Raymond has been tolerating all of his medications well.

His current medications include:
     EPOGEN 500 units b.i.w.
     LASIX 7 mg b.i.d.
     POLYVISOL 1 cc q.d.
     DHT 0.1 mg (0.5 cc) q.d.
     FERINSOL 2 cc q.d.
     CAPTOPRIL 4 mg q.a.m., 3 mg b.i.d.
     ZANTAC 150 ml b.i.d.
     BICITRA 3 mEq q.i.d.
     INTAL 20 mg t.i.d.with VENTOLIN 2 ml via nebulizer t.i.d.

Raymond's physical exam was notable for:
     R 24   HT 73.2cm   WT 9.7kg  
     General: he is alert, comfortable
     Skin: scars of previous surgeries
     HEENT: eyes and throat were clear.  Anterior fontanalle is normal
     Neck: supple, no significant lymphadenopathy.
     Chest: clear to auscultation
     Heart: mitral regurgitation murmur still present.
     Abdomen: soft, non-tender or organomegaly.  G tube button is in place
     Genitourinary: Tanner 1
     Extremities: no edema.
     Neurological: no focal lesions, no meningeal signs
A urinalysis revealed:
     SPEC GR UA  1.006           RBC/HPF     N          
     WBC ENZ UA  N               WBC CAST    N          
     PH UA       6.5             RBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     BLOOD UA    N               WAXY CAST   N          
     GLUCOSE UA  trace mg/dl     SQUAM EPI   N          
     WBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          ALKP        223     U/L       CO 2         25   MEQ/L    
          CA         11.0   MG/DL (H)   CR          2.9   MG/DL (H)
          PHOS        6.1   MG/DL       BUN          69   MG/DL (C)
          NA          139  MMOL/L       K           5.8  MMOL/L (H)
          CL           99  MMOL/L       WBC       15.18   K/MM3    
          RBC        4.62   M/MM3       HGB        13.5    G/DL    
          HCT.       40.7       %       MCV        88.2      FL    
          MCH        29.2      PG       MCHC       33.1    G/DL    
          RDW        15.2       %       HDW        2.72    G/DL    
          PLT UNC     393   K/MM3       RET         0.8       %    


     Raymond is a 16 month old with chronic renal failure secondary to renal dysplasia.  We have discontinued his Lasix.  We have reviewed his ultrasound in comparison with previous films.  The kidneys are the same size which indicates no growth over the last nine months.  We have recommended that mother try to have his blood pressure taken locally as he was too agitated for us to be able to obtain it here today.  His annualized growth velocity is 15 cm/year.

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

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, October 10, 1995.  He has chronic renal failure secondary to dysplastic kidneys. 

     Raymond returns to the renal transplant program today for follow up for dysplastic kidneys.

His current medications include:
     EPOGEN 500 units b.i.w.
     POLYVIFLOR 1 cc q.d.
     DHT 0.1 cc q.d.
     FERINSOL 1.8 cc b.i.d.
     CAPTOPRIL 4 mg q.a.m., 3 mg b.i.d.
     ZANTAC 150 ml b.i.d.
     BICITRA 3 mEq q.i.d.
     VENTOLIN 25 cc in 2 cc NS prn
     AMOXIL 125 mg q.d.

Raymond's physical exam was notable for:
     BP 75/   HT 74.3cm   WT 10.4kg   
     General: chubby looking male 
     Skin: scars of previous surgeries
     HEENT: normal
     Neck: supple, no significant lymphadenopathy.
     Chest: clear to auscultation
     Heart: regular rate and rhythm
     Abdomen: soft, non-tender, positive bowel sounds.  G tube button is in place
     Genitourinary: Tanner 1
     Extremities: no edema.


     Raymond is an 18 month old with dysplastic kidneys doing well.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, January 16, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  

     Since the time of Raymond's last visit he has generally been feeling well.  He has had persistent upper respiratory infection and has been wheezing lately.  In the past he has had problems with recurrent otitis media, which seems to be much improved with the use of prophylactic Amoxicillin.  He continues to have a diet consisting of baby foods including:  fruits, vegetables, and cereals during the day.  He then takes Isomil via G-tube over night.  

Raymond continues to be followed by Dr. Pollack for congenital heart disease.  He recently had his Captopril dose increased to keep up with his increase in weight.  He is stable from that point of view.  He is also followed by orthopedics and will need orthopedic surgery of his feet before school age.  Mrs. Hadow had some questions  about the timing of transplantation in general as well as related to the need for orthopedic surgery.  She also had questions about, Raymond had labs done at Harrington Hospital on January 15th.  These labs included:  BUN 34, creatinine 4.8, Na 145, K 5.7, Co2 30.2, Ca 12.2, Po4 6.3, HCT 42.9, WBC 18.4, Fe 51, TIBC 365.

His current medications include:
     EPOGEN 500 units b.i.w.
     POLYVIFLOR 1 cc q.d.
     DHT 0.5 cc (0.1 mg) q.d.
     CAPTOPRIL 4 mg, 3 mg, 4 mg
     ZANTAC 15 mg b.i.d.
     BICITRA 3 mEq q.i.d.
     AMOXICILLIN 125 mg q.h.s.
     KAYEXALATE  11 g q.o.d.
     BACTROBAN to button and circ. area
     ALBUTEROL .25 + 2cc NS via neb.  t.i.d. prn
     NESERAL to diaper area

Raymond's physical exam was notable for:
     P 96   R 24   HT 76cm   WT 11kg   
     General: anxious toddler ambulating well around the room. 
     Skin: scars of previous surgeries
     HEENT: mild nasal discharge, TM's clear.   Pharynx not injected.
     Neck: supple
     Chest: good aeration throughout with diffuse rhonchi.
     Heart: regular rate and rhythm
     Abdomen: soft.  G tube button is in place.  No palpable masses or organomegaly.
     Extremities: no edema.


     Raymond has a slowly progressing renal insufficiency.  At this time his level of uremia may be due to the intrinsic lesion as well as to the contribution of the Captopril.  In addition the Captopril may be contributing to his hyperkalemia.  It is possible that his BUN could be low with an alteration in diet, however, that is not clear.  Nancy Spinozzi will speak to Mrs. Hadow about this.  He will also continue his Kayexalate for the hyperkalemia.  The hyperkalemia is also exacerbated by the Captopril.  Raymond's metabolic status is not currently optimum.  Calcium is elevated and phosphate is borderline high but acceptable rather than optimal.  I suggested to Mrs. Hadow that these would be reviewed and medicine suggested.  His hematocrit is excellent on his current dose of Epo, however, he has iron deficiency with and iron saturation of 14%.  He was therefore started on ferrous sulfate 15 mg b.i.d.  

We also discussed optimum time of transplant.  At this point it is possible that his potassium and the level of BUN can be adjusted with a dietary and medicational changes.  If this is not the case it may indicate the need for renal replacement therapy.  We would prefer to have Raymond transplanted at a time when respiratory viruses are less prevalent.  This would be more likely in the summertime.  Mrs. Hadow also had some questions on growth hormone therapy.  At this time his growth has plateaued and will need reassessment after correction of his hypercalcemia and his potential Carpenter's Syndrome.  I suggested that if his growth continues plateaued for the next several months and we do plan to transplant him in the very near future, it would make sense to begin growth hormone treatment.  She will further consider this.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, March 12, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  

     Raymond is currently doing well.  He is on a feeding schedule at home which consists of 1080 cc/day mostly consisting of nighttime feeds.  He has recently been started on Cisapride.  He continues on his other medications.  His mother wishes to try po solid feeds, however, she feels that his formula regimen inhibits his solid intake.

His current medications include:
     EPOGEN 500 units b.i.w.
     FERROUS SULFATE 15 mg b.i.d.
     POLYVIFLOR 1 cc q.d.
     DHT 0.5 cc (0.1 mg) q.o.d.
     CAPTOPRIL 4 mg t.i.d.
     ZANTAC 15 mg b.i.d.
     BICITRA 3 mEq q.i.d.
     AMOXICILLIN 125 mg q.h.s.
     KAYEXALATE  11 g q.o.d.
     TITRALAC 5 mEq t.i.d.
     CARAFATE .75 cc q 6 hours
     BIAXIN 125 mg q 12 hours

Raymond's physical exam was notable for:
     BP 74/26  HT 78.9cm   WT 11.9kg   HC 47cm
     General: comfortable, alert, playful and active.
     Skin: no lesions.
     HEENT: eyes and throat clear.
     Neck: supple, no significant lymphadenopathy.
     Chest: clear to auscultation.
     Heart: S1, S2 normal no murmur.
     Abdomen: soft.
     Extremities: no edema.
     Neurological: no focal deficits or meningeal signs.

A urinalysis revealed:
     SPEC GR UA             
     PH UA       8          
     WBC ENZ UA  0          
     BLOOD UA    N          
     PROTEIN UA  +          
     GLUCOSE UA  100        

     Labs at Harrington Hospital on 3/11 include: BUN 97, Cr 5.1, Ca 10.9, PO4 8.5, CO2 24.3, K 5.4, Na 142, WBC 19.8 and HCT 35.0.

     Raymond's height and weight have continued along their growth curve.  He has shown some catch up growth, poor weight and length gain on his last two visits.  We will re-evaluate the merit of growth hormone treatment at his next visit.  We have adjusted his daily feed schedule such that his night time feeds have been reduced dramatically and this has been compensated partially by increasing his daytime feeding.  His total feed schedule schedule now will be 900 cc volume of formula and the rest can be po adlib water.  Mr. Hadow has initiated evaluation as a kidney donor.  Once the evaluation is complete, we will re-assess Raymond's status and set a transplant date.

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

               Sincerely,


               Kinze Brando, MD
               Assistant in Nephrology


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, May 14, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on.

     Raymond comes to clinic with labs drawn yesterday with a rise in creatinine and BUN and a K of 6.8.  He was also followed by GI and  cardiology and pulmonary.  All of the above issues have been stable.  He also has gotten taller and is gaining weight.

His current medications include:
     EPOGEN 500 units b.i.w.
     FERROUS SULFATE 15 mg b.i.d.
     POLYVIFLOR 1 cc q.d.
     DHT 0.5 cc (0.1 mg) q.o.d.
     CAPTOPRIL 4 mg t.i.d.
     ZANTAC 15 mg b.i.d.
     BICITRA 3 mEq q.i.d.
     VENTOLIN .25 cc (1 unit)
     INTAL 20 mg(1 cc) t.i.d.
     KAYEXALATE  11 g q.o.d.
     PROPULSID D/C
     CARAFATE D/C
     BACTROBAN  ointment

Raymond's physical exam was notable for:
     BP 118/65   P 119   HT 81.3cm   WT 12.29kg   HC 46cm
     General: well in no distress
     Skin: no lesions.
     HEENT: moist mucous membranes 
     Neck:  supple, without lymphadenopathy.
     Chest: clear without wheezing.
     Heart: positive 3/6 systolic murmur.
     Abdomen: liver is equal to 1 cm below the right costal margin, G tube button in place.
     Extremities: warm and well perfused.

A urinalysis revealed:
     SPEC GR UA  1.007           WBC/HPF     N          
     PH UA       9               SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  trace           GRAN CAST   N          
     GLUCOSE UA  +               WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     



     In summary, Raymond has continuing deterioration in his renal function.  He however has been able to continue to grow without the need for growth hormone.  His work up for living related donor transplantation is going on and we anticipate a date in August.

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

     We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, June 18, 1996.  He has chronic renal failure secondary to dysplastic kidneys.

     Raymond has been having problems with acute bronchitis for the last few weeks.  He has recently been tested developmentally and is found to be at a developmental age of 16 months as opposed to a chronologic age of 26 months.  His lab values done yesterday show a creatinine of 7.1 mg/dl, BUN of 99, CO2 value was 32.2 and serum potassium 5.0.

His current medications include:
     EPOGEN 500 units b.i.w.
     FERROUS SULFATE 15 mg b.i.d.
     TITRALAC 5 cc t.i.d.
     POLYVISOL 1 cc q.d.
     DHT  0.1 mg q.o.d.
     CAPTOPRIL 4 mg t.i.d.
     ZANTAC 15 mg b.i.d.
     BICITRA 3 mg q.i.d.
     VENTOLIN .25 cc in 2.5 cc NS q2-4 hours
     INTAL .25cc (20 mg/1 cc) t.i.d.
     KAYEXALATE  12.5 g q.o.d.
     SUPRAX 100 mg q.d. x 10 days
     AMORIL 125 mg q.h.s.
     NIZORAL OINTMENT

Raymond's physical exam was notable for:
     BP 112/63   P 137   R 26   HT 82cm   WT 12.7kg   HC 46.5cm
     General: comfortable, alert
     Skin: no lesions.
     HEENT: eyes, nose and throat clear.
     Neck: supple, no significant lymphadenopathy.
     Chest: clear to auscultation.  No rhonci heard at this time, no respiratory distress.
     Heart: unchanged.
     Abdomen: soft, site clean.
     Extremities: 12 toes present.
     Neurological: unchanged.

A urinalysis revealed:
     SPEC GR UA  1.005           WBC/HPF     N          
     PH UA       7.0             SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    N               WBC CAST    N          
     PROTEIN UA  1+              GRAN CAST   N          
     GLUCOSE UA  1+              WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

     Raymond is due for living related donor kidney transplant on August 29th.  We have gone over in detail with Raymond's mother the issues related to pre-transplant nephrectomy, what his likely post op course would be and what to expect after transplant.  We have also emphasized the fact that we will have to monitor his intra-vascular fluid volume very closely in view of his associated cardiac issues.  We will review all of these issues next week and discuss the strategy with the family at the next visit.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, July 16, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  

Raymond's mother says that he has been doing fairly well at home although he has had multiple viral illnesses and continues on antibiotic prophylaxis to prevent otitis media.

His current medications include:
     EPOGEN 500 units b.i.w.
     FERROUS SULFATE 15 mg b.i.d.
     TITRALAC 5 cc t.i.d.
     CAPTOPRIL 4 mg t.i.d.
     ZANTAC 15 mg b.i.d.
     DHT 0.1 mg q.o.d.
     BICITRA 3 mg b.i.d.
     INTAL 20 mg t.i.d.
     AMOXIL 250 mg q.h.s.
     KAYEXALATE 12.5 g q.o.d.
     POLYVIFLO 1 cc q.d.
     
Raymond's physical exam was notable for:
     BP 104/81   P 72   HT 84.2cm   WT 13kg   HC 46.5cm
     General: alert, pudgy little boy, very active in the room.
     Skin: normal.
     HEENT: TM's clear.
     Neck: supple, negative lymph nodes.
     Chest: clear.
     Heart: regular rate and rhythm with 3/6 murmur noted on auscultation.
     Abdomen: soft, G tube in place.
     Extremities: 12 toes present.
     Neurological: normal.
A urinalysis revealed:
     SPEC GR UA  1.008           WBC/HPF     N          
     PH UA       9               SQUAM EPI   N          
     WBC ENZ UA  N               RBC CAST    N          
     BLOOD UA    trace           WBC CAST    N          
     PROTEIN UA  1+              GRAN CAST   N          
     GLUCOSE UA  1+              WAXY CAST   N          
     RBC/HPF     N               BACTERIA    N     

Laboratory studies at this time include:
          BUN  114
          CR  6.8
          NA  141
          K   6.1
          CL  98
          C02  25.1
          CA  11.8
          PHOS  4.6
          GLU  76
          TP  0.33
          CHOL  217
          SGOT  42
          SGPT  36
          LDH  279
          ALK PHOS  306
          TP  7.4 
          ALB  4.5
          URIC  6.4
          WBC  15.2
          RBC  3.95  
          HCT  34.5
          HGB  11.7
          PLT  357

Raymond's status is unchanged.  He is currently in pre transplant status.  We have requested that his mother obtain cardiology reports for us and he will also need to have a VCUG performed.  He will need bilateral nephrectomy, but Dr. Lillehei has not decided whether he will do it pre or intra transplant.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Marie Hadow, M.D.
84 Sayels Street
Southbridge, MA 01550


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, October 15, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's mother reports that Raymond takes po better.  Nancy Spinozzi RD has suggested to decrease his G tube feeds depending on what he takes on a daily basis.  Otherwise Raymond's mother offers no complaints.

His current medications include:
     PREDNISONE 5 mg b.i.d.
     NYSTATIN 3 cc t.i.d.
     NIFEDIPINE 5 mg q.i.d.
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     CYA STUDY # 582-L  40 mg t.i.d.
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs
     VENTOLIN 2 puffs
     ATROVENT 2 puffs
     RANTIDINE 45 mg b.i.d.

Raymond's physical exam was notable for:
     BP 92/57   P 72   R 20   HT 86cm   WT 15.1kg   
     General: well appearing, comfortable in no distress.
     Skin: well healed CVL site with continuing mild erythema and no tenderness or discharge.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: positive occasional wheezing on the right side.
     Heart: positive 2-3/6 murmur systolic ejection murmur on the left para sternal border.
     Abdomen: soft without tenderness or bruits at graft site.
     Extremities: no edema.
     Neurological: no lateralizing signs

A urinalysis revealed:
     SPEC GR UA  1.008           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       6.0             WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   N     
     MICROSCOPC             

Laboratory studies at this time include:
          K           5.0  MMOL/L (H)   MCHC       31.2    G/DL    
          CA          9.8   MG/DL       RDW        21.4       % (H)
          CR          0.8   MG/DL (H)   HDW        3.68    G/DL (H)
          CYA         266   MCG/L       MPV         6.5      FL (L)
          GLU          60   MG/DL (C)   PLT UNC     890   K/MM3 (H)
          PHOS        3.6   MG/DL (L)   NEUT         49       % (H)
          BUN          34   MG/DL (H)   LYMPH        36       % (L)
          NA          138  MMOL/L       MONOS         9       % (H)
          CL          104  MMOL/L       ATYP LY       3       %    
          CO 2         22   MEQ/L       BAND          3       %    
          WBC       19.92   K/MM3 (H)   CELLS C     100    
          RBC        3.23   M/MM3 (L)   ABS NEU   10.36   K/MM3    
          HGB        10.0    G/DL (L)   ABS LYM    7.17   K/MM3    
          HCT.       32.0       % (L)   ABS EOS     .00   K/MM3    
          MCV        99.2      FL (H)   MORPH      SAME    
          MCH        31.0      PG       

Raymond appears to be stable at present.  He is taking po better.  We will adjust his G tube feeds depending on his oral intake and replace Pediasure with free water to maintain caloric and fluid balance.  He is to have a developmental assessment and physical therapy at home.  We discussed with the family to use Ventolin nebulizers when he has URI symptoms.  We will reassess his CYA and creatinine at his next visit.  We will decrease the CYA to 37.5 mg tid.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
Marie Hadow, M.D.
84 Sayels Street
Southbridge, MA 01550


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, October 22, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's mother offers no complaints today.  His weight has remained stable on his 1150 cc of total fluids a day.  His home blood pressure readings have been mildly elevated 120's-130's.

His current medications include:
     PREDNISONE 5 mg b.i.d.
     NYSTATIN 3 cc t.i.d.
     NIFEDIPINE 5 mg q.i.d.
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     CYA STUDY # 582-L  37.5 mg t.i.d.
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.

Raymond's physical exam was notable for:
     BP 130/69   P 121   R 22   WT 15.2kg   
     General: well appearing, comfortable in no distress.
     Skin: no lesions.
     HEENT: within normal limits
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation, no wheezing today.
     Heart: positive 3/6 systolic ejection murmur on the left para sternal border.
     Abdomen: benign, no tenderness or bruits at graft site.
     Extremities: no edema.
     Neurological: no lateralizing signs

A urinalysis revealed:
     SPEC GR UA  1.009           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5               WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   N     
     MICROSCOPC             

Laboratory studies at this time include:
          AST          24     U/L       MCV        97.6      FL (H)
          K           4.8  MMOL/L (H)   MCH        29.7      PG    
          CA         10.1   MG/DL       MCHC       30.4    G/DL    
          CR          0.7   MG/DL       RDW        20.2       % (H)
          CYA         192   MCG/L       HDW        3.62    G/DL (H)
          GLU          87   MG/DL       MPV         6.6      FL (L)
          PHOS        3.5   MG/DL (L)   PLT UNC     826   K/MM3 (H)
          ALT          14     U/L       NEUT         70       % (H)
          BUN          42   MG/DL (H)   LYMPH        21       % (L)
          URIC        6.8   MG/DL (H)   MONOS         5       %    
          NA          139  MMOL/L       ATYP LY       3       %    
          CL          103  MMOL/L       BAND          1       %    
          CO 2         22   MEQ/L       CELLS C     100    
          BILI TO     0.8   MG/DL       ABS NEU   15.29   K/MM3    
          BILI DI     0.2   MG/DL       ABS LYM    4.52   K/MM3    
          WBC       21.53   K/MM3 (H)   ABS EOS     .00   K/MM3    
          RBC        3.40   M/MM3 (L)   MORPH      SAME    
          HGB        10.1    G/DL (L)   NUC RBC       1    
          HCT.       33.2       % (L)   

Raymond continues to be stable.  We would like to increase his Nifedipine 6 mg q.i.d.  He is beginning to perform more physical therapy.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
Marie Hadow, M.D.
84 Sayels Street
Southbridge, MA 01550


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Friday, October 18, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond comes to us with note of increasing facial edema.  He continues to have good urine output.  He is positive by about 200cc's on daily fluid balance.  He was also seen in his local emergency room three days ago for low grade fever.  Chest x-ray revealed mild atelectasis.   He has been asymptomatic for the past two days.  He has also completed developmental assessment and will start physical therapy on Monday.  He has been taking oral feeds well.

His current medications include:
     PREDNISONE 5 mg b.i.d.
     NYSTATIN 3 cc t.i.d.
     NIFEDIPINE 5 mg q.i.d.
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     CYA STUDY # 582-L  37.5 mg t.i.d.
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.

Raymond's physical exam was notable for:
     BP 113/62   P 131   T 36.8   WT 15.0kg  
     General: well appearing, comfortable in no distress.
     Skin: no lesions.
     HEENT: positive for mild periorbital and forehead edema.
     Neck: supple without lymphadenopathy.
     Chest: positive occasional wheezing on the right side.
     Heart: positive 2-3/6 murmur systolic ejection murmur on the left para sternal border.
     Abdomen: no tenderness nor bruits at graft site, G Tube button in place without surrounding erythema or evidence of infection.
     Extremities: no peripheral edema.
     Neurological: no lateralizing signs

Laboratory studies at this time include:
          AST          20     U/L       MCH        30.6      PG    
          K           4.9  MMOL/L (H)   MCHC       30.7    G/DL    
          CA          9.5   MG/DL       RDW        20.6       % (H)
          CR          0.7   MG/DL       HDW        3.73    G/DL (H)
          CYA         134   MCG/L       MPV         6.9      FL (L)
          GLU         100   MG/DL       PLT UNC     831   K/MM3 (H)
          PHOS        3.8   MG/DL (L)   NEUT         64       % (H)
          ALT          18     U/L       LYMPH        27       % (L)
          BUN          36   MG/DL (H)   MONOS         7       %    
          URIC        6.4   MG/DL (H)   BASO          1       %    
          NA          141  MMOL/L       MYELO         1       %    
          CL          107  MMOL/L       CELLS C     100    
          CO 2         23   MEQ/L       ABS NEU   11.31   K/MM3    
          BILI TO     0.9   MG/DL       ABS LYM    4.77   K/MM3    
          BILI DI     0.2   MG/DL       ABS EOS     .00   K/MM3    
          WBC       17.67   K/MM3 (H)   ANISO        2+ (*)
          RBC        3.14   M/MM3 (L)   MACRO        2+ (*)
          HGB         9.6    G/DL (L)   HYPO         2+ (*)
          HCT.       31.3       % (L)   POLYCHRINCREASE (*)
          MCV        99.7      FL (H)   NUC RBC       1    

Raymond continues to have stable renal function.  Because of his positive fluid balance and weight gain we will decrease his total fluid intake by 100cc's a day to a total of 1150cc's/day.  We will increase the cyclosporine to 40mg/40mg/37.5mg.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
Marie Hadow, M.D.
84 Sayels Street
Southbridge, MA 01550


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, October 29, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's mother says things have been going relatively well at home.  She is concerned that he is frequently wetting the bed with his nighttime doses of Lasix and we have agreed that the dosing can be shifted to 6am and 6pm to minimize his urine output in the middle of the night.

His current medications include:
     PREDNISONE 5 mg b.i.d.
     NYSTATIN 3 cc t.i.d.
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     NIFEDIPINE 7 mg q.i.d.
     CYA STUDY # 582-L  40 mg, 40 mg 37.5 mg 
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.

Raymond's physical exam was notable for:
     BP 121/77   P 119   HT 86cm   WT 15.7kg  
     General: alert, obese in no respiratory distress.
     Skin: normal.
     HEENT: cranial cynostosis, cushingoid facies.
     Neck: lymph nodes negative.
     Chest: clear exchange, equal aeration bilaterally.
     Heart: regular rate and rhythm, 3/6 systolic murmur at left upper sternal border, no palpable thrill.
     Abdomen: right healed incisions, soft, non tender graft.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.008           WBC/HPF     1-2        
     WBC ENZ UA  N               RBC/HPF     2-4        
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             
HYALINE CAST  few

Laboratory studies at this time include:
          AST          27     U/L       MCV        93.8      FL (H)
          K           4.6  MMOL/L (H)   MCH        29.2      PG    
          CA          9.9   MG/DL       MCHC       31.1    G/DL    
          CR          0.7   MG/DL       RDW        18.5       % (H)
          CYA         198   MCG/L       HDW        3.49    G/DL (H)
          GLU          85   MG/DL       MPV         6.9      FL (L)
          ALT          16     U/L       PLT UNC     714   K/MM3 (H)
          BUN          35   MG/DL (H)   NEUT         84       % (H)
          URIC        6.0   MG/DL (H)   LYMPH        10       % (L)
          NA          138  MMOL/L       MONOS         4       %    
          CL          100  MMOL/L       BASO          1       %    
          CO 2         25   MEQ/L       BAND          1       %    
          BILI TO     0.8   MG/DL       CELLS C     100    
          BILI DI     0.1   MG/DL       ABS NEU   13.41   K/MM3    
          WBC       15.78   K/MM3       ABS LYM    1.58   K/MM3    
          RBC        3.70   M/MM3       ABS EOS     .00   K/MM3    
          HGB        10.8    G/DL       MORPH      SAME    
          HCT.       34.7       %       

Raymond appears to be doing well with regards to his transplant.  It may be necessary to continue to decrease the amount of formula that Raymond takes every day given his increased po intake for solid foods. Furthermore it may be necessary to reduce the total amount of fluid that he takes, for solid food that he is now taking po represents a water load as well.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
Marie Hadow, M.D.
84 Sayels Street
Southbridge, MA 01550


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, November 5, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's physical activity has continued to improve.  He is closer to baseline and has become more ambulatory with home physical therapy.  

His current medications include:
     PREDNISONE 5 mg b.i.d.
     NYSTATIN 3 cc t.i.d.
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     NIFEDIPINE 7 mg q.i.d.
     CYA STUDY # 582-L  40 mg, 40 mg 37.5 mg 
     CELLCEPT 250 mg b.i.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.

Raymond's physical exam was notable for:
     BP 113/51   P 131   R 22    HT 86cm   WT 15.9kg   
     General: alert, obese in no distress.
     Skin: normal.
     HEENT: cranial synostosis, cushingoid facies.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation without wheezing appreciated.
     Heart: regular rate and rhythm, positive 3/6 systolic ejection murmur at left para sternal border.
     Abdomen: right healed incisions, soft, non tender graft.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.011           WBC/HPF     2-3        
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   1-2 f      
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             

Laboratory studies at this time include:
          AST          33     U/L       MCV        90.3      FL (H)
          K           4.3  MMOL/L       MCH        30.0      PG    
          CA         10.4   MG/DL       MCHC       33.2    G/DL    
          CR          0.7   MG/DL       RDW        17.4       % (H)
          CYA         206   MCG/L       HDW        3.36    G/DL (H)
          GLU          87   MG/DL       MPV         7.0      FL (L)
          PHOS        2.5   MG/DL (L)   PLT UNC     673   K/MM3 (H)
          ALT          21     U/L       NEUT AB    8.22   K/MM3    
          BUN          30   MG/DL (H)   LYMPH A    1.77   K/MM3    
          URIC        5.8   MG/DL (H)   EOS ABS     .14   K/MM3    
          NA          139  MMOL/L       NEUT-A     72.0       % (H)
          CL          101  MMOL/L       LYMPH-A    15.5       % (L)
          CO 2         24   MEQ/L       MONO-A      8.5       % (H)
          BILI TO     0.7   MG/DL       EOS-A       1.2       %    
          BILI DI     0.1   MG/DL       BASO-A       .6       %    
          WBC       11.41   K/MM3       ATYP LY     2.1       %    
          RBC        3.86   M/MM3       ANISO-A       +    
          HGB        11.6    G/DL       HYPO-A       ++ (*)
          HCT.       34.9       %       LEFT SH  ABSENT    

Raymond continues to have stable renal function.  He is doing well.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Marie Hadow
84 Sayels Street
Southbridge, MA 01550

Phyllis Pollack, M.D.
Department of Cardiology 
U Mass Medical Center
55 Lake Avenue North
Worcester, MA 01655


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, November 12, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's mother reports that he is doing fairly well at home.  She is concerned about a small pimply rash on his bottom which does not appear to resolve even with medicated ointments.

