Josephine Carlos-Raboca MD



Josephine Carlos-Raboca MD., F.P.C.P., F.P.S.E.M.

Diplomate: Internal Medicine and Endocrinology

Makati Medical Center, Makati City

February 24, 2009

Medical Abstract

Ms. Katharine Rosemary Webb born on June 27 1950 , British female, first came to see me on November 12, 2007. She was diagnosed with diabetes mellitus type 1 at 50 years of age (7 years prior to consultation) and was on Novomix 14 units before breakfast and dinner, Actrapid 5 units before lunch when I first saw her. She was shifted to Detemir 10 units at bedtime, Aspart(Novorapid) 4 units before lunch and dinner on August 20, 2008 as she was getting hypoglycemic episodes and high fasting blood glucose levels. Her glucose levels are less erratic with current insulin regimen and she feels more comfortable with this although she can still improve glycemic control.

Katharine was also being monitored for her multinodular goiter. In August 2008, she experienced slight weight loss. Thryoid function tests showed normal FT3,FT4 but TSH was decreased and was started on Methimazole 5 mg 2x a day. This was decreased to once a day after 3 months at which dose she is currently maintained.

Personal History: she does not smoke, does yoga 1x a week and occasionally plays badminton.

Past medical history: had biopsy of breast mass which was negative

Multinodular goiter, FNAB on Feb 3, 2005 : colloid goiter with cystic degeneration, lymphocytic thyroiditis/Hurthle cell changes

Osteoporosis

Glaucoma

Dyslipidemia

Family history: her brother also has type 1 diabetes

Ob Gyne: G2P2, menopause at 56 years old

Physical examination: Height 162.5 cm Weight 57.4 kg BP 130/80 PR 84/min

BMI 21.

Head and neck: multinodular goiter

Laboratory Exams:

February 11, 2009 FT4 12.2 pmol/L TSH 2.797 uIU/ml Hba1c 7.9% (4.4-6.4)

November 15, 2008 Hb 13.1 Hct 41.9 rbc 4.6 wbc 4.2 eosinophil 1.0 seg 68 lympho 21 mono 10 platelet 241000

Urine microalbumin 4.1 mg/L urine creatinine 62.9 mg/dl

urine microalbumin/creatinie 6.6

SGPT 61 Hba1c 7.2% FT4 =13.6 pmol/L TSH= 1.627 FT3= 3.8 pmol/l (4.2-12)

Aug 27, 2008 FT4 16.8 pmol/L FT3 4.219 pmol/l TSH 0.082 (0.27-3.23)

July 15, 2008 thyroid ultrasound right lobe 5.2 x 1.9 x 1.6 cm

Multiple solid/complex/cystic nodule biggest is 1.5 cm

Left lobe 4.5 x 2.1 x 2.2 cm

Multiple solid/complex nodules biggest 5.5 cm x 2.9 cm with tiny calcifications

FNAB of thyroid adenomatous goiter

Hba1c 7.6%

March 10,2008 ALT 36 cholesterol 174 mg/dl triglyceride 50 HDL 63 LDL 91 Hbaic 7.9 CK 78 FSH 113

Nov 19, 2007 TSH 0.197 urinalysis negative protein wbc 15 rbc 2.0 sugar 4+

Na 141 K 4.2 calcium 9.3 uric acid 3.2 creatinine 1.0 Hba1c 8.3%

Jan 31, 2005 Ultrasound large solid mass on left thyroid measuring 3.6 cm in length, small solid complex nodules(5) ranging 0.4 – 1.5 cm

Jan 31, 2008 Thyroid Scan : Multinodular goiter

Diagnosis; Diabetes Mellitus type 1

Glaucoma

Dyslipidemia

Post menopause

Osteoporosis

Multinodular toxic goiter

Medications

Levemir 10 unit bedtime

Novorapid 4units before breakfast 6 to 8 units before luch, 8 units before dinner

Methimazole 5 mg AM

Ibandronate 150 mg once a month

Fluvastatin c/o internist

Josephine Carlos-Raboca M.D.

February 20, 2009

Medical Abstract

Jose A. Chua 63 year old male born on November 17, 1944 from Binangonan Rizal has been my patient since April 1998. He was diagnosed to have diabetes mellitus type 2 in 1993 and hypertension in 1989. He also has dyslipidemia and asthma.

Mr. Chua has been a very good patient has been very disciplined with his diet, exercise and medications. His diabetes control has been very good.

Personal history: non smoker, has 3 children

Past medical history: had cervical lymph node excision and treatment in 1980 for TB lymphadenitis

Family history: asthma-father; diabetes mellitus-mother

Physical examination: height 175 cm weight 78.6 kg BP 130/70 PR 82/min BMI 25.6

Head and Neck” funduscopy was normal a year ago, has no goiter.

Heart and Lungs:Normal

Abdomen: Normal

Extremeties: Pedal pulse is good on the right and decreased on the left. Monofilament test is intact.

Laboratory:

February 16, 2009 FBS 5.94 Creatinine 100.9umol/L

Jan 27, 2009 FBS 5.82 BUN 4.0 Creat 99.5 Chol 4.35 Triglyceride 1.8 HDL 0.94 LDL 2.59 VLDL 0.82 LDL/HDL 2.76 Chol/HDL 4.63 Hba1c 6.6% (3.9-6.2)

Urinalysis trace blood, negative protein/glucose

Nov 24, 2008 FBS 6.11 Hba1c 6.7%

Aug 13, 2008 urine microalbumin/ creatinine ratio= 53 2hrppg 5.19

July 16, 2008 ECG old inferior wall infarct

Hexamibe test negative according to patient.

Feb 22, 2008 FBS 112 mg/dl Hba1c 7.0 Creat 1.05 Chol 181 Triglyceride 151 VLDL 30 LDL 110 HDL 41.01 SGPT 17

Summary of Findings:

Diabetes Mellitus Type 2, obese I

Hypertension

Bronchial Asthma

DM nephropathy, early

Dyslipidemia

Medications: Metformin 500 mg 3x a day

Glipizide 2.5 mg 2x a day

Pioglitazone 15 mg a day

Telmisartan 40mg/6.25 mg a day

Gemfibrozil 600 mg 3x a week

Simvastatin 20 mg at bedtime

Aspirin 80 mg a day.

Vigorace once a day.

Josephine Carlos-Raboca M.D.

December 8, 2008

Endocrine Clearance

I saw Mr. Nelson Jose L. Menil 45 year old Filipino born on April 22, 1963 today.

Patient was diagnosed to have type 2 diabetes mellitus last July 2007. Currently his blood sugar in well controlled. He has no symptoms of weight loss, blurred vision, frequent thirst or urination.

Family history is positive for diabetes in mother. He doesn’t smoke nor drink alcohol. He is compliant with diet and daily exercise.

Physical examination: BP 110/70 Height 167. 6 cm, weight 69.5 kg, waist circumference 33 cm, BMI 25, no retinopathy on funduscopy , full pedal pulses.

Laboratory: Dec 5, 2008 FBS 6.1 creatinine 74.16 Hba1c 6.92 cholesterol 4.82 triglyceride 0.91 LDL 3.4 HDL 1.01 urine micral negative

Diagnosis: Diabetes Mellitus type 2, controlled

Overweight

Dyslipidemia

Recommendations: Patient is fit to work.

Continue diet and exercise.

Medications: Metformin 500mg 2x a day and Simvastatin 20 mg daily.

Josephine Carlos-Raboca M.D.

December 8, 2008

Medical Summary

Paragas, Mitzelle Leny T.

Mitzelle Paragas 25 year old female was referred to me on September 6,2005 because of diffuse enlargement of the thyroid noted during her pre-employment physical examination. She was however asymptomatic: no weight loss, palpitations, increased sweatiness or sleep disturbance.

Family history is positive for goiter in auntie and grandmother. Her father is diabetic. She does not smoke nor drink alcoholic beverages. Her past medical history is unremarkable. Menarche was at 14 years of age.

Physical examination: Height 153 cm weight 46 kg BP 110/70 PR 81/min. Other than a small diffuse goiter, the rest of physical examination was unremarkable.

Laboratory: September 7, 2005 FT4 16.3 pmol//l (normal), TSH 3.3 uIU/ml (normal)

March 13, 2008 FT4 22.7 (normal) , TSH 1.8 (normal)

Patient has been on thyroid hormone 100mcg/day since first visit and her goiter has been stable .

Assessment: Patient has a simple goiter(diffuse non toxic goiter). This is a very benign condition and will not have any negative effect on longevity or functional capacity. Prognosis is excellent.

Josephine Carlos-Raboca M.D.

December 3, 2008

Medical Summary

Mercado, Bernard Y.

Mr. Mercado born on August 2, 1954 has been my patient since 1997 for diabetes mellitus type 2. He consulted me for sudden weight loss 4 weeks prior to consult, accompanied by blurred vision, body weakness and drowsiness of about 1 year duration. FBS was 324 mg/dl with an Hba1c of 11.5%. He was put on oral diabetic medications, diet and exercise. He has had regular check ups since then and has been a very good patient.

Patient has had hypertension since 1982 and is under control with medications. Patient is under the care of cardiologist. He underwent hemorrhoidectomy in 2000, lithotripsy in 2001 for renal stones on right kidney. Last ultrasound in 2005 showed nonobstructing right nephrolithiasis, cholecystolithiasis, fatty liver and prostate enlargement.

Currently, diabetes is under good control. FBS on October 24, 2008 was 5.63, AST 40 ALT 23, Hba1c 5.7% . 2 hour postprandial blood glucose ranges between 99-144mg/dl. Other tests taken on April 14, 2008 were : Creatinine 67.18, LDL 2.76, HDL 1.1, triglyceride 1.36, cholesterol 4.33, PSA 1.74 and urine micral 20 mg/L.

He was noted to have a nodular goiter in 2007. Work up revealed multiple nodules on ultrasound (April 14, 2008) with the biggest nodule at 1.98 cm in widest diameter. Fine needle aspiration biopsy was negative for malignancy ( sample was mostly blood). FT4 and TSH were normal.

Mr. Mercado used to smoke but quit the habit in 1996. Family history is positive for hypertension in mother and sister, negative for diabetes.

Pertinent physical examination as of October 30, 2008. BP 120/80 height 172.7 cm Weight 82 kg BMI 27.7 multinodular goiter. Funduscopy done April 4, 2008 was negative for retinopathy.

Assessment:

Diabetes Mellitus type 2, good control; Obese I; Hypertension; Fatty Liver

Cholecystolitiasis; Non-obstructing right nephrolithiasis

Benign Prostate Hypertrophy

Multinodular non toxic goiter

Prognosis: Multinodular non toxic goiters are mostly benign. His goiter has to be monitored and a repeat FNAB is desirable in the future.

His diabetes is under good control and should have a good chance of minimizing risks for complications.

Plan of treatment: Continue medications: Metformin 500 mg 3x a day, Glimepiride 2 mg 2x a day, Pioglitazone 15 mg once a day, Losartan 100 mg 2x a day, Felodipine 5 mg 2x a day.

Josephine Carlos-Raboca M.D.

Abilo, Linette L.

Ms. Abilo 54 year old female first consulted me on October 12, 2002 for her diabetes mellitus type 2 diagnosed 12 years earlier (1990). She had uncontrolled diabetes at that time with a fasting blood glucose of 17.3 mmol/l and Hba1c of 10.19%. She also had hypertension, dyslipidemia, obesity, fatty liver and cholecystolithiasis. She has had treatment for diabetic retinopathy both eyes.

Patient does not smoke nor drink alcohol, has had hysterectomy-oophorectomy and one biological child. Her mother had diabetes.

Recent physical examination: BP 120/80 Height 162 cm weight 83.5 kg BMI 31.8

Fundi stable (seen by ophthalmologist) post panretinal photocoagulation

Management was intensified on first visit. She was advised to improve her diet and to get regular exercise. Oral medications included Rosiglitazone 8 mg a day, Gliclazide 120 mg per day. Metformin 1000 mg twice a day. Atorvastatin 10 mg a day and Quinapril 10mg/HCTZ 12.5 mg a day.

Her glycemic control improved and achieved Hba1c of 7.0% in 2003 to 2006. She was lost to follow up in 2006 and I saw her again on June 25, 2008. She complained of pain and numbness in legs. EMG was done and showed diabetic polyneuropathy.

There was no evidence of renal complication with urine micral test of 20mg/L on June 4, 2008. Other results on same date include normal AST/ALT, LDL 2.87 HDL 1.2 Chol 4.83 Triglyceride 1.74 Uric Acid 338 mmol/l. Her diabetes was poorly controlled on oral medications with an Hba1c of 11%.

Glargine insulin was initiated in addition to Rosiglitazone 4mg/Metformin 1000 mg twice a day, Gliclazide 160 mg twice a day. Glycemic control improved. Latest FBS on Nov 20, 2008 was 6.57, Hba1c was 7.4% creatinine 51.26. ECG old inferior wall myocardial infarction.

Complete Diagnosis:

Diabetes Mellitus type 2,

DM retinopathy Status post panretinal photocoagulation both eyes

DM polyneuropathy,

Obesity I, Dyslipidemia, Fatty Liver

Cholecystolithiasis

Hypertensive Atherosclerotic Cardiovascular Disease

Plan of Treatment: She will need to continue Lantus insulin 10 units bedtime, Rosiglitazone 4mg a day, Metformin 1000 twice a day, Gliclazide 160 mg twice a day, Carvedilol 6.25 once a day, Amlodipine 10 mg a day, Simvastatin 40 mg a day Mondays to Fridays, Gemfibrozil 600 mg Saturday and Sundays. She needs to exert more effort to lose weight. Regular clinic visits will be needed.

Prognosis: She should be able to avoid more complications if she maintains her current motivation level.

Josephine Carlos-Raboca M.D.

September 22, 2008

Medical Summary

Mohamed Rizwie

Mohamed Rizwie 48 year old Sri Lankan first came to see me on June 3, 2006 for his type 2 diabetes diagnosed in 2003 with complaint of fatigue.

He was initially on Metformin which caused him to lose weight so he was switched to Pioglitazone 30 mg once daily. His diabetes was well controlled at the time of his visit with Hba1c of 6.1% (4.4-6.4%) done on May 6, 2006. FBS was 138mg/dl and 2 hour PPBS was 131 mg/dl. Uric acid was 5.2 mmol/L. Blood tests were repeated with normal creatinine, lever function tests, lipid profile, calcium, FT4 and slightly low TSH (0.178).

Past history includes hiatus hernia. He has had microscopic hematuria for 30 years which was being monitored by his nephrologist and said to be stable. Ultrasound of the kidneys done in March 2004 was normal with enlarged prostate measuring 24.58 gm. He had headache with previous intake of Ramipril. His other medications include Allopurinol 100 mg a day, Esomeprazole 40 mg per day and Domperidone 10 mg 3x a day. Patient did not smoke nor drink alcohol. He walks 25 minutes 3-4x a week. His parents were diabetic, father was also hypertensive and he has 4 children.

Initial physical examination showed : weight of 64 kg Height 165 cm PR 76/min BMI 23.5 BP 140/90. Funduscopy done by ophthalmologist in November 2007 was negative for diabetic retinopathy. His pedal pulses were full. The rest of the examination was essentially normal.

Patient has remained well since first visit. Perindopril has been added for hypertension and microalbuminuria. Urine microalbumin/creatinine was 106 on November 14, 2007 which decreased to 40 mg/g on September 6, 2008. Last creatinine was 0.9 mg/dl on July 24, 2008. BP has remained at 100-110/70-80.

For dyslipidemia noted April 2008, he takes Atorvastatin 10 mg 3x a week. Lipid profile on April 18, 2008 showed Chol 199 mg/dl triglyceride 68 HDL 57 LDL 131. As of July 24, 2008, LDL has gone down to 57mg/dl SGPT 30.

He still takes Domperidone and Esomeprazole sometimes for epigastric pain.

His diabetes has remained in good control on current medications of Pioglitazone 45 mg/day and Glipizide 1.25 mg before dinner. Latest FBS on July 24, 2008 was 103 mg/dl, Hba1c of 6.3%. ECG was normal.

Diagnosis: Diabetes mellitus type 2, overweight

DM nephropathy stage 2(microalbuminuria)

Dyslipidemia

Hypertension

Recommendations:

Mohamed is well motivated, pleasant and very compliant with medications and follow up visits. His current weight is 67 kg. It would be advisable for him to lose about 5-8% of his weight. Continue all medications:

Pioglitazone 45mg AM prebreakfast

Perindopril 1 mg AM

Glipizide 1.25 mg before dinner

Atorvastatin 10 mg 3x a week

I would suggest repeating thyroid tests likewise to check any change from baseline.

Josephine Carlos-Raboca M.D.

August 27, 2008

To Whom It May Concern:

I had the opportunity to see and examine Mr. Vergel O. Baroro 31 year old male on August 21, 2008 for thyroid evaluation. One month prior to consultation, he experienced palpitations and elevation of blood pressure. He was seen by a physician and was prescribed propranolol 40 mg twice daily. Thyroid function tests were requested which showed the following results on July 11, 2008: low TSH 0.028 uIU/ml (0.27-3.75) and normal FT4 23.5 pmol/l.

Family history is positive for goiter in mother. He does not smoke and has stopped drinking alcoholic beverage. He has no previous surgery and has two children.

Physical examination showed normal BP on initial visit at 120/80; weight of 75 kg. Height 176.5 cm; BMI 24. Thyroid was minimally enlarged, with no tenderness nor palpable nodule. He had no lid lag no thyroid stare nor exophtahlmos and had no hand tremors. The rest of the physical examination was unremarkable.

Initial impression was subclinical hyperthyroidism. Thyroid tests were repeated on August 22, 2008 which showed normal FT3 6.534 pmol/l, normal FT4 22.249 pmol/l and slightly low TSH 0.139 uIU/L which showed improvement from initial TSH. Thyroid scan showed asymmetrically enlarged thyroid gland with uniform and adequate accumulation of radioactivity. Right lobe measured 6.2 x 2.3 cm and left lobe measured 4.5 x 2.0 cm. Clinically, he improved with decrease in palpitations.

Assessment: Patient had subclinical hyperthyroidism at the time he was first seen by a physician which maybe a phase of subacute thyroiditis. After one month, TSH has improved likewise the palpitations with adequate thyroid uptake of radioactivity which may now indicate resolving thyroiditis. It is likely that thyroid function tests may normalize in a few months.

Recommendation: He is fit to work.

Repeat thyroid function tests after 3-6 months.

Josephine Carlos-Raboca M.D.

Josephine Carlos-Raboca MD., F.P.C.P., F.P.S.E.M.

Diplomate: Internal Medicine and Endocrinology

Makati Medical Center, Makati City

August 27, 2008

To Whom It May Concern:

Vincent Christopher H. Nocom 27 year old male first came to see me on March 23, 1999 for nervousness and sweatiness, diffuse enlargement of the thyroid and sweaty palms. He was a non smoker. Family history was negative for diabetes, an auntie had goiter and grandfather had cancer.

