Personal Medical Records – ROJoson – Sample

 

ROJoson Personal Medical Records (Collated – 16feb22; Updated – 16apr2 -16may14 – 16jul30)

Name: Reynaldo O. Joson

Sex: Male

Age: 67 (January 31, 1949)

 

VACCINATION / IMMUNIZATION

Records: None available at present

Recall:

  • Had basic vaccination / immunization when I was a baby / child (at least BCG, DPT, Polio, Measles)
  • No booster in tetanus toxoid ever since vaccination / immunization at childhood
  • No hepatitis B vaccination (2011; 2012; 2013; 2014; 2016 Jan – HBsAg – non-reactive; Anti-HBS- reactive)
  • No flu vaccination

 

PAST SIGNIFICANT ILLNESS:

Major:

NO hospitalization ever

NO major surgical operation ever

NO major significant illnesses yet

 

Minor:

Circumcision (Grade VI – circa 1962)

Excision of epidermal cyst, prepuce (1972 by Dr. Serafin Hilvano) – no recurrence up to now

Excision of warts – knee; toe – Dr. Nelson Cabaluna (circa 2005) – recurred on toe – applied Duofilm – resolved – no recurrence up to now

Plantar fasciitis (late 2014 to 2015 lasting for about a year – disappeared late 2015 after I did stretching exercises, particular lunges – no recurrence up to now – still doing daily lunge exercise)

Mucus cyst, right thumb (noted circa 1997; 2012 enlarged and distended to the point of wanting to rupture spontaneously – pricked and aspirated;  recurred at least 2 times up to Dec 2013; pricked again; recurred July 2014-  last pricked or aspiration: July 2014 up February 2016 – no recurrence going 2 years now): recurred May 2016 – 2mm – steady in size as of July 30, 2016  (to keep observing)

See https://www.facebook.com/media/set/?set=a.673672092653843.1073741833.231960253491698&type=3

 

CURRENT HEALTH STATUS AND CONCERNS:

Lifestyle

NO smoking (just “tasted” smoking cigarettes in less than a year in 1968.

NO drinking (sips only and occasional – feels unwell after drinking)

Exercises (regular exercises resumed in 2011 after discovery of hypertension – continuing up to the present – 2016 – daily 3-km walk and 30-minute stretching and flexing exercises)

Computer-immersion (daily – continuous – have been trying to have a regular break after 2 hours of computerization)

Work – semi-retired; no more administrative work – retired from PGH; OMMC; MDH Administration in 2014 (age 65); still practicing surgery and medicine at a regulated pace; do blogging as a daily activity; do some consultancy in hospital and health administration as requested

 

BMI = 28.1 (2011jan); 26.5 (16feb1); 23.7 (maintained from April 2016 to July 30, 2016)  – see table below

2011Jan = BMI – 28.1 (overweight)

Ht – 172 cm

Wt – 78 kg

 

2016 July 30 – 70 kg  (BMI = 23.7 – normal)

 

Underweight: < 18.5

Normal weight: 18.5 – 24.9

Overweight: 25 – 29.9

Obese: ≥ 30

 

BP = 140/90  (since 2011 after Dr. Montemayor study – with exercise, diet, and amlodipine 5 mg / day)

2011 Holster – 24-hour monitoring – done in connection of Dr. Beth Montemayor study – average 24-hour BP = 172 / 106 mmHg vs 130/80

 

PR = HR = regular rhythm; 85 beats / min

 

Eyes: with error of refraction (wearing eyeglass since grade school days)

Myopia with astigmatism

Presbyopia starting age 40 (felt old already after I discovered this)

June 25, 2012 – Practically the same refractive errors as in February 16, 2015 (Dr. Terrence Cham; Jose Ong Lim)

February 16, 2015 (George Optical)

OD: -2.00 Dsph = -2.00 Dcyl x90

OS: -1.75 Dsph = -2.00 Dcyl x90

Add +1.50

PD:64.5

NO signs / symptoms of glaucoma

 

No jaundice (never had one before)

Pink conjunctivae (Hgb – mean of 15 since 2011 up to Jan. 2016)

 

Neck: mass, 1 cm, right infra-auricular area, discrete, non-tender (primary diagnosis – nonspecific lymphadenopathy – has been there for more than 15 years now, circa 2000, not increasing in size) [see https://www.facebook.com/media/set/?set=a.1080979035256478.1073741888.231960253491698&type=1&l=f9da498df4]

 

Heart: no murmur

Lungs: clear breath sounds

Abdomen: no mass palpated

 

Extremities:

Masses:

  • Left forearm, below elbow crease, 2 cm, subcutaneous mass, discrete, soft (primary diagnosis: lipoma – has been there for more than 15 years now, circa 2000, not increasing in size)
  • Left forearm, elbow, radial side, 4 cm, below skin, muscular layer, discrete, non-tender (primary diagnosis – hematoma secondary to blood donation – has been there for more than 10 years now, circa 2005, not increasing in size)

See https://www.facebook.com/media/set/?set=a.1080981955256186.1073741889.231960253491698&type=1&l=dc9f71ff29

Numbness, left hand, intermittent, has been there for more than 10 years now (primary diagnosis: carpal tunnel syndrome – has been there for more than 10 year now, circa 2005, tolerable, not worsening)

Thumb Tendinitis, left ( De Quervain’s Tendinosis) – 16feb3 – conservative treatment – analgesics –  slight exercise – relieved after 3 days – still with residual mild discomfort – as of 16feb24 – 3 weeks after.