His current medications include:
     PREDNISONE 5 mg b.i.d.
     NYSTATIN 3 cc t.i.d.
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     NIFEDIPINE 7 mg q.i.d.
     PREDNISONE 5 mg b.i.d.
     CYA STUDY # 582-L  40 mg, 40 mg 37.5 mg t.i.d. 
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.

Raymond's physical exam was notable for:
     BP 116/67   P 126   HT 85.9cm   WT 16.2kg   
     General: alert, playful, obese little boy in no distress.
     Skin: normal.
     HEENT: cushingoid facies.
     Neck: lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm, positive 3/6 systolic ejection murmur at left para sternal border.
     Abdomen: soft, non tender graft.
     Genitourinary: small papules consistent with monilia on buttocks.
     Extremities: baseline polydactyly.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.015           WBC/HPF     0-2        
     WBC ENZ UA  N               RBC/HPF     2-4        
     PH UA       6               WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   1+         
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             
HYALINE CAST  1+

Laboratory studies at this time include:
          K           4.2  MMOL/L       RDW        16.6       % (H)
          CA          9.9   MG/DL       HDW        3.15    G/DL    
          CR          0.7   MG/DL       MPV         7.3      FL    
          CYA         230   MCG/L       PLT UNC     701   K/MM3 (H)
          GLU          90   MG/DL       NEUT         70       % (H)
          PHOS        2.8   MG/DL (L)   LYMPH        19       % (L)
          BUN          29   MG/DL (H)   MONOS         8       %    
          NA          139  MMOL/L       EOS           1       %    
          CL          102  MMOL/L       ATYP LY       1       %    
          CO 2         24   MEQ/L       BAND          1       %    
          WBC       14.99   K/MM3       CELLS C     100    
          RBC        4.26   M/MM3       ABS NEU   10.64   K/MM3    
          HGB        12.0    G/DL       ABS LYM    2.85   K/MM3    
          HCT.       38.2       %       ABS EOS     .15   K/MM3    
          MCV        89.6      FL       ANISO        1+    
          MCH        28.2      PG       HYPO         1+    
          MCHC       31.4    G/DL       POLYCHRINCREASE (*)

Raymond appears to be doing very well with regard to his transplant.  We have discussed with his mother that complete eradication of the monilial type rash in the diaper area is difficult to achieve while on steroids.  His renal function is stable.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Marie Hadow
84 Sayels Street
Southbridge, MA 01550

Phyllis Pollack, M.D.
Department of Cardiology 
U Mass Medical Center
55 Lake Avenue North
Worcester, MA 01655


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, November 19, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond appears to be doing well with no specific problems.  Since the transplant he has had a nightly temperature of 100.4.

His current medications include:
     PREDNISONE 5 mg b.i.d.
     NYSTATIN 3 cc t.i.d.
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     NIFEDIPINE 7 mg q.i.d.
     PREDNISONE 5 mg b.i.d.
     CYA STUDY # 582-L  40 mg, 40 mg 37.5 mg t.i.d. 
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.

Raymond's physical exam was notable for:
     BP 112/79   P 114   HT 85.9cm   WT 16.3kg   
     General: alert, playful, obese little boy in no distress.
     Skin: facial hair.
     HEENT: cushingoid facies.
     Neck: lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm, positive 3/6 systolic ejection murmur.
     Abdomen: soft, non tender graft.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.009           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5               WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   N     
     MICROSCOPC             

Laboratory studies at this time include:
          K           4.7  MMOL/L (H)   RDW        16.5       % (H)
          CA         10.2   MG/DL       HDW        3.13    G/DL    
          CR          0.7   MG/DL       MPV         6.4      FL (L)
          CYA         131   MCG/L       PLT UNC     738   K/MM3 (H)
          GLU          99   MG/DL       NEUT AB    9.94   K/MM3    
          PHOS        2.9   MG/DL (L)   LYMPH A    2.13   K/MM3    
          BUN          27   MG/DL (H)   EOS ABS     .09   K/MM3    
          NA          138  MMOL/L       NEUT-A     75.2       % (H)
          CL          100  MMOL/L       LYMPH-A    16.1       % (L)
          CO 2         24   MEQ/L       MONO-A      6.2       %    
          WBC       13.22   K/MM3       EOS-A        .7       %    
          RBC        4.12   M/MM3       BASO-A       .4       %    
          HGB        12.0    G/DL       ATYP LY     1.3       %    
          HCT.       36.0       %       ANISO-A       +    
          MCV        87.4      FL       MICRO-A       +    
          MCH        29.1      PG       LEFT SH PRESENT    
          MCHC       33.3    G/DL       

Raymond appears to be doing very well with regard to his transplant.  We will begin further tapering of his prednisone of 11/26/96.  In communication with his cardiologist, Dr. Pollack, she would prefer that Raymond would not to be placed on a beta blocker.  She feels that reflex tachycardia with calcium channel blockers is acceptable.  Raymond will start Neutra phos 125 mg 1/2 pack bid.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Marie Hadow
84 Sayels Street
Southbridge, MA 01550

Phyllis Pollack, M.D.
Department of Cardiology 
U Mass Medical Center
55 Lake Avenue North
Worcester, MA 01655


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, November 26, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond is doing well.  He continues to have nightly low grade temperatures from 99.6 to 100.6.  He is quite active and is eating well.

His current medications include:
     PREDNISONE 5 mg b.i.d.
     LASIX 15 mg b.i.d.
     NIFEDIPINE 7 mg q.i.d.
     ZANTAC 3 cc b.i.d.
     NYSTATIN 3 cc b.i.d.
     CYA STUDY # 582-L  40 mg, 40 mg 37.5 mg t.i.d. 
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.
     NEUTRAPHOS 1/2 pkg b.i.d.

Raymond's physical exam was notable for:
     BP 123/58   P 101   HT 86cm   WT 16.5kg   HC 48.5cm
     General: appears cushingoid with increased facial hair, very active and smiling.
     Skin: facial hair.
     HEENT: cushingoid facies.
     Neck: lymph nodes negative.
     Chest: clear.
     Heart: regular rate and rhythm.
     Abdomen: soft, non tender graft.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.012           WBC/HPF     N          
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       6.5             WBC CAST    N          
     PROTEIN UA  trace           RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   N     
     MICROSCOPC             

Laboratory studies at this time include:
          AST          32     U/L       MCH        28.0      PG    
          K           5.4  MMOL/L (H)   MCHC       32.8    G/DL    
          CR          0.7   MG/DL       RDW        16.5       % (H)
          CYA         180   MCG/L       HDW        3.11    G/DL    
          PHOS        3.3   MG/DL (L)   MPV         6.3      FL (L)
          ALT          23     U/L       PLT UNC     658   K/MM3 (H)
          BUN          26   MG/DL (H)   NEUT         74       % (H)
          URIC        5.2   MG/DL       LYMPH        19       % (L)
          NA          138  MMOL/L       MONOS         3       %    
          CL          100  MMOL/L       EOS           1       %    
          CO 2         23   MEQ/L       ATYP LY       1       %    
          BILI TO     0.7   MG/DL       BAND          2       %    
          BILI DI     0.1   MG/DL       CELLS C     100    
          WBC       13.20   K/MM3       ABS NEU   10.03   K/MM3    
          RBC        4.60   M/MM3       ABS LYM    2.51   K/MM3    
          HGB        12.9    G/DL       ABS EOS     .13   K/MM3    
          HCT.       39.4       %       ANISO        1+    
          MCV        85.6      FL       MICRO        1+    

Raymond appears to be doing very well three months status post transplant.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Marie Hadow
84 Sayels Street
Southbridge, MA 01550

Phyllis Pollack, M.D.
Department of Cardiology 
U Mass Medical Center
55 Lake Avenue North
Worcester, MA 01655


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, December 17, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's mother reports that he has been doing well.  He had a fever to 101.6 last week that since then has returned back to his baseline temperature.  She notes that he occasionally turns his left hip outward as he walks.  He is able to bear weight on this and there is no erythema or swelling of the hip area.

His current medications include:
     LASIX 15 mg b.i.d.
     NIFEDIPINE 7 mg q.i.d.
     NYSTATIN 3 cc b.i.d.
     PREDNISONE 10 mg q.d.
     ZANTAC 45 mg b.i.d.
     CYA STUDY # 582-L  40 mg, 40 mg 37.5 mg t.i.d. 
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.
     NEUTRAPHOS 1/2 pkg b.i.d.

Raymond's physical exam was notable for:
     BP 115/73   P 126   R 18   WT 17.2kg   
     General: obese, comfortable, in no distress.
     Skin: positive hirsutism.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: positive 3/6 systolic murmur at left para sternal border radiating to the back.
     Abdomen: soft without tenderness nor bruits at graft site.
     Extremities: no edema, no swelling.  Limitation of motion of both hips.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.013           WBC/HPF     0-1        
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   N          
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             
occ hyaline casts

Laboratory studies at this time include:
          K           5.7  MMOL/L (H)   RDW        16.1       % (H)
          CA         10.1   MG/DL       HDW        3.03    G/DL    
          CR          0.7   MG/DL       MPV         8.1      FL    
          CYA         165   MCG/L       PLT UNC     685   K/MM3 (H)
          GLU         115   MG/DL       NEUT AB    9.57   K/MM3    
          PHOS        4.2   MG/DL (L)   LYMPH A    1.69   K/MM3    
          BUN          25   MG/DL (H)   EOS ABS     .10   K/MM3    
          NA          138  MMOL/L       NEUT-A     79.1       % (H)
          CL          102  MMOL/L       LYMPH-A    14.0       % (L)
          CO 2         24   MEQ/L       MONO-A      4.2       %    
          WBC       12.10   K/MM3       EOS-A        .8       %    
          RBC        4.25   M/MM3       BASO-A       .4       %    
          HGB        12.2    G/DL       ATYP LY     1.5       %    
          HCT.       35.2       %       ANISO-A       +    
          MCV        82.9      FL       MICRO-A       +    
          MCH        28.7      PG       LEFT SH  ABSENT    
          MCHC       34.6    G/DL       

Raymond continues to have stable renal function.  We advised his mother to consult with his orthopaedic surgeon regarding the out turning of his left hip.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Marie Hadow
84 Sayels Street
Southbridge, MA 01550

Phyllis Pollack, M.D.
Department of Cardiology 
U Mass Medical Center
55 Lake Avenue North
Worcester, MA 01655


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, December 31, 1996.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's mother offers no complaints.  He is to be seen by orthopaedics this coming Thursday for follow up of his hip.

His current medications include:
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     NIFEDIPINE 7 mg t.i.d.
     CYA STUDY # 582-L  40 mg, 37.5 mg, 40 mg t.i.d. 
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.
     NEUTRAPHOS 1/2 pkg b.i.d.
     PREDNISONE 10 mg/6 mg q.o.d.

Raymond's physical exam was notable for:
     BP 120/76   P 123  HT 87.3cm   WT 17.1kg   HC 48.25cm
     General: well appearing in no distress.
     Skin: no lesions.
     HEENT: within normal limits.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm 3/6 systolic ejection murmur left parasternal border.
     Abdomen: soft without tenderness nor bruits at graft site.
     Extremities: no edema.
     Neurological: normal.

A urinalysis revealed:
     SPEC GR UA  1.019           WBC/HPF     0-1        
     WBC ENZ UA  N               RBC/HPF     N          
     PH UA       5.0             WBC CAST    N          
     PROTEIN UA  N               RBC CAST    N          
     BLOOD UA    N               GRAN CAST   0-1        
     GLUCOSE UA  N               WAXY CAST   N          
     BACTERIA    N               SQUAM EPI   few   
     MICROSCOPC             

Laboratory studies at this time include:
          AST          32     U/L       HCT.       36.3       %    
          K           5.2  MMOL/L (H)   MCV        80.8      FL    
          CA         10.2   MG/DL       MCH        28.7      PG    
          CR          0.7   MG/DL       MCHC       35.6    G/DL    
          CYA         172   MCG/L       RDW        16.0       % (H)
          GLU         106   MG/DL       HDW        3.10    G/DL    
          PHOS        4.4   MG/DL (L)   MPV         6.8      FL (L)
          ALT          15     U/L       PLT UNC     659   K/MM3 (H)
          BUN          24   MG/DL (H)   NEUT         80       % (H)
          URIC        6.5   MG/DL (H)   LYMPH        11       % (L)
          NA          138  MMOL/L       MONOS         8       %    
          CL          102  MMOL/L       EOS           1       %    
          CO 2         24   MEQ/L       CELLS C     100    
          BILI TO     0.7   MG/DL       ABS NEU    9.41   K/MM3    
          BILI DI     0.1   MG/DL       ABS LYM    1.29   K/MM3    
          WBC       11.76   K/MM3       ABS EOS     .12   K/MM3    
          RBC        4.49   M/MM3       ANISO        1+    
          HGB        12.9    G/DL       MICRO        1+    

Raymond continues to have stable renal function.

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

               Sincerely,


               Clotilde Goldwater, MD
               Director of Nephrology


cc:
Marie Hadow
84 Sayels Street
Southbridge, MA 01550

Phyllis Pollack, M.D.
Department of Cardiology 
U Mass Medical Center
55 Lake Avenue North
Worcester, MA 01655


CONTENT:
Cavinder McPherson, M.D.          RE: Raymond Hadow
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/26/94

Dear Dr. McPherson:

We had the pleasure of seeing Raymond in the Renal Transplant Program on Tuesday, January 14, 1997.  He has chronic renal failure secondary to dysplastic kidneys.  He had a renal transplant on 8/30/96.

Raymond's sister has had a sore throat over the past couple of days and thus his mother is concerned whether Raymond has the same symptoms.  He has remained active and has been afebrile.  Orthopaedics consultation on hip x ray had a question of avascular necrosis.

His current medications include:
     LASIX 15 mg b.i.d.
     ZANTAC 45 mg b.i.d.
     NIFEDIPINE 7 mg t.i.d.
     CYA STUDY # 582-L  40 mg, 37.5 mg, 40 mg t.i.d. 
     CELLCEPT 250 mg q.d.
     BACTRIM SS (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) M-W-F
     INTAL 2 puffs t.i.d.
     VENTOLIN 2 puffs t.i.d.
     ATROVENT 2 puffs t.i.d.
     NEUTRAPHOS 1/2 pkg b.i.d.
     PREDNISONE 10 mg/4 mg q.o.d.

Raymond's physical exam was notable for:
     BP 104/56   P 112   HT 88cm   WT 17.04kg   
     General: well appearing in no distress.
     Skin: no lesions.
     HEENT: injected throat without exudate.
     Neck: supple without lymphadenopathy.
     Chest: clear to auscultation.
     Heart: regular rate and rhythm with a positive 3/6 systolic ejection murmur left parasternal border.
     Abdomen: soft without tenderness nor bruits at graft site.
     Extremities: no edema.
     Neurological: normal.

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

Laboratory studies at this time include:
          K           5.7  MMOL/L (H)   MCHC       32.2    G/DL    
          CA         10.6   MG/DL (H)   RDW        15.9       % (H)
          CR          0.6   MG/DL       HDW        2.77    G/DL    
          CYA         150   MCG/L       MPV         7.5      FL    
          GLU         112   MG/DL       PLT UNC     623   K/MM3 (H)
          PHOS        4.8   MG/DL       NEUT AB    8.25   K/MM3    
          BUN          22   MG/DL (H)   LYMPH A    1.56   K/MM3    
          NA          138  MMOL/L       EOS ABS     .10   K/MM3    
          CL          103  MMOL/L       NEUT-A     78.7       % (H)
          CO 2         24   MEQ/L       LYMPH-A    14.9       % (L)
          WBC       10.49   K/MM3       MONO-A      3.2       %    
          RBC        4.97   M/MM3       EOS-A        .9       %    
          HGB        13.0    G/DL       BASO-A       .4       %    
          HCT.       40.4       %       ATYP LY     2.0       %    
          MCV        81.2      FL       MICRO-A       +    
          MCH        26.2      PG       LEFT SH  ABSENT    

Raymond continues to be stable renal.  We will be sending a throat culture today.  We have decided to discontinue his Lasix for now and observe him off Lasix.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


cc:
Marie Hadow
84 Sayels Street
Southbridge, MA 01550

Phyllis Pollack, M.D.
Department of Cardiology 
U Mass Medical Center
55 Lake Avenue North
Worcester, MA 01655


CONTENT:
Shahin Stone, M.D.          RE: Rosemary Liszt
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/20/94

Dear Dr. Stone:

     We had the pleasure of evaluating Rosemary in the Renal Program on 10/5/95 for recurrent urinary tract infections.
     Rosemary is a 10 month old girl with history of three urinary  tract infections in the past, and the first episode according to her mother was diagnosed in June of this year when she presented with fever.  The  following urinary infections were completely asymptomatic.  She has been treated with antibiotic for ten days for each episode.   According to her mother, she has been having good appetite.  She has been afebrile and she is awake, alert, and she has no history of constipation, nor any current illness at this point.

Her current medications include:


Past medical history:
     Past medication history was unremarkable.  No history of allergies.   Immunizations are up to date.  She has never been admitted to the  hospital.  Her last urinary tract infection was September of this year.

Rosemary's physical exam was notable for:
     BP 101/64   P 140   R 24   T    HT 75.3cm   WT 9.32kg
     General: she appears in no distress.  She is afebrile.   
     HEENT: The head is normocephalic, non-traumatic.  
     Neck: is supple.  No lymph  nodes are palpable.  
     Chest: is clear to auscultation.  
     Heart: II/VI systolic murmur was heard.  
     Abdomen: no masses were  palpable.  Bowel sounds were present.  
     Genitourinary:  examination revealed normal  genitalia for age.  
     Extremities: free range of motion, no edema.   
     Skin: eczema was present.  
     Neurologic: she was awake,  alert and no meningeal signs.
A urinalysis revealed:
     SPEC GR UA  1.005           WBC/HPF     0          
     PH UA       6               SQUAM EPI   1-3        
     WBC ENZ UA  N               RBC CAST    0          
     BLOOD UA    N               WBC CAST    0          
     PROTEIN UA  N               GRAN CAST   0          
     GLUCOSE UA  N               WAXY CAST   0          
     RBC/HPF     0               BACTERIA    N     

Laboratory studies at this time include:


     Rosemary is a 10 month old with recurring positive urine cultures.  She has been on Furadantin prophylaxis since last week.  Work-up has been negative so far,  renal ultrasound was normal and the nuclear VCUG revealed no evidence of reflux.  She has been scheduled to have a radiological VCUG where we will be able to assess her voiding pattern to exclude obstruction and identify if there is any urine residual.  Then, we will repeat the urine culture under  sterile conditions.  Our current assessment is that most likely she has had asymptomatic bacteriuria for the last two episodes, probably as a result of change in intestinal flora after antibiotic treatment for the first urinary tract infection.   She will benefit by continuing on the current antibiotics prophylaxis for at least four to six weeks and then repeat a urine culture to see if there is any evidence of recurrence.  We will discuss this with Dr. Stone and we will see Rosemary as needed.

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

               Sincerely,


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


CONTENT:
Bart Romanov, M.D.          RE: Hugo Page
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/02/81

Dear Dr. Romanov:

     We had the pleasure of evaluating Hugo in the Renal Program on 12/15/94 for asymptomatic hematuria and proteinuria.

     Hugo is a 13 year old boy referred by Dr. Romanov for asymptomatic hematuria and proteinuria found on routine physical exam early in December.  He had no accompaning URI symptoms, no joint pains, edema or rash noted.  He did complain of lower back pain for two days two weeks before but is otherwise asymptomatic.

Past medical history:
     Past medical history is essentially unremarkable.  He has never been hospitalized.  Family history shows two sibilings with orthostatic proteinuria.  There is no evidence of renal disease in the family.

Physical exam:
     BP 135/65   P 65   R 12   HT 73cm   WT 83.5kg
     Physical exam was unremarkable.

Urinalysis:
     SPEC GR UA  1.025           PH UA       7.0        
     PROTEIN UA  1+              BLOOD UA    1+         
     GLUCOSE UA  N               WBC/HPF     N          
     RBC CASTS   clumps    GRAN CASTS   deformed coarse and fine

Laboratory studies at this time include:
          CRU       165.4   MG/DL       IGA         123   MG/DL    
          U PROT       44   MG/DL (H)   LCANA HNEGATIVE   TITER    
          LCANA MNEGATIVE   TITER       

     Lab studies done outside showed a creatinine of .9, a C3 which was normal at 95, urine protein/creatinine ratio of .26, 24 hour protein excretion of 594 mg/dl, urine calcium./creatinine ratio was normal.  Ultrasound done outside was also normal.  ANA was positive and ASLO was negative.

Hugo is a 13 year old boy with asymptomatic hematuria and proteinuria with granular casts and deformed red blood cells in the urine consistent with glomerulonephritis.  There is currently no evidence for active post infectious glomerulonephritis.  The most likely diagnosis is IgA nephropathy and at present because of minimal proteinuria there is no treatment warranted.  However mild proteinuria will be rechecked in 3 months to be sure it is clearing (as expected after non-specific stimulation with intercurrent illness).

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

               Sincerely,


               Joakuim Chef, MD          
               Fellow, Pediatric Nephrology



               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Bart Romanov, M.D.          RE: Hugo Page
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/02/81

Dear Dr. Romanov:

     We had the pleasure of evaluating Hugo in the Renal Program on 3/8/95 for persisting asymptomatic hematuria.

     Asymptomatic since his last review here in mid December.

Past medical history:
     Past medical history as outlined on previous ocassions.

Review of systems:
     Asymptomatic.

Physical exam:
     BP 142/67   P 72    HT 186.6cm   WT 86.4kg
     General: a cooperative teenager
     Skin: intact without purpura, rash or telangiectasia
     HEENT: normal limits
     Neck: supple, lymph nodes not palpable
     Chest: clinically clear
     Heart: regular rate and rhythm
     Abdomen: non-tender, no localizing signs and no abdominal bruits 
     Genitourinary: Tanner 4
     Extremities: no edema or rash
     Neurological: no localizing signs

Urinalysis:
     SPEC GR UA  1.021           WBC ENZ UA  N          
     PH UA       7.5             PROTEIN UA  2+         
     BLOOD UA    1+              GLUCOSE UA  N     mg/dl
     WBC/HPF     1-3             RBC/HPF     0          
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   fine            WAXY CAST   0          
     SQUAM EPI   rare            BACTERIA    0     
     RBC clumps and ocassional strand

Laboratory studies at this time include:
          ALB         4.0    G/DL       CR          0.9   MG/DL    
          TP          7.0   GM/DL       BUN          10   MG/DL    
          IGG         731   MG/DL       IGA         121   MG/DL    
          IGM         132   MG/DL       WBC        6.57   K/MM3    
          RBC        5.10   M/MM3       HGB        13.9    G/DL    
          HCT.       41.2       %       MCV        80.7      FL    
          MCH        27.3      PG       MCHC       33.8    G/DL    
          RDW        13.4       %       HDW        2.20    G/DL    
          PLT UNC     244   K/MM3       NEUT AB    3.68   K/MM3    
          LYMPH A    2.21   K/MM3       EOS ABS     .10   K/MM3    
          NEUT-A     56.0       %       LYMPH-A    33.6       %    
          MONO-A      6.1       %       EOS-A       1.4       %    
          BASO-A       .8       %       ATYP LY     2.1       %    
          LCANA HNEGATIVE   TITER       LCANA MNEGATIVE   TITER    


     1)  Benign recurrent hematuria possibly IGA nephropathy.  2) Mild proteinuria.

1)  At this stage observation is all that is required.  2)  A review by Dr. Romanov in three months and return to the clinic in six months for urinalysis to exclude changes in protein excretion and to monitor blood pressure.

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Bart Romanov, M.D.          RE: Hugo Page
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/02/81

Dear Dr. Romanov:

     We had the pleasure of seeing Hugo in the Renal Program on 8/10/95 for hematuria/proteinuria.
     Hugo is a 14 year old boy followed for persistent asymptomatic  hematuria.  Since his last visit with us, Hugo has been well,  asymptomatic, no rashes, no joint pains.

His current medications include:


Review of systems:
     Negative.

Hugo's physical exam was notable for:
     BP 151/63   P 75   R    T    HT 188.7cm   WT 89.6kg
     General: Hugo appears well, in no distress.  
     HEENT:  Within normal limits.  
     Neck: Supple.  
     Chest: Clear.  
     Heart: Without murmur.  
     Abdomen: Soft, flat, without masses.   No tenderness.  
     GU: Within normal limits. 
     Extremities: Warm and well-perfused.  
     Skin: Without lesions.  
     Neurologic:  No lateralizing signs.
A urinalysis revealed:
     SPEC GR UA  1.018           RBC/HPF     Occ.       
     PH UA       5.0             WBC/HPF     0          
     BLOOD UA    Tr.             SQUAM EPI   0          
     PROTEIN UA  Tr.            BACTERIA    Neg.  
     GLUCOSE UA  Neg.       

Laboratory studies at this time include:
          CRU       109.9   MG/DL       U PROT       16   MG/DL (H)

      Hugo is 14 years old, doing very well with persistent  asymptomatic hematuria.  

At present, the assessment is still either benign recurrent hematuria versus the possibility of IgA nephropathy.  He has a history of mild proteinuria.  At present, no intervention is  necessary.  We will monitor his blood pressure and protein excretion  every 6 months and will see him again in clinic in one year.

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

               Sincerely,


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


CONTENT:
Bart Romanov, M.D.          RE: Hugo Page
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/02/81

Dear Dr. Romanov:

     We had the pleasure of seeing Hugo in the Renal Program on 3/28/96 for to prepare for renal biopsy on a same day admission.
     This biopsy aims at definition of histology possibly IgA nephropathy.   Hugo was first diagnosed with hematuria and proteinuria December of 1994 and has been otherwise asymptomatic.  He has maintained normal renal function and normal blood pressure since that period of time.  He is on no medications.

His current medications include:


Hugo's physical exam was notable for:
     BP 156/83   P 76   R 14   T    HT 189.6cm   WT 93.7kg
     General appearance: comfortable, alert.  
     HEENT:  eyes, nose and throat are clear.  
     Neck: supple, no significant lymphadenopathy.  
     Chest: clear to auscultation.  
     Cardiac: S1, S2 normal, no murmur.  
     Abdomen: soft, no organomegaly.  
     Extremities: no edema.   
     Neurological: no focal deficits or meningeal signs.
A urinalysis revealed:
     SPEC GR UA  1.030           WBC/HPF     neg        
     PH UA       5.0             SQUAM EPI   neg        
     WBC ENZ UA  neg             RBC CAST    -          
     BLOOD UA    small           WBC CAST    -          
     PROTEIN UA  1+              GRAN CAST   -          
     GLUCOSE UA  neg             WAXY CAST   -          
     RBC/HPF     0-1             BACTERIA    neg   

Laboratory studies at this time include:


     Hugo's laboratory values done two days previously reveal  normal prothrombin time, PTT and bleeding time.  His hematocrit is 47%.   Hugo will be admitted overnight post renal biopsy.

     Thank you for the opportunity to participate in Hugo's care.  We would like to review him in 2 weeks.  In the interim, we would be happy to discuss or review Hugo should you or the family wish it.

               Sincerely,


               Neal Sanders, MD       Mitsuko Khan, MD
               Fellow, Pediatric Nephrology Director, Clinical Services


CONTENT:
Bart Romanov, M.D.          RE: Hugo Page
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/02/81

Dear Dr. Romanov:

     We had the pleasure of seeing Hugo in the Renal Program on 4/10/96 for review post biopsy.
     Hugo returns for review post biopsy and for discussion of the results of the biopsy.   

He has remained well with no local pain or tenderness at the biopsy site  which is well-healed.  Past medical history well-known for fluctuating  hematuria and proteinuria and for the recent renal biopsy.

His current medications include:


Hugo's physical exam was notable for:
     BP 152/76   P 81   R 16   T    HT 189cm   WT 94.5kg
     General appearance - a well-hydrated, well-covered  teenager in good physical condition and no distress.  
     HEENT: normal.  Neck supple.  Lymph nodes not palpable.  
     Chest: clinically clear to auscultation.  
     Heart: rate and rhythm regular.   
     Abdomen: non-tender.  
     Genitourinary: Tanner stage IV male development.   
     Extremities: no rash or arthritis.  
     Skin: intact.  
     Neurological: no  focalizing signs.
A urinalysis revealed:
     SPEC GR UA  1.018           GLUCOSE UA  neg        
     PH UA       6               WBC/HPF     0-2        
     WBC ENZ UA  neg             SQUAM EPI   occ   
     BLOOD UA    2+              BACTERIA    neg   
     PROTEIN UA  trace      
     RBC: 5-10 with occassional clumps
CASTS: rare hyaline and fine granular

Laboratory studies at this time include:
          CRU       303.2   MG/DL       U PROT       51   MG/DL (H)

     Hugo has recovered from his biopsy well and the site is  now well-cleared.  The urinalysis today is refractive and the  proteinuria less obvious than on prior occasions and a urinary protein  to creatine ratio had fallen to 0.17, lower than at his previous review. 

