Josephine Carlos-Raboca MD
Josephine Carlos-Raboca M.D., F.P.C.P., F.P.S.E.M.
Diplomate: Internal Medicine and Endocrinology
Makati Medical Center, Makati City
January 19, 2010
To Whom It May Concern:
This is to certify that Mr. Zaldy Uy Ampatuan born on August 27, 1967 has been under my medical care since February 23, 2002. He came to see me for diabetes mellitus type 2 of one year duration and hypertension of 2 years duration. His symptoms were dizziness and chest pain.
Family history was positive for diabetes in mother and hypertension in father. He doesn’t smoke and has had no previous surgery. He has 3 children.
Physical examination showed weight of 88kg height of 160 cm BP of 130/90 BMI of 34 normal fundi. The rest of examination was normal.
Initial examination showed FBS of 128 mg/dl, 2 hour postprandial blood glucose of 301 mg/dl, Hba1c 7.0%, elevated GGTP 152 and SGPT 98 mg/dl. Other tests showed high urine microalbumin 100mg/L, low HDL 34 mg/dl high triglyceride 246 mg/dl normal creatinine 1.0.
Patient has had regular check ups since but blood glucose control has not been satisfactory with lowest Hba1c achieved at 7.8% His TSH was slightly high in 2006 (4.062) but normalized in 2007 without treatment. (1.861). Last treadmill stress test done in 2007 was negative for ischemia.
Patient was confined in October 2-5, 2009 for diabetes. Hba1c 9.3% FBS 184 mg/dl . 2D Echo normal. CT scan showed a 0.9 mm pulmonary nodule.
Diagnosis: Diabetes Mellitus 2
Obesity
Dyslipidemia
Fatty Liver
Pulmonary Nodule R/O PTB
Medications: Glargine(Lantus) insulin 16 units at bedtime
Januvia 100 g once a day
Solosa 2 mg twice a day
Glucophage 500 mg twice a day
Actos 15 mg twice a day
Lipanthly NT 145 mg at bedtime
Aprovel 150 mg once a day
Ursofalk 3x a a day
Josephine Carlos Raboca MD
January 19, 2010
To Whom It May Concern:
This is to certify that Ms. Laila Uy Ampatuan born on February 11, 1943 has been under my medical care since October 19, 1999. She was diagnosed to have diabetes mellitus type 2 five years before she consulted with me. She was on medications which included Gliclazide 80 mg twice a day and Metformin 500 mg twice a day. She had no symptom of polyuria, polyphagia nor polydipsia on first visit.
Family history was positive for diabetes in mother and hypertension in father. She was not a smoker. Past medical history revealed previous TAH-BSO and allergy to co-amoxiclav. Reproductive history showed 15 pregnancies with 12 live term births all by spontaneous vaginal delivery with birthweight below 8 lbs.
Physical examination showed height of 147.3 cm weight of 63 kg BMI of 29.4 kg/cm2. Neck showed thyroid gland enlargement. She had no retinopathy on funduscopy.
Laboratory results showed poor glucose control with Hba1c of 14% and FBS of 260 mg/dl. Urine microalbumin/creatinine ratio was high at 63 mg/g. Her medical regimen needed frequent modification . She required insulin previously and developed edema to Rosiglitazone. Nutritional therapy needed stricter compliance making glucose control difficult. Best Hba1c achieved was 8.4% taken January 13, 2009. Latest was on October 13, 2009 at 8.9%. Most recent tests on November 17, 2009 showed anemia with Hb of 11, fbs 119 mg/dl Creatinine 0.85 eGFR 69.66 SGOT 16 SGPT 10 Cholesterol 96 HDL 35.98 LDL 40.24 Triglyceride 71.27.
MRI of lumbosacral spine September 4, 2004: degenerative joint disease.
In 2007 she had a comprehensive check up in Cedars Sinai, USA. Pertinent findings included a right breast mass 1 cm in size with irregular borders, good carotid arteries, right knee degenerative medial meniSscal tear, insignificant decreased lung volume on spiromety, dense cataract OS> OD. She underwent cataract surgery OS in Makati Medical Center in January 2009.
2D Echocardiogram June 19, 2007 concentric LV hypertrophy with good systolic function but poor diastolic function.
Thyroid ultrasound showed stable multiple nodules ranging from 0.5-1.6 cm. with normal thyroid function. Most recent ultrasound was in April 2009 and thyroid function tests in October 2009.
BMD test in 2007 showed osteopenia (wrist T score -2.24). She took Fosamax for a few months in 2004. At present she is taking Evista .
[pic]Diagnosis:
1. Diabetes Mellitus type 2
2. Obese I
3. DM nephropathy
4. Multinodular non toxic goiter
5. Hypertension
6. Dyslipidemia
7. S/P TAH-BSO
8. Osteopenia
9. S/P cataract surgery, OS.
10. anemia etiology?