T3 and T4 were elevated initially with normal TSH . He was clincially hyperthyroid despite normal TSH which could be due to poor sensitivity of test used and was treated with Methimazole for 32 months. He discontinued his medications in 2001. Upon follow up on October 24, 2003, he had recurrence of palpitations, insomnia, sweatiness and mood swings. Thyroid tests at this time showed low TSH 0.005 uIU/ml, high FT3 5.2 ng/dl (1.5 4.1) and high FT4 2.5 ng/dl (0.8-1.9) .Methimazole was restarted at 10 mg every 8 hours which he stopped in April 2004. At this time FT3 and FT4 were normal with a slightly low TSH (0.249)

He was lost to follow up and was seen by another endocrinologist in May 2008. FBS, SGPT and CBC were done and were normal. Thyroid scan showed minimal thyromegaly, cool nodule on the left lobe and elevated RAI uptake of 33% at 2 hours (Normal 5-15%) and 65% on 24 hours (Normal 20-45%). Ultrasound of thyroid was requested and showed enlargement of the thyroid but no nodule . On July 1, 2008, FT3 5.810 pmol/l and FT4 20.49 pmol/l were normal with slightly low TSH(0.249 uIU/ml (0.27-4.2)

Diagnosis: Grave’s hyperthyroidism which had been relapsing. Treatment option at this time is to resume antithyroid medication or radioactive iodine treatment.

August 20, 2008

Josephine Carlos-Raboca,M.D.

Josephine Carlos-Raboca MD., F.P.C.P., F.P.S.E.M.

Diplomate: Internal Medicine and Endocrinology

Makati Medical Center, Makati City

August 27, 2008

To Whom It May Concern:

This is to certify that Ms. Hilda E. Legaspi has been my patient since October 2001. She was diagnosed to have thyroid papillary cancer in December 2001 after undergoing total thyroidectomy. Postoperatively, she developed hypocalcemia for which she was prescribed maintenance medications of calcium carbonate and vitamin D. She also takes thyroid hormone as adjunctive therapy for the thyroid cancer. No radioactive iodine ablation was given postoperatively as thyroid scan did not show any uptake.

On September 17, 2007, whole body scan showed functioning thyroid tissue. Ultrasound of the neck showed no abnormal looking thyroid tissue on thyroid bed and no cervical lymph nodes.

She underwent radioactive iodine treatment on January 30, 2008 with 100 mci of

I- 131 to ablate remaining thyroid tissue. Post treatment whole body scan did not show any metastasis of the thyroid cancer.

At present she is on thyroid hormone suppression and would still need monitoring of the thyroid cancer.

Assessment: Patient may qualify for temporary disability from work as she may get really weak when she gets off thyroid hormone treatment required for tests of whole body scan and serum thyroglobulin . These are done to assess the status of thyroid cancer.

Josephine Carlos-Raboca M.D.

Josephine Carlos-Raboca MD., F.P.C.P., F.P.S.E.M.

Diplomate: Internal Medicine and Endocrinology

Makati Medical Center, Makati City

September 22, 2008

Medical Abstract

Ms. Rebecca C. Lopez 58 years old female first come to see me on October 16, 2006. She was diagnosed to have Diabetes Mellitus Type 2 in 2001 and has been on oral medications since I last saw her on Aug. 23, 2008.

Past History: She has hypertension diagnosed in 2000. Multinodular Non-toxic

Goiter (2006)

Family History is negative for DM. Father is hypertensive. She is a non-smoker

P.E. Ht: 5’ Wt: 55.4 kg. BP: 130/80 PR: 72 bpm / (+) nodular goiter

Diagnosis: Diabetes Mellitus Type 2

Multinodular Non-Toxic Goiter

Hypertension

Dyslipidemia

Medications: Versant XR 5 mg 2x/day

EugloPlus 3x/day

Piozone 15 mg 1x/day

Zocor 20mg 1x/day

Euthyrox 50 mcg 1x/day

Laboratory: Oct. 11, 2006 FBS 231 Creat 0.64 Trigly 78 HDL 62

Cholesterol 262 UA 3.50 SGPT 63 HBAIC 9.3 %

TSH 1.053 FT4 18

Ultrasound of Thyroid: Multinodular Goiter

June 2, 2008 Micral Test : Negative

FBS 12 Creat 54 Chol 6.10 HDL 2.1 LDL 3.45

SGPT 44 Trigly 4.2 ECG: Normal

Chest X-ray : Atheromatous Aorta

Aug. 23, 2008 FBS 8.16

Josephine Carlos- Raboca M.D.

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