June 24, 2014
Patient noted green stool for a few days about 7 days ago. He
takes green tea capsules, glucosamine, vitamin D, metamucil. He
has had some heartburn at times.
Medications:
METFORMIN 500 mg twice daily
DIFLUNISAL - 500 mg Tablet - one Tablet(s) by mouth daily as
needed for arthritic pain
FINASTERIDE 5 mg Tablet - one Tablet(s) by mouthdaily
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg Capsule
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Capsule
MULTIVITAMIN - (OTC)
Glucosamin/chondroitin
Over the counter antihistamines
Flonase
Irrigate nose with saline daily
Astelastine nasal
green tea capsules, glucosamine, vitamin D, metamucil
Allergies: none
Past medical history:
-Sinus problems had deviated septum and sees Dr. who
operated on him in 2012 with good effect.
-Diabetes A1c 7.6 in 2011. A1C 6/24/2013 12.2
-Knee surgery left knee replaced
-Hip replaced on right side
-Symptomatic internal hemorrhoids
-Banded x 4
-Colonoscopy 2001, 2007, 2012 small adenomas and tics history of
polyps
-prostate high PSA negative biopsy 2007 sees Dr. Eyre
-CPAP machine for sleep apnea 9 mm
-high cholesterol
-high blood pressure
-Sleep apnea on CPAP
-pneumovax
6/24/2014
Family history:
Mother: aneurysm on kidney died at age 90
Father: anemia died at age 87
Brother: thyroid cancer age 67. Brother: melenoma.
Social history: no smoking, very little alcohol. Married
3 children. Sales executive.
Review of systems: Patient denies chest pain, dyspnea, orthopnea,
PND, leg edema, Lightheadedness, syncope, palpitations, ongoing
sinus pain and ear pain, no chest pain and exercises, no
shortness of breath, not depressed, sleeps okay, bowel movements
and urination are good.
Assessment of any Cognitive Impairment:
Patient alert oriented with no cognitive impairment
Depression Screening:
Over the past 2 weeks, patient expresses normal interest/pleasure
in activities.
Over the past 2 weeks, the patient has not felt down, depressed
or hopeless.
Functional Ability:
Patient exhibits a steady gait and has no trouble getting up and
walking from a sitting position.
Patient is self-reliant and able to do household chores.
Patient can handle their own medications.
Patient can handle their own money.
Patient has no difficulty with hearing or site and feels safe in
abode.
Advance Care Planning was discussed and patient will consider
code status and get back in touch with me.
Physical examination: gentleman in no distress. Height 67 inches.
Weight 244 pounds. Pulse 81. Oxygen saturation 98 percent. Blood
pressure 118/76. Thyroid: normal. Lungs: clear. Heart: regular.
No murmurs. Abdomen: soft and nontender. Extremities no edema.
Skin: no suspicious nevi.
Plan:
We discussed the need to lose weight and we discussed in depth
today a weekly intermittent fasting diet of 600 calories and he
is going to try this. I scolded him that we need to really follow
up on his diabetes and we will get blood test today and he's to
call me in a week to go over them; he will come back in 2 months
so we can see how everything's going with a diet and the need for
change in medication. I told him the diabetes will accelerate
heart disease and many other disease processes and so we need to
get on top of his.
Called 6/25/14: A1C 12.2 increase Metformin to 1000 twice daily
and schedule appointment to consider victozia.
Note Date: 06/25/14
June 26, 2014
Patient had a physical exam with me on 6/24/14 and have blood
test. His hemoglobin A1 C came back at 12.2 and I called him
today and asked him to come in immediately.
Medications:
METFORMIN 500 mg twice daily
DIFLUNISAL - 500 mg Tablet - one Tablet(s) by mouth daily as
needed for arthritic pain
FINASTERIDE 5 mg Tablet - one Tablet(s) by mouthdaily
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg Capsule
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Capsule
MULTIVITAMIN - (OTC)
Glucosamin/chondroitin
Over the counter antihistamines
Flonase
Irrigate nose with saline daily
Astelastine nasal
green tea capsules, glucosamine, vitamin D, metamucil
Allergies: none
Past medical history:
-Sinus problems had deviated septum and sees Dr. who
operated on him in 2012 with good effect.
