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PATIENT’S NAME: XXXXXXXXX
DATE OF EXAM: XXXXXXXXXX
HIP NUMBER: XXXXXXXXXXXX
FAMILY DOCTOR: XXXXXXXXX

HISTORY OF PRESENT ILLNESS: This is a 54-year-old woman who is referred to me with hypercalcemia. She denies history of kidney stones or fractures. She has osteoporosis. She just started Fosamax 70 mg a week three weeks ago. She is tolerating it well. She has a history of manic-depressive disorder and was started on Lamictal and Zyprexa about one week ago. She is postmenopausal.

PAST MEDICAL HISTORY: She was hospitalized many times for her manic-depressive disorder.

PERSONAL AND SOCIAL HISTORY: She is a non-smoker and non-drinker.

FAMILY HISTORY: Her family history is negative for diabetes, thyroid disease, and kidney stones and is positive for osteoporosis in her mother.

PHYSICAL EXAMINATION: On physical examination, her weight is 104 pounds. Blood pressure is 130/88 mm Hg. Pulse is 80 per minute and regular. The patient appears weak and tired. 
Neck: No goiter. 
Lungs: Clear. 
Heart: Regular sinus rhythm. 
Abdomen: Soft and benign.

LABORATORY DATA: In May 2005, her calcium was 11.3. In August 2005, her cholesterol was 224, triglycerides 55, HDL 105, LDL 108, fasting sugar 92, potassium 5.5, sodium 142, and creatinine 0.8. She had a normal CBC.

IMPRESSION:
1. Hypercalcemia, etiology to be determined.
2. Osteoporosis.
3. Depression.
4. Fatigue and tiredness.

PLAN:
1. Blood for serum calcium, electrolytes, and 25-hydroxyvitamin D.
2. Referral to medicine doctor.
3. Follow up in two weeks.