Unusual Symptoms

Doctor's File Notes Physical Exam July 26, 2023


Patient Name:

D.O.B: 01/03/1942; 81 yrs 6 mos at the time of visit

Date of Encounter: 07/26/2023
Exam Reason (CC): Physical Exam

Subjective
1. Here for PE
   * No new concerns
   * He started amitriptyline 100 mg 6-8 weeks ago
   * He stopped terazocin and finastride

2. BPH
   * Discussed with him that he needs to see urology if he has reduced stream after stopping finasteride
3. COVID prevention
   * He states that her has never had COVID
   * 5 Mooderna shots. Last one was the bivalent 11/2022

Allergy:
   * Tamsulosin
   * WelChol

PMH:

   * Left hip pain after fracture/repair. The cwement cracked Nov/2014. He had a prosthetic gball placed, but MRSA infection occured afterward, necessitating removal 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, sever hypernatremia of 152, and sacral cellulitis. The patient's Hdt went from 9.9 ti 7.7 wuth a hCT OF 23 DURING THE HOSPITAL STAY. a SERUM fE WAS LOW AT 33. yKTRAsioyuynd if agbem CT head, chest X-ray. lumbar puncture were performed. Internal bleeding did not appear to be entertained when evaqluating 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 carpe3d floor on his knees, unable to stand. The patient acutely decompensated in the emergency room, necessitating intubastion. He suffered hemmorrhagic shock. Emergency uppper endo revealed a duodenal ulcer eroding into the gastroduodenal artery. He subsequently underwent duodenal artery Embolization/IR coil. He required multiople endoscopies to stop further bleeding, and 12 units of PRBC's. Gastrin levels were normnal. No history of NSAID use.



   * 5/30/14 upper endoscopy by Dr. LG revealed a 4 cm distal esophageal mass, adenocarcinoma, a 5 cm hiatal hernia, and 6 mm bulbar ulceration. Adenocarcinoma removed at GE junction 9/2014 at UCSF. Has seen Dr. YB. New Dr at UCSF . Bi-yearly Endos done. Last Endo 7/2020,w clear.



   * March 2013 prostate biopsies at UCSF under Dr. KS showed atypical cells. Re=bioopsy 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 10/2017,but by 11/20/2018 he has declined seeing the urologist and having further biopsies. He still refuses f/u and further Bx's as of 2/9/22, 7/26/2023. He did see Dr. AS at UCSF 10/2022.



   * Adrenal adenoma. Followed by Dr. LE twp tp thjree to,es [er uear/ Om 2016, they told hjim no more f/u needed. PSA's normal.



   * Renal insufficiency early 2014. In September 2014 had normal function.



   * HBa1C's have been mildlyu elevated, but less than 6.0.



  * Dysesthesias with water. He has "not bathed un decades."



   * 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.



   * Chronic Fatigue



   * Alternative care with Dr. C, On numerous supplements per Dr. c.



   * Hypercholesteroiemia



   * Heart scan negative in 2007.



   * Dermatology is with Dr. R.



   * Chronic tremor



   * Sleep study 2013 negative for apneaq



   * Bone density 2014 osteopenia, -1.3.



   * Cecal mass/colon DA seen on colonoscopy 2014. UCSF Removed Sept/2014. 0/15 nodes positive. Seeing Dr. PT. CA arose out of a tublar adenoma. Last colonoscopy/endo 6/12/23 tubular and sessile serrated, endo normal. Recheck 2026.



   * Mediastinal lymph node biopsy Sept. 2014. Benign.



   * Magnesium deficiency.



   * B12 deficiency



   * Podiatry every 3 weeks



   * Calcium ion channel Ab's detected 2022 per Dr. C.



PSH:

   * Left hip fracture September 2013 from trauma. He was told to take antibiotics with any dentistry or chance of infection.



   * Tonsillectomy



   * Adenodarcinoma at GE Jundtion removed 9/2014.



   * Cecal adenocarcdinoma/right hemicolectomy 9/2014.



   * Left Hip prosthesis removal 2015



   * Left Hip replacement 2016.



PH:

   * Mother 103. Alive and well, lost her driver's license age 98.



   * Father deceased 73 bladder cancer. He had an infant apparel business.



   * Brpther 78 alive ane well.



   * No children



SH:

   * The patient is originally from Wilmette Illinoiw. He's been in the bay area since 1970. He lives by himself. He prefers to be alone. He went to dollage for one year and studied at the iLLINOIW inwtitute of Tedhonology th3en went to New York University for night sdhool. He did obtain a stodkbroker license in 1965 bu did not work in the field. His hobby is computers.



Habits:

   * Former smoker



   * Alcohol none



   * Caffeine none



   *Drugs none



   *Exercise none



   *Diet used to consist of frozen dinners mostly. He has improved his diet, and ordering from "fADTOR 75."



Meds: See attached list.

Objective

Vitals:

   BP: 126/70 HR: 102 Temp: 97.6°F RR: 14 Ht: 69 in. Wt: 157 lbs. [-163.8 from 173.8 on 09/28/22} BMI: 23.18 {-0.89 from 24.07 on 09/28/2022} O2: 96.