Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Bariatric Surgical Weight Loss Consult Sample Report

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old super-obese man being seen today upon referral from primary care physician. Consultation requested for evaluation of morbid obesity and consideration of treatment with bariatric surgery. Obesity began at age 20 with weight 250 pounds, weight 295 pounds at age 34 and currently highest weight. Weight loss attempts included own efforts with a maximum weight loss of 50 pounds but always with weight regain. Now, with comorbid conditions including chronic intermittent low back, ankle and foot pains, heartburn and probable sleep apnea. Considering surgical weight loss in hopes of reducing or eliminating these comorbid conditions and live a longer healthy life.

1.  Chronic intermittent low back pain, ankle, foot pain.
2.  Heartburn.
3.  Probable obstructive sleep apnea.

PAST SURGICAL HISTORY:  Tonsillectomy and adenoidectomy.

MEDICATIONS:  Rolaids as needed for heartburn and Tylenol as needed for joint pains.


FAMILY HISTORY:  Father alive at age 64 with hypertension, sleep apnea and overweight.  Mother alive at age 60 and well. Brother alive at age 40, well, but obese. Sister alive at age 30, well, but obese.

SOCIAL HISTORY:  Married for 3 years with wife supportive of possible bariatric surgery. He works full time. Former tobacco smoker. Had more regular alcohol use previously, but quit all alcohol use recently, without any alcohol abuse history. Does not use recreational drugs. Not currently exercising.

REVIEW OF SYSTEMS:  CARDIOVASCULAR:  Currently asymptomatic. Recent EKG is reportedly within normal limits. GASTROINTESTINAL:  Complains of intermittent swallowing difficulty with foods and fluids for the last 3 months. Symptoms occur occasionally and he also occasionally regurgitates, feeling things get stuck. Denies associated nausea, diarrhea, constipation, abdominal pain. He has not had a formal evaluation for this. NEUROLOGIC:  Intermittent numbness of his feet over the last several days. He feels that may be related to standing on his feet for long periods during work; as soon as he is off his feet, symptoms resolve. Denies associated weakness or falls. Remainder of comprehensive review of systems is negative.

GENERAL:  Super morbidly obese (XX)-year-old Hispanic male sitting in exam chair, in no apparent distress.
VITAL SIGNS:  Pulse 72, respirations 16, blood pressure 134/74. Height 5 feet 6 inches, weight 324 pounds, BMI 52.3. Using body mass index of 23, ideal body weight is 142 pounds with an excess body weight of 182 pounds.
HEENT:  PERRLA. Sclerae anicteric. Oral cavity:  Moist, pink; 1+ tonsillar hypertrophy without exudate, erythema, crypts or obstruction.
NECK:  Supple. No JVD, adenopathy or thyromegaly.
LUNGS:  Clear bilaterally.
HEART:  Regular rate and rhythm. No S3, S4, murmur or carotid bruits.
ABDOMEN:  Obese with positive bowel sounds in all quadrants. Softly protruding ventral hernia, easily reducible and nontender. Organomegaly not appreciated secondary to body habitus. No tenderness, masses or rebound.
RECTAL:  Exam deferred.
PERIPHERAL VASCULAR:  Extremities warm and dry, 1+ pitting edema from mid shins to ankles bilaterally with early brawny hyperpigmentation about the ankle areas. No varicosities or cords.
MUSCULOSKELETAL:  Full ROM of all the major joints.

OBSTRUCTIVE SLEEP APNEA QUESTIONNAIRE:  Score equals 11, snores greater than 3 nights a week. Neck size greater than 17 and dozes during the day when not active.

EPWORTH SLEEPINESS SCALE:  Score equals 11, high chance of dozing when lying down to rest in the afternoon with circumstances permitting and when watching TV, moderate chance of dozing when sitting in meeting or sitting quietly after lunch without alcohol, slight chance of dozing with sitting inactive in a public place; for example, a theater or a meeting.

Gastric bypass and adjustable gastric band surgical procedure benefits, risks, expectations of weight loss and limitations were reviewed today. Lifestyle changes must begin immediately and carried out for the best shot and long-term success of any bariatric surgery. Discussed at great length dietary choices, snack behavior, food intake and regular physical activity. Lifelong scheduled visits, lab studies and vitamin and mineral supplementations were reviewed. Lastly, a 2-1/2 to 4 fold increased risk of certain cancers developing related directly to obesity were outlined such as cancers of the breast and colon. Recommendations are made to continue all routine health surveillance through his PCP. All questions were answered.

ASSESSMENT AND PLAN:  The patient is a super morbidly obese Hispanic male with comorbid conditions including multiple joint pains, heartburn and probable sleep apnea. He is interested in surgical weight loss, particularly gastric bypass surgery. He meets the criteria for bariatric surgery as defined by the American Society for Metabolic and Bariatric Surgery using NIH guidelines as long as he complies with the plan as will be listed below:
1.  Lose 40-50 pounds prior to surgery, more weight loss is safer. He may need to lose additional visceral fat several weeks before surgery per the surgeon’s determination and needs the HMR liquid diet 4-5 weeks before surgery.
2.  Obtain recent EKG tracing.
3.  All night sleep study with CPAP titration followed by pulmonary consultation for evaluation of suspected obstructive sleep apnea.
4.  Return for progress check with nurse practitioner at 1 month’s and 3 months’ time and with the nutritionist at 2 months’ and 4 months’ time to comply with national regulations and insurance requirements.
5.  Meet with bariatric surgeon, John Doe, MD, for initial bariatric surgeon consultation in 2 months’ time.
6.  Attend mandatory presurgical skill sessions, optional attendance at gastric bypass support group is recommended.
7.  Start regular exercise. Recommend starting slow and recondition slowly his heart, lungs and musculature.

Ninety plus minutes were spent with the patient today in completing comprehensive history and physical exam, detailed teaching and coordination of care.

Thank you for the referral of this very nice gentleman. We will follow along with you.