 

CBC (2011 – 2016) = normal

(See Files)

 

    11dec23 12dec28 13dec28 14dec27 16jan2 16feb06
FBS (5.55)   5.17 5.79 (H) 5.70 (H) 4.8 (n) 6.3 (H) 5.90 (H)
HBA1C (6.07%)   5.9 6.0 6 5.8 5.60  
               
Cholesterol (5.20)   5.90 (H) 6.50(H) 7.3 (H) 6.4 (H) 6.8 (H)  
LDL (2.60)   4.0 (H) 5.0 (H) 5.8 (H) 4.3 (H) 6 (H)  
Triglycerides (1.70)   1.05 1.44 1.3 1.9 (H) 1.3  
               

(See Files)
ECG = January 18, 2011; October 30, 2014 – normal sinus rhythm; left axis deviation; non-specific ST-T wave changes

2-D Echo (October 30, 2014 – age 65) – normal sized left ventricle with adequate wall motion and preserved overall systolic and diastolic function; mild aortic valve sclerosis; normal pulmonary artery pressure

(See Files)

Other Notes:

Had a major car accident on January 31, 2016, felt asleep and hit a truck. No physical injury though.   Wake-up call to be more careful in driving.

Family History:

Stroke: Father at age 63; one older brother at about age 55; uncle (older brother of father); mother at last 70 (several mild stroke – 2015-2016 – age 86)

Diabetes: Mother; older brother

 

Overall assessment of current health status and concerns:

With definite health problems and concerns:

  • Hypertension (chronic)
  • Hypercholesterolemia (chronic)
  • Diabetes mellitus (chronic)
  • Carpal tunnel syndrome (left hand – chronic) – on and off, tolerable (as of April 2016)
  • De Quervain’s tendinosis (left thumb – recent) – no more (as of March 2016)

 

 

Risks for Death and Disability

  • Stroke and heart attack – Factors: Age; Overweight; Hypertension; DM; Hypercholesteleronemia
  • Disability of the left hand – Factors: Carpal tunnel syndrome; De Quervain’s tendinosis
  • Accidents – Factors: Age; Decreased mindedness

 

Resolutions:

 

Target: To stay alive and not crippled at least up to age 80 to see my son stable in the practice of medicine (13 years to go)

 

Reduce risk for stroke:

Take medicines for hypertension; hypercholesterolemia; diabetes mellitus

Bring weight down to reach a normal BMI

Control diet (type of foods and amount)

Continue stress management and control

Continue daily exercise (1.5 hours a day – walking and stretching and flexing)

Continue to control work

 

Disability of the left hand:

Control usage – avoid strenuous activity but keep on stretching and flexing left hand

 

Accidents:

Be always vigilant on avoiding risks for accidents

 

Others:

Continue living a healthy lifestyle – control stress; manage diet; continue but control work; do daily exercise; do daily relaxation

 

 

Priority Action Plans:

Control hypercholesterolemia and diabetes mellitus  (within one month) – Still has to normalize as of July 30, 2016

Bring BMI down to normal (within three months) – Accomplished as of April 23, 2016 (within 2 months – from March 1, 2016 to April 23, 2016)

 

 

 

 

April 1, 2016; May 14, 2016; July 30, 2016

Progress Report (From February 22, 2016)

  Weight  (kg) Height (cm) BMI

Normal weight: 18.5 – 24.9

Overweight: 25 – 29.9

Obese: ≥ 30

2011 Jan 83 172 28 (overweight)
2016 Feb1 78   26.4
2016 March 1 77   26.0
2016 March 13 76.5   25.7
2016 March 28 74.5   25.2
2016 April 23 72   24.9 (NORMAL)
2016 May 14 71.5   24.7
2016 June 15 70   23.7
2016 July 30 70   23.7
  Target 71   24.5
Underweight: < 18.5

Normal weight: 18.5 – 24.9

Overweight: 25 – 29.9

Obese: ≥ 30

     

 

    11dec23 12dec28 13dec28 14dec27 16jan2 16feb6 16apr2 16may14 16jun11 16jul30
FBS (5.55)   5.17 5.79 (H) 5.70 (H) 4.8 (n) 6.3 (H) 5.90 (H) 5.90 (H) 5.50 5.20 5.60 (H)
HBA1C (6.07%)   5.9 6.0 6 5.8 5.60   5.4 5.3  
                       
Cholesterol (5.20)   5.90 (H) 6.50(H) 7.3 (H) 6.4 (H) 6.8 (H)   6.70 (H) 6.00

(H)

6.1 (H) 6.20 (H)
LDL (2.60)   4.0 (H) 5.0 (H) 5.8 (H) 4.3 (H) 6 (H)   5.1 (H) 4.4 (H) 4.5 (H) 4.4 (H)
Triglycerides (1.70)   1.05 1.44 1.3 1.9 (H) 1.3   1.13 1.05 0.67 1.02
HDL (1.56)               1.28 1.32 1.33 1.48

 

(See Files)

  16jan2 16apr2 16may14 16jun11 16jul30
FBS (5.55) 6.3 (H) 5.90 (H) 5.50 5.20 5.60 (H)
HBA1C (6.07%) 5.60 5.4 5.3  
           
Cholesterol (5.20) 6.8 (H) 6.70 (H) 6.00

(H)

6.1 (H) 6.20 (H)
LDL (2.60) 6 (H) 5.1 (H) 4.4 (H) 4.5 (H) 4.4 (H)
Triglycerides (1.70) 1.3 1.13 1.05 0.67 1.02
HDL (1.56)   1.28 1.32 1.33 1.48

 

BP:

BP before July 2016 – 140 / 90 (with Amlodipine 5mg OD since 2011)

BP: 120/80  (July 2016)

 

ROJ@16jul30

 

 

 

 

 

 

 

 

 

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