PINNACLECARE MEMBER:
This clinical summary is based exclusively upon medical records obtained and provided by PinnacleCare. The patient has never been seen or examined by Dr. Jeffrey Farber.
The patient’s current physicians include:
1. Dr. Joe E. Doctor, Primary Medical Doctor, PinnacleCare, 250 West Pratt
Street, Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212. Last visited 01/01/07.
2. Dr. Jane E. Doe, psychiatrist, PinnacleCare, 250 West Pratt Street, Suite 1100,
Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, recurrent major depressive disorder, dysthymic disorder, anxiety disorder, last seen 01/01/07.
3. Dr. James E. Smith, orthopedic surgeon at PinnacleCare, 250 West Pratt
Street, Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, spinal stenosis s/p laminectomy and fusion, diffuse osteoarthritis s/p b/l TKR, last seen 08/15/06.
4. Dr. Mary S. Thomas, gastroenterologist, PinnacleCare, 250 West Pratt Street,
Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, treating ischemic colitis, last visited 10/28/06.
5. Dr. Sue Q. Brown, pain management, PinnacleCare, 250 West Pratt Street,
Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, treating chronic diffuse osteoarthritic pain, last visited on 05/15/06 for epidural steroid injection for post laminectomy syndrome.
6. Dr. Janet P. Miller, ophthalmology, PinnacleCare, 250 West Pratt Street, Suite
1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, cataracts, last visited 09/01/06.
The patient’s past physicians include:
1. Dr. Sara T. Williams, cardiologist, PinnacleCare, 250 West Pratt Street, Suite
1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, for mitral valve prolapse and hypertension.
2. Dr. Charlie M. Adams, PinnacleCare, 250 West Pratt Street, Suite 1100,
Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, dermatology, treated actinic keratoses on 11/30/05.
3. Dr. Tory G. Lopes, neurologist, PinnacleCare, 250 West Pratt Street, Suite
1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, right C 5-6 cervical radiculopathy, last seen 01/19/05.
4. Dr. Margaret H. Jessup, gynecology, PinnacleCare, 250 West Pratt Street,
Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, performed endometrial biopsy 2006.
5. Dr. Steve P. James, general surgeon, PinnacleCare, 250 West Pratt Street,
Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212, last operation was cholecystectomy and ventral hernia repair on 07/05/05. Previously treated ischemic colitis with a right hemicolectomy May 2001.
The patient’s regional medical facility/hospital is:
PinnacleCare, 250 West Pratt Street, Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212
The patient’s local medical facility/hospital is:
General Hospital, 250 West Pratt Street, Suite 1100, Baltimore, Maryland 21201, phone 800.555.1212, fax 800.555.1212
Problem List:
1. Osteoarthritis: symptomatic with chronic nonmalignant pain in lumbar
and cervical spine, both shoulders and knees s/p b/l TKR, with less disease in hips. Shoulder x-rays 06/03/06 reveal b/l humeral head degenerative changes with questionable areas of ischemic necrosis. Lumbar spine x-rays 08/07/05: severe DJD L1-2 and L2-3. Cervical neck CT 05/20/05: DJD C2-3 and C5-6.
Spine MRI 02/12/05: moderate L5 spinal stenosis, DJD throughout lumbar spine.
2. Ischemic colitis: related to chronic intermittent abdominal pain. First
episode in June 2000 with subsequent right hemicolectomy. Recurrent ischemic colitis of transverse colon with hospitalization at University of Jamesville in Summer 2006. Flexible sigmoidoscopy 06/23/06 revealed ischemic colitis at hepatic flexure. Mesenteric doppler study 09/13/05: some stenosis of SMA and IMA based on peak systolic velocities.
3. Post-laminectomy syndrome: s/p spinal lumbar decompressive
laminectomy with fusion L3-L5 for symptomatic lumbar spinal stenosis March 2003. Last caudal epidural steroid injections, last on 03/28/06 by Dr. Tom Bodwell.
4. Chronic depression: with associated fatigue and insomnia. On
antidepressant treatment, followed approximately monthly by psychiatrist.
5. Frequent falls: August 1999 with resultant T12 compression fracture, plus
6. Anxiety Disorder, NOS: Formerly treated with xanax in addition to
7. Hypertension, controlled on medication.
8. Hyperlipidemia, on medication. 9. Obesity
10. Osteopenia: T-score of -1.4 at femoral neck, -0.8 at total hip and -0.9 at radius
on 01/24/06 DEXA scan. No significant change from June 2003 study.