Hugo then shows a borderline blood pressure 154/89 which is at initial  review, falling to 135/75 after five to ten minutes.  This may have been  due to the stress of the discussion of biopsy results.  He shows a less  active urine with at this stage an only mildly increased protein output.  

The biopsy confirms the clinical impression of IgA nephropathy and with  minimal proteinuria it is probably reasonable to watch and review the  protein excretion through your office in two to three months and to  return here for review in six months.  Patients with IgA nephropathy who  show fluctuating degrees of proteinuria are at mildly higher risk of  progressive disease and hence the protein should be monitored closely.   Certainly his blood pressure should also be monitored since this is a  treatable cause of potential progression of renal disease.  I would  suggest that should his proteinuria continue at low grade with  intermittent bursts of higher grade proteinuria, early Enalapril therapy  would be appropriate.  Should the proteinuria continue to show an upward  trend or should there be a more active urinary sediment, consideration  of therapy to decrease inflammation or of Imuran steroid therapy to  balance inflammation and potential progression of his of his IgA  nephropathy should be explored.  At this stage with a urinary protein to  creatinine ratio of 0.17 and with the relatively inactive urinary  sediment, I would suggest that it's most reasonable to follow his  protein excretion and to respond to changes in protein or blood

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Bart Romanov, M.D.          RE: Hugo Page
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/02/81

Dear Dr. Romanov:

We had the pleasure of seeing Hugo in the Renal Program on 8/28/96 for IgA nephropathy.
Hugo returns to clinic today for follow-up of his IgA  nephropathy.  He was inadvertently scheduled today to see Dr. Herrin  when Dr. Herrin is on vacation.  Thus I am seeing Hugo today for Dr.  Herrin.  Hugo and his parents report no problems.  He has no problems  with edema or hematuria.



Hugo's physical exam was notable for:
     BP 147/69   P 68   R    T    HT 188.9cm   WT 94kg
     Mouth was clear.  Neck was supple without  adenopathy.  Lungs were clear.  CV:  Regular rate and rhythm without  murmur.  Abdomen was soft and nontender with no hepatosplenomegaly and  extremities had no edema.
A urinalysis revealed:
     SPEC GR UA  1.027           WBC/HPF     0          
     WBC ENZ UA  -               RBC/HPF     0          
     PH UA       5               WBC CAST    0          
     PROTEIN UA  tr              RBC CAST    0          
     BLOOD UA    neg             GRAN CAST   0          
     GLUCOSE UA  -               WAXY CAST   0     
     BACTERIA    -               SQUAM EPI   0-1   

Laboratory studies at this time include:
          CRU       215.7   MG/DL       U PROT       29   MG/DL (H)

Hugo continues to do well.  His blood pressure again this  visit has borderline systolics in the 140s.  However his diastolics are  normal.  Hugo had a history in the past according to his family of  being very nervous when he comes to the doctor, and having high  systolics in the hospital and having normal blood pressures when checked  on the outside.  Thus I have given the family a blood pressure recording  sheet to check his blood pressures at home several times in the next  week and to call Dr. Herrin with the values.  Hugo's values showed a  very inactive sediment today with very minimal proteinuria considerably  less than before.  His protein creatinine ratio when checked in July was  0.1 and his protein creatinine ratio today is also 0.1.

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

               Sincerely,


               Thilo Beaker, MD
               Attending, Pediatric Nephrology


CONTENT:
Loocie Sanders, M.D.          RE: Norma Knox
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/02/86

Dear Dr. Sanders:

     We had the pleasure of evaluating Norma in the Renal Program on 2/16/95 for reflux.

     Norma is in long term follow-up on suppressive therapy with surveillance cultures being negative.  She continues on bactrim 60l mg daily with the last documented urinary tract infection 18 months prior to this visit.  Last review was in July 194 and at that time reflux was still persisting.  

There has been no enuresis or loss of urinary control and a repeat radionuclide cystogram and ultrasound were performed with this visit.

Current medications include:
     BACTRIM 60 mg q.d.

Past medical history:
     Vesicoureteric reflux

Review of systems:
     No symptomatology for intercurrent infection or intercurrent disease.

Physical exam:
     BP 96/50   P 59   HT 126cm   WT 26.7kg
     General: Well appearing cooperative 8 year old 
     Skin: Intact
     HEENT: Within normal limits
     Neck: Supple, lymph nodes not palpable
     Chest: Clinically clear
     Heart: Regular rhythm and rate without murmur
     Abdomen: Soft, without flank tenderness or suprapubic tenderness
     Genitourinary: Normal external genitalia
     Extremities: No edema
     Neurological: No focal signs

Urinalysis:
     SPEC GR UA  1.011           PH UA       5-6        
     PROTEIN UA  N               BLOOD UA    N          
     GLUCOSE UA  N               WBC/HPF     N          
     RBC/HPF     N               SQUAM EPI   rare  
     CASTS       N

     1)  Persistent vesicoureteric reflux grade 2 on the left and grade 1 on the right with continuing renal growth.

2)  No documented intercurrent bacteriuria or infections

     We have asked Norma to return in .

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Loocie Sanders, M.D.          RE: Norma Knox
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/02/86

Dear Dr. Sanders:

     We had the pleasure of seeing Norma in the Renal Program on 5/15/96 for vesicoureteral reflux.
     This 9 year old girl comes to us for follow up bilateral Grade I-II  vesico-ureteral reflux.  Today's ultrasound  shows little growth of the right kidney compared to previous study.  The RNC revealed resolution of reflux on the right and persistence of Grade II reflux  on the left.  She has not been acutely ill since her last visit with us.   She has had no recurrence of UTI on Bactrim prophylaxis.   

Review of systems is negative for fever, flank pain, or vomiting.

Her current medications include:
     BACTRIM 1.5 tsp q.d.
     BACTRIM 120 mg Trimethoprim q.d.

Norma's physical exam was notable for:
     BP 94/52   P 63   R 14   T    HT 131.2cm   WT 28.9kg
     On physical exam, Norma is well hydrated, well  nourished, in no distress.  
     HEENT: moist mucous membranes.  
     Neck: supple,  without lymphadenopathy.  
     Chest: clear.  Heart without murmur.  
     Abdomen: soft and flat without masses or tenderness.  
     Extremities: warm and  well perfused.  
     Skin: without lesions.  
     Neurologic: no lateralizing  signs.
A urinalysis revealed:
     SPEC GR UA  1.013           WBC/HPF     0-1        
     PH UA       7               SQUAM EPI   few        
     WBC ENZ UA  -               RBC CAST    0          
     BLOOD UA    -               WBC CAST    0          
     PROTEIN UA  -               GRAN CAST   0          
     GLUCOSE UA  -               WAXY CAST   0          
     RBC/HPF     0               BACTERIA    -     

Laboratory studies at this time include:


     In summary, Norma shows continued improvement of her  vesico-ureteral reflux.  We recommend continuation of surveillance urine cultures to be  done every three months.  We have also reinforced the need for frequent  voiding as well as the need to continue on her  prophylactic antibiotics.  We would like to review another ultrasound and RNC prior to her next visit.

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

               Sincerely,


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


CONTENT:
Sebastian Rolf, M.D.          RE: Emmet Bruce
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/14/83

Dear Dr. Rolf:

We saw Emmet in the Endocrine Program on 10/9/95 for slow growth.

History: The mother of this 12 and 3/12 year old male reports that she has always been concerned about his growth, however in the last year his stature has fallen from the 5th percentile to below the 5th percentile and his weight has fallen from the 5th percentile to below the 5th percentile. 

His feeding history is that he was initially breastfed for two days and then changed to SMA formula for one year.  Prior to one year of life he had marked weight gain and mother reports that they had thought about restricting his oral intake.  After one year of life his oral intake decreased spontaneously.  She denies any recent dramatic change in his appetite in the last year.  She reports he is a picky eater.  In the morning he will have toast and cereal, at lunch he may not eat at school, depending on what is being served.  After school he has a snack, sandwich or meatballs and spaghetti, and dinner is typically rice, meat and beans.  He has milk 1-2x a week and drinks a large amount of soda.  His stooling is once or twice a day; it is soft, formed, with no blood or mucous, and no diarrhea.  He urinates 3-4x a day without recent change.

Current medications: None.

Past medical history:  He was born to a 19 year old G3 P3.  Pregnancy was complicated by hypertension.  She had a cesarean section for breech position.  Her prenatal screens were negative.   His birth weight was 7 lb. 11 oz.  He was discharged home with mother after eight days of hospitalization.  He had no immediate health problems in the perinatal period.   

His hospitalizations and surgeries are notable for an inguinal hernia repair at age one year old.  His illnesses include arthrogryposis that is thought to be hereditary as there is a strong family history on the maternal side.  He is receiving physical therapy three times a week, he is followed by orthopedics.  According to mother he was previously evaluated by genetics.  The nature of that consult is not available to us at this time, however mother states that everything was negative.  In addition, he has migraine headaches that have been occurring since approximately 1-1/2 years.  They are primarily left temporal.  He  occasionally has some emesis associated with severe headaches.  He had a head CAT scan that was normal in  May, 1995.  He is followed by neurology.  The migraines are treated with Tylenol with relief.  The frequency of the migraines varies from several times a week to one every few weeks. 

His immunizations are up-to-date.  He had a PPD that was negative last week.  He has no known drug allergies.  He travelled recently to the Dominican Republic (July and August).  He had no diarrheal illnesses while there. 

Social history:  He lives with his mother and two siblings.  He is in the 6th grade and does well in school.

Family history:  Negative for any gastrointestinal disease, endocrine disease and thyroid disease.  His family history is notable for multiple aunts, uncles and cousins with contractures.  Mother states that the entire family is short.  Mother has a history of migraine headaches, sinus infections and retinal detachment.  Emmet has two siblings, ages 9 years old and 7 years old, both of whom are healthy.  Mother's height is 4'11", father's height is 5'2", that gives Emmet a mid -parental height of 5'3" or 63".

Physical exam:
Ht: 134.5 cm    Wt: 26.7 kg    Arm span: 133 cm    U/L ratio:  0.89
BP: 110/60              Pulse: 106              Pubic hair: Tanner I    
R. testis: 2.5 x 1.1 cm L. testis: 2.3 x 1.1 cm Phallus length: 8 cm    
Mid-shaft diam.: 1.7 cm      Bone age: 11 years
In general, he is alert in no acute distress.  He has no rashes on physical exam.  His HEENT is unremarkable.  He is normocephalic  atraumatic.  He has bilateral flat discs on fundoscopic exam.  His pupils are equal, round and reactive.  His extraocular movements intact.  He has no nystagmus.  His tympanic membranes are gray and mobile.  He has large external ears but is not dysmorphic.  His oropharynx is without erythema, lesions or exudate.  His neck is supple without  significant lymphadenopathy.  His lungs are clear to auscultation.  Heart: regular rate and rhythm, normal S1, S2 no murmur. Abdomen: bowel sounds present.  Soft, nontender, nondistended, with no  hepatosplenomegaly or masses.  On genital exam has normal male genitalia, his testes are descended bilaterally.  He is tanner I.  On extremity exam he has multiple contractures of the knees and elbows.  Neuro:  Reflexes are 2+ throughout, his toes are downgoing, he has full strength and contractures as noted above.

Previous labs include spine x-rays in 2-95 that show a spina bifida occulta at L5.  Apparently Emmet had thyroid function tests done at the Greater Lawrence Center on September 28; however, we have no record of those as today is a holiday, the center is closed and we have not been able to obtain that record.

Laboratory studies from 10/9/95:  Bone age 11 years (1 S.D=10.4 months).  IGF BP3 pending.   IGF-1=205 ng/ml (180-440).  T4=11.1 mcg/dL, TSH=1.4 uU/ml. Creatinine=0.5 mg/dL, BUN 14=mg/dL.  ESR=11 mm/hr.  UA:  SG=1.020, pH=5.0, micro=negative, dip=negative.  CBC=normal, dif=normal with 9.9% EOS.

Impression: This is a 12 year old male with a recent decrease in growth velocity and poor weight gain.  The differential diagnosis includes constitutional delay or genetic short stature with a strong family history. However, other concerns would be nutritional issues surrounding some other chronic illness that is ongoing but as yet undiagnosed.  The last possibility would include a hormonal deficiency.  At this time we obtained a complete blood  count and differential, ESR BUN and  creatinine, and urinalysis.  Additional studies include thyroid function tests, IGF1 and IGF BP3 as a screening for growth hormone deficiency.  We also obtained a bone age.

Disposition: We would like to follow Emmet closely in our clinic every 3-4 months in the next year to  determine growth velocity.  We have also encouraged him to increase his oral intake by snacking more and increasing the caloric density of his foods.



Sincerely,




Thilo Beaker, MD              Maritza Brezny, MD             
Resident in Pediatrics             Attending in Endocrinology


CONTENT:
Herman Rolf, M.D.          RE: Emmet Bruce
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/14/83

Dear Dr. Rolf:

I saw Emmet in the Endocrine Program on 12/16/96 for followPup of short stature.

History: Emmet is now 13-1/2 years old and is in the 7th grade.  He says he has been well except for allergies, especially affecting his eyes.  He notes the onset of body hair and apocrine odor last Summer.  Mother continues to be concerned about his growth, as his younger brother is heavier and stronger. 

His review of systems reveals that he continues to have migraines about one every 2 months.  Other than that, his review is non-contributory. 

He is no longer receiving physical therapy because the family has no insurance currently.

Current medications: None.

Physical exam:
HT: 140.5 cm    WT: 29.8 kg
BP: 105/65              Pulse: 80               Pubic hair: Tanner II   
On physical examination today, this is a slim young guy with a downy mustache.  The skin is of normal turgor.  The eye exam is normal but for some redness in conjunctiva.  The thyroid is normal.  There are shotty cervical and axillary lymph nodes. The heart has a normal sinus rhythm, with an early systolic, low-pitched murmur, maximum at the apex. The abdomen is benign.  The genitalia show hair on fringe of scrotum.  The phallus appears to be prepubertal and uncircumcised.  The testes are of normal consistency.  Neurologically, the deep tendon reflexes are 1+ and equal and the balance is grossly normal. 

No laboratories were done today.


Impression: Emmet has grown at a rate of about 5.14 cm per year, which is a normal growth rate.  He has entered into early puberty.  His bone age done the last year was within 1 year of his chronologic age, and he comes from a rather short family.  In sum, then, he probably has genetic short stature.

Disposition: I think that he can be followed up in your office and if there is concern about his growth, then we will see him again, but at this time it looks like everything is normal. 

Thanks for letting us share in his care.



Sincerely,




Maritza Brezny, MD             
                             


Problem list to date:

Transcribed by Hasseman_s


CONTENT:
Gleide DeNiro, M.D.          RE: Susanna Byrne
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/19/94

Dear Dr. DeNiro:

     We had the pleasure of seeing Susanna in the Renal Program on 1/12/95 for hydronephrosis.
     
    Susanna is an almost one month old child who was one of twins.  Actually there were in utero triplets but only two survived.  She was born by spontaneous vaginal delivery at the Brigham and Women's Hospital at 36 weeks gestation.  She was twin A.  Both twins were fine and were able to go home soon after birth.  She was noted in utero ultrasound to have unilateral hydronephrosis.

Follw-up examination at Saint Joseph's Hospital on January 4, 1995 demonstrated moderately severe right sided hydronephrosis and a normal left kidney.  A voiding cystoureterogram on January 6th demonstrated no reflux and a normal bladder.

Current medications include:
     AMOXICILLIN 1 ml q.d.

Physical exam:
     BP 93/66   P 86   R 24   HT 50.6cm   WT 3.09kg
     General: Appears active and alert and healthy
     Skin: no rashes noted
     HEENT: sutures open, anterior fontanel 2 x 2 and soft.  Read reflux is seen bilaterally.
     Chest:  No rales or wheezes heard 
     Heart: S1 normal, S2 split, no S3 or S4 murmur.
     Abdomen: benign, no masses or tenderness.  Right kidney vaguely palpable with no obvious masses.
     Genitourinary: normal
     Extremities: normal

Urinalysis:
     SPEC GR UA  1.004           WBC ENZ UA  N          
     PH UA       6               PROTEIN UA  0          
     BLOOD UA    0               GLUCOSE UA  0     mg/dl
     WBC/HPF     0-2             RBC/HPF     0          
     WBC CAST    0               RBC CAST    0          
     GRAN CAST   0               WAXY CAST   0          
     SQUAM EPI   0               BACTERIA    0     


     A review of the VCUG was normal.  The renal ultrasound demonstrates moderate to severe right sided hydronephrosis with no obvious ureter.  I think that the degree of the hydronephrosis is sufficient to require further study.  I think that she should have an IVP done within the next couple of weeks.  I also think that it will probably demonstrate a UPJ obstruction.  At that point, determination of whether surgery is necessary should be made.  I would guess that will be a judgment call at that point.

     In the mean time, she should continue on the Amoxicillin. We have asked Susanna to return in two weeks.  Thank you for allowing us to share in Susanna's care.  If you have any questions or concerns, please do not hesitate to contact me.

               Sincerely,


               Clotilde Goldwater, MD
               Director, Pediatric Nephrology


CONTENT:
Pulanski, M.D.          RE: Cesar Madison
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/31/90

Dear Mr. & Mrs. Madison:

The results of Cesar's lab tests in January are the following:

     Glucose 79 mg./dl
     Glycohemoglobin .9% (normal, non diabetic 5.2-7.8%)
     Thyroid tests are completely normal.

This glycohemoglobin is somewhat on the high side and probably consistent with more of the higher blood sugars that he had been seeing prior to this visit.  Once you feel as though the Cesar's nutrition is getting to a more consistent pattern, then we need to start working on the insulin to try to bring down his average blood sugar and the glycohemoglobin.  If you have not been calling in to Kathleen, please give her or myself a call so that we can take a closer look at his blood sugars and see what the next step is.  

Sincerely,


Maritza Brezny


CONTENT:
Vivianne Brando, M.D.          RE: Cesar Madison
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  01/31/90

Dear Dr. Brando:

We had the pleasure of seeing Cesar in the Endocrine Program on 1/24/95 for .

History:  We had the pleasure of meeting your patient, Cesar Madison, when he came to the diabetes clinic on 1/24/95.  This now 4 11/12 year old has had diabetes since 4/94.  He received his initial hospitalization and teaching at Maine Medical Center.  His parents manage well and were able to take care of a sick day this last December with frequent insulin supplements and ketone monitoring.  Cesar's current insulin dose is 2-1/2 - 3 units of regular and 10 units of Humulin Lente in the morning, 0-1/2 of regular and 2-1/2 of Lente at suppertime.  His total dose then is 0.68 units per kg per day.  Mom and dad both give his shots and adjust his regular according to his blood sugars.  He generally is symptom free, although he does have nocturia.  Complains occasionally of headaches.  He denies GI symptoms and has only rare muscle aches and pains.    He does have ketones in the morning occasionally for which he is given extra fluids with rapid resolution.  He has measured low blood sugars occasionally, but he has never been symptomatic.  He follows a carbohydrate-based diet and the complaint is that he's always hungry.

Past medical history:  Negative for any CNS problems.  Has had a heart murmur which was evaluated and was thought to be normal.  There was a question early on of milk intolerance, but he drinks milk now.

Family history:  Positive for NIDDM and high blood pressure in the maternal grandmother and for obesity in a paternal aunt.  There's a question of Hashimoto's thyroiditis in the paternal grandmother.  Otherwise, Cesar's 6 yrs. old brother Kyle and his parents are all in good health.

Physical exam:  
Height: 113.4 cm        Weight: 22.2 kg         
General:  he is a well developed, well nourished youngster who is active but very cooperative.
Skin:  hypertrophy at the arms and legs but otherwise is normal
HEENT:  Normal 
Neck: Thyroid is just palpable & normal
Chest: 
Heart: Grade II/VI vibratory murmur.
Abdomen:  normal; no hepatosplenomegaly
Genitourinary:  
Extremities: 
Neurological:  normal 2+ and equal deep tendon reflexes.

Laboratory studies:  T4 7.9, TSH 2.5, thyroid antibodies undetectable.  Glucose 79, glycohemoglobin 11.9 (norms 5.2-7.8%).

Impression: Cesar has insulin dependent diabetes mellitus with markedly variable blood sugars, often in the 200 & 300's but occasionally quite low.  He is on a fairly reasonable dose of insulin.  He is always hungry and so we have chosen today to first address the nutritional planning issues and get him on a meal plan and to explore the knowledge base of the folks.  Once that's happened, we will be more aggressive about insulin adjustment.

Disposition: For today I have just decreased the morning Lente to 9.5 with no changes in his sliding scale in the morning.  I've left the evening Lente at 2.5.  I've asked his mother to try giving a little more regular in the afternoon and perhaps only 2 of Lente to avoid middle of the night and morning lows.  We may need to address this by changing the insulin.  As noted, Cesar and his folks saw the nutritionist today and will be scheduled to see the teaching nurse to continue their diabetes education.  We'd like in particular to review sick days and be sure they've got that down.  Phone numbers were given for emergencies.  Because of the family history of Hashimoto's, I obtained thyroid tests and antibodies today and find no indication of a problem that needs to be followed up at this time.  We've asked them to come back to clinic in three months.
Thank you for letting us share in the care of Cesar.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology


CONTENT:
Plato, M.D.          RE: Kiki Suttner
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/10/87

Dear Dr. Plato:

We had the pleasure of seeing Kiki in the Endocrine Program on 4/6/95 for precocious puberty.

History: Kiki a 7 and 7/12 year old who is is referred to us with a history of clear vaginal mucosa discharge over the past two years.  Kiki has also had increased breast development over the past six months.  By history, she developed labial adhesions approximately one year ago for which she received 5-7 days of Estrogen cream.  She's completely off this topical application.  She's had no vaginal bleeding or spotting.  Her discharge is clear and nonpurulent.  She has also had two vaginal yeast infections following courses of antibiotics.  Her parents have noted fine pubic hair over the past six months.  She has no axillary hair or apocrine odor.

Current medications: Poly vi Flor.

Past medical history:  Birth History:  Birth weight was 8 lb 8 oz after a full term pregnancy.  NSVD.  Colic in the early months of life that resolved.  Her growth and development have been completely normal.  She's had chronic otitis media for which she has been on antibiotic prophylaxis in the past.  She never had PE tubes.  No hospitalizations or surgeries.  No history of urinary tract infections.

Review of systems:  Kiki has had headaches since December 1994, but occurring only every 3-4 weeks.  She has no visual changes or nausea.  There is no history of nasal congestion or fevers.  She has had two strep throats treated with penicillin over this past winter.  She has an excellent appetite and energy level.  There are no changes in thirst or urination.  She awakens once a night to urinate, but not to drink.  There have been no significant changes in her weight with only steady weight gain accompanying growth.  She has one normal bowel movement per day and denies abdominal pain.

Family history:  Remarkable only for adult onset diabetes mellitus in a maternal great aunt and greatgrandmother.  No other endocrinopathies.  Maternal menarche at 11 years of age.  Dad's development reportedly "average".

Physical exam:  
Height: 129 cm          Weight: 30.4 kg         BP: 102/70              
Pulse: 80               Arm span: 128.5         Breast: Tanner II       
Pubic hair: Tanner I    
U/L ratio = 0.99
General: Happy, alert, in no acute distress.
Skin: Without acne, rashes, or other lesions.
HEENT: PERRL.  EOMI.  Fundoscopic exam within normal limits.  Oropharynx clear.
Neck: No thyromegaly, no LAD.
Chest: Clear to auscultation.  Right areola 1.2 x 1.9 cm, Left areola 2.0 x 2.1 cm.  
Heart: Regular RR, without murmur.
Abdomen: Soft, no masses or hepatosplenomegaly.
Genitourinary: Pale (estrogenized) vaginal mucosa.  No clitoromegaly.
Extremities: No clubbing, cyanosis or edema.
Neurological: Nonfocal with reflexes +2 and toes bilaterally downgoing.

Laboratory studies:  GnRh stimulation tests (4/11/95): LH (baseline - 0.78 IU/L, 11-1)  FSH (baseline 3.50 IU/L, maximal 7.30), consistent with early puberty.

Impression: Kiki is a 7 7/12 year old with history of breast development and vaginal discharge since the age of six years.  Clear evidence of estrogen effect on physical exam manifested in breast buds and pale vaginal mucosa.  No evidence of androgen effect.  Clinical picture represents early central activaiton resulting in precocious puberty.  The GnRH stimulation test make this diagnosis.

Disposition: A GNRH stimulation test was performed in the CAT-CR on April 11, 1995, at 9:30am.  Results from this test, summarized above.  After discussign the GnRH stimulation tests results with Kiki's mother, we elected  to to wait on Depot Lupron at this time.    We will reevaluation with a bone age in 2-3 months and make a final decision about starting this therapy.
Thank you for letting us share in the care of Kiki.

Sincerely,


Sotiria Bonaparte, MD         Ariel Adler, MD           
                             Attending in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Kiki Suttner
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/10/87

Dear Dr. Blue:

We had the pleasure of seeing Kiki in the Endocrine Program on 6/8/95 for follow-up of precocious puberty.

Kiki is now a 7 9/12 year old who was referred to us in April, 1995, with a six month history of breast development and a two year history of clear vaginal discharge.  There was no history of apocrine odor, axillary hair, or pubic hair.  We carried out a GnRH simulation test on 4-11-95 that revealed early activation of the hypothalamic-pituitary axis.  The bone age obtained in April, 1995, was also advanced by 2 years.  The decision was made to see her back in follow-up for a repeat bone age as well as re-evaluation.

Current medications: Multi-vitamin tablet.

Review of systems:  She has only occasional headaches and no visual problems.  She has had no change in urination or thirst.  She has a good appetite and no problems with abdominal pain, constipation or diarrhea.  She has had no endocrine problems since we last saw her.  Psychologically, she is having a difficult time with the pubertal development as none of her classmates have entered puberty and she is the object of teasing.  Her vaginal discharge is still persistent and she has had recurrent yeast vaginitis.

Physical exam:  
Height: 130.6 cm        Weight: 31.2 kg     Arm span: 129 cm.      
BP: 102/66              Pulse: 88                       
Breast: Tanner II       Pubic hair: Tanner II   
General: Well appearing and alert.
Skin: Clear without acne or other lesions.
HEENT: PERRL, EOMI, fundoscopic exam within normal limits.
Neck: No thyromegaly or lymphadenopathy.
Chest: CTA.
Heart: RRR, without murmur.
Abdomen: Soft, without masses or hepatosplenomegaly.
Genitourinary: Scant vaginal discharge.  No chafing or clitoromegaly. Mucosa estrogenized.
Extremities: Warm, well perfused.
Neurological: Nonfocal, DTR's 2+ and toes bilaterally downgoing.

Laboratory studies:  4-11-95:  GnRH simulation test: baseline LH 0.78 mIU/ml with a peak of 9.3 at 45 minutes.  Baseline FSH 3.5 mIU/ml with a peak of 7.3 at 45 minutes.  This isa  pubertal response.  Bone age in 3/95: chronologic age was 7 6/12 years while the bone age was 9 6/12 years.

6/8/95:  Androstenedione 33 ng/dl (normal), estradiol 27 pg/ml, IGF-1 468 ng/ml

Impression: 
Kiki is a 7 9/12 year old with breast buds, early pubic hair and history of profuse vaginal discharge.  Early activation of central hypothalamic-pituitary axis seen on GnRH stimulation testing.  As early pubertal changes definitely seem to be affecting Kiki adversely from a psychological standpoint, the decision was made with the family to initiate GnRH analog therapy to suppress puberty.

Disposition: Kiki will be started on Lupron 7.5 mg IM q month.  She will have repeat GnRH simulation testing done every 4 months to assess for adequate H-P-G suppression.  We would like to see Kiki again in the clinic in 4 months.

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


Sincerely,




Sotiria Bonaparte, MD                Nilto Carter, MD             
Fellow in Endocrinology             Attending in Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Kiki Suttner
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/10/87

Dear Dr. Blue:

We saw Kiki in the Endocrine Program on 10/5/95 for central precocious puberty.

History: Kiki is an 8 1/12 year old first referred to Endocrine clinic in April 1995.  A GnRH stimulation test revealed early activation of the hypothalamic-pituitary-gonadal axis, and at her last clinic visit in June, the decision was made to initiate a course of depot Lupron therapy.  She is now status-post four q 28 day Lupron injections.  Her parents note her vaginal discharge has markedly decreased.  She denies headaches, nausea, vomiting, diarrhea or constipation, or changes in her urination.  She has an excellent energy level and appetite.  However, Kiki complains today of intermittent double vision at least 4-5 times per week.

Current medications: depot Lupron  7.5 mg IM q 28 days.