11. right breast mass
12. degenerative joint disease
13. diastolic dysfunction
Currently she is doing well with medications which include the following:
1.Glimepiride 1 mg before dinner
2. Metformin 1000 mg after breakfast and dinner
3. Sitagliptin 100 mg before lunch.
4.Fenofibrate 200 mg at bedtime
5. Pioglitazone 15 mg before breakfast and dinner
6.Telmisartan 20 mg after breakfast
7. Rosuvastatin 10 mg at bedtime
8. DHA/EPA 800 mg a day
9.Raloxifene 60 mg at lunch
10. Caltrate Plus twice a day
Josephine Carlos-Raboca, M.D.
December 1, 2009
To Whom It May Concern:
This is to confirm that Dr. Marcus Haldon Hodge who was diagnosed to have Type 1 diabetes mellitus (insulin dependent) 32 years ago is scheduled for medical consultations at my clinic on December 8 and 10, 2009 at 1430h. He will undergo laboratory tests on the morning of December 9, 2009 at 0700h.
Dr. Josephine Carlos-Raboca
Josephine Carlos-Raboca M.D., F.P.C.P., F.P.S.E.M.
Diplomate: Internal Medicine and Endocrinology
Makati Medical Center, Makati City
November 27, 2009
Patient: Natividad, Susana C.
Date of Birth: April 3, 1965
Dr. Diana H. Peralta
P & D Paralta Medical Clinic
Makati Cit, Philippines
Dear Doctor:
Ms. Susana C. Natividad, a Filipina teacher from Paranaque City has been my patient since April 16, 2009 for type 2 diabetes mellitus and nodular non toxic goiter.
She presented with frequent thirst and urination but no weight loss. Initial fasting blood glucose was 14.93 mmol/l and Hba1c of 9.2%. She also had dyslipidemia on examination with cholesterol level of 6.67 triglyceride 1.38 HDL 1.28 LDL 4.76.
Susan was advised lifestyle modification consisting of dietary intake of 1500 calories per day with simple sugar restriction as well as regular exercise most days of the week. Medications include Glimepiride 1 mg a day, Metformin 500 mg twice a day and Simvastatin 20 mg at bedtime.
Physical examination showed normal BP 110/70 Height 160 cm weight 50.5 kg BMI 19.5. Fundi are normal. Neck examination showed a nodular goiter. She was euthyroid on thyroid function testing. TSH was 1.963, FT4 was 13.4 and FT3 was 4.076. Thyroid ultrasound showed a 2.3 cm x 2.1cm x 1.4 cm complex nodule on the right lobe. A fine needle aspiration biopsy done on the thyroid nodule showed benign features consistent with adenomatous goiter with cystic degeneration and she was prescribed thyroxine for thyroid suppression.
Latest laboratory examinations done on Novemebr 12, 2009 showed Hba1c 6.4% ,cholesterol 3.6, triglyceride 1.05, HDL 1.2, LDL 1.95, FBS 5.92, creatinine 37.8, SGPT 17.7, SGOT 17.1, normal CBC, urine mciroalbumin/creatinine ratio of 18 mg/g.
Assessment: Patient has type 2 diabetes mellitus, uncomplicated and under control. She also has a nodular non toxic goiter, benign on fine needle aspiration biopsy.
Recommendations:
Lifestyle modification as advised.
Continue medications:
Glimepiride 1 mg before breakfast;
Metformin 500 mg after breakfast and dinner;
Simvastatin 20 mg every other night;
L thyroxine 50 mcg before breakfast.
Regular clinical monitoring.
She is fit from an endocrine standpoint to carry out teaching duties.
Josephine Carlos-Raboca M.D.
October 30, 2009
Patient: Stinson, Yulanda
Birthday: October 29, 1953
Dr.Vyas
US Embassy Clinic
Roxas Blvd. Manila
Dear Dr. Vyas,
I saw Ms. Stinson last October 26, 2009 and she claims she is feeling better compared to her previous visit. She weighed 127.6 lbs which was 3 lbs less than 8 weeks before. Her BP was stable at 110/70.
New laboratory results showed negative urine microalbuminuria. FT4 was normal but TSH was slightly low so Synthroid was reduced by 50 mcg per week.
Her lipid profile showed slightly elevated LDL of 114 mg/dl, triglyceride of 186 mg/dl,cholesterol of 207 mg/dl with satisfactory HDL of 56 mg/dl. SGOT and SGPT were normal. FBS was elevated at 210 mg/dl. No adjustment was made on diabetes medications nor a lipid lowering agent added. Patient would like to try to be more compliant with diet and exercise program to achieve better control of her diabetes and dyslipidemia.
Medications:
1. Synthroid 125mcg Mondays to Saturdays, 62.5 mcg on Sundays.
2. Glimepiride 4mg 2x a day.
3. Metformin 1000mg 2x a day.
4. Sitagliptin 100 mg before breakfast.
5. Pravastain 80 mg daily.
6. Lisinopril 20 mg a Day.
7. Sumatriptan 50 mg a day.
8. Fluoxitine 20 mg daily.
Josephine Carlos-Raboca M.D.
Medical Certificate
I hereby certify that, after tests and examination, Ms. Evangeline N. Raboca, 77 year old female, is in good health and is fit to travel.