11. Chronic abdominal pain: s/p EGD 07/18/05 with negative biopsy at GE
junction. Suspected partial obstruction at the level of surgical anastomosis with recommendation for colonoscopy with balloon dilation of the anastamosis. Also related to colonic ischemia.
12. Anterior abdominal wall seroma: subsequent to hernia repair in October
2004. Last evaluated 11/30/06 by Dr. Jim J. Jones (surgeon) down to 3cm x 3cm on exam, recommending conservative treatment. Seroma measured 8.5cm on abdominal CT scan 11/20/06. Abdominal sonogram 09/25/06: 8.5 x 6.1cm anterior abdominal wall mass with mixed fluid and solid components c/w seroma, hematoma, or lymphocele.
13. PPD positive: no history of treatment for latent tuberculosis.
14. Mitral Valve Prolapse: latest echocardiogram 06/23/06 revealed normal MV
with minimal MR. Prior echo 10/26/04 revealed mild MVP with mild MR (along with normal biventricular size and function, LV EF 60-65%). Older echo 09/22/03: mild prolapse of anterior MV leaflet with mild left atrial
dilatation and normal LV function. Prior similar studies performed 11/27/02, 10/23/01, 05/03/00 (moderate TR with mild increase in right heart pressure).
15. Possible right C5-6 cervical radiculopathy: s/p EMG studies 05/09/05.
16. Sigmoid diverticulosis: noted on abdominal CT scan 12/22/06.
17. Noncardiac chest pain: Last active in December 2006. Prior work-up
included negative cardiac catheterization 11/27/01 by Dr. Marc D. Davis and negative adenosine stress test on 11/05/03: normal imaging, no ischemia, normal LV EF, normal stress EKG. Similar prior stress tests on 11/09/01 (persantine study which suggested small area of reversible ischemia and prompted cardiac cath (negative)), Echocardiogram 06/23/06: normal MV with minimal MR, normal chamber sizes, normal WM and normal systolic function. latest EKG 01/06/07: NSR. Left axis deviation. LVH. No significant ST –T wave changes or Q waves. Also, CT angiogram of chest performed 12/29/04 for chest pain was negative for pulmonary embolism.
18. Abdominal wall hernia: moderate midline anterior abdominal wall hernia of
the inferior-most aspect of the abdomen containing some loops of small bowel noted abdominal CT scan 11/20/06.
19. Cataracts: with planned right eye cataract extraction by Dr. Harris.
20. Partial urethral stricture: followed by urologist, Dr. Wellington, s/p serial
21. Recurrent headaches: formerly treated with
acetaminophen/butalbital/caffeine (Fioricet) in April 2006.
22. Probable CTS. Past Medical Conditions, currently inactive:
1. Acute nausea and vomiting after taking a dose of sustained release
morphine for chronic pain: evaluated in ED visit on 11/20/06: work-up including repeat abdominal CT to image chronic seroma, EKG, lab work. Treated with IV fluids, IV antiemetics. Symptoms improved and patient was discharged home.
2. Klebsiella UTI treated with oral antibiotics in August 2005.
3. Syncopal episode attributable to zolpidem (Ambien) use August 2005 with
associated ED visit on 06/24/06. Head CT revealed mild to moderate atrophy and no strokes, bleeds, or masses.
4. Actinic keratoses treated with cryotherapy by Dr. Bruce K. Edwards on
5. Baker’s cyst drained in 2005.
6. Right greater trochanteric bursitis treated with local steroid injection
7. Community-acquired pneumonia x 2 episodes. December 2001: both
8. Episode of superficial thrombophlebitis of right foot March 2003 treated
with course of NSAID tx. Doppler sonogram 03/11/03 revealed no DVT.
9. Fungal dermatitis of groin September 2002.
10. Post-operative anemia after July 2001 hospitalization.
11. T12 vertebral compression fracture December 2000.
12. Palpitations: work-up with cardiac Holter monitor July 1997 was negative.
Evaluated by cardiologist, Dr. Bill Riles.