Physical exam:
Ht: 133 cm        Wt: 32.9 kg
BP: 100/60        Pulse: 80               
Breast: Tanner II       Pubic hair: Tanner II   
General appearance: well-developed, well-nourished, healthy appearing. Skin: no acne or other lesions.  HEENT: PERLA, EOMI.  Funduscopic exam within normal limits.  Neck: without thyromegaly or lymphadenopathy.  Chest: clear to auscultation.  Cor: regular rate and rhythm without murmur.  Abdomen: soft, without masses or  hepatosplenomegaly.  GU: estrogenized mucosa as before, but decreased vaginal discharge.  Extremities: warm and well-perfused.  Neuro:  nonfocal.  DTRs 2+ and toes bilaterally downgoing.

Laboratory studies:  9/18/95: GnRH stimulation test: Baseline LH 0.2 IU/ml with a peak of 0.4 IU/L at time 30 minutes.  Baseline FSH 0.5 IU/ml with a peak of 0.6 IU/L from time 15 minutes onward.  These result are consistent with suppression of the hypothalamic-pituitary-gonadal axis.

Impression: Kiki is an 8 1/12 year old with a history of central precocious puberty currently receiving depot Lupron therapy.  She is adequately suppressed at the present time on her current dose of Lupron.  As lesions of the central nervous system (e.g., brain tumors) can cause central precocious puberty and she has an abnormal neurologic complaint of diplopia, we recommend ordering a cranial MRI.

Disposition: We recommend that Kiki continue her current Lupron dose of 7.5 mg IM q 28 days.  We would like to see Kiki back in Endocrine clinic in 4 months to assess growth velocity and pubertal staging.   If there is any evidence of escape from suppression of the hypothalamic-gonadal-pituitary axis, she will require a repeat GnRH stimulation test.  The family will schedule a head MRI in the next 2 weeks.



Sincerely,




Sotiria Bonaparte, MD            Leif Pavarotti, MD             
Fellow in Endocrinology         Attending in Endocrinology   


Addendum: Cranial MRI on 10/15/95 without evidence of an intracranial mass lesion.  Sellar and suprasellar areas within normal limits.  Normal appearing pituitary.


cc:  Cheryl Suttner 26 Cyr Street  West Bridgewater, MA  02379


CONTENT:
Nekia Blue, M.D.          RE: Kiki Suttner
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/10/87

Dear Dr. Blue:

We saw Kiki in the Endocrine Program on 2/22/96 for central precocious puberty.

History: Kiki is an 8 5/12-year-old who was last seen in our clinic in 10/95.  As you know, she has been treated with Lupron monthly injections as a GnRH stimulation test last spring revealed early activation of the hypothalamic pituitary gonadal axis.  At that time she was troubled by copious vaginal discharge that was primarily superficial cells (consistent with estrogen effect).  She has been doing well on this therapy (initiated - 6/95).  She has occasional headaches as before, but no nausea, vomiting, or change in bowel or bladder habits.  She has an  excellent energy level and appetite.  She complains today of persistent urinary incontinence, worsened by heavy exercise and sneezing.  She notes that she must wear pads in her underwear because of a persistent "dribble".  The incontinence has been a long-term problem.

Current medications: Lupron 7.5 mg IM q 28 days, Poly-Vi-Fluor.

Physical exam:
HT: 134.7 cm            WT: 35.1 kg
BP: 98/72               Pulse: 80                    
Breast: Tanner II       Pubic hair: Tanner II   
General Appearance:  Well-nourished, healthy appearing girl.  Skin without acne or other lesions.  HEENT benign.  Neck without thyromegaly or lymphadenopathy.  Chest clear to auscultation.  Cor:  Regular rate and rhythm without murmur.  Abdomen soft without masses or hepatosplenomegaly.  GU:  Vaginal mucosa non-estrogenized today, with no appreciable vaginal discharge.  Neuro:  Nonfocal.  DTR's 2+ and toes bilaterally downgoing.

Impression: Kiki is an 8 5/12-year-old with a history of central precocious puberty by GnRH stimulation testing, currently receiving Depot Lupron therapy.  Of concern to the patient and family today is persistent urinary incontinence.  Her vaginal discharge has been markedly decreased by the Lupron therapy, but she notes bothersome wetting that appears to be urine.  We therefore are recommending an  evaluation by a urologist to help us sort out this issue.

Disposition: We have recommended that Kiki continue her current Lupron regimen of 7.5 mg by IM q 28 days for 4 more months, to complete a one year course.  We have also suggested that Kiki see one of the pediatric urologists here at Children's Hospital, Dr. Craig Peters.  We would like to see her again in clinic in 4 months to reassess her growth velocity and pubertal staging. 

Thank you for letting us share in Kiki's care.


Sincerely,






Sotiria Bonaparte, MD         Bernardo Red, MD           
Fellow in Endocrinology      Chief, Division of Endocrinology


CONTENT:
Nekia Blue, M.D.          RE: Kiki Suttner
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  09/10/87

Dear Dr. Blue:

We saw Kiki in the Endocrine Program on 9/16/96 for follow-up of central precocious puberty.

History: Kiki is now 9 years old and was last seen in our clinic in 2/96.  As you know, she has been treated with Lupron monthly injections over the past year, receiving her last injection this past June.  She underwent an extensive evaluation by the Children's Hospital Urology Service, and an IVP and pelvic CT were negative, ruling out an ectopic ureter. 

On review of systems, she is premenarcheal.  Her parents note that her vaginal discharge is markedly decreased from before.  She has occasional headaches as before, but no nausea or vomiting or change in bowel or bladder habits.  She has an excellent energy level and appetite.  At this time, she denies problems with urinary incontinence or enuresis.

Current medications: Poly-Vi-Flor QD.

Physical exam:
HT: 138.1 cm            WT: 38.9 kg
BP: 107/57              Pulse: 85                   
Breast: Tanner III      Pubic hair: Tanner II   
General appearance: well-nourished, healthy appearing girl.  Skin:  without acne or other lesions.  HEENT benign.  Neck without thyromegaly or lymphadenopathy.  Chest: clear to auscultation.  Cor: normal sinus rhythm without murmur.  Abdomen: soft, without masses or hepatosplenomegaly.  Vaginal mucosa with slight estrogenization and no appreciable vaginal discharge.  Neuro: nonfocal.  DTRs 2+, and toes bilaterally downgoing.

Impression: Kiki is a 9 year-old with a history of central precocious puberty by GnRH stimulation testing, who has just completed one year of Depo Lupron therapy. The patient is having decreased vaginal discharge from before, and the urinary symptoms also appear to be improved.

Disposition: We would like to see Kiki again in clinic in six months to reevaluate her development.  If her pubertal development appears normal, we will sign off for the present time unless further issues arise. 

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


Sincerely,





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

cc: Division of Urology  Children's Hospital


CONTENT:
Mireille Green, M.D.          RE: Jane Rinehart
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/19/92

Dear Dr. Green:

We saw Jane in the Endocrine Program on 11/2/95 for optic glioma.

History: Jane is currently 3 and 7/12 years old and is referred for neuroendocrine evaluation secondary to her optic glioma.  Her twin brother has the same diagnosis and has received chemotherapy; their mother was diagnosed with neurofibromatosis during pregnancy.   Jane was originally diagnosed with type I NF at age 2-3 months.  Her brother was diagnosed with an optic glioma at age 18 months.  Because of macrocephaly, MRIs were obtained on Jane at age 1 and 2 years which were reportedly normal.  One month ago, she presented with a 6 week history of persistent but only occasional vomiting.  A repeat MRI revealed a large optic glioma.  She has recently started chemotherapy with an induction course of 10 weeks of Carboplatin and Vincristine, to be followed by maintenance therapy of  weekly injections with 4 weeks on treatment and 3 weeks off.  She also has had a central line placement.  

She lives with her brother and both parents.

Current medications: On antibiotics for an ear infection.

Past medical history:  Twin pregnancy, C-section at 34 and 1/2 weeks secondary to amniotic leak, birth weight 4 lbs, 13 oz, birth length 17-3/4 inches.  She spent 2 weeks in the NICU for mild respiratory distress and jaundice.  Her eyesight is reportedly normal, as is her hearing.  Her development has been only mildly delayed, especially in fine motor skills.  She walked at age 18 months.   Her speech has been almost on target.  She and her brother attend preschool with early intervention; they also have PT and OT.  Her appetite is fair to good.  She has had no severe infections, and her immunizations are up to date.  Her only operation has been CVL placement.

Family history:  Brother and mother with NF type I.  Paternal grandfather with type II diabetes diagnosed at age 40 years.  Prior pregnancy ended in a miscarriage and fetus had Turner syndrome.  The mother's height is 5', the father's height is 5'10".

Physical exam:
Height: 102.3 cm    Weight: 20.7 kg        HC: 54.5 cm
Pulse: 110          Breast: Tanner I       Pubic hair: Tanner I    
Healthy and happy looking young girl in no distress.  Skin: multiple freckles scattered over the body and axillae, and large cafe-au-lait spots mainly on the abdomen.  No subcutaneous nodules.  HEENT: Fundi not visualized, no nystagmus.  Neck: not cooperative for palpation of thyroid gland.  Chest: clear to auscultation.  Heart: regular rate and rhythm without murmurs.  Abdomen: soft, without masses.  Genitalia: normal female, prepubertal, with no signs of estrogen effect.  Neurologic: nonfocal.  Bone age: 4.6 years

Impression: Young girl with type I neurofibromatosis, receiving chemotherapy for an optic glioma.  We do not anticipate neuroendocrine deficiencies at this time.  However, she has a high risk of development of precocious puberty.  If she requires radiation therapy in the future, there would be an increased risk of neuroendocrine deficiencies.  Jane has been growing well so far, but chemotherapy might affect her appetite and growth temporarily.

Disposition: Today we ordered a baseline bone age.  We would like to see her again in Endocrine clinic in 6 months, or sooner if she has any breast development.



Sincerely,




Fuli Meisner, MD         Leif Pavarotti, MD             
Fellow in Endocrinology          Attending in Endocrinology


CONTENT:
Mireille Green, M.D.          RE: Jane Rinehart
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/19/92

Dear Dr. Green:

We saw Jane in the Endocrine Program on 9/26/96 for neurofibromatosis/optic glioma.

History: Jane is now 4-1/2 years old and almost one year into her chemotherapy for an optic glioma involving the optic chiasm and the optic radiations.  She receives vincristine and Carboplatin for four weeks and then is off for three weeks.  She has tolerated this treatment very well and has had no problems with infections.  She denies headaches, nausea, or vomiting. She has not received any radiation therapy.  

Her parents deny any history of apocrine odor.  She has had no vaginal discharge or bleeding, and they have not noted any breast development.  Her growth is good, and her appetite has improved since her last visit.  There is no history of polydipsia, polyuria, nocturia, or enuresis.  She has no skin problems, constipation, seizures, or neurologic problems.  She is currently in Special Education Preschool, but plans are made for a mainstream school class.  Her vision is 20/80 in both eyes, a combination of refractional error and nerve damage.  She had a repeat MRI in June with no changes in her tumor.

Current medications: vincristine and Carboplatin as above, Bactrim twice a week for otitis media prophylaxis.

Physical exam:
Height: 109 cm          Weight: 26.3 kg    HC: 56 cm
BP: 128/75              Pulse: 131              
Breast: Tanner I        Pubic hair: Tanner I    
Calm and much more cooperative than at her last visit.  She has multiple cafe-au-lait spots and freckling, but no nodules.  Her pupils are equal in size and react normally to light.  Her skin is otherwise normal. Neck is supple without thyromegaly.  She has no lymph nodes, and her lungs are clear to auscultation.  She has no palpable breast tissue.  Her heart has regular rate and rhythm, no murmurs, and her abdomen is soft without masses.  Vaginal mucosa is bright red.  Extremities are normal and she has symmetric neurological exam.

Bone age: 5.9 years

Impression: 4-1/2 year-old girl with optic glioma secondary to NF-1.  Her tumor is stable on chemotherapy.  There are no signs of accelerated growth, precocious puberty, other endocrinopathies.  Her bone age has advanced 1.3 years in ten months, which is probably normal.

Disposition: We emphasized to the father the importance of close follow-up of her pubertal status. In addition we would like to obtain baseline thyroid function tests and an IGF-1 level in the near future.  This could be coordinated with other blood drawings.  Her parents were given the appropriate requisitions for these tests.  We would like to see Jane in six months.



Sincerely,




Fuli Meisner, MD         Rene Daley, MD         
Fellow in Endocrinology          Fellow in Endocrinology      



cc:  Thomas J. McLaughlin, M.D., FAAP  Liberty Tree Associates  
     140 Commonwealth Avenue, Suite 207  Danvers, MA 01923

     R. Michael Scott, M.D.  Department of Neurosurgery  Bader 3  
     Children's Hospital  300 Longwood Avenue  Boston, MA 02115

     Richard Robb, M.D.  Division of Ophthalmology  Children's Hospital


CONTENT:
Antonio Matlock, M.D.          RE: Michel Foxe
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/17/81

Dear Dr. Matlock:

We had the pleasure of seeing Michel in the Endocrine Program on 3/6/95 for short stature.

History: Michel is a 13 year 7 month old boy who was treated at Massachusetts General Hospital from December 1983-1988 for acute lymphoblastic leukemia.  He has been in remission since then and off all medications.  He has history of attention deficit disorder (ADD) and is on Ritalin.  He has been evaluated for short stature by Dr. Crawford who recommended close observation.   The reason for this visit is that in January, 1995, his pediatrician, Dr. Matlock, noted that his linear growth which has been below 5th centile, has deviated further from the 5th centile over the past 12 months. 
 
In August, 1994, a chemistry screen was normal; his IGF-1 done in April, 1993, was low side (101.3 with normal being 110-656 ng/mL at Metpath).  His bone age in 1991 at Hitchcock Clinic was 9 years at a chronologic age of 9 years 8 months.

Current medications: Ritalin 5 mg bid.

Past medical history:  He's in seventh grade and an average student.

Review of systems:  He feels fine and there are no complaints.

Family history:  There is no history of delayed puberty on either side of his family.  Father's height 5' 11", mother's height 5' 1".

Physical exam:  
Height: 138.2 cm        Weight: 33.8 kg         BP: 90/60               
Pulse: 80               U/L ratio:  0.95        Arm span: 135           
Pubic hair: Tanner I    R. testis: 2.9 x 1.4 cm L. testis: 2.8 x 1.3 cm 
Phallus length: 6 cm    Mid-shaft diam.: 2 cm   
General: Healthy appearing boy in no acute distress.  
Skin: Normal; no acne, facial or axillary hair. 
HEENT:  Normal.
Neck: Small palpable thyroid, no lymphadenopathy.
Chest: Clear to auscultation.
Heart: Normal heart sounds and no murmurs.
Abdomen: Benign, no hepatosplenomegaly.
Neurological: Non-focal; PERL, EOMI, funduscopy was normal

Impression: His growth data for the past three years was re-plotted on a longitudinal growth chart (Bayer and Bayley).  Viewed in this way, his pattern of growth is consistent with constitutional growth delay.  His thyroid function is normal.  The LH and testosterone levels are consistent with the physical exam findings of early puberty.  His serum IGF-1 level is low for age but the IGFBP-3 level is within the normal range.

My impression is that the clinical picture and endocrinologic test results are best explained by constitutional delay of growth and puberty.  I anticipate a gradual acceleration of growth and the appearance of signs of secondary sexual development in the year ahead.  I cannot completely rule out the possibility of partial GH insufficiency as a result of GH neurosecretory dysfunction, but my index of suspicion is low at this time and I do not believe that formal GH provocative testing is warranted at this time.  

I would be grateful to have the opportunity to re-evaluate his growth and development in six months.


Laboratory studies pending at this time include: Serum T4 8.3 5g/dL, TBGI .98, TSH 2.1 5U/mL; LH 0.53, FSH 0.72 IU/L;     testosterone 16 ng/dL; DS 38 5g/dL; IGF-I 150 ng/mL, IGFBP-3 2.8 mg/L.
His bone age was 12 6/12 (SD=12 months).
Thank you for letting us share in the care of Michel.

Sincerely,


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


Addendum: Michel Sheppard, M.D.
Fellow in Endocrinology


CONTENT:
Antonio Matlock, M.D.          RE: Michel Foxe
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  08/17/81

Dear Dr. Matlock:

I saw Michel, age 14 years 7 months, for follow-up of short stature and delayed puberty.   

Medications:  Ritalin 10 mg qa.m., 5 mg before lunch.  He does not take any vitamins or nutritional supplements. 

He has enjoyed good health.  He has a good appetite, and according to his father, he eats more than in the past.  He has three meals, an afternoon and evening snack.  He reported no gastrointestinal symptoms.   

Bedtime is 9:00 p.m.; he sleeps undisturbed.  He reported no insomnia, enuresis or nocturia.   

He is in 8th grade, and passing with C grades.  He reported no headaches, visual disturbance, or hearing impairment.   

He is physically active, plays on a hockey team three days per week and has good energy and stamina.

Current medications: None.

Physical exam:
HT: 144.9 cm            WT: 36.2 kg
BP: 110/60              Pulse: 70                      
Breast: Tanner I        Pubic hair: Tanner I    
R. testis: 3.8 x 2.0 cm L. testis: 3.6 x 2.0 cm 
Phallus length: 9.0 cm  Mid-shaft diam.: 2.3 cm 
He looked well, had good color and hydration.  Skin was smooth and warm.  HEENT was unremarkable; no thyromegaly or lymphadenopathy.  Cardiorespiratory examination was normal.  Abdomen revealed no organ enlargement of masses.  He has normal male genitalia.  Extremities were normal.  Neurologic exam was entirely unremarkable.  In particular, optic fundi revealed sharp disks and normal vessels.  He had 2+ symmetric deep tendon reflexes.
Bone age: 13 years

Laboratory studies: Serum DS 44 5g/dL, LH .60, FSH.60 IU/L, testosterone 41 ng/dL; bone age 13 years (SD=11 months).

Impression: Plotted on a Bayer and Bayley growth chart, Michel's growth is consistent with constitutional growth delay.  His rate of growth has accelerated compared with the data provided by you in November, 1995 and compared to my previous measurement.  In addition, examination of his genitalia indicates progression of puberty.  The clinical findings are supported by biochemical evidence of puberty and modest skeletal maturation since I first saw him.

Disposition:  I reassured Michel that his growth and physical development appear to be normal, albeit delayed.  No intervention is necessary at the present time.  He should be monitored at six to twelve month intervals to ensure that growth and physical development continue to progress normally.


Sincerely,






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


CONTENT:
Jos Welby, M.D.          RE: Errol Freneau
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/23/86

Dear Dr. Welby:

We had the pleasure of seeing Errol in the Endocrine Program on 2/28/95 for diabetes.

History: Errol is an 8 8/12 year old boy diagnosed with IDDM in January of 1995.  This is his first clinic visit after discharge from the hospital.

Current medications: He is on Humulin, 30 units per day (0.61 unit per kg per day), divided as follows:  AM 6 units of Regular and 14 units of NPH, PM 4 units of Regular and 6 units of NPH.  Injections are given by the parents, alternating sites between the upper and lower extremities, buttock and abdomen.  He had a session with the diabetes teaching nurse 2 weeks ago.

No hyper/hypoglycemic symptoms are reported.  He is on a three meal/ three snack diet.  

Blood glucose monitoring is done four times a day using the Elite glucose meter.  His blood glucose profile is as follows:  Pre-breakfast 123-170, pre-lunch 97-209, pre-dinner 113-173 and QHS 146-215.

Physical exam:  
Breast: Tanner I        Pubic hair: Tanner I    
General:  alert, in no distress
Skin:  no acne, no stiffness, injection sites look normal.
HEENT:  EOMI, PERLA, lens clear, fundi no retinopathy
Neck:  thyroid not palpable
Chest:  lungs clear
Heart:  normal S1, S2 no murmur
Abdomen:  not obese, no organomegaly
Genitourinary:  prepubertal genitalia
Neurological:  no tremors, DTR +2 over the knees

Impression: New onset IDDM, reasonably well controlled on the current insulin regimen with occasional mild hyperglycemia.

Disposition:   
1.  Maintain the current insulin regimen.  

2.  Follow-up appointment in six weeks.
Thank you for letting us share in the care of Errol.

Sincerely,


Zulma Montague, MD         Maritza Brezny, MD             
Fellow in Endocrinology      Attending in Endocrinology
  


Problem list to date:

Transcribed by Sullivan_ma


CONTENT:
Jos Welby, M.D.          RE: Errol Freneau
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/23/86

Dear Dr. Welby:

We had the pleasure of seeing Errol in the Endocrine Program on 2/28/95 for diabetes.

History: Errol is an 8 8/12 year old boy diagnosed with IDDM in January of 1995.  This is his first clinic visit after discharge from the hospital.

Current medications: He is on Humulin, 30 units per day (0.61 unit per kg per day), divided as follows:  AM 6 units of Regular and 14 units of NPH, PM 4 units of Regular and 6 units of NPH.  Injections are given by the parents, alternating sites between the upper and lower extremities, buttock and abdomen.  He had a session with the diabetes teaching nurse 2 weeks ago.

No hyper/hypoglycemic symptoms are reported.  He is on a three meal/ three snack diet.  

Blood glucose monitoring is done four times a day using the Elite glucose meter.  His blood glucose profile is as follows:  Pre-breakfast 123-170, pre-lunch 97-209, pre-dinner 113-173 and QHS 146-215.

Physical exam:  
Breast: Tanner I        Pubic hair: Tanner I    
General:  alert, in no distress
Skin:  no acne, no stiffness, injection sites look normal.
HEENT:  EOMI, PERLA, lens clear, fundi no retinopathy
Neck:  thyroid not palpable
Chest:  lungs clear
Heart:  normal S1, S2 no murmur
Abdomen:  not obese, no organomegaly
Genitourinary:  prepubertal genitalia
Neurological:  no tremors, DTR +2 over the knees

Impression: New onset IDDM, reasonably well controlled on the current insulin regimen with occasional mild hyperglycemia.

Disposition:   
1.  Maintain the current insulin regimen.  

2.  Follow-up appointment in six weeks.
Thank you for letting us share in the care of Errol.

Sincerely,


Zulma Montague, MD         Maritza Brezny, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Jos Welby, M.D.          RE: Errol Freneau
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/23/86

Dear Dr. Welby:

We saw Errol in the Diabetes Program on 10/24/95 for IDDM.

History: Errol is currently 9-4/12 years.  He is on Humulin:  6-7 units of regular and 13-14 units of NPH before breakfast,  3-4 units of regular and 6 units of NPH before dinner (the total daily dose is 31 units, or 0.64 units/kg/day.)  

Blood glucose monitoring is done twice a day, before breakfast and before dinner and is occasionally done at school.  The glycemic profile is significant for elevated fasting levels (mid 100's to 200 mg/dl) with occasional hypoglycemic episodes (blood glucose 35-50 mg/dl) before lunch, especially following gym classes.  These episodes are symptomatic, and occur 1-2x/week.  Errol is inconsistent with his diet intake and often skips snacks.

Physical exam:
HT: 147.8 cm    WT: 48.3 kg
Breast: Tanner I        Pubic hair: Tanner I    
General appearance:   Mildly overweight male child. Thyroid not palpable.  Injection site atrophy or hypertrophy. Fingers: no calluses.

Laboratory studies:  glycosylated hemoglobin 8.1%

Impression: Insulin-dependent diabetes mellitus with increased insulin requirements, as indicted by fasting hyperglycemia.  The glycohemoglobin level is in the target range, reflecting the wide diurnal variability in blood glucose values.  This variability is due to Errol's inconsistent food intake.  He lost 1 kg since his last visit in July, 1995, but is still overweight for height (> 95%).  The weight loss is attributable to a healthier home diet (his mother is successfully following a diet for weight control with good results).

Disposition: 
We recommend: 
1.  Increasing the NPH to 7 units before dinner, maintaining the same dose of regular insulin (3-4 units). 
2.  Decreasing the morning regular dose to 5-6 units, maintaining the NPH dose between 13 and 14. 
3.  A meeting with the dietician will be scheduled at the next visit to review Errol's meal plan.  
We would like to see Errol back in 3 months.



Sincerely,




Zulma Montague, MD             Maritza Brezny, MD             
Fellow in Endocrinology          Attending in Endocrinology


CONTENT:
Jos Welby, M.D.          RE: Errol Freneau
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/23/86

Dear Dr. Welby:

We saw Errol in the Diabetes Program on 1/16/96 for insulin dependent diabetes mellitus.

History: 
Errol is now 9 and 7/12 years old, and has had diabetes since January, 1995.  He is on Humulin: 6-7 units of regular and 13 units of NPH before breakfast, 6 units of regular and 8 units of NPH before dinner (the total daily dose is 34 units, or 0.7 u/kg/day).  

Errol is doing well and denies symptoms of uncontrolled diabetes.  
Blood glucose monitoring is done twice a day at home (before breakfast and before dinner), and occasionally before lunch at school.  The glycemic profile is significant for elevated fasting levels (in the range of 200 mg/dL), and elevated pre-dinner levels (200-300 mg/dL).  Errol reports symptomatic hypoglycemic episodes, at a frequency of two per week, usually before bedtime.  There is no documentation in the log book of the hypoglycemic episodes.

He is in the 4th grade and is doing well.  He has straight A's.  His last ophthalmologic exam was in December, 1994.

Physical exam:    HT: 149.5 cm    WT: 48.5 kg      BP: 95/60               
Injection sites:  No atrophy or hypertrophy.   Fingertips:  No calluses or infection.

Laboratory studies:  HGB A1C 6.%

Impression: Insulin-dependent diabetes mellituswith adequate control as reflected by a glycohemoglobin level in the target range.  He is maintaining a steady growth in height on a curve parallel to but above the 90th percentile.  He only gained 200 gm in the past 3 months.  His  current weight-for-height is on the 95th percentile.  The lack of weight gain reflects improved household dietary habits.

Disposition: The insulin dose was rearranged to 8 units of regular and 16 units of NPH before breakfast, 4 units of regular and 9 units of NPH before dinner.  Errol and his mother were urged to enter hypoglycemic levels in the log book in addition to potential precipitating events. 

Errol's diabetes care will be transferred to Dr. Nilto Carter in Lowell Pediatrics as the geographical location is more convenient for the family.



Sincerely,




Zulma Montague, MD              Nilto Carter, MD             
Fellow in Endocrinology           Associate in Endocrinology


CONTENT:
Sabie Shields, M.D.          RE: Nate Kimmel
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/15/94

Dear Dr. Shields:

     We had the pleasure of seeing Nate in the Renal Program on 06/07/95 for Renal Calcification.
     Giancarlo Kimmel was seen in the Renal Division on the 7th of June, 1995  for calcification in the right kidney.  Giancarlo is a 6-1/2 month old boy  who was seen in this clinic because of calcification detected during his  admission in late February.  His initial admission had been for GI  reflux which continues to be followed by Dr. Miller in GI.  At that  stage an ultrasound showed calcification of the upper pole of his right  kidney with an obstructed right renal vein and echogenic linear focus in  the inferior vena cava.  He has continued on GI medication.  He is  currently on Zantac 1 cc twice a day and Reglan 0.4 cc 4x a day.  Since  last review he has done well.  He is now able to roll front to back,  back to front.  He smiles, has good head control and is starting to sit.

His current medications include:
     Zantac 1cc b.i.d.
     Regalin 0.4cc q.i.d.

Nate's physical exam was notable for:
     BP 100/59   P 109   R 20   T    HT 64.2cm   WT 6.85kg
     General:  He appeared well.
     Skin:  Mild candidal rash.
     HEENT: Normal
     Neck:  Supple, no masses.
     Chest:  Clear
     Heart: 2 heart sounds.
     Abdomen:  Soft, nontender. 
     Genitourinary:  Circumcised, both testes descended. 
     Extremities: Edematous 
     Neurological: Developmentally appropriate.
     Lymph nodes: Not palpable.
A urinalysis revealed:
     SPEC GR UA  1.005           RBC/HPF     Neg.       
     PH UA       7               WBC/HPF     Neg.       
     PROTEIN UA  tct             SQUAM EPI   Neg.       
     GLUCOSE UA  Neg.            BACTERIA    Neg.  

Laboratory studies at this time include:


     Assessment:  Giancarlo is doing well.  We will do an ultrasound today to  review his renal calcification.  His laboratory investigations on the  5th of May showed a creatinine of 0.2 and a BUN of 5, showing normal  renal function.  The calcification is most likely secondary to some  infectious insult peri- or prenatally.  I plan to review him again in 12  months' time with another ultrasound.

     Thank you for the opportunity to participate in Nate's care.  We would like to review him in 12 months.  In the interim, we would be happy to discuss or review Nate should you or the family wish it.

               Sincerely,


               Giancarlo Piggy, MD        Antonio Khan, MD
               Fellow, Pediatric Nephrology Instructor in Pediatrics


CONTENT:
Stalin, M.D.          RE: Laura DeLong
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/26/84

Dear Ms. Stalin:

I have seen Laura DeLong in the Endocrine Clinic for obesity.  I recommended that she start a regular exercise program in addition to making some dietary changes.  When I spoke with you on March 21, 1995, you said that she has signed up for an aerobics class twice weekly for 1 1/2 hours.  This is a good start.  In addition, she could use either bicycle, treadmill, or climber for 2 thirty minute sessions per week after adequate training i the use of these machines.  Her general health is excellent and there is no contraindication to any of these modalities, so I would go with whichever she likes best and is most apt to continue.  My only concern, given her age and weight, is that attention be paid to any complaints of knee or hip pain and that training be done at an appropriate pace to avoid injury.

