Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Laparoscopic Gastric Bypass Consult - 2
Consult for laparoscopic gastric bypass.
(Medical Transcription Sample Report)
He is a 22-year-old male who is 312 pounds, 6 feet tall, and a BMI of 42. He has been overweight for 15 years since the age of 8, at his highest 330 pounds, at his lowest 200. He is attempting surgical weight loss because most of his childhood and entire life, he has been overweight. He had some initial success with diets, but results are not long lasting and he gains the weight back. His goal is to have a Lap-Band surgery as a tool to help him to more healthy life and to help resolve his poor eating habits. He feels that the weight adversely affects his life physically. Most days he has back, knee, and ankle pain and makes walking upstairs quite difficult. When he loses weight he always regains it and he gains more than he lost. His biggest weight loss was 45 pounds and it was two months before he gained it back. He was on the Atkin's Diet when he was 16-years-old. He lost the 45 pounds in two months. He saw quick results. It was unsuccessful because it was just a diet as soon as he reintroduced carbs he gained the weight back. He has participated in multiple commercial weight loss programs, Weight Watcher's for four months in 2004 and lost 35 pounds over one to two months, Weight Watcher's for two months in 2007 and lost 20 pounds over one month, Atkin's Diet for three months in 2002 and lost 45 pounds over two months, Slim Fast for two months in 2003 and lost ten pounds over two months, Nutri-Systems for two months in 2005 and lost five pounds over one month, New York Sports Club exercising for seven years in 2001 to present and no weight loss, and personal trainer 25 sessions in 2007 and 2008 and no weight loss. He has tried multiple calorie and fat reduction diets including Atkin's, South Beach, and various fad diet books and magazines. He has been on medically supervised weight loss programs. PAST MEDICAL HISTORY:
He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor. He exercises three times a week at home and does cardio. He has difficulty walking two blocks or five flights of stairs. Difficulty with snoring. He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling. He has gastroesophageal reflux disease.PAST SURGICAL HISTORY:
Includes reconstructive surgery on his right hand 13 years ago. SOCIAL HISTORY:
He is currently single. He has about ten drinks a year. He had smoked significantly up until several months ago. He now smokes less than three cigarettes a day.FAMILY HISTORY:
Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes. Denies obesity and hypertension in other family members.CURRENT MEDICATIONS:
He is allergic to Penicillin.MISCELLANEOUS/EATING HISTORY:
He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program. He had a poor experience with the Greenwich program. Eating history, he is not an emotional eater. Does not like sweets. He likes big portions and carbohydrates. He likes chicken and not steak. He currently weighs 312 pounds. Ideal body weight would be 170 pounds. He is 142 pounds overweight. If
he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.REVIEW OF SYSTEMS:
Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin. Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.PHYSICAL EXAMINATION:
He is alert and oriented x 3. Cranial nerves II-XII are intact. Afebrile. Vital Signs are stable. Neck is soft and supple. Lungs clear to auscultation. Heart is regular rhythm and rate. His abdomen is soft and nontender. He has no palpable herniations. Extremities are nonedematous.IMPRESSION/PLAN:
I have explained to him the risks and potential complications of laparoscopic gastric banding in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, slippage of the band, erosion of the band, esophageal dilatation, injury to the band, port, or tubing necessitating replacement of the band, port, or tubing, injury to the esophagus, stomach, small intestine, large intestine, spleen, or liver, and possible mortality in 1 to 2000 patients. He understands. He is going to see Dr. XYZ and receive a letter of recommendation from him. He will see Lynn Holmberg, mental health evaluation Mary Ziller, and pulmonary clearance by Dr. XYZ. He will have upper GI, ultrasound for gallstones, H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar. After these are performed, we will submit him for insurance approval.
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