13. Lower extremity DVT 30 years ago. All Procedures and Surgeries:
1. Laparoscopic cholecystectomy and incisional ventral hernia repair with mesh September 2005 with residual periumbilical seroma. Performed by Dr. Joe E.Doctor at PinnacleCare Medical Center, Baltimore, Maryland.
2. Total right knee replacement November 2003 and left total knee replacement in November 2004 performed by Dr. Sara L. Mary at PinnacleCare Medical Center, Baltimore, Maryland
3. Right preauricular inclusion cyst s/p incision and drainage in May 2002.
4. Spinal lumbar decompressive laminectomy with fusion L3-L5 for
symptomatic lumbar spinal stenosis March 2003 for chronic low back pain performed by Dr. John R. Toney at PinnacleCare Medical Center, Baltimore, Maryland
5. Right hemicolectomy for ischemic colitis in June 2002 performed by Dr. Joe
E. Doctor at University of PinnacleCare in Summer 2006.
6. Excisional left breast biopsy 05/03/01. pathology: fibroadenoma and
intraductal papillary epithelial hyperplasia (benign).
7. b/l Tubal ligation 1979
8. Hernia repair 1978
9. Varicose vein repair 1958 Allergies: Shellfish: hives Medications:
The medications listed are appropriate for this patient based on the medical records provided.
The following medications are recommended for reevaluation to confirm appropriateness, contraindications and redundancy:
Medication Reason for Concern
Has high anticholinergic properties and should be avoided in older adults. Consider substituting with desipramine or nortriptyline (also tricyclic antidepressants but with fewer anticholinergic side effects).
This is a skeletal muscle relaxant with central nervous system (CNS) effects that should be avoided in older adults due to higher risks of CNS side effects such as sedation, dizziness, and irritability.
Social History:
Nonsmoker. Social alcohol. No drugs. Homemaker. Gravid 4, para 4. Widowed. Raised in Baltimore.
Advanced Directives: Recorded. Family History:
1. Mother died at 92 from heart failure.
2. Father died at age 84 from complications of DM.
4. Brother died from ulcerative colitis.
6. 3 living siblings: one with ulcerative colitis.
Health Maintenance History with Recommendations:
1. Cervical cancer screening: PAP 10/29/04, 10/30/03, 01/14/03, 12/20/00,
1/10/00 all negative. If patient is not sexually active, she can forego further PAP smears, in light of having >3 annual negative PAP smears.
2. Colon cancer screening: last colonoscopy June 2006.
3. Mammogram: 03/28/06: negative. Recommend routine annual follow-up.
4. DEXA: 01/24/06: T-score of -1.4 at femoral neck, -0.8 at total hip and -0.9 at
radius, consistent with osteopenia, and no significant change from November 2002 study. Follow-up DEXA study is recommended January 2008.
7. Td booster 9/22/95. She is due for repeat booster: should be done every ten
9. Lipid panel: Last checked 01/04/07. Patient’s total cholesterol is high >235
(total cholesterol 264 on 01/04/07). She has a high good cholesterol (HDL) of 57 and bad cholesterol (LDL) only slightly above target of <160 (161). Target LDL (according to National Cholesterol Education Program Adult Treatment Plan 3 (NCEP, ATP 3)is based upon having advanced age and treated hypertension as 2 cardiac risk factors and an HDL of 60 or greater as one protective risk factor, thus having just one risk factor.). Liver function tests appropriately monitored, all within normal limits when last checked 01/04/07. Lipid panel and liver function tests should be repeated in three months after increasing dose of cholesterol medicine ezetimibe/simvastatin from 10/10 to 10/20 once daily.
10. Screening for thyroid disease with TSH on 01/04/07 within normal limits
(1.73). This should be repeated in three to five years.
11. Diabetes screening: 01/04/07 with fasting blood glucose (105).
Recommendations:
Based only on the review of the available records I would recommend:
1. She should strongly consider discontinuing amitriptyline due to its high
degree of anticholinergic properties which are associated with high rates of sedation, confusion, dry mouth, constipation, urinary retention, and blurry vision. If needed, newer less anticholinergic tricyclics can be substituted, such as desipramine or nortriptyline.
2. She should strongly consider discontinuing metaxalone, given the lack of
obvious indication for use along with its CNS mode of action and tendency to cause sedation and dizziness in older adults.