-Diabetes A1c 7.6 in 2011. A1C 6/24/2013 12.2
-Knee surgery left knee replaced
-Hip replaced on right side
-Symptomatic internal hemorrhoids
-Banded x 4
-Colonoscopy 2001, 2007, 2012 small adenomas and tics history of
polyps
-prostate high PSA negative biopsy 2007 sees Dr. Eyre
-CPAP machine for sleep apnea 9 mm
-high cholesterol
-high blood pressure
-Sleep apnea on CPAP
-pneumovax 6/24/2014
-Shingles vaccine 6/25/14
Review of systems: Patient denies chest pain, dyspnea, orthopnea,
PND, leg edema, Lightheadedness, syncope, palpitations, ongoing
sinus pain and ear pain, no chest pain and exercises, no
shortness of breath, not depressed, sleeps okay, bowel movements
and urination are good.
Physical examination: gentleman in no distress.
I demonstrated injection of victozia in office and educated
patient and he is able to inject drug.
Plan:
A1C 12.2 increase Metformin to 1000 twice daily and victozia
started at 0.6 for one week and then 1.2 thereafter and warned
about risk of pancreatitis and thyroid cancer. If tolerates
victozia will switch Bydureon(exenatide microspheres). Will test
sugars daily and will get urine protein/albumin ratio.
July 17, 2014
Patient had a physical exam with me on 6/24/14 and have blood
test. His hemoglobin A1 C came back at 12.2 and I called him
today and saw him on the next day 6/25/14 and started him on
victozia. On this medication he has noted less appetite. He also
has no epigastric pain but more burping and some lower abdominal
cramps. He doesn't have diarrhea. I had also increased his
metformin to 1000 mg from 500 twice daily.
Medications:
Victoza 1.2
METFORMIN 1000 mg twice daily
DIFLUNISAL - 500 mg Tablet - one Tablet(s) by mouth daily as
needed for arthritic pain
FINASTERIDE 5 mg Tablet - one Tablet(s) by mouthdaily
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg Capsule
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Capsule
MULTIVITAMIN - (OTC)
Glucosamin/chondroitin
Over the counter antihistamines
Flonase
Irrigate nose with saline daily
Astelastine nasal
green tea capsules, glucosamine, vitamin D, metamucil
Allergies: none
Past medical history:
-Sinus problems had deviated septum and sees Dr. who
operated on him in 2012 with good effect.
-Diabetes A1c 7.6 in 2011. A1C 6/24/2013 12.2
-Knee surgery left knee replaced
-Hip replaced on right side
-Symptomatic internal hemorrhoids
-Banded x 4
-Colonoscopy 2001, 2007, 2012 small adenomas and tics history of
polyps
-prostate high PSA negative biopsy 2007 sees Dr.
-CPAP machine for sleep apnea 9 mm
-high cholesterol
-high blood pressure
-Sleep apnea on CPAP
-pneumovax 6/24/2014
-Shingles vaccine 6/25/14
Family history:
Mother: aneurysm on kidney died at age 90
Father: anemia died at age 87
Brother: thyroid cancer age 67. Brother: melenoma.
Social history: no smoking, very little alcohol. Married
3 children. Sales executive.
Review of systems: Patient denies chest pain, dyspnea, orthopnea,
PND, leg edema, Lightheadedness, syncope, palpitations, ongoing
sinus pain and ear pain, no chest pain and exercises, no
shortness of breath, not depressed, sleeps okay, bowel movements
and urination are good.
Physical examination: gentleman in no distress. He is frequently
burping. He also has some nausea. Height 68 inches. Weight 234
pounds. This is a loss of weight of 10 pounds in 3 weeks.
Blood-pressure 118/75. Pulse 88. Lungs clear. Heart regular.
Abdomen is soft and nontender there is no epigastric tenderness
or anything suggestive of pancreatitis.