October 14, 2009, Makati City
Josephine Carlos-Raboca
September 3, 2009
Patient: Fudotan, Maria Helen Ortiz
Date of Birth: 20 May 1968
File Number:
Maria Helen O. Fudotan 41 year old female has been my patient since November 5, 2005 for a nodular non toxic goiter. She underwent right thyroid lobectomy with isthmusectomy on February 22, 2006. Histopathological diagnosis was: multinodular adenomatous colloid goiter. Postoperatively she developed hypocalcemia and subclinical hypothyroidism and has been on calcium and thyroid hormone replacement since. At present, patient is also being managed for obesity and dyslipidemia.
Family history is negative for goiter and cancer. She does not smoke nor drink alcoholic beverages. Obstetric history: G1P1.
Physical Examination: Height 155 cm Weight 75.4 kg BP 120/80 PR 87/min BMI 31.4 Waist Circumference 35.5 inches. The rest of the physical examination is normal.
Laboratory:
August 28, 2009 FT3 4.491 pmol/L FT4 20.174 pmol/L TSH 3.215
September 3, 2009 ionized calcium 1.16mmol/l FBS 4.87 Creat 60.71 mmol/l Cholesterol 5.92 Triglyceride 0.75 HDL 1.44 LDL 4.14 VLDL 0.34 Chol/HDL 4.11 SGPT 19.58 SGOT 15.29 PTHintact 53 pg/ml (15-65)
Hb 133 HCT 0.416 WBC 8.15 RBC 4.74 Neut 0.59 Lymp 0.32 Platelet adequate
Assessment: Patient’s general condition is fine. Calcium and thyroid hormone levels are normal. Her cardiovascular risk factors include obesity and dyslipidemia.
Diagnosis: Obesity II (Asia Pacific) ; Dyslipidemia ; Euthyroid on thyroid hormone replacement Status post thyroidectomy.
Management: Weight loss of 5-10% in 6 months through proper diet and regular exercise of at least 30 minutes 5x a week.
Medications: Calcium carbonate 600 mg 3x a day; Levothyroxine 100 mcg a day.
Prognosis: Prognosis is excellent for thyroid condition . Cardiovascular risk will improve with weight loss and control of dyslipidemia.
Josephine Carlos-Raboca M.D.
September 2, 2009
Patient: Stinson, Yulanda
Birthday: October 29, 1953
Dr.Vyas
US Embassy Clinic
Roxas Blvd. Manila
Dear Dr. Vyas,
Thank you for referring Ms. Yulanda Stinson whom I saw on September 2, 2009. Present complaints include tinnitus, bouts of depression, poor memory, poor sleep, decreased stamina, cold intolerance and weight loss for about 3 months.
Past medical history includes:
1. Diabetes mellitus type 2 diagnosed in 2005 on medications of Glimepiride 4 mg 2x a day, Metformin 1000 mg 2x a day.
2. Hypertension: on Lisinopril 20 mg a day.
3. Hypothyroid probably secondary to silent thyroiditis on Levothyroxine 112 mcg a day.
4. Dyslipidemia on Pravastatin 80 mg a day.
5. Appendectomy in 1999
6. CS delivery 22 years ago.
7. Sleep Apnea Syndrome on CPAP but compliance is poor.
8. She is also on Fluoxitene 20 mg a day and Sumatriptan 50 mg a day.
Personal History: She does not smoke. She drinks alcohol occasionally. She has no regular exercise program.
Family History: Parents are both hypertensive; mother is diabetic and has thyroid problem.
Obstetric history: G1P1, Cesarian Section delivery; menopause at 44 years of age, not on HRT.
Physical Examination: Height 150 cm Weight 59.4 kg BP 120/80 PR 92/min BMI 26
HEENT: no goiter
Heart and Lungs: Normal
Abdomen: normal
Extremeties: normal
Latest abnormal laboratory exams on August 28, 2009 include an elevated TSH > 60, Hba1c 9.6%, FBS 191 mg/dl, LDL 134 mg/dl, VLDL 39, Triglyceride 184 mg/dl, cholesterol 231mg/dl.
Assessment and Recommendations:
1. Her diabetes is poorly controlled. She was advised to get dietary counseling at the Makati Medical Center Diabetes Care Center. She was prescribed 1500 calories per day with simple sugar restrictions, 3 meals and 2 snacks. Sitagliptin 100 mg before breakfast was added to her current diabetes medications. Repeat FBS in 6 weeks.
2. She is overweight and needs to lose 5% of her present weight in 6 months. 30 minutes exercise 5 x a week will be good for her.
3. Her hypertension is under control. Maintain Lisinopril 20 mg a day.
4. She is still hypothyroid and I increased her T4 dose to 125 mcg per day. Repeat FT4. TSH in 6 weeks.
5. Her lipid levels are still high. Maintain Pravastatin, improve diet and get regular exercise. Repeat lipid profile in 6 weeks.
6. I recommend that she sees our sleep specialist for her sleep apnea.
7. We need to correct her thyroid status. If tinnitus does not improve, consult ENT doctor.
8. She is due for retina check up with an ophthalmologist. (Last check up was 11/2 years ago.
9. Follow up on October 26, 2009 with results of FT4, TSH, FBS, Lipid Profile urine microalbumin/creatinine ratio.
Summary of Medications:
1. Glimepiride 4mg 2x a day.
2. Metformin 1000mg 2x a day.
3. Sitagliptin 100 mg before breakfast.
4. Levothyroxine 125 mcg before breakfast
5. Pravastain 80 mg daily.
6. Lisinopril 20 mg a Day.
7. Sumatriptan 50 mg a day.
8. Fluoxitine 20 mg daily.
Josephine Carlos-Raboca M.D.