3. Strong consideration should be given to taking a daily aspirin 81mg for stroke
and heart attack prevention given risk factors of advanced age and hypertension.
4. She should be counseled regarding her risk for developing diabetes. Her
fasting glucose values have been just below cut offs for the diagnosis of impaired glucose tolerance (a precursor of diabetes). Numerous recent values range 100-105 and the cut off is 110. A repeat fasting glucose along with a HbA1C should be repeated within 6 months after she is instructed on behavioral modifications with regards to diet, exercise, and weight loss.
5. Her 10-year cardiac risk as calculated from the National Cholesterol
Education Program is 11%. This means that 11 of 100 people with her level of risk will have a heart attack in the next 10 years. Thus, as mentioned previously in the health maintenance section, consideration should be given to increasing the dose of her cholesterol medicine ezetimibe/simvastatin from 10/10 to 10/20 once daily. Lipid panel and liver function tests should then be repeated three months after increasing the dose.
6. If not already done, she should designate a Health Care Proxy.
7. She should undergo a repeat DEXA scan in January 2008 and be encouraged
to do weight-bearing exercises to further promote bone health and prevent fractures.
8. Her dose of calcium and Vitamin D is unclear. She should take calcium
supplements of 1200mg daily and Vitamin D 800 IU daily with meals for treatment of osteopenia in addition to continuing with daily raloxifene.
9. As she lives alone and has had several prior falls, she should be strongly
encouraged to wear life line devise/necklace (records indicate she has but does not wear) at all times.
10. She should be counseled to avoid all NSAIDs, including over-the-counter
agents, given her episode of prior acute renal failure and ischemic colitis as well as hypertension.
11. She should continue to receive endocarditis prophylaxis with antibiotics prior
to undergoing high-risk invasive procedures (including dental procedures that involve bleeding).
12. Her PPD history should be clarified. If she has not received treatment for
latent tuberculosis infection, this should be considered in the context of other high risk characteristics, given its ability to decrease the lifetime risk of recurrent tuberculosis by roughly 90%.
Brookdale Department of Geriatrics and Adult Development
Le rythme normal d’évacuation des selles La constipation varie beaucoup d’un individu à l’autre :il peut aller de trois fois par jour à troisfois par semaine. Les médecins estimentdonc qu’il y a constipation quand il y amoins de trois selles par semaine maiscela ne correspond pas toujours à ce queressentent les patients. La constipation Quels sont les symptômes est trois f
HOSPICE APPROVED MEDICATIONS Page 1 of 4 High Peaks Hospice & Palliative Care, Inc. (HPH&PC) has developed a formulary of drugs that are appropriate for managing pain and symptoms related to the terminal illness. The drugs listed are considered preferred drugs for hospice use. HPH&PC pays for medications related to the hospice diagnosis and for pain and symptom management for
The patient’s past physicians include: 
Spine MRI 02/12/05: moderate L5 spinal stenosis, DJD throughout lumbar spine.
2. Ischemic colitis: related to chronic intermittent abdominal pain. First 
dilatation and normal LV function. Prior similar studies performed 11/27/02, 10/23/01, 05/03/00 (moderate TR with mild increase in right heart pressure).
15. Possible right C5-6 cervical radiculopathy: s/p EMG studies 05/09/05. 
4. Actinic keratoses treated with cryotherapy by Dr. Bruce K. Edwards on 
8. Hernia repair 1978 
The medications listed are appropriate for this patient based on the medical records provided.
The following medications are recommended for reevaluation to confirm appropriateness, contraindications and redundancy:
Medication 
6. 3 living siblings: one with ulcerative colitis.
Health Maintenance History with Recommendations: 
Recommendations: 
10. She should be counseled to avoid all NSAIDs, including over-the-counter
agents, given her episode of prior acute renal failure and ischemic colitis as well as hypertension.
11. She should continue to receive endocarditis prophylaxis with antibiotics prior
to undergoing high-risk invasive procedures (including dental procedures that involve bleeding).
12. Her PPD history should be clarified. If she has not received treatment for
latent tuberculosis infection, this should be considered in the context of other high risk characteristics, given its ability to decrease the lifetime risk of recurrent tuberculosis by roughly 90%.
Brookdale Department of Geriatrics and Adult Development