Assessment and plan:
Patient's insurance company does not cover Victoza I had given
him samples of this and he will now be transitioned to the once
weekly Bydureon(exenatide microspheres). 2 mg every 7 days. He
has had symptoms of increased burping and gas off and on for a
year now worse and on increased metfromin. Plan will start
Omeprazole 20 mg and plan upper endoscopy. Sudden onset of
worsening diabetes and abdominal symptoms will get CT to exclude
pancreatic problem.
I am writing to report the results of your recent Pathology test:
Gastrointestinal mucosal biopsies, four:
1. Gastroesophageal junction:
- Squamous mucosa with a rare eosinophil, likely nonspecific.
- Scant glandular gastric-type epithelium, within normal limits.
- No intestinal metaplasia identified in this limited sample.
2. Gastric body:
- Fundic mucosa, within normal limits.
3. Gastric antrum:
- Antral mucosa with regeneration of gastric pits, consistent
with a chemical-type gastropathy.
4. Duodenum:
- Duodenal mucosa, within normal limits.
All okay on biopsies.
August 5, 2014
Thank you very much for referring Mr. to me. As you
know, he was found to have type 2 diabetes about two years ago,
but the chances are that he had it longer than that. He has two
recent A1c levels of 12.2 and 10.5%. He has been trying several
medications. He is taking Byetta 10 mg subcutaneously twice a
day without any problems. On the other hand, he continues to
have problems with metformin. He feels nauseated. He does not
have any diarrhea. He does not have all his energy with this. I
think that at this point we should stop the metformin and try
some of the other oral agents.
At one point, he did get a prescription to get a Bydureon, but he
could not get it because it was out of stock at the pharmacy. He
also is trying to take Victoza, but it was not covered by his
insurance.
He sleeps well at night. He gets up in the morning feeling
somewhat nauseated. He is not exercising. He is not testing his
blood sugars.
He also has hyperlipidemia and he is taking simvastatin 20 mg a
day, which is controlling his lipids quite well except for a mild
increase in triglycerides. A recent CAT scan shows that he has
significant fatty liver.
His blood pressure is very well controlled with Dyazide and he
takes that everyday.
He also has gastroesophageal reflux for which he takes 20 mg of
omeprazole.
He had had problems with his knees and is taking glucosamine.
He was found to have low levels of vitamin D and is taking 2000
units of vitamin D everyday.
His review of systems is not very contributory. He has a dry
mouth and nausea. He gets up at night to urinate, but not very
often.
He is also taking finasteride for an enlarged prostate. About
seven years ago, he had several biopsies of the prostate taken by
Dr. This was all normal and his PSA has significantly
decreased by now with the finasteride.
He feels hot most of the time. He gets up in the morning feeling
fine. He has no problems relaxing. He has very little stress in
his life at the present time.
His usual weight is 236 pounds for his height of 5 feet 9 inches.
Ideal weight for him would be about 200 pounds. He is not
watching his diet that much at the present time.
Past surgical history includes a left total knee replacement and
right total hip replacement, both of them done at the Baptist.
He does not drink alcohol and he does not smoke. He exercises by
playing golf and going to the gym at least once a week under
normal circumstances, but now with the nausea feeling he is
unable to do. He works for 40 hours a week.
His father died of cancer. Mother died of a blood clot. He has
a brother who died of melanoma. He has two daughters and a son
who are all healthy.
On physical examination today, his weight is 237 pounds, blood
pressure 130/80. Examination of the head; ear, nose, and throat
is normal. He has no retinopathy. He has very mild lens
opacities. Both ear canals are completely normal. Neck reveals
normal carotid pulsations without any bruits. Thyroid glands
palpated within the normal limits. Skin examination is normal
except for minimal keratoses in the back of his chest. Spine is
straight with no kyphosis. Muscle mass is normal for his age and
sex. Lungs are clear to auscultation. Heart sounds are normal
sinus rhythm with no murmurs. Abdomen is soft and nontender.