Thank you for your support and help for Laura.



Sincerely,



Maritza Brezny, M.D.
Attending in Endocrinology


CONTENT:
Zylpha Plutarch, M.D.          RE: Laura DeLong
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/26/84

Dear Dr. Plutarch:

We had the pleasure of seeing Laura in the Endocrine Program on 3/13/95 for obesity.

History: This 10 8/12 year old girl started gaining weight at around 4 years of age.  Laura was seen at Tufts University in January, 1991, for evaluation of pubic hair when she was 6 1/2 years old.  The impression was premature adrenarche/exogenous obesity.  She's in the fourth grade and is an average student.

Current medications: Inhaler prn for asthma.

Past medical history:  Forty week pregnancy with vaginal delivery.  Immunizations are up to date.  History of asthma since she was 3 years old.  Hypertension was first diagnosed in February, 1995.

Review of systems:  Negative except SOB with running.

Family history:  Mother is also obese and has sickle cell trait.  Mother's height is 5'3", father's height is reportedly 5'10".

Physical exam:  
Height: 153 cm (95th centile)         
Weight: 105.8 kg (95th centile for height)        
BP: 110/70                   Pulse: 88               
U/L ratio:  0.82             Arm span: 171 cm.           
Breast: Tanner II            Pubic hair: Tanner II   
General: Obese, African-American girl.
Skin: Acanthosis nigricans on her neck and in her axillary area.
Neck:  Fundoscopy was normal, obese, no goiter. 
Chest: Clear to auscultation.
Heart: S1-S2, no murmurs.
Abdomen: Obese, no hepatosplenomegaly.
Extremities: No edema.
Neurological: Nonfocal.

Laboratory studies:  Cholesterol 156 ng/dl, triglycerides 72, HDLC 4.3, insulin 164.7 mcU/ml, glucose (random) 93, Gly Hb 7.8 ) 5.2-7.8).  Bone age 11 years.

Impression: Morbid obesity.  Lipids are very normal, bone age shows no advancement.  Thus, puberty is normal.  However, she has a very high insulin level with normal random glucose and high normal glycohemoglobin suggesting a high risk for NIDDM.  Clearly this youngster and her family need instruction and support in weight control.  This may best be accomplished at NEMC's Center for Obesity or I can schedule her with pediatric nutrition here.  I will talk with mom to discuss the options.

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


Sincerely,




Kenneth Sheppard, M.D.              Maritza Brezny, M.D.             
Fellow in Endocrinology             Attending in Endocrinology


CONTENT:
Maritza Brezny, M.D.          RE: Laura DeLong
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  07/26/84

Dear Mrs. DeLong,

How has Laura done with her exercise program?  I notice that you have cancelled or missed two appointments and so we missed comparing notes on her progress.  Please call to reschedule with me in the Endocrine Clinic.  If you have questions, please leave a message for me (617-355-7476).



Sincerely,




Maritza Brezny, M.D.
Attending in Endocrinology


CONTENT:
Gregory Steinbeck, M.D.          RE: Bart Edwards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/81

Dear Dr. Steinbeck:

We had the pleasure of seeing Bart in the Diabetes Program on 6/20/95 for insulin-dependent diabetes mellitus.

History: Bart is a 14 and 2/12 year old boy with insulin-dependent diabetes mellitus diagnosed in February, 1995.  He also has bipolar disorder and is followed every other week by Dr. Mezzacappa in the Dept. of Psychiatry.

He is on Humulin insulin:  7 units of regular and 13 units of NPH in the A.M., 4 unit of regular and 7 units of NPH in the P.M.  His total daily dose is 31 units or 0.48 unit/kg/dy.

Injections are self-administered, rotating sites among upper and lower extremities and belly.  

No hyperglycemic symptoms are reported.  Occasional hypoglycemic episodes following decreased intake.  No severe reactions are reported.

He is on a 3 meal and 3 snack diet.  He reports eating candy 3-4 times per week. 

Blood glucose monitoring is done by the One Touch Basic glucose meter twice a week.  His mother is trying hard to convince him to check his blood sugar 4 times a day.  His pre-breakfast values average 120 mg/dL and pre-dinner values range between 120-340 mg/dL.  Occasional hypoglycemic values are recorded.

Current medications: Clonidine 1 mg qid, Ativan 1 mg q pm and q hs, Pamolol 100 mg q hs.

Physical exam:  
Height: 177.9 cm        Weight: 64.2 kg         
BP: 125/75              Pulse: 102              
Breast: Tanner II       Pubic hair: Tanner IV   
General: Alert and in no distress.  Minimal gynecomastia.
Skin: Hypertrophy apparent over the right side of the abdomen.
HEENT: EOMI, PERLA, and no retinopathy.
Neck: Thyroid edges palpable, smooth and soft.
Chest: Clear.
Heart: No murmur.
Abdomen: No organomegaly.
Neurological:  No tremors.  Deep tendon reflexes +2 over the knees.

Laboratory studies:  4/7/95  TSH 2.6 5U/mL, HbA1 9.7%.
6/20/95:   Random plasma glucose 210 mg/dl, glycosylated hemoglobin 9.7% (nl. 5.2-7.8).

Impression: Recently diagnosed insulin dependent diabetes mellitus in the honeymoon period.  Inadequate compliance reflects typical adolescent behavior that is complicated by bipolar disorder.

Disposition: We recommend:
1. Maintain A.M. dose, 7 units of regular and 13 units NPH.
2. Sliding scale for the regular insulin in the P.M.  Blood glucose less or equal to 200, 4 units; blood glucose 201-250, 5 units; blood glucose 251-300, 6 units; blood glucose more than 300, 7 units.
3.  Maintain 7 units of NPH in P.M.
We would like to see Bart back in 3 months.  Today, he met with the nutritionist and social worker in the diabetes clinic.

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


Sincerely,




Zulma Montague, MD         Bernardo Bird, MD         
Fellow in Endocrinology      Clinical Director of Endocrinology
                             Associate Professor of Pediatrics, HMS


CONTENT:
Gregory Steinbeck, M.D.          RE: Bart Edwards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/81

Dear Dr. Steinbeck:

We saw Bart in the Diabetes Program on 3/26/96 for insulin-dependent diabetes mellitus.

History: Bart is a 14-11/12 year old youth who was diagnosed with IDDM in February 1995.  He was last seen in our clinic in November 1995.  In the interim, he was hospitalized several times for depression.

He is on Humulin:  9 units of Regular and 18 units of NPH before breakfast, 5 units of Regular and 10 units of NPH before dinner (the total daily dose is 42 units or 0.61 units/kg).   

He denied symptoms of uncontrolled diabetes.  He also denied hypoglycemic episodes.  He denied insulin omission but has not been compliant with q.i.d. blood glucose monitoring, and does not follow an ADA meal exchange plan.  The glycemic profile (bid monitoring) indicated levels in the target range.

Current medications: Trazedone p.r.n. for sleep, and Serzone b.i.d. for  depression.

Physical exam:
HT: 183.1 cm    WT: 68.6 kg     BP: 125/85      Pulse: 72               
Thyroid:  edges palpable.  Injection sites:  hypertrophy over the abdomen, other injection sites satisfactory.

Laboratory studies:  HbA1c  7.4 (normal 4-6) %; urinalysis had no glucose, ketones or protein.

Impression: Insulin dependent diabetes mellitus is well controlled as reflected by a glycohemoglobin level in the target range.  The importance of q.i.d. blood glucose monitoring and adherance to an ADA meal exchange plan was discussed at length with Bart and his mother.

Disposition: 1.  The morning NPH was increased to 20 units, and the pre-dinner NPH was increased to 11 units.  The b.i.d. dose of regular insulin remains the same.

2.  An ophthalmologic exam is scheduled for this afternoon.

3.  As part of the clinic visit, the family met with the diabetes clinic social worker .

We would like to see Bart back in 6 weeks.



Sincerely,




Zulma Montague, MD          Bernardo Bird, MD         
Fellow in Endocrinology       Clinical Director of Endocrinology
                              Associate Professor of Pediatrics, HMS 
                

cc:  Mrs. Susan Edwards  15-b Algonquin Terrace  Plymouth , MA  02360

     Dr. Metzacapa  Psychiatry Department   Judge Baker Guidance Center 
     295 Longwood Avenue  Boston, MA 02115


CONTENT:
Benise, M.D.          RE: Bart Edwards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/81

Dear Dr. Benise:

We saw Bart in the Diabetes Program on 10/8/96 for follow-up of insulin-dependent diabetes mellitus.

History: Bart is now 15 and 6/12 years old.  He is on 9 units of regular and 20 units of NPH before breakfast, and 5 units of regular and 11 units of NPH before dinner.  The total daily dose is 45 units, or 0.62 u/kg/day.  

Bart denies polyuria, enuresis, or polydipsia, but reports nocturia (once per night).  He reports occasional symptomatic hypoglycemic episodes related to increased activity.  He has no mid-morning snack, a variable dinnertime, and increased junk food intake as he is presently working at McDonald's.  Compliance with blood glucose monitoring remains erratic; t.i.d. monitoring was only done for the past three to four weeks.  The available glycemic profile indicates levels in the target range.

Current medications: None.

Physical exam:
HT: 186.3 cm    WT: 72.1 kg
BP: 132/61              
Eyes: EOMI, PERRLA.  Thyroid: not palpable.  Lungs: clear.  Heart: no murmur.  Abdomen: not obese, no organomegaly.  Neurologic exam: grossly nonfocal.  Injection sites: hypertrophy over the abdomen.  Fingertips: satisfactory condition.


Laboratory studies:  Hemoglobin A1C - 8.5%.

Impression: Despite inconsistent blood glucose monitoring and increased junk food intake, the diabetes remains adequately controlled as evidenced by a glycohemoglobin level at the upper limit of the target range.  In addition, Bart is maintaining a steady weight gain and steady linear growth.

Disposition: We recommend maintaining the same insulin dose, avoiding foods with high fat content, and monitoring blood glucose QID.  We also recommend taking a snack prior to periods of physical activity.  We would like to see Bart back in three months.



Sincerely,




Zulma Montague, MD         Maritza Brezny, MD             
                                                          


Problem list to date:
INSULIN-DEPENDENT-DM                         11/18/96  
Transcribed by Montague


CONTENT:
Leary, M.D.          RE: Bart Edwards
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/21/81

Dear Dr. Leary:

We saw Bart in the Diabetes Program on 10/8/96 for follow-up of insulin-dependent diabetes mellitus.

History: Bart is now 15 and 6/12 years old.  He is on 9 units of regular and 20 units of NPH before breakfast, and 5 units of regular and 11 units of NPH before dinner.  The total daily dose is 45 units, or 0.62 u/kg/day.  

Bart denies polyuria, enuresis, or polydipsia, but reports nocturia (once per night).  He reports occasional symptomatic hypoglycemic episodes related to increased activity.  He has no mid-morning snack, a variable dinnertime, and increased junk food intake as he is presently working at McDonald's.  Compliance with blood glucose monitoring remains erratic; t.i.d. monitoring was only done for the past three to four weeks.  The available glycemic profile indicates levels in the target range.

Physical exam:
HT: 186.3 cm    WT: 72.1 kg       BP: 132/61              
Eyes: EOMI, PERRLA.  Thyroid: not palpable.  Lungs: clear.  Heart: no murmur.  Abdomen: not obese, no organomegaly.  Neurologic exam: grossly nonfocal.  Injection sites: hypertrophy over the abdomen.  Fingertips: satisfactory condition.

Laboratory studies:  Hemoglobin A1C - 8.5%.

Impression: Despite inconsistent blood glucose monitoring and increased junk food intake, the diabetes remains adequately controlled as evidenced by a glycohemoglobin level at the upper limit of the target range.  In addition, Bart is maintaining a steady weight gain and steady linear growth.

Disposition: We recommend maintaining the same insulin dose, avoiding foods with high fat content, and monitoring blood glucose QID.  We also recommend taking a snack prior to periods of physical activity.  We would like to see Bart back in three months.



Sincerely,




Zulma Montague, MD         Maritza Brezny, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Animal, M.D.          RE: Isabella Kolchak
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/83

Dear Dr. Animal:

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

History: I appreciated receiving your recent letter concerning the experience you, your wife and daughter had at the Children's Hospital.   

I was delighted to hear that your experience working with Ms. Kathleen Walsh was such a positive one.  I have had the good fortune to work with Kathleen for over four years in her capacity as the diabetes nurse specialist at Children's Hospital.  I agree completely that we are indeed fortunate to have such a fine person on the staff.  I can only say that your favorable experience has been repeated over and over again with other families who have had the opportunity to work with her.   

Thank you again for your letter and I hope that you are all doing well and coping with the day to day demands of life with diabetes.

Physical exam:  




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

Sincerely,


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


CONTENT:
Aurimar Swartzenegger, M.D.          RE: Isabella Kolchak
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/83

Dear Dr. Swartzenegger:

We had the pleasure of seeing Isabella in the Endocrine Program on 4/11/95 for .

History: Isabella is an 11 and 7/12 year old girl who was diagnosed with IDDM in February 1995.  This is her first clinic visit after being discharged from the hospital.  

She is on Novolin 11 units pre-breakfast,  6 units of NPH pre-dinner.  She receives a total of 17 units, or 0.44 U/kg/day.   

The injections are self administered, rotating sites between the upper/lower extremities and belly.  

Occasional symptomatic hypoglycemic episodes are reported following increased activity.   No severe reactions are reported.  No symptoms of hypoglycemia are reported.   

She is on a three meal, three snack diet and feels comfortable with the meal exchanges.   

Blood glucose monitoring is done three times a day:  pre-breakfast values range from 110-129 g/dL, pre-dinner 83-150 mg/dL, bedtime 70-125 mg/dL.  Low blood glucose readings (55-65) occur at bedtime.

Physical exam:  
Breast: Tanner II       Pubic hair: Tanner III  
General: Alert in no distress.  
Skin:  No acne.  No atrophy or hypertrophy at the injection sites.  
HEENT: Eyes EOMI, PERRLA.  Lens clear.  
Neck: Thyroid not palpable.  
Chest: Lungs clear.  
Heart: Regular rate and rhythm, no murmur.  
Abdomen: Soft, no organomegaly.  
Neurological: No tremors.  DTR's are brisk over the knees.

Impression: New onset insulin dependent diabetes mellitus, currently in the honeymoon period.  The HBA1C level of 9.2% on 4/11/95 indicates major improvement in the blood glucose control.


Laboratory studies pending at this time include: GLY HGB     9.2       %       
Disposition: We recommend:

1.  Maintain the current insulin regimen.
2.  Encouraged extra snacks prior to exercise.
3.  We encourage blood glucose monitoring at school at lunch time.
Thank you for letting us share in the care of Isabella.

Sincerely,


Zulma Montague, MD         Nilto Carter, MD             
Fellow in Endocrinology      Associate in Endocrinology   


Problem list to date:

Transcribed by Sullivan_ma


CONTENT:
Aurimar Swartzenegger, M.D.          RE: Isabella Kolchak
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/83

Dear Dr. Swartzenegger:

We had the pleasure of seeing Isabella in the Diabetes Program on 7/18/95 for insulin dependent diabetes mellitus.

History: Isabella is now 11 and 9/12 years old.  She is on Novolin insulin -1-2 units of Regular and 11 units of NPH before breakfast; 0.5-1.5 units of Regular and 6 units of NPH before dinner (average total daily dose 20 units or 0.5 units/kg)

No hyperglycemic symptoms are reported.  Occasional symptomatic hypoglycemia is reported following an increase in activity.  Isabella is on a 3 meal 3 snack diet.  She is very active, plays tennis and swims 3-4 times per week.

Blood glucose monitoring is done with a One touch meter.  The blood glucose profile is significant for elevated blood glucose values before breakfast, as well as occasional elevations up to 300 before lunch and dinner.  This is reflected by an elevation of the glycohemoglobin level to 10.1%.

Physical exam:  
Height: 150.2 cm        Weight: 39.9 kg         
BP: 100/60              Pulse: 78               
Breast: Tanner II       Pubic hair: Tanner II   
Skin: Injection sites are normal. Neck: Thyroid edges are palpable. The exam is otherwise unremarkable.

Laboratory studies:  TSH 0.80 uU/mL, GLY HGB 10.1%, TPO AB <0.3 U/mL, TG AB <0.3 U/mL

Impression: The fasting hyperglycemia or "Dawn" phenomenon is related to the development of puberty; so, we changed the insulin schedule to a tid regimen,  moving the evening NPH dose to bedtime.  The total daily dose of insulin will remain the same for now.  Also, there is no evidence of an autoimmune thyroid disease.  

We would like to see Isabella back in 3 months.

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


Sincerely,





Zulma Montague, MD             Nilto Carter, MD             
Fellow in Endocrinology          Attending in Endocrinology


CONTENT:
Aurimar Swartzenegger, M.D.          RE: Isabella Kolchak
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/83

Dear Dr. Swartzenegger:

We saw Isabella in the Diabetes Program on 10/24/95 for IDDM diagnosed in February, 1995.

History: Isabella is currently 12 years old.  She is on Novolin: 2.5-4 units of regular and 21 units of NPH before breakfast, 3-5.5 units of regular before dinner, and 10 units of NPH before bedtime (the total daily dose is 38.5 units, or 0.94 units/mg/day).  

She reports frequent symptoms attributable to hypoglycemia (shaky, hungry) between 10:00 and 12:00 am on school days; the associated blood glucose levels were 80 mg/dl (5-10 minutes after a glucose tablet).  She has an early lunch (10:30 a.m.) at school.  These symptoms do not tend to occur over the week-end.  She denies severe hypoglycemic reactions.

Blood glucose monitoring is done four times/day and is significant for elevated fasting levels (150-200 mg/dl).  Isabella denies nocturia or enuresis.   

She is otherwise doing well, is very active and is doing well at school.

Physical exam:
Height: 152 cm       Weight: 40.7 kg
Breast: Tanner II    Pubic hair: Tanner II   
Thyroid is palpable, no nodules.  Injection site:  No atrophy or hypertrophy.  Fingers:  No calluses.  Examination was otherwise unremarkable.

Laboratory studies:  GLY HGB = 11.3 %

Impression: Fasting hyperglycemia, increased insulin requirements.

The glycohemoglobin level is elevated and indicates an increased insulin requirement, as her previous glycohemoglobin level was 10.1 %.  This also reflects the absence of severe or frequent hypoglycemic episodes.  Isabella's symptoms may reflect true hypoglycemia or a sudden drop in the blood glucose from higher levels to a low normal level.

Disposition: 1.  We recommend changing the insulin from NPH to Lente to help prevent a midmorning drop in the blood glucose levels, as Lente reaches a lower blood level peak when compared to NPH.  We also recommend increasing the bedtime dose of Lente to 11 units to treat the fasting hyperglycemia. 

2.  We recommend blood glucose monitoring during a symptomatic episode, prior to treatment.  We also recommend skipping the 9:00 a.m. snack, and increasing the lunch and early afternoon snack.  

We would like to see Isabella back in 3 months.



Sincerely,




Zulma Montague, MD             Maritza Brezny, MD             
Fellow in Endocrinology          Attending in Endocrinology


CONTENT:
Aurimar Swartzenegger, M.D.          RE: Isabella Kolchak
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/83

Dear Dr. Swartzenegger:

We saw Isabella in the Endocrine Program on 4/23/96 for follow-up of insulin-dependent diabetes mellitus diagnosed in February 1995.

History: Isabella is currently 12 and 6/12 years old.  She is on Novolin:  5-8 units of Regular and 25 units of Lente before breakfast, 7-8 units of Regular  before dinner and 18 units of Lente before bedtime.  The total daily dose is 57 units or 1.28 u/kg/day. 

Isabella denies symptoms of uncontrolled diabetes, but reports vaginal  itching relieved by antifungal cream.  She does not report hypoglycemic  events. 

Isabella remains very active both in tennis and soccer.  She has a medic  alert tag but does not wear it regularly. 

Blood glucose monitoring is done 4 times/day and the glycemic profile is significant for elevated levels (mid 200's) throughout the day.

Physical exam:
HT: 155.3 cm    WT: 44.4 kg      BP: 100/50      Pulse: 71               
Breast: Tanner II       Pubic hair: Tanner III  
Thyroid edge is palpable.  Injection site no atrophy or hypertrophy.  Finger tips no calluses.

Laboratory studies:  Hb A1C 7.3%.

Impression: The glycemic profile has markedly improved over the last year and is currently within the target range.  Hypoglycemic episodes are not reported anymore.  Isabella is advancing into puberty and is growing along the 50th percentile for both height and weight.

Disposition: The insulin regimen will be increased to a total of 1.37  u/kg/day to improve the glycemic profile.  The new sliding scale of regular is increased to 6-9 units of Regular before breakfast and 6-9 units of Regular before dinner.  Lente will be increased to 27 units before breakfast and 19 units before dinner.  Isabella will have a formal dietary evaluation at the next visit.


Sincerely,




Zulma Montague, MD           Nilto Carter, MD             
Fellow in Endocrinology        Associate in Endocrinology


CONTENT:
Aurimar Swartzenegger, M.D.          RE: Isabella Kolchak
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/83

Dear Dr. Swartzenegger:

We saw Isabella in the Diabetes Program on 7/30/96 for insulin-dependent diabetes mellitus.

History: Isabella is now 12 and 9/12 years old.  She is on Humulin:  6-9 units of Regular and 30 units of Lente before breakfast, 6-9 units of Regular before dinner, and 19 units of Lente before bedtime.  The total daily dose is 64 units, or 1.37 U/kg/day. 

Isabella denies symptoms of uncontrolled diabetes except for occasional nocturia.  She denies hypoglycemic episodes.  She was less active this summer, and sleeps late in the morning.  She does not get the morning insulin injection before 11 a.m., and gets the dinner dose at 6:30 p.m., and the bedtime dose around 10 p.m.  Blood glucose monitoring is done 3-4x a day.  The glycemic profile is significant for fasting levels in the mid to high 200's.   

Psychosocial:  Isabella went to the Clara Barton Camp for the first time, but stayed for only 4 days out of the 2 weeks she had signed up for. She apparently had a bad experience and was homesick.  She plans to resume tennis and run on the treadmill.

Physical exam:  HT: 157.5 cm    WT: 46.4 kg
Thyroid: not palpable.  Injection sites:  no atrophy or hypertrophy.  Fingertips:  no calluses.

Laboratory studies:  HGB A1C 7.6 %

Impression: Insulin dependent diabetes mellitus with adequate control as reflected by a glycohemoglobin level in the target range.  Fasting hyperglycemia is due to delayed insulin administration in the morning.  Isabella is otherwise doing well and is maintaining a steady growth along the 50th percentile in height and weight.

Disposition: 1.   We recommend taking insulin earlier in the morning  (9 a.m.).  Isabella understands the rationale behind this recommendation and is willing to comply with it.  She will fax us a glycemic profile in 1 week for revision.  Adjustments in the insulin schedule/dose will be done as necessary. 

We would like to see Isabella back in 3 months.



Sincerely,




Zulma Montague, MD            Nilto Carter, MD             
Fellow in Endocrinology         Associate in Endocrinology


CONTENT:
Aurimar Swartzenegger, M.D.          RE: Isabella Kolchak
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/25/83

Dear Dr. Swartzenegger:

We saw Isabella in the Diabetes Program on 11/5/96 for follow-up of insulin-dependent diabetes mellitus diagnosed in February, 1995.

History: Isabella is 13 and 1/12 years old.  She is on Novolin:  8-11 units of Regular and 32 units of Lente before breakfast, 15-18 units of Regular before dinner, and 21 units of Lente before bedtime.  The total daily dose averages 69 units or 1.4 U/kg/day.   

Isabella denies polyuria, enuresis, or polydipsia, but reports occasional nocturia (once/night).  She also reports occasional hypoglycemic episodes, usually during gym class despite eating a snack prior to gym.

Review of systems:  Isabella is not feeling well today.  She is complaining of nasal congestion, stomach ache and nausea but is afebrile.

Physical exam:
HT: 159.1 cm    WT: 49.2 kg        Temperature 36.9 
BP: 124/65              Pulse: 71               
Breast: Tanner III       Pubic hair: Tanner III  
HEENT: throat mild erythema, no exudate, no petechia, tonsils not enlarged, lymph nodes not palpable.  Thyroid: not palpable.  Lungs: clear.  Heart:  no murmur.  Abdomen:  soft, mild epigastric tenderness, no rebound, no guarding, no masses.  Injection sites: no atrophy or hypertrophy.  Fingertips: no calluses.

Laboratory studies:    Hb A1c - 7.6%.

Impression: Insulin-dependent diabetes mellitus with an adequate control as indicated by a glycohemoglobin level in the target range.  Instructions to prevent exercise-related hypoglycemia were given:  decrease the morning Regular insulin by 2 units and/or double the snack prior to gym.  In addition, Isabella has an acute viral syndrome.

Disposition: 
We would like to see Isabella in 3 months.


Sincerely,



Zulma Montague, MD          Nilto Carter, MD             
Fellow in Endocrinology       Associate in Endocrinology


CONTENT:
Steve Montague, M.D.          RE: Luther Catron
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/25/81

Dear Dr. Montague:

We had the pleasure of seeing Luther in the Endocrine Program on 2/21/95 for evaluation of hyperthyroidism.

History: Luther is a 13 11/12 year-old who presents with a six month history of weight loss and fatigue.  He has a persistent problem with sinusitis and accompanying faitigue, but this year's case was worse.  In addition to a poor energy level, he has had a markedly decreased appetite, twenty-five pound weight loss, increasingly loose stools, increased anxiety, and decreased concentration span.   His school performance has definitely suffered from this symptomatology.  He has also had to stop participation on the wrestling team because of weakness and fatigue. He admits to intermittent sore throats with his congestion, but denies dysphonia or dysphagia.

As you know, Luther was seen in your office on 2/7/95 where a T4 was 19.8 mcg/dl and a TSH 0.04 mcIU/ml.  A referral was made to our clinic.

Current medications: Augmentin 250 mg TID, Bromfed 15cc BID, Nasocort 2 sprays BID

Past medical history:  Birth Hx: Born at 36 weeks after a pregnancy complicated by preterm labor at 6 months requiring pesery placement and bed rest.  Was delivered by C-Section.  Birth weight was 6 pounds, 13 ounces.  Length 21 inches.  Was in the NICU for one week before discharge.  Neonatal course notable for jaundice and mild HMD.  Infections: chronic otitis, sinusitis, and Strep throats.  Illnesses: Mild exercise-induced asthma  No hospitalization or surgeries.  ROS: As above.  Also no visual changes, dizziness, abdominal pain.  Sleep through the night.  No changes in thirst or urination.  Diet Hx: Breakfast: bagel, butter, juice.  Lunch: sandwich, fruit, 2% milk, pretzels.  Dinner: meat, vegetables, salad with dressing, bread, 1% milk.  Snacks (afternoon and night): soda or juice, crackers.

SHx: In 8th grade at Hingham Jr. High.  Problems this year with concentration and subsequent decline in grades.  On wrestling team.

Family history:  Notable for IDDM in paternal 1st and 2nd cousin.  AODM in  paternal grandfather, aunt, and uncle.  No thyroid disease or  other endocrinopathies.

Physical exam:  
Height: 170.5 cm        Weight: 65.5 kg         BP: 142/76              
Pulse: 120              Pubic hair: Tanner IV   R. testis: 4.8 x 2.8 cm 
L. testis: 4.3 x 2.6 cm Phallus length: 11.4 cm Mid-shaft diam.: 3.2 cm 
General: Anxious appearing.  Tremulous.  Pleasant.
Skin: warm.  Moist palms.
HEENT: No lid lag.  PERRL, EOMI.  O/P- clear.
Neck: Goiter - gland 3X normal.  Lobes 4.5 x 2.5 bilaterally. Consistency - fleshy, soft.  No nodules.  Shotty post cervical LAD.
Chest: Lungs clear  Cor: regular tachycardia, no murmur.
Abd: soft, no masses or HSM.
GU: normal pubertal male genitalia.
Ext: pulses 2+, warm. Moderate tremor of outstretched hands.
Neuro: mild prox. muscle weakness. Reflexes 2+ UE, 3+ LE. No  clonus.

Laboratory studies:  2/21/95 15:13  CBC (WBC 7.7, 55P 31L, Hct 37.3, PL 301), CPK 55 U/L, T4 22.2 mcg/dl, TBGI 1.37, TSH <0.05 mcIU/ml. TT3, thyroid Ab panel, DHEA-S - pending. HbA1 - 7.9% (nl upper limit - 7.8%).

Impression: Diffuse toxic goiter in 13 11/12 year old boy with a family history of autoimmune disease making screening for polyglandular disorders appropriate.  Would watch patient closely for symptoms of glucose intolerance given mildly elevated HbA1.

Disposition: PTU 100mg TID.  Luther and his mother to contact you or us if he develops fevers or sore throat as a recheck of a CBC will be warranted.  Return to the Endocrine Program in 6 weeks.
Thank you for letting us share in the care of Luther.

