Virtual_proofer_7a HISTORY AND PHYSICAL EXAMINATION HISTORY He is a 75-year-old gentleman referred by his wife for evaluation of a bunch of blood

tests that were recently done. They included glycohemoglobin of 6.1, he eats sweets, a mild anemia, hematocrit 34, but no other tests were done in this regard, a mildly reduced vitamin D, he is not taking any, and borderline elevated 5.89 TSH; FTI normal at 2.3, normal 1.4 to 3.8. He carries diagnosis of hyperlipidemia, hypertension, gout, BPH. CURRENT MEDICATIONS His current medications include allopurinol, Crestor 10, Diovan 320, Flomax 0.4, labetalol 200 twice a day, potassium citrate 540 two tablets twice a day. ALLERGIES He has no known drug allergies. SOCIAL HISTORY: Engineer, retired, married, one child. No smoking, rare or occasional alcohol. No drug abuse. review of systems: He has had a hernia repair. No other significant review of systems. PHYSICAL EXAMINATION VITAL SIGNS: He had a Blood pressure of 130/74, pulse 72, respirations 12, weight 167 pounds. NECK: No JVD. No carotid bruits. No lymphadenopathy. No thyromegaly. CHEST: Chest was clear. Coarse. HEART: S1, S2 within normal limits. No S3, S4, or murmur. ABDOMEN: Endomorphic. EXTREMITIES: Peripheral pulses 2+. No peripheral edema. PLAN I reminded him, as I had told his wife before, he has a card, home number, office number, email, fax, and my cell phone. So, if he ever has questions, he can call me. So, we told him today step-by-step is that he has impaired glucose tolerance. It is not diabetes, but it is not normal. We will try a diet first, which means no sweets. We discussed that in detail, but he can have one fruit with each meal, one calorie per serving soda and Jell-O, and he can have bread, rice, potatoes, but he must get rid of the sweat stuff and we will reevaluate when he comes in. For blood pressure, his pressure is under control. We can keep the same medicine. Unclear why he is taking potassium, but his potassium is normal at 4.6, so we will keep it. Hyperlipidemia, we do not have a recent cholesterol, so he will keep the same medicine. We will reevaluate. For BPH, his PSA was recently normal, 2/10, so we are not worried at the present time. For vitamin D, we are going to give him a prescription for 1000 units a day, but he can get it over the counter, and for anemia, we are going to check a wide screen of blood tests, making sure there is no serious cause. I should note he had a colonoscopy in 2008, which is reassuring. Also, he has a mildly elevated TSH, but it might be normal for age, given our new

knowledge about TSH. He has no symptoms, so we are going to watch his thyroid function and TSH over time and then make a decision if we should give him thyroid hormone. We will make an ambulatory visit for 6 weeks, but we will see him in 3 months. Actually, more important, he will get the blood test about a week before and then bring in the blood test when he comes in the next time. If he has any problems between now and 3 months, he will call me. Virtual_proofer_7b

SUBJECTIVE A 38-year-old man is here for followup after being seen at the ***** Hospital Emergency Room on December 19th because the day or two before that he had been developing episodes of what felt like palpations with feelings of tightness in his chest and trouble getting enough air and feeling somewhat winded. He was observed in the emergency room where his monitor apparently was okay. They did an EKG and chest x-ray and some blood work and felt he was fine and dismissed him to follow up here. He continues to have occasional spells of palpitations. In fact, yesterday was a good day, but this morning he had some regular heartbeats that he could feel in his chest. He gets these spells of tightening in the chest that come and go, not directly correlated to activity. He feels like he has air trapped in his lungs. He is not having any coughing or fevers. He smokes a pack and a half per day. Drinks 3 pots of coffee per day and has had a rough year with stress. His mother died this year. December is also the anniversary month for his father's death. His wife thinks he needs an antidepressant. He also has a history of borderline sleep apnea evaluated about 4 years ago, did not need CPAP, was recommended to sleep on his side. His wife still observes that he has spells where he stops breathing at night. He has not noticed any worsening in how he feels in that regard. PHYSICAL EXAMINATION vital signs: Temperature 98.4, blood pressure 118/70, pulse 100, respirations 16. General: A well-developed, well-nourished appearing man, in no distress. Neck: No adenopathy or thyromegaly. Lung: Exam is clear. Heart: Regular rate and rhythm. No murmurs. ASSESSMENT 1. Complaint of palpitations, atypical chest tightening, and dyspnea - may all be stress-induced, but also he is using enough caffeine and nicotine to stimulate irregular heartbeats. 2. Intermittent dyspnea, may be stress-induced, but also he may have some chronic obstructive pulmonary disease going on, given his chronic smoking. PLAN We are go to go ahead and order a 24-hour Holter monitor and pulmonary function studies with and without bronchodilator. In the meantime, he may try Ativan 0.5 mg 1 b.i.d. to see if it helps, improve how he feels, which would be reassuring for him. I also asked that he try to start cutting back on his caffeine intake, needs to consider why he is still smoking and try to quit. We are going to sit up followup in about 4 weeks and we will decide where we need to go from there. I did briefly talk to him about antidepressants as well and what they can do for him. The patient was not inclined to start something like that right now.