Liver is barely palpable on the right upper quadrant. Upper
extremities are completely normal. Lower extremities showed
excellent pulses, absent ankle jerks, but normal knee jerks. He
has mild decrease in vibratory sensation. Filament sensation is
completely normal.
With Mr. we need to get him to lose weight, at least 20
pounds, and also to normalize his blood sugars. These feeling of
nausea and that he has is most likely due to metformin. He is
one of these unfortunate persons who cannot tolerate these
medications. We are going to stop it at the present time and he
should slowly start feeling better in the next couple of days. I
am going to start him on Onglyza once a day. We are going to add
a little bit of glipizide in the form of 10 mg twice a day. He
will continue on the Byetta for the time being. Later on, as he
is losing more weight. We are going to try to cut down on the
oral agents, particularly on the glipizide.
We are going to give him a glucose meter for him to start
checking his blood sugars initially twice a day. He is going to
do it fasting in the morning and two hours after a meal. I will
ask him to give me a call in about two weeks with the results of
his blood sugars.
As soon as he starts feeling better, we are going to ask him to
start walking and playing more golf. We are also going to ask
him to start going to the gym to help him with the weight loss.
.
Active Medication list as of 08/06/14:
Medications - Prescription
DIFLUNISAL - diflunisal 500 mg tablet. one Tablet(s) by mouth
daily as needed for arthritic pain
EXENATIDE [BYETTA] - Byetta 10 mcg/dose(250 mcg/mL)2.4 mL
subcutaneous pen injector. one injection sq twice daily
FINASTERIDE - finasteride 5 mg tablet. one Tablet(s) by mouth
daily - (new list)
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. one puff(s) nare once daily
GLIPIZIDE - glipizide 10 mg tablet. one tablet(s) by mouth BID ac
HYDROCORTISONE ACETATE [ANUCORT-HC] - Anucort-HC 25 mg
suppository. 1 Suppository(s) rectally at bedtime Use three
nights prior to you next appoinment and as needed for rectal
bleeding
HYDROCORTISONE-PRAMOXINE - hydrocortisone-pramoxine 2.5 %-1 %
rectal cream. 1 Drop Topically twice a day as needed for itching
Apply to perianal area for itching
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. one
capsule(s) by mouth daily
ONDANSETRON - ondansetron 4 mg disintegrating tablet. one
tablet,disintegrating(s) by mouth up to four times daily prn
vomiting
SAXAGLIPTIN [ONGLYZA] - Onglyza 5 mg tablet. one tablet(s) by
mouth once a day
SIMVASTATIN - simvastatin 20 mg tablet. 1 Tablet(s) by mouth once
a day
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - Dyazide 37.5 mg-25 mg
capsule. one Capsule(s) by mouth daily
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 1,000
unit capsule. one Capsule(s) by mouth daily - (OTC)
MULTIVITAMIN - multivitamin capsule. 1 Tablet(s) by mouth once a
day - (OTC)
HISTORY OF PRESENT ILLNESS: comes in today after his
recent visit. He had had an episode of diarrhea with some nausea
and vomiting last night, probably related to something that he
ate. What is of concern to him is that his urine was very dark.
He was concerned that there was something going on with his
urine.
PHYSICAL EXAMINATION:
ABDOMEN: On physical examination, his abdomen was completely
normal.
VITAL SIGNS: Blood pressure was 120/70. His pulse was 72 per
minute. His temperature was normal.
ASSESSMENT AND PLAN: Up on analyzing the urine, it was
completely normal. He then remembered having eating some beets
the night before and we believe that that is the cause for the
changes in the color of his urine.