Sincerely,


Sotiria Bonaparte, MD         Mitsuko Simpson, MD             
                             Chief Emeritus


CONTENT:
Steve Montague, M.D.          RE: Luther Catron
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/25/81

Dear Dr. Montague:

We had the pleasure of seeing Luther in the Endocrine Program on 4/10/95 for hyperthyroidism.

History: Luther is a 14 and 2/12 year old who was last seen in our clinic in 2/95 at which time he was markedly hyperthyroid.  His chief complaint at that time included weakness, poor energy level, decreased appetite, weight loss, increased anxiety, and decreased concentration span.  Since his last visit, he has a much improved energy level and appetite.  He is doing dramatically better in his classes as he is better able to concentrate.  He denies heat intolerance.  His stools are less loose than  before.  He has put on 4 kg since his last clinic visit.  He denies fevers or sore throat since starting PTU.  However, he developed an rash over his anterior neck that has now resolved.  Otherwise, he has tolerated the PTU well.

Current medications: PTU 100 mg tid, Augmentin 250 mg tid, Bromfed 15 cc bid.

Physical exam:  
Height: 172 cm          Weight: 69.5 kg         BP: 112/78              
Pubic hair: Tanner IV   
General: Quiet but well appearing adolescent male.  
Skin: Clear except for excoriated crusted areas on anterior surface of right neck. 
HEENT: PERRL.  EOMI.  No lid lag.  Fundoscopic exam within normal limits.   
Neck: Thyroid 4.5x2 cm bilaterally.  Firm, diffuse in consistency.  No bruit.  Lymph nodes; shotty cervical lymphadenopathy.  
Chest: Clear to auscultation.  
Heart: Regular rate and rhythm without murmur.  
Abdomen: Soft without hepatosplenomegaly.  
Genitourinary: Normal male, testes bilaterally descended.  
Extremities: Warm, well perfused.  
Neurological: Nonfocal.  Reflexes 2+.  Toes bilaterally downgoing.  No tremor.  

Laboratories:  (4/10/95)  WBC 8.97, hematocrit 42.2, platelet 326, T4 5.0 mcg/dL, TSH less than 0.05 mIU/mL, TBGI 0.90.

Impression: 14 and 2/12 year old two months into medical therapy for Grave's disease.  Labs at this visit consistent with mild oversuppression by the PTU.  We will therefore decrease Luther's dose to 100 mg bid and recommend a recheck of thyroid function tests in one month.   After obtaining these repeat laboratories, we will consider the need for supplemental L Thyroxine therapy in addition to the PTU.

Disposition: We would like to see Luther again in the clinic in three months for re-evaluation.  In the interim, we will be talking with the family regarding the patient's repeat test results and the need for starting L-thyroxine therapy.
Thank you for letting us share in the care of Luther.

Sincerely,


Sotiria Bonaparte, MD         Maureen Shields, MD             
                             Attending in Endocrinology


CONTENT:
Steve Montague, M.D.          RE: Luther Catron
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/25/81

Dear Dr. Montague:

We had the pleasure of seeing Luther in the Endocrine Program on 6/12/95 for follow-up of hyperthyroidism.

History: Luther is a 14 6/12 year old who was last seen in our clinic in April, 1995.  He was first diagnosed with Grave's disease in February, 1995.  At that time he was markedly hyperthyroid.  Since his last visit, he has a much improved energy level and appetite.  He continues to have a better concentration span in his classes.  He denies temperature intolerance.  He has one normal bowel movement per day.  He was diagnosed last week with an otitis media, but denies fevers or sore throat since starting PTU.  He has had no rash over the past two months.  He has overall tolerated the PTU.

Current medications: PTU 100 mg bid, Biaxin and Zestin (decongestant).

Physical exam:  
Height: 172.6 cm        Weight: 70.2 kg         
BP: 118/78              Pulse: 84               
Pubic hair: Tanner IV   
General: Well appearing adolescent male.
Skin: Clear.
HEENT: Benign, with lid lag or exophthalmus.
Neck: Thyroid 4 x 2 cm bilaterally.  Diffusely enlarged and firm in consistency.  No bruits or focal areas.  No cervical lymphadenopathy.
Chest: CTA.
Heart: RRR, without murmur.
Abdomen: Soft, no organomegaly.
Extremities: Warm and well profused.
Neurological: Nonfocal.  DTR's 2+ with normal relaxation.

Laboratory studies:  May 16, 1995:  T3U 29% (nl 25-36%), T4 5.1  (nl 4.5-12 mcg/dL), TSH 3.4 (nl 0.3-5 mIU/ml.

June 12, 1995:  T4 5.1 ug/dL, TSH 6.90 uU/mL, TBGI 0.90

Impression: Luther is a 14 6/12 year old with Grave's disease diagnosed in February, 1995.  His last visit in April, 1995, was consistent with oversuppression by PTU.  Repeat TFT's were normal one month ago after decreasing the PTU dose.  Labs obtained today are in the hypothyroid range.  We have therefore decided to initiate L-thyroxine therapy as part of the current regimen.

Disposition: The family was called with the results of these tests and a prescription for Synthroid called in.  We would like to see Luther again in clinic in 3 months for a re-evaluation.  We recommend rechecking TFTs in one month.

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


Sincerely,




Sotiria Bonaparte, MD                Maureen Shields, MD             
Fellow in Endocrinology             Attending in Endocrinology


CONTENT:
Steve Montague, M.D.          RE: Luther Catron
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/25/81

Dear Dr. Montague:

We saw Luther in the Endocrine Program on 9/7/95 for hyperthyroidism.

History: Luther is a 14 9/12 year old who was last seen in our clinic in 4-95.  As you know, he was originally diagnosed with Grave's disease in 2-95.  Symptomatically, he is much improved.  He has had a good energy level and appetite.  He denies headaches or tremulousness.  He denies changes in bowel or bladder function.  He is currently practicing on the varsity football team with no problems.

Current medications: Levoxyl 44 mcg PO q.d., PTU 100 mg PO b.i.d., and Bromfed.

Physical exam:
Ht: 175 cm    Wt: 71 kg     BP: 128/80      Pulse: 80               
Breast: Tanner IV       Pubic hair: Tanner IV   
General appearance:  Well and strong appearing.  No tremor.  Thyroid 4x2 cm. bilaterally, diffusely enlarged with fleshy consistency.  No nodules or lymphadenopathy.  DTRs upper extremities 2+, lower extremities 3+ and toes bilaterally downgoing.  Exam otherwise completely within normal limits, without evidence of thyroid dysfunction.

Laboratory studies:  Laboratories: TFTs (8-95) T4 7.1 mcg/DL, TSH less than 0.3 microunits/ML.  Laboratory studies at this visit include: 
(9/7/95) TBGI 1.01, TT3 224 ng/dL, T4 8.9 ug/dL, TSH<0.05 uU/mL

Impression: A 14 9/12 year old several months into therapy for Grave's disease.  TFTs obtained today consistent with over replacement with L-thyroxine therapy.  We will currently keep Luther's PTU dose at 100 mg b.i.d. and decrease his L-thyroxin dose approximately 10%.

Disposition:  Luther's family was called with these results and his L-thyroxine dose was decreased to 37.5 mcg PO q.d.  PTU was left at the current dose.  We would recommend a recheck of Luther's TFTs in 4-6 weeks given the change made today.  Please FAX a copy of these results to us so that we can help with interpretation and to update his file here.  Due to cumbersome insurance repay issues, we made an agreement with Luther's mother that we would see him in the endocrine clinic every six months.  However, we would recommend periodic follow up every six months in your office as well.  Therefore, Luther would see a  physician every three months.  

Thank you for letting us share in the care of Luther.  Please do not hesitate to call us if questions arise.


Sincerely,




Sotiria Bonaparte, MD             Nilto Carter, MD             
Fellow in Endocrinology          Associate in Endocrinology


CONTENT:
Steve Montague, M.D.          RE: Luther Catron
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/25/81

Dear Dr. Montague:

We saw Luther in the Endocrine Program on 2/1/96 for follow-up of hyperthyroidism.

History: Luther is now a 14 and 11/12 year old and was last seen in our Clinic in 6/95.  He was diagnosed with Grave's Disease in 2/95.   At that time, he was markedly hyperthyroid.  Since his last visit here, he has had a good energy level and appetite.  He has recently had difficulty in school, but reports that his concentration span is normal.  He went through a difficult period during the fall, but his grades are now beginning to turn around.  On review of systems, he continues to have intermittent sinusitis.  He otherwise is sleeping through the night and has had no changes in his bowel or bladder function.

Current medications: PTU 100 mg. PO b.i.d., Levoxyl 37.5 micrograms PO q.day, and Duravent.

Physical exam:
HT: 177 cm    WT: 71.6 kg     Pubic hair: Tanner V    
BP: 122/72     Pulse: 60               
General: well-appearing young adolescent male.  Skin clear.  HEENT:   Under eye circles.  Oropharynx clear.  Neck:  full as before, about 2.2 cm. bilaterally.  Diffusely enlarged with fkeshy consistency.  Lymph nodes:  mild cervical lymphadenopathy.  Lungs: clear to auscultation.  COR:  Normal sinus rhythm without murmur.  Abdomen:  Soft without organomegaly.  GU:  Tanner V genitalia.  Extremities:  well-perfused.   Reflexes:  2+ and toes bilaterally downgoing.

Laboratory studies:  at this time include:  TSH 1.60uU/mL.  Past labs: (12/29/95) T4 8.6 mcg/dl, TSH 0.5 mcU/ml.

Impression: 14 11/12 year old with Grave's disease diagnosed one year ago.  One month ago, his TFTs were within normal limits.  He is euthyroid appearing on exam.  We rechecked a TSH that is normal and reassured us that is current regimen is adequate.

Disposition: The family will be called with the results of these tests.  We would like to see Luther again in three months for reevaluation.   Thank you for letting us share in his care.



Sincerely,




Sotiria Bonaparte, MD            Nilto Carter, MD             
Fellow in Endocrinology         Associate in Endocrinology


CONTENT:
Steve Montague, M.D.          RE: Luther Catron
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/25/81

Dear Dr. Montague:

We saw Luther in the Endocrine Program on 5/30/96 for follow-up for hyperthyroidism.

History: Luther is now 15 3/12 years old and was last seen in our clinic in  2/96.  He was diagnosed with Graves' disease in 2/95.  He has had some problems with depression since his last visit here.  Over the winter, he had a decreased energy level and claimed to be sleeping more and had little interest in school.  He has greatly improved since starting Prozac three weeks ago.  He claims that his appetite is good now, as well as his energy level.  He denies tremors, palpitations, constipation or diarrhea or muscle cramps.

Current medications: Prozac 20 mg PO qday, Duravent 1 PO b.i.d., Levoxil 37.5 mcg PO qday.

Physical exam:     HT: 177.8 cm    WT: 76.5 kg
BP: 139/74              Pulse: 60               Pubic hair: Tanner V    
Well-appearing male, skin clear.  HEENT:  PERRL, EOMI, neck diffusely enlarged (thyroid approximately 30 gm in size).  No nodules.  No lymphadenopathy.  Lungs are clear to auscultation.  Cor: normal sinus rhythm without murmurs.  Abdomen soft without organomegaly.  Extremities well-perfused.  Neuro, non-focal reflexes 2+.  Toes bilaterally downgoing.

Laboratory studies:  TBGI 0.99,  TT3  122 ng/dL, T4 7.2 ug/dL, TSH  1.30 uU/ML

Impression: 15 3/12 year old with Graves disease, diagnosed 15 months ago.  He is euthyroid appearing today on exam and was biochemically euthyroid on TFTs obtained three months ago.  We are stopping his PTU and L-thyroxine therapy to see if his disease has gone into remission.

Disposition: We would recommend a recheck of TFTs in four to six weeks.  We will arrange follow-up after these laboratories return.  

Thank you for letting us share in his care.


Sincerely,




Sotiria Bonaparte, MD         Ariel Adler, MD           
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Steve Montague, M.D.          RE: Luther Catron
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/25/81

Dear Dr. Montague:

We saw Luther in the Endocrine Program on 11/25/96 for follow-up for Grave's disease.

History: Luther is 15 years 9 months and was last seen in our clinic in May, 1996.  He was taken off thyroid medications at that time and had a three month remission.  However, he began to feel increasingly tremulous and weak.  Thyroid functions were checked in your office and revealed a suppressed TSH.  Tapazole was restarted at a dose of 10 mg PO b.i.d.   

Luther states that he feels better since starting this medication.  He  has had mild hyperdefecation, but no changes in his urination or thirst.   He denies headaches or visual changes.  He is not weak and desires to  participate on the wrestling team.

Current medications: Tapazole 10 mg PO b.i.d. and Prozac.

Physical exam:
HT: 180.5 cm            WT: 87.3 kg
BP: 129/68              Pulse: 69               
General appearance:  well-nourished, well-developed adolescent.  Skin:  warm and dry.  HEENT:  PERRL, EOMI, no lid lag.  Gland approximately 40 gm in size symmetrically enlarged with fleshy consistency.  Lungs:  clear to auscultation.  Cor:  normal sinus rhythm without murmur.  Extremities:  well-perfused.  Neuro:  mild tremor.  Reflexes 2+ and toes bilaterally downgoing.

Laboratory studies: 11/06/96: T4 7.1 ug/dL, TBGI 1.05, TT3 163 ng/dL (H),
TSH <0.03 uU/mL (*).

Impression: Graves disease.  The patient is mildly hyperthyroid on exam today, but appears symptomatically improved on reinitiation of Tapazole therapy.  Continuing thyroid hormone blockade therapy.

Disposition: We would recommend rechecking his thyroid functions in three to four weeks.  We counseled Luther to limit strenuous exercise until his thyroid function tests have completely normalized.  We would like to see him again in clinic in three months.  

Thank you for letting us share in his care.


Sincerely,





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


CONTENT:
Duff Pavarotti, M.D.          RE: Lenny Pinckney
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/02/93

Dear Dr. Pavarotti:

We had the pleasure of seeing Lenny in the Endocrine Program on 3/6/95 for short stature.

History: As you know, Lenny is now a 2 year old who was initially diagnosed with failure to thrive at 4 months of age.  At that time he had been fed solid foods too early and was hospitalized for evaluation of his failure to thrive.  Since that time with the introduction of increased amounts of formula he was gaining weight well and was changed to whole milk at 1 year of age.  Since approximately six months he has been growing along approximately the 6-10% for height and along the 5% for weight until this two year check when both height and weight dropped to less than the 5%.  He had no history of signs or symptoms to suggest thyroid problems.  He has a good diet, eating three meals a day with snacks and is not described as a picky eater.  

Developmentally, he walked at 11 months and has approximately 3/4 of his language intelligible.  He is however, only using simple words without any combinations and uses mostly proper names.  His social history is notable for having a single parent mother who is currently in the National Guard and he is in day care during the day.

Current medications: He is currently on no medications.

Past medical history:   His medical history is otherwise only as above.  He has no surgical history.

Family history:  Notable for having a 23 year old healthy mother and a 27 year old healthy father.  Mother's height is 5' 6".  Father's height is 5'7".  Father's family history is unknown because he is adopted.  Mother's family history is notable for having several half siblings one of whom has schizophrenia.  There is a cousin with insulin dependent diabetes.  No history of thyroid disease.  There is no family history of late bloomers.

Physical exam:  
Height: 82 cm           Weight: 10.21 kg        BP: 95/60               
Pulse: 120              U/L ratio:  1.13        Arm span: 83            
Height and weight are less than 5%.
General: Alert and active.  Was very quiet during the exam.
Skin: Large hyperpigmented macule extending from the right side of his mouth over the right side of his jaw.  There were no other hyperpigmented areas noted.
HEENT: Noted to have a slightly widened nasal bridge with a down slanting outer canthus bilaterally.  He is also noted to have a slightly high arched palate.
Neck: Normal, with no redundancy in skin folds.  Supple with shotty adenopathy.
Chest: Clear to auscultation.
Heart: Regular rate and rhythm.  No murmur was noted.  
Abdomen: Benign with no masses or hepatosplenomegaly.
Genitourinary: He was circumcised, with testes descended bilaterally, both 1 by 1 cm.  
Extremities: He had normal carry angle.  Pulse is equal and 2+. 
Neurological: His quadriceps reflexes were 2+ bilaterally with downgoing toes bilaterally.

Laboratory studies:  IGF BP3-          (1.4-3.0), IGF-1 46 (31-160 ng/ml), T4-13.6 mcg/dL, TBGI-0.9 (.88-1.13), TT3-158, TSH-4.6, CO2-21, Na-139, K-4.4, CL-105, creatinine-0.2, BUN-10, glucose-85, ESR-17, WBC-4.78  18 neutro, 66 lymphs, 6 mono, 1 eo, 7 Atyp lymph, 2 bands, Hct-32.7, Hgb-11.0, platelets-347k. 
 Bone age 2 years 9 months, SD 3.9 months.

Laboratory evaluation is normal except CBC is consistent with viral infection.  Bone age is, if anything, mildly accelerated.  This picture is consistent with genetic (familial) short stature.

Impression: Lenny is a now 2 year old with history of having his height and weight approximately in the 5%, with a more recent drop in his height and weight less than the 5%.  Up to this point his head has been growing along the 25%, which is most suggestive of a constitutional growth delay.  However, given the recent drop in his height and weight a work-up is indicated at this time.

Disposition: Bone age today to see if his bone age is delayed, which would support the diagnosis of constitutional growth delay.  We would like to check additional blood work at this time including a CBC, sed rate, urinalysis, lytes with a CO2 and BUN/creatinine to rule out other  chronic disease.  In addition we would like to check thyroid function studies and IGF-1 levels to rule out thyroid or growth hormone deficiency as the cause in the fall of his height and weight.  He is to return to the Endocrine Clinic in three months for further evaluation.
Thank you for letting us share in the care of Lenny.

Sincerely,


Macarthur Gonzo, MD               Maritza Brezny, MD             
                             Attending in Endocrinology


CONTENT:
Duff Pavarotti, M.D.          RE: Lenny Pinckney
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/02/93

Dear Dr. Pavarotti:

We had the pleasure of seeing Lenny in the Endocrine Program on 6/26/95 for short stature.

History: Lenny was last seen in March of this year for slowing growth.  He has been well in the interim and is quite active.  He is currently potty training.  His appetite is good and food well balanced.  He sleeps well with one nap during the day.  He is talking lots and putting words together according to his mother.

Current medications: None.

Review of systems:  Noncontributory.  Positive only for ringworm which is being treated and for two minor accidents which resulted in stitches in his lip and a broken front tooth.

Physical exam:  
Height: 85 cm           Weight: 10.8 kg         
His length increased 3cm in four months.  His weight increased .6kg.  His head circumference is 49cm.
General: He is well developed with adequate subcutaneous tissue. 
Skin: Normal except for the ringworm lesion on his abdomen.  Some resolving scraps. 
HEENT: Grossly normal except for the broken incisor.
Neck: Thyroid is not palpable.  He has some shotty nodes in the inguinal and anterior cervical spaces.
Chest: Clear.
Heart: Normal.
Abdomen: Benign.
Genitourinary: Normal male genitalia with bilaterally descended testes.
Extremities: Normal.
Neurological: DTR's 2+ and equal.  Plantars are downgoing.

No studies were ordered today.

Impression: A previous extensive evaluation was entirely normal and the bone age was slightly advanced for his chronologic age.  This picture is compatible with genetic or familial short stature.  We will continue to follow him periodically during this year and intend to repeat his bone age in March, 1996.  His mother is not concerned with his growth as she sees him in good health and developing properly.

Disposition: Lenny is to return to the clinic in 4-5 months.
Thank you for letting us share in the care of Lenny.

Sincerely,


Maritza Brezny, MD             
Attending in Endocrinology
  


Problem list to date:
GROWTH-DISORDERS                             05/25/95  
FAILURE-TO-THRIVE                            05/25/95  
SHORT-STATURE                                05/25/95  
Transcribed by Hasseman_s


CONTENT:
Mitsuko Piggy, M.D.          RE: Lillian Pons
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/30/84

Dear Dr. Piggy,

I saw this 10 and 1/2 year old lovely girl in Lexington today for osteopenia by xray noted on her ankle film in February, following an injury several weeks before.

A more complete letter with results will follow, but I could find nothing on history or exam to make me suspect that she has metabolic bone disease or nutritional osteopenia. I repeated the ankle films (bilaterally) and had a lateral spine film taken and reviewed them with a senior pediatric radiologist at Children's this afternoon. Although the initial review of the February film could be interpreted as normal and an artifact of film/development technique,
the repeat films do tend to confirm hypodensity of her bones generally.

I have, therefore, ordered a metabolic screening including, Vit D levels, PTH level, serum and urine Ca, Phosphorus, serum Alk Phosphatase, lytes and urinalysis and amino acid screen.

In the final analysis, she could even have idiopathic juvenile osteoporosis, and I would welcome a chance to view her other outside bone films.

Thanks for referring Lillian.


Sincerely,




Nilto Carter MD

cc: Joseph M. DeMichele MD


CONTENT:
Mitsuko Piggy, M.D.          RE: Lillian Pons
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/30/84

Dear Dr. Piggy:

We had the pleasure of seeing Lillian in the Endocrine Program on 4/27/95 for .

History: As I indicated in my earlier note I had seen Lillian on 4-27-95.  She was referred for question of demineralization of her bones at the age of 10 5/12 based on an ankle film taken on 2-27-95 for trauma to her left ankle.  At that time,  she was seen by Dr. DeMichele who took x-rays which showed bony changes in the left ankle.  Evidently she had been followed with frequent x-rays since age 6 months of life for asymmetry in her hips and a slight "windblown deformity" of her legs.   This was noted by Dr. Michael Millis and Orthopedic Surgery at Children's on 6-13-85.

Since the ankle injury in February, she has not recovered fully with the respect to full strength in that ankle.  Although she continues to run playing soccer and doing other sports/ballet there is still some weakness.  She has always been extremely active playing hard and without sign of injury until recently and she has not sustained any fractures.

Past medical history:  Essentially unremarkable except for some allergies.  She has never been on Prednisone or other glucocorticoids.  She has a normal dietary intake containing an abundance of calcium and supplemental vitamin D in those dairy products.  She has never had any weight decrease and she has been growing and gaining well.  Her only previous follow-up has been for these orthopedic issues noted above.

Family history:  Family history is remarkable for postpartum symptoms of thyrotoxicosis in her mother who may well have sustained a postpartum thyroiditis.  There are other thyroid problems in the family.  A paternal grandmother is osteoporotic, but no one has developed metabolic bone disease or has had bowing, Rickets, or premature osteopenia.  She is the younger of two siblings.  Her 16 year old sister is well.  Mother is 65"tall, father is 71".

Physical exam:  
Height: 104.9 cm        Weight: 30.6 kg         BP: 107/63              
Pulse: 96               U/L ratio:  0.4         Arm span: 148           
Breast: Tanner I        Pubic hair: Tanner I    
U/L ratio = 0.93, is age appropriate.
A bone age read by me at 10 5/12 years is 10 years of age.
General: She looks entirely well and is a normal height and weight for her age.  She is at the 75% for height and the 25% for weight.  She looks her stated age.  No features consistent with Marfan's syndrome.
Skin: No hyperelasticity of skin.
HEENT:  Sclerae are not blue in color.  Lenses are not dislocated. 
Neck: No thyromegaly or lymphadenopathy. 
Chest: Clear.
Heart: No murmurs.
Abdomen: Femoral pulses are normal.  
Genitourinary: No visceromegaly.  Very early Tanner stage II pubic hair is the only sign of pubertal change.
Extremities: No hyperextensible joints. 
Neurological:  No scoliosis, clinodactyly, or abnormalities of her creases.  No arachnodactyly.  She has no dysmorphic features.

Laboratory studies:  March, 1995:  CBC had a hemoglobin of 12.3 and was otherwise normal.

Impression: I ordered x-rays today and reviewed them with the radiologist at Children's including both ankles and compared them with the films from February, 1995.  From lateral spine and hand films for bone age her bones do look demineralized generally.  I have ordered metabolic bone studies including serum, calcium, phosphorous, magnesium, alkaline phosphatase, electrolytes, Vitamin D metabolites, parahormone assay, TFTs, CBC, and sed rate.  I've also ordered urinalysis and urine amino acid screen.  These were all normal.  She had formal bone densitometry at the Brigham and Women's Hospital which showed significant osteopenia, 2 SD below normal for age in lumbar spine.

Disposition: She probably has idiopathic juvenile osteopenia, which is usually a self-limited condition resolving in puberty due to the effects of estrogen.  We should rule out a variant of osteogenesis imperfecta, which an only be assayed via biochemical analysis from fibroblasts grown from a  tin skin biopsy.  I will ask the parents to schedule an appointment with Dr. Ingrid Holm of our Division, who is skilled in doing this simple biopsy in the clinic setting.
Thank you for letting us share in the care of Lillian.

Sincerely,


Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Mitsuko Piggy, M.D.          RE: Lillian Pons
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  11/30/84

Dear Dr. Piggy:

Lillian was back in follow-up to see me for osteopenia on 02/01/96 at 11-2/12 years of age.  I am pleased that she is beginning pubertal development as evident by advancement in growth velocity and in weight.  She also is having some breast budding.  She has not had any difficulties with respect to orthopaedic problems, fractures, etc., as she had previously based on my last visit with her nine months ago.   

Her bone density studies done on 5/09/95 at the Brigham and Women's Hospital showed that her lumbar spine was two standard deviations below age adjusted normals for both density and that was cause for some concern.  We felt, however, that with estrogenization, this problem would be self-limited.  We took the liberty today of going further to make sure that she does not have a variant of osteogenesis imperfecta that could account for this.

Current medications: None.

Physical exam:
HT: 150.2 cm            WT: 36.5 kg   
Arm span: 155 cm        U/L ratio:  0.93
Breast: Tanner II       Pubic hair: Tanner II   
The remainder of the exam was unremarkable.  She had skin biopsies for genetic analysis for osteogenesis. Which will take months to come back, since this is sent to Seattle for determination after fibroblasts are cultured.

Based on the above, I would like to see her again in approximately a year and would consider repeating a bone densitometry two years after her original test was done, around May 1997.   

Thanks for allowing us to share in her care.

Sincerely,







Nilto Carter, MD             
Associate in Endocrinology


CONTENT:
Zylpha Ibsen, M.D.          RE: Benny Bumbry
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/23/77

Dear Dr. Ibsen:

     We had the pleasure of evaluating Benny in the Renal Program on 3/16/95 for past nephrotic syndrome now in remission.
     In remission since 1988 with steroid responsive multiply relapsing nephrotic syndrome in the past and now this represents likely cure.

Past medical history:
     Steroid responsive multiply relapsing nephrotic syndrome.

Review of systems:
     Asymptomatic with good growth ready for college applications hence this present review.

Physical exam:
     BP 105/65   P 80   R 16   WT 86.3kg
     General: Well covered, well hydrated
     Skin: Normal
     HEENT: Normal, without cataracts or lens opacities
     Neck: Supple, lymph nodes not palpable
     Chest: Clinically clear
     Heart: Rate and rhythm regular
     Abdomen: Non-tender
     Genitourinary: Normal male, Tanner stage 3-4
     Extremities: Normal, without edema, rash, purpura, or striae.  There is a right plantar wart noted on the sole of the right foot.
     Neurological: No localizing signs

Urinalysis:
     SPEC GR UA  1.024           PH UA       5.5        
     PROTEIN UA  N               BLOOD UA    N          
     GLUCOSE UA  N               WBC/HPF     0-1        
     RBC/HPF     0-1             SQUAM EPI   rare  
     CASTS       rare

     Past steroid responsive nephrotic syndrome in remission of therapy since 1988.  This represents most likely a cure for this disorder.

Right plantar wart.

Transferred to local internist cover and college clearance forms prepared.

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

               Sincerely,


               Mitsuko Khan, MBBS, FRACP
               Director, Clinical Services


CONTENT:
Tuba Domingo, M.D.          RE: Casimir Hippias
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/10/95

Dear Dr. Domingo:

We had the pleasure of seeing Casimir in the Endocrine Program on 3/20/95 for abnormal thyroid function tests.  .

History: Casimir was born to a 30 year old mother whose past medical history is notable for hypothyroidism.  Delivery was induced at 38 weeks gestational age because of maternal hypertension.   Birth weight 7 pounds 9 ounces.  Post-natal course was initially complicated by temperature instability leading to a sepsis work up and 7 days of in-hospital antibiotics.  Following discharge to home at one week of life, he did well.   Mother describes good energy and alertness, vigorous feeding of four ounces formula every three hours, normal stools three times a day, and normal sleep pattern when compared to an older sibling.  Mother does describe frequently mottled skin color, but no hoarse cry or other abnormalities.

Current medications: None.

Past medical history:  As above.

Family history:  Mother diagnosed with hypothyroidism (? Hashimoto disease) five years ago, now on Synthroid replacement therapy.   Mother's height 5'3", father's height 6'0".