Virtual_proofer_7c LETTER Today, I had the pleasure of seeing our mutual patient, *****, in followup in the ***** Clinic at ***** on **/**/****. As you know, the patient has a history of ischemic heart disease and aortic valve disease and has struggled with symptoms of chronic heart failure. More specifically, he had difficulty with right-sided heart failure. His left ventricular function had actually improved a good deal, and he was somewhat intolerant of beta-blockers, and his renal function precluded our ability to prescribe ACE inhibitors or ARBs. Despite all this, he settled down very nicely in the past year or two. He comes in today in routine follow up, and although he does have Unna boots in place for venous ulcerations in his legs, his heart failure symptoms are nicely controlled. He fatigues easily and does develop exertional dyspnea. However, his edema and abdominal bloating are doing better. His medications include Synthroid 75 mcg daily, Celebrex 100 mg b.i.d., aspirin 81 mg daily, torsemide 100 mg daily, calcium carbonate 500 mg t.i.d., multivitamin daily, warfarin as directed, Zoloft 100 mg daily, Prilosec OTC 20 mg daily, Flonase p.r.n., Lantus and NovoLog insulin as directed, allopurinol 100 mg daily, simvastatin 40 mg daily, saw palmetto daily, vitamin C 1000 mg daily. On examination, his blood pressure is 124/78 with a pulse of 76 and regular. His weight is 223 pounds, which is stable. His venous pressure is normal with no hepatojugular reflex demonstrable. His pulses have normal upstrokes and volumes. His lungs are remarkably clear to auscultation. His chest reveals a left ventricular impulse that is sustained and just beyond the midclavicular line. His first heart sound is normal and his second heart sound splits paradoxically. I could not appreciate a gallop. There is a soft systolic murmur in the outflow tract. His abdomen reveals no gross organomegaly, and he has edema down at the ankles to the midcalves, but none above that. I think the patient is doing nicely with his cardiovascular disease at this point and I would not recommend a change. We will see him in followup in 6 months. I did order an echocardiogram as it has been quite some time since we have reevaluated his heart function. Please feel free to contact me with any questions or concerns. I have noticed you were following his laboratories and they had been quite stable of late.

Virtual_proofer_7d OPERATIVE REPORT PREOPERATIVE DIAGNOSIS Soft tissue forehead mass. POSTOPERATIVE DIAGNOSIS Soft tissue forehead mass.

OPERATION PERFORMED Excision of soft tissue forehead mass. ANESTHESIA Lidocaine 1% with epinephrine. ANESTHESIOLOGIST None. SPECIMEN Soft tissue mass, forehead. ESTIMATED BLOOD LOSS Less than 20 cc. INDICATION Ingrowing mass on the forehead. FINDINGS A fatty mass. PROCEDURE The patient was placed on the stable in supine position and the forehead was prepped and draped in the usual fashion. Incision was marked over the visible mass and infiltrated with 1% Xylocaine solution. Incision was made with a scalpel blade and there was significant amount of bleeding, which was unable to be controlled with the cautery, so that Xylocaine with epinephrine was ejected and this completely stopped the bleeding. We were able to work down through the subcutaneous tissue and on to the capsule of the mass. Once on the capsule of the mass, we quickly realized there was a lipoma. We were able to open the capsule of the mass and dissect the lipoma free from the surrounding tissue using blunt dissection until we were able to completely deliver the mass out of the wound. We removed the mass in its entirety making the final disconnections with Bovie electrocautery. We searched the wound copiously and so no evidence of bleeding and approximated the deep fashion layer using 4-0 Vicryl interrupted sutures. We then approximated the subcutaneous tissue with 4-0 Vicryl interrupted sutures and we approximated the skin with a Dermabond glue dressing. The patient was taken to recovery room in table condition. All counts reported as correct.