Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Weight Loss Evaluation
Description: Patient with morbid obesity.
(Medical Transcription Sample Report)
REASON FOR VISIT: Weight loss evaluation.
HISTORY OF PRESENT ILLNESS: Ms. ABC is a 34-year-old woman. She has suffered from obesity for a while. She has made attempts at nonsurgical weight loss and has not been successful. She does have a history of pulmonary embolus and a right lower lobe lobectomy. She is currently doing a lean and green diet and trying to cut out her bad carb intake. She did mention having some issues with fruits that did upset her stomach. Last visit, we had talked about her exercising. She has Gazelle, I believe, and she was going out with her husband bring it up for her to utilize. Apparently, she made space for it, but it has not been bought up, so she is still planning on getting that exercising machine. She is planning to start the patches to quit smoking, and she is going to be starting the Medifast in the next couple of weeks. She did not feel quite well today. She has a lot going on with her kids starting back at schools, so she is feeling a bit stressed.
PHYSICAL EXAMINATION: Her temperature is 97.6, her pulse is 72, weight is 309.4 pounds, her blood pressure is 142/94. She has a headache. BMI is 45.5. She has lost 5.6 pounds since her last visit. She is alert and oriented, in no apparent distress.
ASSESSMENT/PLAN: Patient with morbid obesity. She has a history of pulmonary embolus and right lower lobe lobectomy. She is scheduled for a gastric bypass in 03/10 and a temporary IVC filter for pulmonary embolus. She is doing the lean and green. I encouraged her to continue to work with it and try to continue to cut out eating breads and things such as cookies. May be with the holidays over that will be a bit easier. I would like her to see the pulmonologist given that she has a history of right lower lobe lobectomy. She is scheduled to get an ABG and pulmonary function tests recently, but had to reschedule for those in 02/10. We did again review the plan for surgery. She will need to do, at least continue to work on losing weight, the closer we can get to 10% the better. I will see her again next month as we get closer to her surgery date.
Keywords: consult - history and phy., medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight,