D.O.B.:01/03/1942; 80 yrs. 2 mo at the time of visit
Seen by JH, M.D.
Date of Encounter: 03/09/2022
Exam Reason (CC): Physical Exam
Subjective
1. Here for PE
* No new complaints, other than he stated that about every 8-9 months he feels weak.
* No new complaints, other than he stated that about every 8-9 months he gets weaker.
* He only walks about 50 steps/day
* He is seeing his usual consultants, alternative care, psychiatry, etc.
* He needs an endoscopy as well as a colonoscopy, and was referred to Dr. Ostroff. Last endo 2020 2021 (Hx of esophageal CA 5/2014) and last colonoscopy 2019 (Cecal CA 9/2014.)
Allergy:
Tamsulosin, WelChol, Lyrica
PMG:
* :Left hip pain after fracture/repair. The cement cracked Nov/2014. He had a prosthetic ball placed, but MRSA infection occurred afterward, necssitating removeal and 6 months of antibiotics, He received a prosthetic placement when the infection resolved in 2015.
* February 25. 2014 hospitalized at UCSF after sustaining loss of consciousness. The patient was found to have altered mental status, severe hypernatremia of 152, and sacral cellulitis. The patient's Hct went from 9.9 to 7.7 with a Hct of 23 during the hiospital stay. A serum Fe was low at 33. Ultrasound of abd, CT head, chest X-ray, lumbar puncture were perfoprmed. Internal bleeding did not appear to be entertained when evaluating the records sent to me from UCSF. He was sent home with a HCT of 26.
* 3/19/14. Admit, CPMC for presyncope. The caregiver said the patient was crawling on the carpeted floor on his knees, unable to stand. The patient acutely decompensated in the emergency room, necessitating intubatiion. He suffered hemmorrhagic shock. Emergency upper endo revealed a duodenal ulcer eroding into the gastroduodenal artery. He subsequently underwent duodenal artery Embolization/IR coil. He required multiple endoscopies to stop further bleeding, and 12 units of PRBC's. Gastrin levels were normal. No history of NSAID use.
* 5/30/14 upper endoscopy by Dr. LG revealed a 4 cm distal esophageal mass, adenocarcinoma, a 5cm hiatal hernia, and 6mm bulbar ulceration. Adenocarcinoma removed at GE junction 9/2014 at UCSF. Has seen Dr YB. New Dr at UCSF 2017. Bi-yearly Endos done. Last Endo 7/2020 7/2021, clear
* September 2021 I fell and fractured my left little finger. Next day CPMC Emergency X-ray and splint. 9/24/21 Dr. LV Orthapediast, X-ray and splint. 11/5/21 Dr. LV Orthapediest, X-ray and removed splint. 11/10/21 CPMC Davies Hand therapy.
* March 2013 prostate biopsies at UCSF under Dr KS showed atypical cells. Re-biopsy February 2014 showed several specimens to contain a high-grade prostatic intraepithelia neoplasia. He is currently being followed with PSA's. Next visit was supposed to be 10/2107, but by 11/2018, he has declined seeing the urologist and having further biopsies. He still refuses f/u and further Bx's as of 3/9/22.
* Adrenal adenoma. Followed by Dr. KE two to three times per year. In 2016, they told him no more f/u needed. PSA's normal.
* Renal insufficiency early 2014. In September 2014 had normal function
* HbA1C's have been mildly elevated, but less than 6.0
* Dysesthesias with water. He has "not bathed in decades." I bathe daily, but have not been able to shower in 4 or 5 years.
Dysesthesias is pain on the skin. My pain is in the muscle. It takes 5 or 6 days before it goes away. Currently I take Acetaminophin for the pain. There have been times when the pain has lasted 10 days and I needed Norco for the pain. The pain is primarily in my abdomen but it is everywhere.
* I experience what in the Fibrmyalgia community is called "muscle buzzing." It is everywhere but more noticable in my midriff.
* Vitamin D3 levels have been okay on treatment of high dose D3. Hx of deficiency.
* Psychiatry is with Dr. AK. Patient has a long history of depression requiring many meds, ECT. ECT was a big mistake. My then psychiatrist sent me to ECT without first sending me to a psychpharmacologist. I didn't need the ECT.
* Chronic fatigue
* Alternative care with Dr. MC. On numerous supplements per Dr. MC.
* Hypercholesterolemia
* Heart scan negative in 2007
* Dermatology is with Dr. VR.
* Chronic tremor
* Sleep study 2013 negative for apnea.
* Bone density 2014 osteopenia, -1.3.
* Cecal mass/colon CA seen on colonoscopy 2014. UCSF Removed Sept/2014. 0/15 nodes positive. Seeing Dr PT. CA arose out of a tubular adenoma. Last colonoscopy 1/2019, and No polyps then.
* Mediastinal lymph node biopsy Sept 2014. Benign
* Magnesium deficiency.
* B12 deficiency
* Genetic testing 5/2017 for cancer, showed no disease-causing variants, no Lynch Syndrome.
* Polypharmacy. I have discussed with him since 2008, that he has too many supplements and medications. Since 2015 he has been taking about 66 pills per day. He will not reduce them. I take 13 prescription drugs amounting to 22 pills. I take 12 supplements amounting to 29 pills.
* Neovascular AMD with active CNV OS. Avastin injections 2020. Dry AMD OD. Dr AA. Posterior vitreous detachment OU.
* Abdominal ultrasound 12/2020 9/14/21. Adrenal adenoma, no change in size.
* Podiatry every 3 weeks every 3 months for toe nail fungus.
*PSH:
* Left hip fracture September 2013 from trauma. He was told to take antibiotics with any dentistry or chance of infection.
* Tonsillectomy
* Adenocarcinoma at GE Junction removed 9/14
* Cecal adenocarcinoma/right hemicolectomy 9/2014.
* Left Hip prosthesis removal 2015.
* Left Hip replacement 2016
FH
* Mother 103. Alive and well, lost her driver's license age 98.
* Father deceased 73 bladder cancer. He had an Infant apparel business.
* Brother 76 alive and well
* No Children.
SH:
* The patient is originally from Willamette Illinois. He's been in the bay area since 1970. He lives by himself. He prefers to be alone. He went to college for one year and studied at the Illinois Institute of technology then went to New York University for night school for one year. He did obtain a stockbroker license in 1965 but did not work in the field I was a stockbroker for 3 years.. His hobby is computers.
Habits:
* Former smoker. I quit in 1969.
*Alcihol very little
* Caffeine none
* Drugs none
* Exercise none
* Diet Used to consist of frozen dinners mostly. He has improved his diet, and ordering from "Freshly."
Meds:
The meds list I provided my provider is here.
* Atorvastatin Calcium 20 mg Tab sig: TAKE 1 TABLET DAILY
* Brintellix 10 mg Tab sig: 1 tablet orally daily
* Ciclopirox 8 % Solution sig: 1 application topically to affected area daily
* EnLyte Cap sig: 1 cap in am
* Ferrous Furnarate 18 mg every other day
* Gabapentin 300 mg/6ML Solution sig: 3 BID Gabapentin 1400 mg daily
* Guaifenesin sig: 1800 mg per day Guaifenesin discontinued 2021
* Hydrocodone-Acetaminophen 5/325 mg Tab sig: prn
* L-carnitine 1,000 mg sig: 4 PO BID L-Carnitine 2000 mg/day
* Magnesium L threonate 300 mg sig: 6 caps with lunch Magnesium Glycinate 3 caps/day
* Melatonin 5 mg Tab sig: 1 orally daily Melatonin 6 mg/day
* Methylphenidate 20 mg Tab sig: 45 mg with breakfast and 20 mg noon
* Montelukast Sodium 10 mg Tab sig: 2 tabs in evening I don't take this drug
* Nuvigil 150 mg Tab
* Optizinc 45 mg sig: 1-2 caps with lunch Zinc Carnosine 16 mg/day
* Pantoprazole Sodium 40 mg Tab sig: 1 tablet orally daily
* PEG 3350-KCl-Na Bicarb-NaCl 420 GM Solution I don't take this drug
* Pure Adrenal sig: 3 tabs am, 2 at 12 noon
* Rexulti 0.5 mg Tab sig: 3 QDRexulti 2.0 mg/day
* Terazosin 2 mg Cap sig: TAKE 2 CAPSULES DAILY
* Vitamin D3 7500 IU 5000 IU/day
* Wellbutrin 100 mg Tab sig: 2 tablets orally 2 times per day
* Ziprasidone 60 mg Cap sig: 2 orally daily
* 5HTP 100 mg sig: 3 QHS 100 mg/day
* Acetaminophen Extra Strength 500 mg Tab sig: prn
* Acetyl L carnitine 500 mg sig: 2 PO PM
* CoQ10 400 mg sig: 2 PO AM
* Lubricant eye drops
* Magnesium Malate sig: 1275 mg daily I no longer take this drug
* Pure Adrenal 400 sig: 5/day
* Safe Cell glutathione sig: 300 mg bid
* SAME 400 mg sig: 5 per day
* VSL#3 Cap sig: 2 cap/day I no longer take this drug
* Acetyl-L-Carnitine 1000 mg/day
* Glutathion Suppositories 1 gm ea 4/week
* Trintellix 10 mg one cap/day
* Objective
* Vitals
BP: 148/78 HR 94 Temp: 98.4 frg F RR: 14 Ht: 71.25 in. (shoes)
Wt: 170.6 lbs. (shoes) [-0.4 from 171 lbs on 01/08/2021] BMI: 23.63 [-0.91 from 24.54 on 01/08/2021] O2: 96
PE:
GENERAL: The patient is well-developed and in no acute distress. Behavior and mentation are appropriate.
EYES: Vision is grossly intact. The pupils are equal and reactive to light. Eyes move conjugately. Funduscopic exam is unremarkable.
HENT: Normocephalic. Hearing was grossly intact. Tympanic membranes are clear. Mouth and throat reveal no abnormalities.
NECK: Supple without nodes or enlarged thyroid.
RESP: Clear to auscultation and percussion.
CVS: Regular rate and rhythm without murmur or gallop. There is no neck vein distention. Distal pulses are adequate. No carotid bruits.
ABDOM: Bowel sounds are present. There is no palpable mass, tenderness, or organomegaly.
GU: Penis and scrotum are unremarkable. There are no hernias. Hypospadia
MSS: There are no joint deformities. Range of motion is grossly within normal limits. There is no edema. Back flexion is adequate.
NS: Cranial nerves II through XII are grossly intact. Motor exam reveals symmetrical strenght. There are no sensory abnormalities. Deep tendon reflexes are symmetrical. Gait is normal. There is no tremor or ataxia.
SKIN: There are no suspicious lesions, rashes, or bruises.
LYMPH: No enlarged llymph nodes or splenomegaly.
PSYCH: No evidence of disordered thought process. Memory seems appropriate.
RECTAL: There no anal lesions. No rectal masses. Prostate exam, reveals a 2+ size gland without nodularity or infiltration.
Data: Glutathione L 646 02/08/2022