Physical exam:  
Height: 55.8 cm         Weight: 4.02 kg         Pulse: 150              
Phallus length: 2.8 cm  Mid-shaft diam.: 1.1 cm 
General: Alert, well appearing, smiling intermittently.  
Skin: With cutis marmorata, otherwise no jaundice or rashes.  
HEENT: Head circumference 36 and 3/4 cm.  Anterior fontanelle is open and normal, pupils equal, round and reactive to light, extraocular muscles intact.
Neck: Without thyromegaly.  
Chest: Clear.  
Heart: Regular rate and rhythm, no murmurs.  
Abdomen: Without hepatosplenomegaly.  
Genitourinary: Normal male.  
Extremities: Without clubbing, cyanosis or edema.  
Neurological: Normal deep tendon responses, positive startle reflex, positive incurvation reflex, positive hand grasp.   

Laboratories:  From one week of age - T4 13.2 mcg/dL, TSH 1.1 mcU/mL, THBR 1.02, anti TPO antibodies greater than 30 (from the Brigham and Women's Hospital).   From Children's Hospital today:  TSH 1.2 mcU/mL,  T4 13.7 mcg/dL, TBGI 0.79, anti TPO antibodies pending.

Impression: Casimir is a five week old boy with a maternal history of presumed auto-immune thyroiditis and a question of mottled skin.   On exam today, the baby appears normal, with good growth and development.  The elevated anti-TPO antibody is almost certainly attributable to transplacental passage from the mother and not reflective of primary thyroid disease.

Disposition: We will await the results of anti-TPO antibody, and would like to see Casimir again in four weeks.
Thank you for letting us share in the care of Casimir.

Sincerely,


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


CONTENT:
Tuba Domingo, M.D.          RE: Casimir Hippias
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/10/95

Dear Dr. Domingo:

We had the pleasure of seeing Casimir in the Endocrine Program on 4/17/95 for possilbe hypothyroidism.

History: As you know, Casimir is now a 2 month old who has been doing well recently except for mild upper respiratory infection manifested as nasal congestion.  He has a vigorous appetite taking 7 ounces of formula every three and a half to four hours during the day and sleeps from 11:00 pm to 5:00 am without difficulty.   At the time of his evaluation here, we found his exam notable for cuti mammarata, otherwise there was no evidence of hypothyroidism.   

Laboratory tests obtained 3/20/95 were notable for normal TSH at 1.2 mcU/mL, T4 at 13.7 mcg/dL and still strongly positive TPO antibodies at 11.6 U/mL.  Casimir continues to have bowel movements with almost every feed though still looks intermittently mottled when cold.

Physical exam:  
Height: 59.2 cm         Weight: 5.16 kg         BP: 74/                 
Pulse: 120              Pubic hair: Tanner I    
General: 
Skin: Texture was normal, turgor was good.   
HEENT: Revealed intact extraocular movements.  Equally responsive pupils. Moist oropharynx.  
Neck: Without thyromegaly.  
Chest: Clear to auscultation.  
Heart: Regular rate and rhythm.  
Abdomen: Soft without hepatosplenomegaly or masses.  
Genitourinary: Testes were 0.8x1.6 bilaterally.  Tanner stage I.  
Neurological: 2+ and equal deep tendon reflexes with normal relaxation phase.  Muscle tone was normal.

Laboratory studies:  T4 12.4 ug/dL, TPO AB 1.7  U/ML (H), TBGI 0.84 (C), TG AB 0.4 U/ML (H), TSH  1.90 uU/mL

Impression: Casimir is a now 2 month old who continues to have intermittent skin mottling, now only when cold, with continued positive antibodies of lower titer suggestive of decay of maternally passaged immunoglobulins.   Previous laboratories were notable for normal thyroid function tests though still elevated antibodies.  We would like to ensure that hypothyroidism does not develop.  We will repeat thyroid function tests and hope to see Casimir again in one to two months time for repeat evaluation with the eventual hope with further follow up unnecessary should thyroid function tests again be normal.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Thyroid function tests were again normal.


CONTENT:
Tuba Domingo, M.D.          RE: Casimir Hippias
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/10/95

Dear Dr. Domingo:

We had the pleasure of seeing Casimir in the Endocrine Program on 5/30/95 for abnormal thyroid function tests.

History: As you know, Casimir is a 3 and a half month old who was seen in the endocrine clinic approximately one month ago at which time he had normal thyroid function testing and declining anti-thyroid antibodies.  He has remained quite active, drinking formula every 3-3.5 hours for a total of approximately 5 - 7 ounce bottles per day.  He is intermittently constipated although this improves with extra liquid.  He has no recent illness though has had mild nasal congestion currently.

Current medications: None.

Physical exam:  
Height: 63.5 cm         Weight: 6.49 kg         BP: 90/                 
Pulse: 124              Pubic hair: Tanner I    R. testis: 2 x 1 cm     
L. testis: 2 x 1 cm     Mid-shaft diam.: 1.1 cm 
General: He is a well appearing, alert and active child.  
Skin: Texture was normal.  Turgor was good.  
HEENT: Revealed intact extraocular movements.  Equally responsive pupils.  3 cm anterior fontanelle, posterior fontanelle closed.  
Neck: Without thyromegaly.  
Chest: Clear to auscultation.  
Heart: Regular rate and rhythm without murmur.  
Abdomen: Soft without hepatosplenomegaly  or masses.  
Genitourinary: Normal Tanner stage I.
Neurological: 2+ and equal deep tendon reflexes with normal relaxation phase.  Muscle bulk and tone was normal.

Laboratory studies:  T4 12.4 ug/dL, TPO AB 0.5 U/mL, TSH 2.10  uU/mL, TG AB <0.3 U/mL.

Impression: Since his last visit, Casimir has exhibited normal growth and weight gain and is clinically euthyroid.  His last TFT's were normal with diminishing antibodies which is reassuring, consistent with simply seeing maternal crossing of marker antibodies for Hashimoto's thyroiditis.

Disposition: We repeated laboratory tests today and should thyroid function tests again be normal and antibodies continuing to diminish, we would only suggest having Casimir return in the future as needed.  There is slightly increased risk of Hashimoto's thyroiditis within families but this could develop at any time during Casimir's life.  You should monitor him at regular visits in terms of linear growth and weight gain and refer him back should he exhibit signs suggestive of hypothyroidism.
Thank you for letting us share in the care of Casimir.

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Thyroid function tests were again normal, and anitbodies nearly gone.


CONTENT:
Mitsuko Goldwater, M.D.          RE: Charlene Vernier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/12/87

Dear Dr. Goldwater:

We had the pleasure of seeing Charlene in the Endocrine Program on 5/15/95 for evaluation of precocious puberty.

History: Charlene is a 7 year 11 month old girl who in January, 1994,  was noted to have breast development of approximately 1cm without evidence of pubic hair.  In September, 1994, she was seen again and was noted to have an increase in breast development plus some evidence of fine pubic hair.  At that time she had an ultrasound done of her ovaries/pelvis laboratory evaluation.  The ultrasound showed both ovaries to be within normal limits with a tiny cyst on the right ovary.  This was thought to be normal for that age.  She had no masses.  Her bone age of the left hand was consistent with 7 years 10 months when she was the chronologic age of 7 years and 1 month.  She also had an x-ray done of the sella turcaca which was unremarkable.

Current medications: None.

Past medical history:  She is adopted so there is no past medical history.  At this time she lives with her step parents.  She is in first grade in school and there is a question of attention deficit disorder.  At school she works with a tutor.

Review of systems:  No SOB, no chest pain, nausea, vomiting, or diarrhea.  No evidence of polyuria or polydipsia.  No headaches or problems with her eyes.

Physical exam:  
Height: 123.4 cm        Weight: 25.4 kg         BP: 90/60               
Pulse: 80               U/L ratio:  1.04        Arm span: 120           
Pubic hair: Tanner I    
General: Pleasant, active white female.  Very active during physical exam.
Skin: Normal
HEENT: Normal.  Fundoscopy sharp discs.  EOMI, PERRL. 
Neck: Small palpable thyroid.  Lymphnodes are normal.
Chest: CTA.
Heart: Regular rate and rhythm.
Abdomen: Soft, no hepatosplenomegaly or masses.
Genitourinary: Left breast Tanner II and right breast is Tanner III.
Extremities: No tremors.
Neurological: Nonfocal.

Impression: Charlene exhibits accelerating linear growth and progression in secondary  sexua characteritcs consistent with central puberty.  We discussed Charlene's with her stepmother and recommended the following studies:  GNRH stimulation test, MRI,  and a bone age.  Depending on the results of the GNRH test we will try to delay on the onset of puberty with Lupron, since Charlene would benefit psychosocially and perhaps staturally from puberatl delay at this time.

Disposition: Dr. Shields will call the family if any results are abnormal.  He would like to see Charlene again in four months.
Thank you for letting us share in the care of Charlene.

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Kenneth Shepherd, M.D.
Fellow in Endocrinology

Charlene had a pubertal response to GnRh, and head MRI was normal.  I will further discuss initiation of Lupron therapy with the family.


CONTENT:
Mitsuko Goldwater, M.D.          RE: Charlene Vernier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/12/87

Dear Dr. Goldwater:

We had the pleasure of seeing Charlene in the Endocrine Program on 7/31/95 for .

History: We had the pleasure of seeing Charlene DuPont in the Endocrine Program on  July 31, 1995 for follow-up of precocious puberty.  Charlene is now an  8-1/12 year old who has recently started on Lupron therapy for  suppression of idiopathic precocious puberty.  Her previous evaluation  has included a normal MRI scan of the head, pubertal GnRH stimulation  testing and a bone age consistent with chronologic age.  Her first  Lupron dose was administered 7/24/95 and she experienced no difficulty  subsequently.  She denies headache, change in affect, vaginal bleeding,  though mother does report continued enlargement in the size of the  breasts since her last visit to the Endocrine Program in March.  Of  note:  Charlene continues to exhibit symptoms consistent with attention  deficit disorder for which the family is considering initiating  medication.

Physical exam:  
Height: 125.6 cm        Weight: 27.3 kg         BP: 94/60               
Pulse: 84               Breast: Tanner III      Pubic hair: Tanner I    
Charlene was a well appearing girl with a height of  125.6 cm, weight of 27.3 kg, blood pressure 94/60, pulse 84.  Breasts  Tanner stage III, pubic hair Tanner stage I.  Skin texture is normal.   Trigger was good.  HEENT exam revealed flat discs, intact extraocular  movements.  Neck was without thyromegaly.  Examination of the chest  revealed 5 cm of breast tissue bilaterally.  Cardiac exam showed regular  rate and rhythm without murmur.  Abdomen was soft without  hepatosplenomegaly or masses.  Neurologic exam showed 2+ and equal deep  tendon reflexes with normal relaxation phase.

Impression: Charlene has exhibited continued advancement in breast  development, though only received her first Lupron injection one week  age.  As such, effects would not yet be anticipated and actually in the  first month after therapy mild agonist effects of Lupron can indeed be  seen.  We plan to repeat GnRH testing after the third dose of Lupron to  ensure this dose adequately suppresses her hyperthalamic pituitary  gonadal access but would elect to continue her on 7.5 mg of Lupron IM at  28 day intervals until this testing can be obtained.  Return to clinic  in 3 months.

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

Sincerely,


Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Mitsuko Goldwater, M.D.          RE: Charlene Vernier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/12/87

Dear Dr. Goldwater:

We had the pleasure of seeing Charlene DuPont in the Endocrine Program on  July 31, 1995 for follow-up of precocious puberty.  Charlene is now an  8-1/12 year old who has recently started on Lupron therapy for  suppression of idiopathic precocious puberty.  Her previous evaluation  has included a normal MRI scan of the head, pubertal GnRH stimulation  testing and a bone age consistent with chronologic age.  Her first  Lupron dose was administered 7/24/95.  She experienced no difficulty  subsequently.  Charlene denies headache, change in affect, or vaginal bleeding,  though mother does report continued enlargement in the size of the  breasts since her last visit to the Endocrine Program in March.  Of  note:  Charlene continues to exhibit symptoms consistent with attention  deficit disorder for which the family is considering initiating  medication.

Physical exam:  
Height: 125.6 cm        Weight: 27.3 kg         
BP: 94/60               Pulse: 84               
Breast: Tanner III      Pubic hair: Tanner I    
Skin texture is normal.   Turgor was good.  HEENT exam revealed flat discs, intact extraocular  movements.  Neck was without thyromegaly.  Examination of the chest  revealed 5 cm of breast tissue bilaterally.  Cardiac exam showed regular  rate and rhythm without murmur.  Abdomen was soft without  hepatosplenomegaly or masses.  Neurologic exam showed 2+ and equal deep tendon reflexes with normal relaxation phase.

Impression: Charlene has exhibited continued advancement in breast  development, though only received her first Lupron injection one week  ago.  As such, effects would not yet be anticipated and actually in the  first month after therapy mild agonist effects of Lupron can indeed be  seen.  We plan to repeat GnRH testing after the third dose of Lupron to  ensure this dose adequately suppresses her hypothalamic-pituitary -gonadal axis but would elect to continue her on 7.5 mg of Lupron IM at  28 day intervals until this testing can be obtained.


Sincerely,




Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Mitsuko Goldwater, M.D.          RE: Charlene Vernier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/12/87

Dear Dr. Goldwater:

I saw Charlene in the Endocrine Program on 10/13/95 for idiopathic precocious puberty.

History: As you know, Lilly started on Lupron therapy 7.5 mg every 28 days on July 24, 1995.  During this time, her mother reports no noted increase in breast size, change in pubic hair or onset of vaginal bleeding.  She has  infrequent headaches associated with sinus congestion but has otherwise been well.  Since beginning her Lupron replacement, Lilly's mother reports more attentiveness and less aggression in Lilly with good to excellent school performance.

Physical exam:
Ht: 127.5 cm    Wt: 29 kg      BP: 94/64        Pulse: 80               
On examination today, Lilly was a well appearing girl.  Skin texture and  turgor were normal.  HEENT examination revealed flat optic discs and intact extraocular movements.  Neck was without thyromegaly.  Examination of the chest revealed 4 cm breasts, but on the left 4.8 cm.   The remainder of the examination was unremarkable.

Our impression is that since the last visit, Lilly has exhibited reduction in breast size and improved behavioral and school performance suggesting adequate suppression of sex steroids.  She has had some continued mild acceleration in linear growth and weight gain which may be residual from her prior sex steroid production.  To assess formally the adequacy of her therapy, we obtained a GnRH stimulation test today and will base any adjustment of Lupron dose upon the results of this study.  We hope to see her again in three to four months.



Sincerely,




Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Charlene's GnRH stimulation test confirmed appropriate suppression of puberty.


CONTENT:
Mitsuko Goldwater, M.D.          RE: Charlene Vernier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/12/87

Dear Dr. Goldwater:

I saw Charlene in the Endocrine Program on 3/1/96 for precocious puberty.  As you know, Charlene is now 8 and 9/12 years old and continues on Lupron Depot suppressive therapy every 28 days.  Charlene has been in general healthy, though for the past one to two days, has complained of significant dysuria.  A GnRH stimulation test obtained 10/13/95 showed adequate pubertal suppression on her current Lupron Depot replacement therapy.  She reports no headaches, and maintains a good energy level.  Her behavioral problems in school  have markedly improved, and mother reports no significant change in breast size, though slight advancement in pubic hair.

Current medications: Lily's only medication is Lupron 7.5 mg q. 28 days.

Physical exam:
Height: 128.7 cm      Weight: 31.4 kg
BP: 119/80            Pulse: 84               
Breast: Tanner III    Pubic hair: Tanner II   
On examination today, Lily was a well-appearing girl.  Skin texture was normal.  Turgor was good.  Disks were flat.  There was no thyromegaly.  There was approximately 3 cm of atrophic breast tissue palpated bilaterally.  Heart revealed regular rate and rhythm.  Abdomen was soft without hepatosplenomegaly or masses.  GU exam was notable for pink vaginal mucosa without discharge.  Neurologic exam showed 2+ and equal deep tendon reflexes with normal relaxation phase.

Impression: Charlene currently has no evidence of continued growth acceleration and has significant reduction in breast tissue.  This, together with her suppressed GnRH stimulation test is reassuring in terms of adequacy of therapy.  We would like to continue her on 7.5 mg of Lupron for which a dose was given today.  Also, because of her dysuria, we are obtaining a clean catch urine specimen to ensure a urinary tract infection is not present.  As part of her ongoing assessment, we would like to obtain a bone age through your office prior to her next visit, and will discuss this with mother.

Thank you for allowing us to participate in Lily's care.  She should return to clinic in three to four months.



Sincerely,




Maureen Shields, MD             
Attending in Endocrinology   


Addendum: Urine creatinine was negative.


CONTENT:
Mitsuko Goldwater, M.D.          RE: Charlene Vernier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/12/87

Dear Dr. Goldwater:

I saw Charlene in the Endocrine Program on 6/21/96 for follow-up for precocious puberty.

History: As you know, Charlene is now a 9 year old who has been maintained on Lupron for suppression of early pubertal development.  She has been overall healthy, except for an episode of emesis yesterday for unclear reasons.  Her mother reports some limitation of oral intake secondary to mildly excessive weight gain, although she denies recent increase in frequency of stomach aches, constipation, diarrhea.  She does report headaches one to two times per month.  Charlene's mother does report the onset of pubic and axillary hair  although no significant change in breast development.

Current medications: Lupron 7.5 mg IM q. 28 days.

Physical exam:
HT: 130.3 cm    WT: 31.5 kg    BP: 103/52        Pulse: 85               
Breast: Tanner I        Pubic hair: Tanner II   
Charlene was a happy, healthy appearing girl.  Skin texture was normal, turgor was good.  HEENT examination revealed intact extraocular movements.  Examination of the chest revealed Tanner I breasts with some subcutaneous fat tissue present.  GU examination is notable for Tanner II-III pubic hair.  Neurologic exam was non-focal.

Impression: Since her last visit, Charlene had exhibited appropriate linear growth and weight gain.  She has no evidence of pubertal progression as evidenced by increasing breast size or vaginal discharge.  Because of her continued adequate suppression by physical examination, we have elected to continue her on 7.5 mg of Lupron q. 28 days and would consider taking her off of this suppressive therapy in  approximately six to twelve months to let her pubertal development proceed normally.  There are still some concerns according to the mother about psychosocial issues, which are being addressed by the family.

Thank you for allowing us to participate in Charlene's care.


Sincerely,




Maureen Shields, MD             
Attending in Endocrinology


CONTENT:
Mitsuko Goldwater, M.D.          RE: Charlene Vernier
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  06/12/87

Dear Dr. Goldwater:

I saw Charlene in the Endocrine Program on 12/16/96 for follow-up of precocious puberty.

As you know, Charlene is now a 9 6/12ths year old who has been on Lupron for suppression of precocious puberty.  Since her last visit with Dr. Muglia, she has had no significant illnesses.  Since she last saw Dr. Muglia, she has been placed on Ritalin, 5 mg. two times per day, five days a week, to improve school performance.  According to Mom, this has been a significant improvement in Charlene's behavior.  Mom also has some anxiety regarding some sexual interest that Charlene has been presenting.

Current medications: Ritalin 5 mg. two times per day, five times per week and Lupron 7.5 mg. q. month.

Physical exam:
Height: 133.2 cm        Weight: 33.4 kg
BP: 110/51              Pulse: 86               
Breast: Tanner I        Pubic hair: Tanner II   
General appearance:  she is alert and cooperative.  Skin has normal turgor and texture; there is no acne.  HEENT, pupils equal and equally reactive to light and accommodation. EOMI.  Fundi are normal.  Neck:  the thyroid has normal size and consistency.  Lungs are clear.   Heart, regular rate and rhythm.  Abdomen soft, nontender, no hepatosplenomegaly.  GU:  red vaginal mucosa.  Extremities, she has no axillary hair and no  body odor.  Neurologic:  deep tendon reflexes are 2+/4+ and equal bilaterally.

Impression: The assessment at this time is that Charlene is well-controlled on Depot Lupron.  She has remained on an identical velocity curve as previously.  She currently has no signs of estrogen action.  The assessment also includes behavioral issues that may be more significant than her physical issues.

Disposition: The plan then is to continue Lupron.  I would like to obtain a bone age in six months to follow her pubertal development.   I have asked that Mrs. Vernier contact Ellen Goodman, our social worker, regarding whether some type of counseling or intervention may be indicated to help Charlene and her family.

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



Sincerely,




Ariel Adler, MD           
Attending in Endocrinology


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

We had the pleasure of seeing Sandy in the Endocrine Program on 3/30/95 for congenital hypothyroidism.

History: Sandy is an 8 day old girl with reportedly abnormal thyroid function tests from the State Newborn Screening Program Lab.    The State Lab tests were done on March 24, 1995 at which time Sandy had a T4 of 7.27 mcg/dL and a TSH of greater than 200 mcU/mL.   Sandy's TFT's were repeated at Children's Hospital on March 29, 1995 (day of life #7) at which time she had a T4 of 8.2 mcg/dL and a TSH of 232 mcU/mL.   

Birth history is significant for mother being a 35 year old G4, P3, 1 spontaneous abortion woman who had no problems in pregnancy.   She denies Iodine exposure and medications during pregnancy.   The baby was delivered by repeat C-section at 39 weeks gestational age.   Birth weight 6 pounds 6 ounces.   She went home from the hospital with her mother on day of life #3 from Leonard Morse Hospital in Natick.    

The baby's current sleep schedule is she sleeps 2-3 hours between feedings.   Her feeding schedule at present is ProsoBee 1 ounce per hour or 2 ounces per 2 hours.

Current medications: None.

Review of systems:  Skin: baby is slightly jaundiced.   HEENT: negative.  Cardio-Resp: negative.   GI: She has 2-4 bowel movements per day.   GU: normal.  Neurologic: normal.

Family history:  Sandy has no siblings with thyroid disease.   Her maternal grandmother has an unknown thyroid disorder.   Her parents are alive and well.   The baby has two siblings, a 14 month old sister and a 5 and 9/12 year old brother.   Mother's measured height is 5 foot.  Father's height is 5'7.5".

Physical exam:  
Weight: 2.71 kg         Pulse: 150              
Length:  47.6 cm.  
General: She is a consolable baby girl.    
Skin: Slightly jaundiced but sclera are not jaundiced; no periorbital edema.   
HEENT: She has a palpable open anterior and posterior fontanelle.   
Neck: No palpable thyroid gland.  Lymph nodes are not palpable.   
Chest: Clear.  
Heart: Regular rate and rhythm without a murmur.  
Abdomen: Slight umbilical hernia.   
Genitourinary: Normal female genitalia.   
Extremities: Normal temperature.  
Neurological:  Reflexes are +2/4 bilaterally in her upper and lower extremities.

Impression: Sandy has congenital hypothyroidism that she is presently compensating for with a T4 of 8.2 mcg/dL.   We will start her on Synthroid 25 mcg/qd.

Disposition: Return to clinic in two weeks at which time we will check her thyroid function tests and weight gain.
Thank you for letting us share in the care of Sandy.

Sincerely,


Rahul Hagen, MD           Rahul Ibsen, MD                
Fellow in Endocrinology      Attending in Endocrinology   


Addendum: TFT's after Sandy was on Synthroid for 14 days (done at the State Lab): T4 15 mcg/dL and TSH 22 mcU/mL.  These results indicate a response to L-thyroxine.

Problem list to date:
CONGENITAL-HYPOPITUITARISM                   04/18/95  
Transcribed by Sullivan_ma


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

We had the pleasure of seeing Sandy in the Endocrine Program on 4/28/95 for congenital hypothyroidism.

History: Sandy is a five week old girl with congenital hypothyroidism diagnosed by the state laboratory newborn screening program.  She was started on Synthroid (25 mcg qd) on March 30, 1995.  Her current sleeping schedule is  that she awakens every 2-3 hours to feed.  Her current formula is Enfamil with low iron (2-3 oz/feed).  She has bowel movements daily or every other day.  Stools have been hard recently, therefore, mother has been giving her small amounts of Karo syrup with water, which results in stool softening.  Mother describes her cry as normal.  Her skin is not jaundiced.

Current medications: Synthroid 25 mcg qd (prepared by crushing a tablet and putting it in a small amount of milk on a spoon).

Physical exam:  
Height: 53.6 cm         Weight: 3.76 kg         Pulse: 120              
Head circumference = 36.5 cm.
General: She is a consolable infant in her father's arms.
Skin: No jaundice.
HEENT: AFO &F.
Neck: No thyromegaly.
Heart: Regular RR without murmur.
Abdomen: No hepatosplenomegaly or umbilical hernia.
Genitourinary: Normal female.
Neurological: DTR's +2/4 bilaterally in her LE.

Laboratory studies:  April 13, 1995 done at the state lab:  T4 15 mg/dL, TSH 22 mcu/ml.

Impression: Sandy has congenital hypothyroidism with a good response to her Synthroid.  Because her TSH was slightly above the normal range for the state lab (< 20 mcu/ml) we are increasing her Synthroid to 37.5 mcg qd.  Her mother was instructed to obtain TFT's at the Norwood Department of Public Health on May 1, 1995.  Those filter papers will be sent to the state lab who will forward the results to us.

Disposition: Studies ordered:  T4 and TSH.  Sandy should return to clinic in one month.

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


Sincerely,





Rahul Hagen, MD           Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

We had the pleasure of seeing Sandy in the Endocrine Program on 5/26/95 for congenital hypothyroidism.

History: Sandy is a 2 month old girl with congenital hypothyroidism on Synthroid since day of life #8.  She had thyroid function tests drawn at the Norwood Department of Pubic Health on May 22, 1995 and the results of those are: T4 = 12.21 mcg/mL and TSH = 9.45 mcU/mL.  Her sleeping schedule is as follows; in the daytime she takes 2-3 hour naps and is awake for one to two hours between naps.  At night time she is sleeping 4-6 hours.  Her currently diet is Enfamil with low iron, 3-4 ounces every two to three hours.  She has bowel movements every one to two days.   Her mother is still using Karo syrup mixed in with four ounces of water twice a day and the baby continue to strain with bowel movements.

Current medications: Synthroid 25 mcg qd.  Mother prepares this by crushing the tablet in milk.  The baby has missed no doses of medication.

Physical exam:  
Height: 22.5 cm         Weight: 4.71 kg         Pulse: 132              
Breast: Tanner I        Pubic hair: Tanner I    
General: She is a consolable, smiling infant in her father's arms.  
Skin: Not jaundiced.  Soft and she has heat rash on her chest.  
HEENT: Anterior fontanelle open and full.  
Neck: No palpable thyroid tissue.  
Chest: Lungs clear.  
Heart: Regular rate and rhythm without murmur.  
Abdomen: No umbilical hernia.  
Genitourinary: Normal female.  
Neurological: +2/4 deep tendon reflexes bilaterally in her upper and lower extremities.

Impression: Sandy is growing along the 50th percentile for height and weight.  We are increasing her dose to 37.5 mcg q day which will give her approximately .8 mcg/kg and we reviewed the procedure of crushing one and a half tablets and giving them with a small amount of fluid as opposed to mixing them in with the bottle of formula.  

Studies ordered:  Thyroid function tests should be drawn at the Department of Pubic Health and mailed to the State Lab in Norwood in four weeks.

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

Sincerely,


Rahul Hagen, MD           Maureen Shields, MD             
Fellow in Endocrinology      Attending in Endocrinology   


Addendum: 5/22/95:  T4 = 12.21 mcg/dL and TSH = 9.45 mcU/mL.  Dr. Mitchell at the State Lab feels Sandy's recent TFT's are acceptable, based on their normal range.  Sandy will have a T4 and TSH done on July 24, 1995.


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

We had the pleasure of seeing Sandy in the Endocrine Program on 8/15/95 for congenital hypothyroidism.

History: Sandy is a 5 month old girl with congenital hypothyroidism on  Synthroid 37.5 mcg qd.  She had her last set of thyroid functions drawn  on 7/24/95 and run at Massachusetts Screening Lab with a result of T4 1 4.25 mcg/dl.  Her mother gives a clinical history of Sandy rolling back to front and front to backwards.  She is also lifting her head and making sounds.  Her sleep schedule is that she takes a 15 minute nap during the daytime and falls asleep at 9 p.m. and sleeps until 6 a.m.  Her current eating schedule is Enfamil with Low Iron 4 to 6 oz every 2 hours and she is also beginning to eat cereals and baby fruits.  She is beginning to teethe.

Current medications: Synthroid 37.5 mcg qd.

Physical exam:  
Height: 63.7 cm         Weight: 6.88 kg                    
BP: 88/54               Pulse: 124              
She is well-hydrated and interactive.  Her skin is soft and not dry.  HEENT:  Anterior fontanel open and full.  Neck: No palpable thyroid tissue.  Lungs are clear.  Heart: Regular rate and rhythm without murmur.  Abdomen: No umbilical hernia.  GU: Normal female anatomy.  Neurologic: +2/4 deep tendon reflexes in her upper and lower extremities.

Impression:  We had a lengthy discussion with Mrs. Bowie about the need to correlate the State Laboratory and Children's Hospital venous blood drawing thyroid function tests.  Sandy's mother believes that her growth and development are appropriate compared to Sandy's siblings and mother refuses venous blood draws at present.

Disposition: Sandy is clinically euthyroid.  However, we will increase her Synthroid dose to 50 mcg qd and request that Mrs. Bowie have filter paper blood work done at monthly intervals.  We will ask Mrs. Bowie to have TFTs done in 1 month and at monthly intervals thereafter, and we would like to schedule a visit for Sandy to return to clinic in 2 months.