August 6, 2009
Patient: Zahd, Fritz Schilt
Date of Birth: April 14, 1946
Problem 1: Follicular Thyroid Cancer r/o recurrence Stage II (T3NXM0)
June 2002 Total thyroidectomy in Switzerland
2002. RAI 81 mci I-131 in Switzerland
June 2005 RAI 100 mci I-131 St Luke’s Medical Center
May 2006 Radio-guided Neck exploration, L parathyroidectomy SLMC post op hypocalcemia
July 2007 Left Modified Radical Neck Dissection, Dr. Randy Lopa , UP-PGH
Note: A letter from MD in Switzerland mentioned no evidence of disease through laboratory studies and ultrasound examinations till consult with Dr. Al de Villa on March 8, 2008. Due to elevated Thyroglobulin in 2006, he underwent a radio guided neck exploration surgery at SLMC but no mass was identified; only parathyroid was ressected and he developed hypocalcemia postoperatively.
In July 2007, Left MRND was done at UP-PGH.
Pathology:
July 28, 2007 PGH
Positive for metastatic carcinoma, morphologically compatible with follicular carcinoma 1/9 Lymph nodes Level IV
Negative for tumor, seven lymph nodes level II, 6 lymph nodes Level III and 3 Lymph nodes Level V
Ultrasound of Neck: MMC
April 24, 2008 S/P thyroidectomy
0.4 cm hypoechoic focus Left paratracheal area exact nature undetermined.
0.6 x 0.3 cm hypoechoic focus L parajugular area consistent with node
August 6, 2009 MMC
Normal cervical lymph nodes bilateral( several lymph nodes with intact configuration and fatty hila both parajugular regions and submandibular areas. The largest is in right parajugular area measuring 1.2 x 0.4 cm.
Hypoechoic focus 0.4 cm in left paratracheal area just above clavicle is again noted with no change in size and similar focus with same measurement in the contralateral aspect also noted; both may represent small lymph nodes.
Whole Body Scan
March 3, 2005 using 5 mci I-131 was negative (SLMC, I presume) TSH 58.64 uIU/ml ,low antiTg, Tg 2.35 ng/ml while off T4. On T4 suppression, repeat Tg was 4.8 on May 5, 2005 so RAI was given 100 mci.
April 24, 2008 no detectable accumulation of RAI in anterior neck or elsewhere in body. (MMC)
CT Scan of Neck
May 15, 2007 Makati Medical Center Normal CT Scan of the Neck
Comment: PET SCAN (April 2006) showed hypermetabolic focus on left neck which I believe was removed in last surgery at PGH July 2007. I can’t explain why this was not shown on the CT Scan of the neck done preop ( May 15, 2007.) Post op, Tg went down, although off T4, Tg was still high at 3.75. RAI treatment might not be beneficial at this point considering that tumor does not take up RAI . The plan is to monitor serial levels of Tg, on and off T4.
Would consider PET Scan if Tg levels are going up. New therapeutic agents should be considered in this situation. (rising TG, negative WBS, positive PET Scan).
Thank you for your referral.
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 10, 2009
Patient: Chan, Yau Choi T.
Date of Birth : November 25, 1967
File No. 13052950074
Mr. Yau Choi T. Chan, 41 year old male first consulted me on July 27, 2009. He was diagnosed to have diabetes mellitus type 2 in 2003 and has been taking Metformin 850 mg twice or thrice a day depending on his meal intake. He denies experiencing weight loss in the past year, polyuria, polydipsia, polyphagia, numbness and blurred vision.
Past medical history is unremarkable. He does not smoke but drinks red wine occasionally. He does not exercise and has one child. Family history is negative for diabetes.
Physical examination: Height: 170 cm Weight 102.2 kg BP 110/80 PR 82/minute BMI 35.3 Waist Circumference 108 cm
Head, eyes, ear, throat: normal (no retinopathy on funduscopy at the Eye Referral Center)
Neck: no goiter
Heart and Lungs: Normal
Abdomen: globular, no organomegaly
Extremeties: full peripheral pulses
Laboratory Exams:
July 2, 2009 FBS 189mg/dl; Hba1c 10.9%; Creatinine 0.96 mg/dl; Uric Acid 6.04 (4.3-7.0 mg/dl); Triglyceride 119; Cholesterol 152; VLDL 23; LDL 90; HDL 37; LDL 90; SGPT 48.4 ; Hb 159 Hct 0.478 WBC 5.5 Neutrophil 61; Lymphocyte 35: Platelet count 181
Urinalysis trace protein ; +glucose; wbc 1-3
July 24, 2009 urinalysis was negative for protein
July 25, 2009 FBS 9.25 mmol/l Hba1c 9.8% ( 4.27-6.07)
August 9, 2009 FBS 125.91 mg/dl 2hour postprandial plasma glucose 99.11 mg/dl
Urinary microalbumin 10 mg/dl urine creatinine 128 mg.dl
urine microalbumin/creatinine ratio is 8 mg/g (0-16 mg/g)
August 10, 2009 ECG Normal
Diagnosis: Type 2 Diabetes Mellitus
Obese II
Dyslipidemia – Low HDL
Assessment: At time of visit, patient still had poor glucose control although he had no sign of chronic complication. He received education on diabetes and proper diet. With adjustment of medication, his FBS and PPBG improved which he has to maintain to reduce his risk for diabetes complications. Other cardiovascular risk factors present in patient other than diabetes are a low HDL and obesity.
Management: 1. Lifestyle modification: weight loss of about 5-10% in 6 months; diet – 1750 calories /day, avoid simple sugars and fats and; regular exercise lasting 30 minutes 5 times a week.
2. Medications include Sitagliptin 100 mg once a day before dinner and Metformin 1000 mg after breakfast and dinner.
3. Raise HDL with exercise.
Prognosis: At this time when patient is still free of complications, intervening aggressively will give him a good prognosis.
Josephine Carlos-Raboca, M.D.
Medical Summary
Garlit, Josefina M.
I first saw Ms. Josefina M. Garlit 50 year old female on May 9, 2008 for treatment of her thyroid problem. She was treated for Grave’s Disease at the University of Santo
Tomas Hospital in February 2007 and had undergone radioactive iodine treatment. When she came to me she was hypothyroid and complained of double vision, puffy eyelids and exophthalmos. She was started on Levothyroxine. Her hypothyroidism is now corrected at a dose of T4 50 mcg Mondays to Saturdays and 25 mcg on Sundays.
Incidentally, she also presented with impaired fasting glucose for which nutritional therapy and regular exercise were advised.
On June 16, 2009, Hba1c was elevated to 7.2% so Metformin 500 mg a day was started and after 2 months, FBS rose to 7.2 mmol/l. She is now considered as type 2 diabetic and her metformin was increased to 500 mg twice a day.
Patient does not drink alcohol nor smoke. Family history is positive for goiter in mother and sister. She had 4 pregnancies all delivered by cesarian section.
Pertinent physical examination findings: Height 172.7 cm weight 74.5 kg BMI 25.25 BP100/80 PR 88
+exophthalmos , palpable pea sized nodule right thyroid
Normal fundi
Laboratory Tests:
May 05, 2008 FBS: 5.95, TSH: 75.0, T3: 0.49
June 23, 2008 FBS: 6.12, TSH: 0.285
July 31, 2008 TSH: 0.303, FT4: 1.77, FBS: 5.47, BUN: 3.02, BUA: 0.327,
Creatinine: 81.9, Cholesterol: 3.84, Triglycerides: 1.12, HbA1c: 5.32
February 26, 2009 FT4: 1.39, TSH: 0.430, FBS: 6.63
June 8, 2009 2’PPBS: 6.65, HbA1c: 7.2%, TSH: 2.82
July 27, 2009 2’PPBS: 4.16, HbA1c: 5.4, TSH: 0.250
July 31, 2009 HbA1c: 5.70, Creatinine: 47.54, True Glucose: 7.22, SGOT: 18.19
SGPT: 21.69, Cholesterol: 3.83, Triglycerides: 0.69, HDL: 1.40, VLDL: 0.31,
LDL: 2.21, HDL Ratio: 2.74 ECG: Within Normal Limit
Diagnosis: Diabetes Mellitus Type 2
Obese I
Grave’s Disease with ophthalmopathy post RAI now hypothyroid adequately replaced with thyroid hormone
Medications: Metformin 500 mg 2x a day.
Levothyroxine 50 mcg Mondays to Saturdays, 25mcg Sundays
Recommend: Diet 1600 calories /day avoid simple sugars
Weight loss 5-10%.
Regular exercise 5x/week for 30 minutes each time
Urine microalbumin / creatinine ratio
Prognosis: Lifetime thyroid hormone replacement.
Intensive diabetes care. Longterm diabetes monitoring for glycemic control, dyslipidemia and other complications.
Josephine Carlos-Raboca, M.D.
July 21, 2009
Medical Summary
Egana, Aurora B
Aurora B. Egana first came to see me on October 27, 2007 for her multinodular toxic goiter. She was diagnosed and treated for this condition in 2005 at the Philippine General Hospital. When she came to see me patient had atrial fibrillation. Thyroid scan showed cold nodules and a dominant hyperfunctioning nodule. Due to her heart condition and age considerations radioactive iodine treatment with 30 mci was given on February 20 2008. Patient was lost to follow up thereafter as she had plans of migrating to Canada.
A year after, July 13, 2009, patient came back to get a clearance and was hypothyroid. She was given thyroid hormone replacement. A residual thyroid mass was present. Fine needle aspiration biopsy of both thyroid lobe nodules was done which showed colloid goiter on the left and a suspicious Hurthle cell tumor on the right thyroid.
Patient was diagnosed with diabetes mellitus in 2007 and currently controlled on oral medications: An ophthalmology referral showed no retinopathy but a macular hole was noted.
Patient is a non smoker and had no family history of cancer or goiter and had 4 pregnancies and deliveries.
Currently patient is doing fine.
Laboratory Tests:
July 9, 2009 ECG: Arial fibrillation with controlled ventricular rate, Frequent premature ventricular contraction in bigeminy, Consider inferior wall ischemia.
July13, 2009 Thyroid Ultrasound: Normal size right thyroid and enlarged left thyroid. Solid and complex masses, both lobes and isthmus.
July 16, 2009 Thyroid Tc99m Imaging: Nodular enlarged left lobe.
TSH 13.958 uIu/mL, FT4 10.727 pmol/mL, FT3 2.889 pmol/L
Clinical Chemistry SGPT 29.0 U/L, SGOT 26.0 U/L, Creatinine 1.0 mg/dL, BUA 3.83 mg/dL, HbA1c 6.3%, Cholesterol 165.19 mg/dL, Triglycerides 90.87 mg/dL, HDL 61.13 md/dL, ALDL 83.18 mg/dL, FBS 99.89 mg/dL
Urinalysis Color: Yellow, Transparency: Clear, pH: 6.0, Reaction: 1.020, Sugar: (-), Protein (Albumin): (-), Ketones: (-), Nitrites: (-), Leucocytes Esterases: Trace, Blood (hemoglobin): (-), RBC: 1, WBC: 3, Epithelial Cells: 3, Bacteria: 27
Micro Albumin Crea Ratio urine microalbumin : 10.7 mg/dL, urine creatinine: 144 mg/dL, urine microalbumin creatinine ratio: 7 mg/g
Hematology Hemoglobin 12.50 g/dL, hematocrit 38.90%, RBC 5.72, WBC 5.31, Eosinophils 1.00%, Segmenters 55.0%, Lymphocytes 34.0%, Monocytes 10.0%, Platelet count 227,000.00 /uL, MCV 68.0um^3, MCH 21.90 pg, MCHC 32.10%, RDW15.70%
July 20, 2009 Fine needle Aspirate Biopsy: Cell findings are suspicious for a Hurthle cell tumor, right. Cell findings are consistent with a colloid nodule, left.
Medications:
L-thyroxine 25 mcg daily
Pioglitazone 15mg once a day
Vildagliptin 50mg once a day
Amlodipine 5mg once a day
Aspirin 80mg once a day
Prognosis:
As a diabetic, patient is at high risk for cardiovascular event especially with her chronic atrial fibrillation.
Her multinodular goiter, hypothyroid status is being corrected with thyroid hormone replacement which would be needed for life. A definitive surgery to rule out Hurtle malignancy is a consideration although Hurtle cell changes may still be benign however as seen in thyroiditis. Other than surgical option, patient may be monitored closely clinically.
Josephine C. Raboca M.D.
To Whom It May Concern:
This is to certify that Ms. Rosalina Basa Gomez 81 year old female, has been my patient since 1994.
She is currently taking several medications for multiple medical problems which include diabetes mellitus, hypertension and dementia.
Ms. Gomez plans to travel and with her medical condition, she would require a travel companion/ caregiver to assist her.
Yours truly,
Josephine Carlos-Raboca, M.D.
June 26, 2009
To Whom It May Concern:
I saw Joseph Dalrymple on June 22, 2009 for follow up of his thyroiditis which presented as weight loss since November 2008. He consulted me for this problem on February 20, 2009 and was diagnosed with thyroiditis on March 6, 2009 on second visit.
At present, he is doing fine although he experiences slight tiredness which I would attribute to his cardiomyopathy more than his thyroid problem.
His thyroid function tests are normal. As agreed with patient, his thyroid hormone replacement has been discontinued to see natural course of thyroiditis which oftentimes may revert back to normal.
A repeat FT4 and TSH is due in 2 months in time for a follow up visit with me.
Sincerely,
Josephine Carlos-Raboca,M.D.
This is to certify that Ms. Jean Brown born Nov. 5, 1953 has been my patient since March 2, 2009. She was diagnosed to have diabetes mellitus type 1 in 1991 and has been using an insulin pump for the past 6 years. Her pump is now malfunctioning and is no longer covered by warranty. She would thus need a replacement immediately as this is essential for good diabetes control and prevention of complications. The recommended model is a Medtronix Paradigm 522.
This certification is issued upon the request of the patient for insurance purposes.
Yours truly,
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
June 19, 2009
Magugat, Rizalito C. 61 year old Filipino born on May 30, 1947 has been my patient since January 2001. He presented with body weakness, polyuria and polydipsia of one month duration. He was diagnosed to have diabetes mellitus type 2 confirmed with a 75 gm OGTT. Initial Hba1c was 10.3%.
He was prescribed a diet plan of 1650 calories per day with simple sugar restrictions, regular exercise and Metformin 500 mg twice a day. His glycemic control has been on target since 2003 with a consistent Hba1c below 7% . Current medications are Metformin 500 mg 3x a day and Glimepiride 1 mg a day.
In August 2001 he was diagnosed to have hypertension . BP has been under good control. Current medications are Olmesartan 20 mg a day and Enalapril 10 mg a day.
Gemfibrozil was added to his regimen for dyslipidemia in June 2003 with a predominantly elevated triglyceride. This was subsequently changed to Simvastatin 20 mg at bedtime.
His mother, brother and sister are diabetic. He does not smoke nor drink alcohol. His past medical history was unremarkable.
Physical examination. Height 176.6 cm weight 88.5 kg BP 140/80 BMI 29.8 He had no retinopathy on funduscopy. The rest of the physical examination was normal.
Laboratory examinations
Hba1c
April 2006 6.2%
July 2006 6.0%
April 2007 6.2%
Dec 2007 6.8%
April 2008 6.8%
Oct 2008 6.2%
Mar 2009 6.3%
Jan 2007 urine microalbumin 64mg/dl urine creatinine 118 mgdl UAC 54
May 2, 2007 Treadmill stress test: incomplete right bundle branch block; no subjective nor objective evidence of myocardial ischemia during exercise and post exercise, recovery period,no arrhythmia
Patient achieved 77% of PMTHR at 7.0 METS and treadmill exercise duration 6.40minutes
Exaggerated BP response to exercise
July 22, 2008 Ultrasound of Kidneys
renal parenchymal disease, bilateral
Right renal cortical cyst 2cm in size
unremarkable urinary bladder
urine microalbumin creatine ratio > 253
Jan 28, 2009 ECG sinus bradycardia left anterior hemiblock right ventricular hypertrophy left atrial abnormality FBS 95 uric acid 5.51 cholesterol 94 triglyceride 87 VLDL 32.21 LDL 45 chol/HDL 2.92
Jun 2, 2009 HBsag reactive SGPT 36 Serum creatinine 1.22
Final Diagnosis: Diabetes Mellitus Type 2 good control
Diabetic nephropathy , stage 2
Dyslipidemia
Hypertension
Medications: Glimepiride 1 mg OD
Metformin 500 mg TID
Aspilet 80 mg OD
Enalapril 10 mg OD
Olmesartan 20 mg OD
Simvastatin 20 mg OD
Josephine Carlos-Raboca M.D.
April 22, 2009
Joseph Dalrymple born August 14, 1969.
Joseph came to see me on April 17, 2009 for a follow up visit for his autoimmune thyroiditis. He did get some improvement in terms of decreased anxiety although he still had difficulty getting enough sleep with an average of 4 hours per day. He still moves his bowels 3-5 times a day.
Physical examination showed weight gain of 5 kg since last visit. Present weight was 95.5 kg, BP was normal at 120/80 and pulse rate was 68/min. FT3 was normal at 4.48 pmol/l, FT4 was also normal at 15.308 pmol/l with a slightly elevated TSH 6.25 uIu/ml consistent with subclinical hypothyroidism. This is still expected of the course of his disease.
The hypothyroid phase may be transient or may progress. I have decided to give him thyroid hormone replacement at 12.5 ug/day for the possible benefit of improved cardiac function on the background of his cardiomyopathy.
His follow up visit is on June 22, 2009 with a repeat FT3, FT4,TSH and 2D Echocardiogram.
Josephine Carlos-Raboca,M.D.
April 7, 2009
Mr. Tarsicio Castaneda, 59 year old Colombian born on March 8, 1950 consulted me for the first time on March 20, 2009 because of an elevated Hba1c done during a routine check up done on February 16, 2009. He experiences frequent thirst and urination. He lost 1 kg in 3 months but was intentional.
Family history is positive for diabetes. He does not smoke cigarette but drinks alcohol occasionally. He has benign prostatic enlargement and is under the care of Dr. Rodolfo Herrera. He had bilateral retinal detachment 30 years ago due to trauma.
Physical examination: weight 75 kg; height 169cm; BP 120/80;PR 84/min; BMI 27. The rest of the examination was unremarkable.
He was advised to undergo a 75 gm oral glucose tolerance test which showed impaired fasting glucose.
Other laboratory exams are as follow:
February 16, 2009 FBS 90 Cholesterol 152 mg/dl Triglyceride 216 mg/dl HDL 33 mg/dl LDL 95 VLDL 43.4 HDL ration 4.61 Hba1c 6.3% ( 4.27-6.07)
ECG- Normal
March 21, 2009 75 gm OGTT Fasting 101.9 1hour = 147.39 2 hour=92.8
Diagnosis: Impaired Fasting Glucose (prediabetic)
Overweight
Dyslipidemia (high triglyceride, low HDL)
Recommendation:
1.Weight reduction of 5-10% in 6 months through diet that is low in simple sugars and fats;
2. regular aerobic exercise 30 minutes 5 times a week;
3. Metformin 500 mg twice a day.
4. Repeat FBS, Lipid Profile and Hba1c after 3 months.
5. Follow up with results.
Josephine Carlos-Raboca M.D.
March 24, 2009
Mr.James Andrew Thornton consulted me for the first time on August 8, 2006 due to diabetic foot on the right which started 2 weeks prior to consult as blisters after exercising on the treadmill. Eventually the blisters got infected. H e was confined at that time for debridement. He was referred to a vascular surgeon, Dr. Victor Gisbert. His medication included Pletaal at that time.
