Consult - History and Phy.
Sample Name: Bariatric Consult - Surgical Weight Loss - 2
Description: Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.
(Medical Transcription Sample Report)
ABC was seen in my office on October 6, 2008 for evaluation for elective surgical weight loss. ABC is a 51-year-old female with a BMI today of 43. She is 5'4" tall and weighs 252 pounds. She is motivated to attempt surgical weight loss because she has been overweight for over 20 years and wants to lose weight slowly and be more active with her grandchildren and be healthier. She is mainly affected physically by her weight. When she loses weight she always regains it and she always gains back more weight than she has lost. At one time, she lost 25 pounds and gained the weight back in about six months. She has done numerous commercial weight loss programs including Weight Watcher's for six months in 1997, 1999, 2002, and 2004 with a 10 to 25-pound weight loss, TOPS Program in 1998 with a ten-pound weight loss, hypnosis for four months in 1988 with a 20-pound weight loss, an exercise program for two months in 2008 with six-pound weight loss, and Six Week Body Makeover for one month in 2008 with a two-pound weight loss. She did Nutri-Systems for six months in 1995 with a 20-pound weight loss and she was under your medical supervision in 2006 where she actually gained 12 pounds. She is on Meridia from one month previously.
PAST MEDICAL HISTORY: She had a negative stress test four to five years ago. She gets short of breath in walking about 30 steps. She has had non-insulin dependent diabetes for about eight years now. She has a left knee arthritis and history of hemorrhoids.
PAST SURGICAL HISTORY: Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.
PSYCHOLOGICAL HISTORY: Negative except that she was rehabilitated for alcohol addiction in 1990.
SOCIAL HISTORY: The patient is married. She is an office manager for a gravel company. Her spouse is also overweight. She drinks on a weekly basis and she smokes
about two packs of cigarettes over a week's period of time. She is doing this for about 35 years.
FAMILY HISTORY: Diabetes and hypertension.
MEDICATIONS: Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.
ALLERGIES: She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.
REVIEW OF SYSTEMS: Otherwise, negative.
PHYSICAL EXAM: This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.
ASSESSMENT/PLAN: This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass. ABC will be asking for a letter of medical necessity from XYZ. She will also need an EKG and clearance for surgery. She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.
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