Unusual Symptoms

Doctor's File Notes Follow Up Dr. OAB December 9, 2025

Notes from Care Team

A Note to Patients: Symptoms are concisely summarized to inform treatment recommendations. For reasons of privacy and brevity, this note does not attempt to capture all experiences that were discussed.

Progress Notes

CK at 12/9/2025 8:55 AM
I performed routine venipuncture to draw blood from the patient during today's visit at Center for Geriatric Care. This documentation is intended to alert coders that venipuncture service was provided at Center for Geriatric Care today.

FOLLOW UP VISIT

Assessment and Plan

Long term systemic steroid user

Patient taking hydrocortisone 5 mg BID. Patient now able to take cortisol stimulation test.
Plan:
- Cortisol stimulation test ordered and instructions regarding medication provided.
Chronic fatigue syndrome
Referral to rheumatology was declined as patient's previous testing has been normal. Continue to be concerned for polypharmacy; patient is committed to his current medication/supplement regimen prescribed by outside physician.
Plan:
- Referral to Osher for chronic fatigue
Breast pain, left
Patient with months of left nipple pain. On exam, no masses palpated. No nipple discharge.
Plan:
- Diagnostic mammogram ordered
Bilateral leg edema
Mild pitting edema on bilateral feet and ankles. Lungs are clear on exam, less concern for heart failure. Patient spends much of his day sitting at computer. Advised to elevate legs and use compression stockings. If edema does not improve or worsens, can trial furosemide and consider TTE to rule out heart failure.
Plan:
- Labs: CMP, ProBNP

Patient Instructions

Summary from our visit today:

• 1. I have ordered the cortisol stimulation test. You will need to schedule the test before 10 am at the UCSF infusion center.
•    a. The day prior to the test
•    b. Take hydrocortisone in the morning before 9 am.
•    c. DO NOT TAKE pm dose of hydrocortisone
•    d. On the day of the test
•    e. DO NOT take hydrocortisone or any other steroid in the morning until the test is completed !!!
•    f. After obtaining baseline labs, the provider will administer cosyntropin either intravenously or intramuscularly.
•    g. A second blood test will be repeated 45-60 min after the injection.
•    h. OK to resume hydrocortisone after the second blood test is completed.

Return in about 6 months (around 6/9/26)
Follow-up: Cortisone test, rheumatologist referral

History of Present Illness

Left breast pain has been present for several months. NO trauma to the area. No lumps or bumps noticed. Has not noticed if anything looks different. No nipple discharge. Maternal cousin had breast cancer. Does not hurt unless he touches the area. Localized at the nipple area.
Swollen feet has been going on for months. Not painful. Has not noticed if the swelling is worse any time of day.
If lamictal doesn't work out, Dr. MC will try Cymbalta, depakote, tegretol, trileptal. Hoping it will help with his hyperesthesia to water and improve strength.

Social History

Social History Narrative

Was living in New York in the 60s, moved to San Francisco in the 70s. Worked as a computer consultant. Retired about 8-9 years ago. To fill the time he reads the paper, visits with friends, watch TV, rest, managing money. Enjoys working on computers reading articles, going on Second Life (social environment). Lives alone with no pets. Friends live nearby. Brother lives in suburban Chicago, "sort of close", talks to him once a week. Describes the relationship as "friends". Never married. He feels he would turn to his friend Russ. Friendship with Russ and other friends and friends on Second Life bring him joy, reading brings joy. Feels like he is leading a content life.

Patient Active Problem List

• BPH with obstruction/lower urinary tract symptoms
• Prostate cancer (CMS code)
• Benign prostatic hyperplasia
• Family history of bladder cancer
• Colonic mass
• Bladder tumor
• History of elevated PSA
• Other mechanical complication of prosthetic joint implant
• Meningioma (CMS code)
• Generalized weakness
• Chronic fatigue syndrome
• Polypharmacy
• Osteopenia of neck of femur
• Anemia
• Long term systemic steroid user
• Hyperesthesia

Objective

Vitals:

• 12/09/25 0900
• BP: 122/54
• BP
• Location: Left upper arm
• Patient Position: Sitting
• Cuff Size: Adult
• Pulse: 88
• Weight: 78.8 kg (173 lb 11.2 oz)
• Body mass index is 24.45 kg/m².

• 12/09/25 122/54
• 09/10/25 124/54
• 07/29/25 124/58

• 12/09/25 78.8 kg (173 lb 11.2 oz)
• 09/10/25 78.7 kg (173 lb 8 oz)
• 07/29/25 77.6 kg (171 lb)

• Cardiovascular:
• Rate and Rhythm: Regular rhythm.
• Pulmonary:
• Breath sounds: Normal breath sounds. No wheezing.
• Chest:
• Breasts:
• Left: Tenderness present.
• Comments: Area of tenderness, no masses palpated, no nipple discharge