I didn’t see Mr. Thornton since then till he was confined at Makati Medical Center on August 16, 2008 for diabetic foot again and back abscess. The physician whom he saw in the interval period is not known to me.
On admission, BP was 100/60 height 188 cm weight was not recorded as he was unable to stand. BUN was 45 mg/dl creatinine was 1.4. On discharge BP was 120/80, BUN 37.9 and creatinine was 1.2.
Final Diagnosis: Diabetic foot with Characot’s arthropathy, left
Anemia secondary to chronic disease
Diabetes Mellitus type 2
Atherosclerotic heart disease
Osteoporosis
Peripheral Vascular Disease
S/p post debridement, appplicaiton of VAC dressing, left foot
S/P spinal surgery/anterior debridement L4-L5 with bone graft
S/P external fixator application left ankle.
Josephine Carlos-Raboca M.D.
March 19, 2009
Ms. Primitiva M. Perez 69 year old Filipina born February 25, 1940 has been my patient since July 8, 2004. She was diagnosed with diabetes mellitus type 2, obese in 1994.
Past History: S/P thyroidectomy 1974
TAHBSO 1985
Hypertension, osteoarthritis
Cataract surgery, both eyes
Personal history: non smoker
Family history: diabetes in mother , brother, sister
Daughter died of cerebral aneurysm 2005
OB Histrory: G3P3
Pertinent Laboratory and diagnostic findings:
Jan 12, 2004 Ultrasound right hepatic lobe hyperechogenic focus probably hemangioma, renal microcalculi and beginning parenchymal changes
Aug 14, 2007 ECG diffuse nonspecific ST-T changes, ischemia not ruled out
Sept 2008 Creat 1.0 LDL 114 HDL 50 Cholesterol 114 triglyceride 135 uric acid 7.2 sgpt 23
February 2009 chest xray atherosclerotic aorta
ECG left atrial enlargement
Hba1c 9.1%
March 19, 2009 FBS 120 mg/dl
Medical events/ treatment
Aug 2007 Pneumococcal vaccination
May 2008 hospitalized for bleeding peptic ulcer disease
Current medications: Sitagliptin 50mg/Metformin 500mg BID
Glimepiride 2mg BID
Detemir 15 units bedtime
Irbesartan 150 mg OD
Trimetazidime 20 mg BID
Eterocoxib 120 mg as needed
Diagnosis: Diabetes Mellitus type 2 insulin requiring for control
Hypertension
Osteoarthritis
Hyperuricemia
Obese
Remarks: 1. tests due:
thyroid function tests, urine microalbumin /creatinine
2. intensify glucose control
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
March 19, 2009
Angelicca Arnie Soledad born March 11, 1984
Angelicca came to see me for the first time on May 2, 2008 for obesity, diabetes mellitus type 2 of 5 years and irregular menses. She has not been taking her diabetes medications at the time I saw her.
She was not a smoker, had a father who had diabetes, was nulligravid, and took Bangkok slimming pills at 16 years old.
Pertinent physical exam showed mild hirsutism. BMI 38.5; weight 88.2kg ; height 162.5 cm BP 110-120/80-90.
Laboratory:
Dec 08 urine micral negative; creatinine 46.36; Hba1c 8.16% ; ECG normal; FBS 8.26 cholesterol 4.77; LDL 3.28; HDL 1.1; triglyceride 1.01; SGPT 62; SGPT 91
Diagnosis: Diabetes Meliitus Type 2
Obese II
Polycystic Ovarian Syndrome
Fatty Liver
Medication: Metformin 2 gm per day
Diane 35
Prognosis: High risk for cardiovascular disease
Recommend: Improve glycemic control, weight loss, regular exercise
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
March 19, 2009
Medical Consultation Report
Joseph Dalrymple, born August 14, 1969.
I saw Joseph on February 20, 2009 . He was referred to me for elevated FT3, FT4 and low TSH by his cardiologist, Dr. Enrique Campos, who was seeing him for cardiomyopathy.
He presented with weight loss of 40 lbs since Nov. 2008 . However he claims he did not observe any change in sleep pattern, bowel movement or perspiration.
He does not smoke nor drink alcoholic beverages. Family history is negative for diabetes and thyroid disease.
Physical examination did not show any thyroid enlargement, no neck tenderness, no hand tremors, nor eye signs of thyroid disease.
Laboratory Findings:
Elevated FT3, FT4,low TSH, elevated thyroglobulin antibody, low RAIU uptake and decreased uptake on thyroid imaging.
Diagnosis: Patient has autoimmune Thyroditis (silent or painless thyroiditis) which may go through the hyperthyroid phase lasting for two months or more.
Prognosis: This may spontaneously resolve and go back to euthyroid phase but may be recurrent. Some may develop permanent hypothyroidism later on.
Treatment: Symptoms can be alleviated with propranolol or sedatives. Prednisone may help sometimes but is not necessary.
Plan: He is due for repeat thyroid tests after 6 weeks.
Thank you.
Josephine Carlos-Raboca M.D.
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 dmeasuring 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 units bedtime
Novorapid 4units before breakfast 6 to 8 units before lunch, 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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