Note Date: 11/19/14
Medications - Prescription
DIFLUNISAL - diflunisal 500 mg tablet. one Tablet(s) by mouth
daily as needed for arthritic pain
EXENATIDE [BYETTA] - Byetta 10 mcg/dose(250 mcg/mL)2.4 mL
subcutaneous pen injector. one injection sq twice daily
FINASTERIDE - finasteride 5 mg tablet. one Tablet(s) by mouth
daily - (new list)
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. one puff(s) nare once daily
GLIPIZIDE - glipizide 10 mg tablet. one tablet(s) by mouth BID ac
HYDROCORTISONE ACETATE [ANUCORT-HC] - Anucort-HC 25 mg
suppository. 1 Suppository(s) rectally at bedtime Use three
nights prior to you next appoinment and as needed for rectal
bleeding
HYDROCORTISONE-PRAMOXINE - hydrocortisone-pramoxine 2.5 %-1 %
rectal cream. 1 Drop Topically twice a day as needed for itching
Apply to perianal area for itching
NYSTATIN-TRIAMCINOLONE - nystatin-triamcinolone 100,000
unit/gram-0.1 % topical ointment. apply locally twice a day
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. one
capsule(s) by mouth daily
ONDANSETRON - ondansetron 4 mg disintegrating tablet. one
tablet,disintegrating(s) by mouth up to four times daily prn
vomiting
SAXAGLIPTIN [ONGLYZA] - Onglyza 5 mg tablet. one tablet(s) by
mouth once a day
SIMVASTATIN - simvastatin 20 mg tablet. 1 Tablet(s) by mouth once
a day
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - Dyazide 37.5 mg-25 mg
capsule. one Capsule(s) by mouth daily
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 1,000
unit capsule. one Capsule(s) by mouth daily - (OTC)
MULTIVITAMIN - multivitamin capsule. 1 Tablet(s) by mouth once a
day - (OTC)
--------------- --------------- --------------- --------------HISTORY OF PRESENT ILLNESS: Mr. comes in because of the
recent onset of constipation. In the past, he had problems with
hemorrhoids that required treatment here at the medical center.
He was doing very well for the last five or six months. For the
last couple of weeks, he noticed that he has significant
constipation. He has been taking Metamucil and stool softener
every day. He also has some lower abdominal discomfort. He may
go for two days without moving his bowels. Then, it will take
him an hour to relieve himself.
He is taking all his usual medications including Byetta 10 mg
twice a day. His blood sugars are more or less controlled with
occasional increases up to 116 mg/dl. He put on 9 pounds in
weight.
PHYSICAL EXAMINATION:
GENERAL: Today, he has 2 to 3+ external hemorrhoids. He also
has 1+ internal hemorrhoid. Rectum is completely empty. His
prostate is slightly enlarged. Guaiac is negative. He had, had
a colonoscopy recently.
ASSESSMENT AND PLAN: I am going to give him an appointment to
put outside around the hemorrhoid because that might be playing a
role in his constipation. I will ask him to increase the stool
softener to two a day and Metamucil also to twice a day. We will
wait about two weeks and see if he gets better or not.
.Procedure
Tissue received Report Date
date
11/08/2012
11/08/2012
Previous biopsies: 12-43038C
07-48174C
07-22531C
05-01871C
(and more)
Diagnosed by
11/12/2012
DR. I
GI BX (2 JARS)
NEEDLE PROSTATE BIOPSIES 12.
COLON BX (1).
PROSTATE BX'S.
DIAGNOSIS:
1. Nasal sinus contents, right (A):
Sino-nasal type mucosa with fibrosis, squamous metaplasia and chronic
inflammation including eosinophils; bone fragments.
2. Nasal sinus contents, left (B):
Sino-nasal type mucosa with fibrosis, squamous metaplasia and chronic
inflammation including eosinophils; bone fragments.
Clinical: Chronic sinusitis; turbinate hypertrophy.
Gross: The specimen is received fresh in two parts, both labeled with the the
medical record number.
Part 1 is additionally labeled "right nasal sinus contents." It consists of multiple
pink-tan fragments of tissue measuring 2.0 x 1.5 x 0.4 cm in aggregate. The
specimen is placed in histo wrap and entirely submitted in cassette A.
Part 2 is additionally labeled "left nasal sinus contents." It consists of multiple
pink-tan fragments of tissue measuring 1.9 x 1.6 x 0.4 cm in aggregate. The
specimen is placed in histo wrap and entirely submitted in cassette B.