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

Sincerely,



Rahul Hagen, MD           
Fellow in Endocrinology


CONTENT:
Pavarotti, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Mrs. Pavarotti:  

Insulin dose:  10R/29N pre-breakfast;  25R pre-dinner;  19N bedtime 	

Height:   165.7 cm       Weight:  64.7 kg        Tanner stage  4 

Laboratory test results:
Glycosylated hemoglobin*  	7.6 % (normal 5.2-7.8)
Urinalysis	1000mg glucose, no ketones, no protein
  
Comments:   The glycosylated hemoglobin confirm the excellent control of diabetes.  Congratulations!  However, the price for such good control is an increased risk for episodes of severe hypoglycemia.  We discussed a decrease in evening insulin to prevent night time hypoglycemia as reported to me in clinic.  A bedtime snack is important to prevent hypogglycemia during the night.


Sincerely yours,





Ruben Diaz, M.D., Ph.D.
Fellow in Endocrinology

*Glycosylated hemoglobin reflects average blood glucose levels during the previous 8-12 weeks.  Most people with diabetes have values above normal.  Below is a guide to assess diabetes control in the past 8-12 weeks:  
Glycohemoglobin	Average Blood Glucose
5.2 -7.8%		70 - 110 mg/dl (normal range )
8.0-10.0%		120 - 200 mg/dl
10.0 -12.0%		200 - 260 mg/dl
12% or above		260 mg/dl or higher


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

I saw Sandy in the Endocrine Program on 1/2/96 for congenital hypothyroidism.

History: Sandy is a 9-month-old girl with congenital hypothyroidism who has been on Synthroid 50 mcg. q.a.m.  Her mother reports that laboratory values were drawn on December 29, 1995 and sent to the State Lab that same day. 

Sandy's appetite is good.  She is drinking Enfamil with low iron 6-8 oz. q.2-4 hours and takes 2 naps a day.  She has bowel movements 1 or more times per day.  She has 2 teeth at present and is cutting her top teeth now.  She has been able to pull to stand for the past 3 weeks.

Current medications: Synthroid 50 mcg. q.a.m. given every morning by mixing the  Synthroid with her formula on a spoon and she takes each dose.

Physical exam:
Length: 70.5 cm    WT: 7.62 kg    HC: 43 cm
BP: 80/46               Pulse: 156              
She is a smiling, well-hydrated baby in no apparent distress.  Skin is soft and not dry.  Neck:  no thyromegaly.  Lymph nodes: none.  Lungs are clear.  Breasts: Tanner I.  Heart: regular rate and rhythm without murmur.  Abdomen is soft, nontender, no hepatosplenomegaly, no umbilical hernia.  GU: normal prepubertal female.  Neurologic:  she has active, brisk reflexes and she moves all four extremities.

Laboratory studies at the New England Regional Newborn Screening Program Lab, was last done on 11/16/95 with a T4 of 16.45 and a TSH of 5.35; on 12/28/95 T4 15.13 mcg/dL and TSH 0.27 mcU/mL.

Impression: Our clinical assessment is that Sandy is clinically euthyroid and we will continue her on her current Synthroid dose.  Our follow-up plan is to check the T4 and TSH at monthly intervals and we would like Sandy to return to clinic in 2 months.



Sincerely,




Rahul Hagen, MD           
Attending in Endocrinology   


cc:  Marvin Mitchell, M.D.  and Rosalie Hermos, MPH 
     New England Regional Newborn Screening Lab  305 South St., 
     Jamaica Plain, MA 02130


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

I saw Sandy in the Endocrine Program on 2/27/96 for follow-up of congenital hypothyroidism.

History: Sandy is a 9-month-old girl with congenital hypothyroidism  who takes Synthroid 50 mcg. q.a.m.  Her mother reports that  laboratory values were drawn on January 29, 1995 and sent to the State  Lab that same day. 

Sandy's appetite is good.  She is drinking Enfamil with low iron 6-8  oz. q.2-4 hours and takes 2 naps a day.  She has bowel movements 1 or  more times per day.  She has 2 teeth at present and is cutting her top  teeth now.  She has been able to pull to stand for the past 3 weeks.

Current medications: Synthroid 50 mcg. q.a.m. given every morning by mixing the Synthroid with her formula on a spoon as she takes each dose.

Physical exam:
Length: 70.5 cm    WT: 7.62 kg    HC: 43 cm    BP: 80/46     Pulse: 156              
She is a smiling, well  hydrated baby in no apparent distress.  Skin is soft and not dry.  Neck:  no thyromegaly.  Lymph nodes: none.  Lungs are clear.  Breasts: Tanner  I.  Heart: regular rate and rhythm without murmur.  Abdomen is soft,  nontender, no hepatosplenomegaly, no umbilical hernia.  GU: normal  prepubertal female.  Neurologic:  she has active, brisk reflexes and she  moves all four extremities.

Laboratory studies at the Newborn Screening Lab: results from last week are pending.

Impression:  Our clinical assessment is that Sandy is clinically  euthyroid and we will continue her on her current Synthroid dose.  Our  follow-up plan is to check the T4 and TSH at monthly intervals and we  would like Sandy to return to clinic in 2 months.



Sincerely,




Rahul Hagen, MD           
Attending in Endocrinology   


cc:  Marvin Mitchell, MD  Rosalie Hermos, MPH
     New England Regional Newborn Screening Lab  305 South Street
     Jamaica Plain,  MA 02130


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

Sandy is a 14 month old girl who has been on  Synthroid for treatment of congenital hypothyroidism since one week of age.  Currently, she has eight teeth; she has bowel movements once per day; she is continuing on formula because she does not like whole milk and prefers to eat foods over formula.  She began walking at slightly older than 12 months of age and she has three to four words in her vocabulary.

Current medications:  Synthroid 50 mcg q.a.m.  which is given with her food.   She has not missed any doses.

Physical exam:
Length: 75 cm    WT: 8.66 kg    HC: 44 cm
BP: 89/41               Pulse: 136              
Breast: Tanner I        Pubic hair: Tanner I    
She is a well-hydrated female toddler in no  apparent distress.  Skin has no lesions and is not dry.  HEENT:  pupils  equal, round and reactive to light.  Neck:  no thyromegaly.  Lymph  nodes:  none.  Lungs:  clear.  Heart:  regular rate  and rhythm without a murmur.  Abdomen:  no hepatosplenomegaly.  GU:   normal female genitalia.  Neurologic:  DTRs are +2/4 bilaterally in her  upper and lower extremities.

Laboratory studies:  Sandy has been having bimonthly T4 and TSH levels checked at the State  Laboratory and on April 18, 1996, her T4 was equal to 15.1 mcg/dl and  her TSH 0.15 mu/ml.  These are within normal limits.

Impression: Sandy continues to be clinically euthyroid and  developmentally appropriate.  She is attaining the appropriate height,  weight, language and motor milestones.  Our plan is to continue  Synthroid at 50 mcg q.d. and follow thyroid function tests in two  months.



Sincerely,




Rahul Hagen, MD           
Attending in Endocrinology   


cc:  Rosalie Hermos, MPH  State Laboratory Institute  20 South  Street  Jamaica Plain, MA  02130


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

I saw Sandy in the Endocrine Program on 7/30/96 for follow-up of congenital hypothyroidism.

History: Sandy continues on 50 mcg of Synthroid each morning.  Review of systems:  She has bowel movements one or more times per day.  She is recently having a problem sleeping through the night while she is teething but continues to nap twice a day.  She now has 12 teeth.  She says several one syllable words and follows directions.

Current medications: Synthroid 50 mcg q.a.m., no doses have been missed.

Physical exam:
HT: 77.9 cm             WT: 8.93 kg
BP: 69/48               Pulse: 95               
In general, she is a well hydrated female toddler actively playing with her mother.  Skin shows no lesions and is soft and without dryness.  HEENT:  Her left eye rotates inward.  Neck: she has no palpable thyroid gland and lungs are clear.  Heart: regular rate and rhythm without a murmur.  Abdomen: soft, nontender, no hepatosplenomegaly.  Neurologic: +2/4 bilaterally upper extremity and lower extremities deep tendon reflexes.

Laboratory studies:  on 7-17-96, Sandy had a T4 at the New England Regional Newborn Screening Program of 12.04 mcg/dl and a TSH equal to 0 mcg per ml.

Impression: Our assessment is that Sandy is clinically euthyroid and achieving her  developmental milestones appropriately.  For height, she continues along the 25-50th percentiles and for weight she is closer to the 10th percentile.

Disposition: Our plan is to recheck her thyroid function tests at bimonthly intervals at the state laboratory.  We would like Sandy to return to clinic in two months.  Sandy may benefit from an opthalmology exam for left esotropia.  

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


Sincerely,






Rahul Hagen, MD           
Attending in Endocrinology

cc:  Rosalie Hermos, MPH, New England Regional Newborn Screening Program, 
     305 South Street, Jamaica Plain, MA


CONTENT:
Jas Bear, M.D.          RE: Sandy Bowie
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  03/22/95

Dear Dr. Bear:

I saw Sandy in the Endocrine Program on 10/15/96 for follow-up of congenital hypothyroidism.

History: Sandy is an 18 1/2 month old female with congenital hypothyroidism, who  has been followed since birth.  She had normal thyroid function  tests on September 25, 1996, at the State Laboratory Institute.  On  review of symptoms, her mother notes that she had a temperature for a  few days with a slightly decreased appetite; she has bowel movements  once per day; she sleeps well throughout the night and takes one to two  hour naps per day.  In terms of her developmental milestones, she walks  up steps with her hand held and says few words.  In terms of her dental  development, she has 12 teeth and is cutting her one year molars.

Current medications: Synthroid 50 mcg. q.d.   She misses no doses.

Physical exam:
Length: 81 cm    Weight: 9.5 kg
BP: 86/54               Pulse: 120              Breast: Tanner I        
Pulse rate 120 crying.   General: well hydrated girl in no apparent  distress.  Skin: no lesions, texture is normal.  HEENT:   left esotropia and neck has no palpable thyroid tissue.  Lungs: clear.  Breasts: Stage Tanner I.  Heart: regular rate and rhythm without  a murmur.  Abdomen:  no hepatosplenomegaly and soft.  GU:  normal  female.  Neurological: Deep tendon reflexes are +2/4 bilaterally in her upper and  lower extremities.

Prior laboratory studies on September 25, 1996,  Sandy had a T4 equal to 11.12 ug/dl and a TSH equal to 0.64 units/ml.

Impression: Sandy continues to be clinically euthyroid and is meeting her  developmental milestones.  She has a mild left esotropia for which her  mother may choose to consult to and discuss the need for ophthalmology  referral.  We plan to have Sandy's thyroid function test checked in  December or January of 1996 and we would like her to return to Clinic in  three months.  We recommend continuing her Synthroid on 50 mcg. q.d.   Thank you for letting me share in her care.


Sincerely,



Rahul Hagen, MD           
Attending in Endocrinology                             

cc:  Rosalie Hermos, MPH  State Laboratory Institute  305 South Street  Jamaica Plain,  MA  02130


CONTENT:
Welby, M.D.          RE: Remy Olney
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/19/92

Dear Dr. Welby:

     We had the pleasure of seeing Remy in the Renal Program on 6/8/95 for Vesicoureteral Reflux.
     Remy is a 2-1/2 year old boy referred to our clinic after a  radionuclide cystogram revealed Grade II reflux on the right.  This  study was obtained during the family work-up.  The patient's sister, presented  earlier this year with pyelonephritis and reflux.  Since the test  results the patient has been maintained on amoxicillin and appears to be  tolerating this well.  Remy has no significant past medical history  including especially no history of of unexplained infections, no history  of urinary tract infections and he has no known allergies.  In addition,  there is no history of kidney problems in the family.

His current medications include:
     AMOXICILLIN 50 mg q.h.s.


Remy's physical exam was notable for:
     BP 108/65   P 129   R    T    HT 96.5cm   WT 15.1kg
     General: Remy was playful and well appearing.  
     Skin: No rashes
     HEENT: Unremarkable 
     Neck: Neck was supple, he had no lymphadenopathy 
     Chest: Clear to auscultation
     Heart: Regular rate and rhythm with a normal S1 and split S2. No murmurs.  
     Abdomen:  Soft and nontender with no palpable masses or abdominal bruits. 
     Genitourinary:  Tanner I with descended testes bilaterally.  
     Extremities: No edema
     Neurological:  Nonfocal.
A urinalysis revealed:
     SPEC GR UA  1.015           RBC/HPF     None       
     PH UA       6               WBC/HPF     None       
     BLOOD UA    Neg.            SQUAM EPI   None       
     PROTEIN UA  Neg.  mg/dl     BACTERIA    Neg.  
     GLUCOSE UA  Neg.       

Laboratory studies at this time include:


     Remy has Grade II reflux on the right which was detected in screening,  due to his older sister's presentation with pyelonephritis and reflux.   The positive test and subsequent treatment will greatly reduce the  likelihood that Remy will ever have kidney damage secondary to his  reflux.  It is appropriate to treat Remy with prophylactic antibiotics  until documentation is obtained that the reflux has resolved.  It is  likely that his reflux will resolve within the next several years and we  will plan on scheduling an ultrasound and radionuclide cystogram in 6  months.  In the meantime, the amoxicillin may be changed to Furadantin,  as this has less of an effect on the bowel flora and is thus less likely  to be associated with the emergence of resistant pathogens.  As  Furadantin can be associated with nausea, we recommend taking it with  meals and in particular with milk.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Red, M.D.          RE: Remy Olney
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  12/19/92

Dear Dr. Red:

     We had the pleasure of seeing Remy in the Renal Program on 1/25/96 for reflux.
     Remy is a 3-year-old with a history of Grade 2 reflux on the  right side that was found on a screening test.  There is no history of  urinary tract infection since last visit.  No complaints, no history of  fevers or upper respiratory infections since found during last visit in  1995.  Remy was switched to oral Macrodantin, however the mother states  that he hasn't been complying with that and sometimes complaining of  abdominal pain.  He has not had a surveillance culture since last visit.

His current medications include:


Remy's physical exam was notable for:
     BP 100/68   P 90   R 24   T    HT 101.8cm   WT 17.1kg
     On physical examination he is awake, alert, in no distress.  
     The head is normocranial/atraumatic.  
     Pupils equal, round and reactive to light.   
     Neck: is supple, lymph nodes not palpable.  
     Chest: is clear to  auscultation.  
     Heart:  no murmur was found.  
     Abdomen:  bowel sounds  present, no hepatosplenomegaly.  
     GU:  Testes were descended.   
     Extremities:  no deformity.  
     Skin:  no rash.  
     Neurologic examination:  intact, no meningeal signs
A urinalysis revealed:
     SPEC GR UA  1.025           WBC/HPF     -          
     PH UA       7.0             SQUAM EPI              
     WBC ENZ UA  -               RBC CAST    0          
     BLOOD UA    -               WBC CAST    0          
     PROTEIN UA  -               GRAN CAST   0          
     GLUCOSE UA  -               WAXY CAST   0          
     RBC/HPF     -               BACTERIA    -     

Laboratory studies at this time include:


     ASSESSMENT:  Remy is a 3-year-old with reflux.  Today RNC reveals no  changes in the reflux, however he is reporting that he hasn't been on  prophylaxis for months.  No urinary tract infection, no fever, no otitis  media have been documented since then.  It is important for us to  emphasize the need for prophylaxis and also routine urine cultures during follow up.  We would like to recommend urine cultures every 3 months and suggest continuing on Macrodantin 25 mg once a day for the next month.  Also we would suggest repeat the RNC in 12 months and  when the result available we would like to see him.  Meanwhile we will send a urine culture today and we will contact  the pediatrician and/or the parents if there is any positive urine  culture.

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

               Sincerely,


               Stefano Animal, MD         Mitsuko Khan, MD
               Fellow, Pediatric Nephrology Director, Clinical Services


CONTENT:
Shahin Stone, M.D.          RE: Juliet Terhune
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/19/89

Dear Dr. Stone:

     We had the pleasure of evaluating Juliet in the Renal Program on 4/20/95 for .
     Vecicoureteric reflux defined after a urinary tract infection and longer term follow up initially carried out at Mass General Hospital.  Transferred for continuity of care.

Her current medications include:
     BACTRIM 10 ml q.h.s.


Past medical history:
     As outlined vesicoureteric reflux in follow up.

Review of systems:
     Asymptomatic without febrile illness and with normal surveillance cultures.

Juliet's physical exam was notable for:
     BP /   P    R    T    HT cm   WT kg
     The patient arrived outside of clinic times after her x-rays and a formal physical examination was not performed.  A urinalysis from the catheterization showed negative urine culture.
A urinalysis revealed:


Laboratory studies at this time include:


     Vesicoureteric reflux now clear.  Ultrasound shows interval renal growth with normal appearing renal tissue and no evidence for hydronephrosis or dilatation.

     Thank you for the opportunity to participate in Juliet's care.  We would like to review her in  review will be planned only if there is a further problem.  In the interim, we would be happy to discuss or review Juliet should you or the family wish it.

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Marissa Crane, M.D.          RE: Henrietta Adamson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/16/93

Dear Dr. Crane:

We had the pleasure of seeing Henrietta in the Endocrine Program on 4/27/95 for premature thelarche.

History: Many thanks for referring Henrietta, age 24 months with precocious breast development.  This was initially noted in October 1994 by a grandparent.  There is no history of vaginal discharge or bleeding, no axillary or pubic hair, no apocrine odor and no growth spurt.  She has had a few acniform lesions on her face but does have a history of eczema and has had such acniform lesions in the past.  Her mother does have estrogen pills at home but Henrietta has no access to them.  

There is a family history, in a paternal aunt, of vaginal bleeding and premature breast development in infancy which resolved and this aunt progressed normally through puberty.  There is no history of headaches, abdominal or pelvic pain or visual disturbance.  Henrietta is very healthy and is growing and developing otherwise normally.   

The breast development has been followed over the past five months and there has been no change noted.  Initially, it was noted that only the right breast was enlarged.

Physical exam:  
Height: 89 cm           Weight: 12.6 kg         BP: 82/50               
Pulse: 80               
General: This was a healthy young girl.  
Skin: Revealed no cafe au lait spots.   
Neck: There was no goiter and she was clinically euthyroid.   
Chest: Normal. 
Heart: Normal. 
Abdomen: Normal. 
Breasts:  Tanner II breasts bilaterally.    
Genitourinary: There was no pubic or axillary hair.  The vaginal mucosa was red and Prepubertal.   
Neurological: Normal but I was unable to perform fundoscopy.

Impression: Premature thelarche without evidence of precocious puberty.   Her prior growth data do not show evidence of a growth spurt.  We explained to her parents that this is a common occurrence and that our plan would be to observe her for six months.  Today we are going to obtain a bone age.  Her mother is going to call us before six months if there is any evidence of progression.

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

Sincerely,


Rahul Ibsen, MD                
Attending in Endocrinology   


Addendum: Karen McCowan, M.D.
Fellow in Endocrinology


CONTENT:
Marissa Crane, M.D.          RE: Henrietta Adamson
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  04/16/93

Dear Dr. Crane:

We saw Henrietta in the Endocrine Program on 12/21/95 for premature thelarche.

History: Henrietta is a 2 and 8/12-year-old girl with a history of premature thelarche.  We last saw Henrietta in April, 1995 when she was first evaluated for this problem.  At that time she had small bilateral Tanner II breasts with no other signs or symptoms of precocious puberty.  Since that time Henrietta's parents report that she has been doing very well, with no further breast development.  Although they are not sure, they think that in fact, the breast tissue has reduced in size.  There has been no breast discharge, and no breast tenderness.  There is no evidence of pubic hair, as well as no vaginal discharge.  There has been no acne or apocrine odor noted.  In  addition, Henrietta has continued to grow at her normal rate.  From a general medical point of view she continues to do very well with normal development.

Current medications: None.

Physical exam:
Length: 93.7 cm       Weight: 14.2 kg
BP: 80/40             Pulse: 96               
Breast: Tanner II     Pubic hair: Tanner I    
General appearance:  Alert, active, happy caucasian girl in no distress.  
Skin:  Warm, pink, no lesions.  
HEENT:  Normocephalic/ atraumatic, pupils equal, reactive to light, extraocular muscles full.  Oropharynx clear.  
Neck: supple, no thyromegaly.  
Lymph nodes: within normal limits.  
Lungs: clear to auscultation.  
Breasts:  Tanner II; left breast approximately 0.5 cm in diameter, right breast approximately 1 cm in diameter.  No discharge.
Heart:  Regular rate and rhythm, normal S1 and S2, no murmur.  
Abdomen: soft, nontender, nondistended, no masses, no hepatosplenomegaly.  
GU:  Prepubertal external female genitalia, no pubic hair, vaginal mucosa red, no discharge.  
Extremities:  No clubbing, cyanosis or edema.  
Neurologic:  Within normal limits.

Laboratory studies:  Bone age 2 and 3/12 years at chronologic age 2 and 0/12 years.

Impression: Henrietta is a 2 and 8/12-year-old girl with a history of premature thelarche.  She has shown no further development of breasts, and in fact, has had a regression of her breast tissue.  There are still no other signs of pubertal development.  We feel that this represents a normal developmental variation, and would expect her remaining breast tissue to continue to decrease in size over time.

Disposition: Henrietta does not need to return to Endocrine Clinic unless there are any further issues which develop, or if her parents notice an increase in breast size and/or other signs of pubertal development.



Sincerely,




Yale Neptune, MD               Rahul Ibsen, MD                
Fellow in Endocrinology         Attending in Endocrinology


CONTENT:
Matlock, M.D.          RE: Rudolph Martens
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  02/08/79

Dear Dr. Matlock:

     We had the pleasure of seeing Rudolph in the Renal Program on 6/14/95 for Microscopic Hematuria.
     Shawn is a 16 year old boy who has been followed by Dr. Khan since the age of 12 with microscopic hematuria.  At presentation, he had  a raised anti-DNA of 340 Todd units, creatinine of 0.6 and BUN of 13.  His calcium  to creatinine ratio was normal at 0.02.  He had a slightly elevated  protein to creatinine ratio at that stage of .44 which has been followed  and most recently was 0.1.  His serum complements have been normal and  his serum IgA was done at his initial presentation was 151.

His current medications include:
     Doxycycline T b.i.d 14.5 mg.

Review of systems:
     He has been well.  He has noticed no episodes of  microscopic hematuria.  He has had no urinary tract infections.  His  health has been well.

Rudolph's physical exam was notable for:
     BP /   P    R    T    HT 163.7cm   WT 57kg
     General:  He was a bright, pleasant boy.
     Skin:  No rashes.  
     Neck: Supple, no masses. 
     Heart: Two heart sounds. 
     Abdomen: Soft,  nontender.  
     Genitourinary: Tanner 1. 
     Extremities: No edema.  

A urinalysis revealed:
     SPEC GR UA  1015            GLUCOSE UA  Neg.       
     PH UA       7               RBC/HPF     4-5        
     BLOOD UA    Tce             WBC/HPF     0          
     PROTEIN UA  Tce   mg/dl     BACTERIA    Neg.  
     CASTS       Some clumps of RBC and occasional strands
SQUAM EPI Rare

Laboratory studies at this time include:
          CRU       215.6   MG/DL       U PROT       27   MG/DL (H)

     Given that Shawn still has persistent microscopic  hematuria, we have tested his parents urine.  His mother has microscopic hematuria and his father has no hematuria.  The most likely  diagnosis for this is benign familial hematuria.  Poststreptococcal  glomerulonephritis is less likely since microscopic hematuria has persisted for four years.  Iga nephropathy is still possible but less likely given the urine refindings.  We will continue to follow him in this clinic and will  review him again in 12 months time.

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

               Sincerely,


               Mitsuko Khan, MD
               Director, Clinical Services


CONTENT:
Ijnanya Meisner, M.D.          RE: Bart Davis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/03/94

Dear Ijnanya,

I have asked Mrs. Davis to see you for evaluation and treatment of previously untreated familial hypophosphatemic rickets for which her daughter is the index case.

Her 2 year old, Shannon, is fairly severely affected with bowing and Mrs. Davis's 13 year old daughter (by a different father) was also reported to have "Blount's Disease" in early childhood but metabolic studies were never done. All three individuals have AM serum phosphorus levels less than 2 mg/dl. On 5/3/95, at the Children's Hosp. lab, Linda Davis had a Ca of 8.3 mg/dl, Phosphorus of 1.3 mg/dl, Alk Phos of 215 U/L PTH of 65 pg/ml. Vitamin D metabolites on her are pending.

Mrs. Davis and her 13 year old daughter are both less than 5 feet tall, although they have minimal bowing. Mrs. S has had multiple root canal procedures but no other sequelae. Fortunately, Mrs. S's one year old son is unaffected and has normal Phosphorus and Alk Phos values.

Ingrid Holm and I are rounding up the remaining members of this large pedigree for screening and DNA analysis.


Sincerely,





Nilto Carter MD
Associate in Endocrinology

cc: Mrs. Linda Davis, 41 Valley Road, Dorchester MA 02124
    Dr. Kuperstein, Quincy Pediatrics


CONTENT:
Ijnanya Meisner, M.D.          RE: Bart Davis
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  05/03/94

Dear Ijnanya,

I have asked Mrs. Davis to see you for evaluation and treatment of previously
untreated familial hypophosphatemic rickets for which her daughter is the index
case.

Her 2 year old, Shannon, is fairly severely affected with bowing and Mrs.
Davis's 13 year old daughter (by a different father) was also reported to
have "Blount's Disease" in early childhood but metabolic studies were never
done. All three individuals have AM serum phosphorus levels less than 2 mg/dl.
On 5/3/95, at the Children's Hosp. lab, Linda Davis had a Ca of 8.3 mg/dl,
Phosphorus of 1.3 mg/dl, Alk Phos of 215 U/L PTH of 65 pg/ml. Vitamin D
metabolites on her are pending.

Mrs. Davis and her 13 year old daughter are both less than 5 feet tall,
although they have minimal bowing. Mrs. S has had multiple root canal procedures
but no other sequelae. Fortunately, Mrs. S's one year old son is unaffected and
has normal Phosphorus and Alk Phos values.

Ingrid Holm and I are rounding up the remaining members of this large pedigree
for screening and DNA analysis.


Sincerely,





Nilto Carter MD
Associate in Endocrinology

cc: Mrs. Linda Davis, 41 Valley Road, Dorchester MA 02124
    Dr. Kuperstein, Quincy Pediatrics


CONTENT:
Attilio Hammer, M.D.          RE: Susan Streicher
123 Santa Clause Lane                                   CH# XX XX XX
Death Valley, CA  90210                                 DOB:  10/02/90

Dear Dr. Hammer:

We had the pleasure of seeing Susan in the Endocrine Program on 6/5/95 for .

History: We had the pleasure of seeing your patient Susan Streicher on 6/5/95.  As you know, she is a four and a half year old white female who presented with clitoromegaly which was noted on your annual check up this year.  This patient is a former 24 week preemie who was on ventilator for the first 6-8 weeks of life but came off the ventilator without complications or developing bronchopulmonary dysplasia.  She has no significant medical sequellae.

She was not exposed to medication in utero.  Her clitoris size had not previously been noted, but in retrospect, her mother thinks it may have been somewhat large.  The patient has no pubic hair or other virilizing features.  Susan has grown along the 5th percentile more or less all her life although on her last exam, you had noted that she had gained on 3/4 of a pound in the prior year.  She has since gained approximately 2 pounds in the ensuing two months.   There is no family history of virilization or any endocrinologic abnormalities.  No history of unexplained early deaths in the family.  

The labs which you drew, indicated that her testosterone was below assay level of 4.0.  Her 17 hydroxy progesterone was 20, well within normal.  The DHEA was not run because of poor specimen preparation.

Current medications: None.

Past medical history:  Notable for pregnancy which ended at 24 weeks secondary to chorioamneoitis.  Growth and development were along the 5th percentile for height and weight.  Her nutrition has been good.

Review of systems:  Negative.

Family history:  The patient's family history is unremarkable.  She has a younger sibling who was a 36 week infant and has no significant medical issues.

Physical exam:  
Height: 99.2 cm         Weight: 13.8 kg         
General: She was pale, small and in no acute distress.  
Skin: Benign.  
HEENT: Benign.  
Neck: Normal, full range of motion and supple.  No lymph nodes were palpable.  
Chest: Clear to auscultation.   
Heart: Regular rate and rhythm.  S1, S2 without murmurs.  
Abdomen: Benign.  
Genitourinary: Clitoris was .8 cm wide and 1.5 cm high.  
Extremities: Benign.  
Neurological: Grossly intact.

Impression: This is a 4 and a half year old female with clitoromegaly.  The differential diagnosis includes congenital adrenal hyperplasia, (non-salt wasting) and  gonadal dysgenesis.   She has been scheduled for an ACTH stimulation test which will be done on June 23, 1995 with results pending two-three weeks after that point.  Please feel free to call with any questions or concerns.

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

Sincerely,


Antonio Daley, MD             Ariel Adler, MD           
                             Attending in Endocrinology   


Addendum: Antonio Daley, M.D.
Fellow in Endocrinology


