Consult - History and Phy.
Sample Name: Bariatric Consult - Surgical Weight Loss - 3
Description: Evaluation for bariatric surgery.
(Medical Transcription Sample Report)
I had the pleasure of meeting Ms. ABC for evaluation for bariatric surgery. As you know she is a pleasant 54-year-old female who has multiple medical problems and is seeking evaluation for laparoscopic gastric banding. I saw her on October 3, 2008 in the office after she had attended a Fairfield County Bariatrics and Surgical Specialists seminar. She is 5'7" tall and weighs 242 pounds. She has been overweight since age 27. She is now at her highest adult weight.
PAST MEDICAL HISTORY: Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke. She denies any history of cancer. She does have a history of hepatitis which I will need to further investigate. She complains of multiple joint pains, and heavy snoring.
PAST SURGICAL HISTORY: Includes hysterectomy in 1995 for fibroids and varicose vein removal. She had one ovary removed at the time of the hysterectomy as well.
SOCIAL HISTORY: She is a single mother of one adopted child.
FAMILY HISTORY: There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family. Her mother is alive. Her father is deceased from alcohol. She has five siblings.
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAM: She is a 54-year-old obese female. She does not appear to have any significant residual deficits from her stroke. There may be slight left arm weakness.
ASSESSMENT/PLAN: We will have her undergo routine nutritional and psychosocial assessment. I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss. She is otherwise at increased risk for future complications given her history, and weight loss will be a good option. We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.
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