Bariatric / Weight Loss Medical Transcription Sample Reports / Examples


HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old morbidly obese man being seen today upon referral from primary care physician. He has had obesity since his middle ages with the lowest weight in 5 years at 225 and currently at highest weight ever. Weight loss attempts in the past have included supervision by a dietitian, Weight Watchers, Atkins diet, Nutrisystem, Optifast diet and own efforts. Maximum weight loss has been 35 pounds but always with weight regain. Now with comorbid conditions including sleep apnea, diabetes type 2, hypertension, past myocardial infarction. The patient is pursuing surgical weight loss in the hopes of reducing or eliminating these comorbid conditions and living a longer healthier life. This consultation was requested by his primary care physician for evaluation of obesity and consideration of bariatric surgery.

PAST MEDICAL HISTORY:
1.  Diabetes type 2 with an average blood sugar of 130.
2.  Obstructive sleep apnea, on CPAP therapy.
3.  Hypertension.
4.  Hyperlipidemia.
5.  Statis post myocardial infarction.
6.  Coronary artery disease, status post CABG.
7.  Benign prostatic hypertrophy.
8.  Chronic intermittent low back pain.
9.  Sternal dehiscence with a large sternal hernia following gastric bypass surgery.

PAST SURGICAL HISTORY:
1.  Coronary artery stenting.
2.  Coronary artery bypass graft.
3.  Tonsillectomy as a child.

MEDICATIONS:
1.  Metoprolol 75 mg twice daily.
2.  Avapro 150 mg twice daily.
3.  Lipitor 20 mg daily.
4.  Lasix 20 mg daily.
5.  Flomax 0.4 mg daily.
6.  Aspirin 325 mg daily.
7.  Folic acid 400 mcg daily.
8.  Multivitamin daily.
9.  Saw palmetto 450 mg daily.

ALLERGIES:  NKDA.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient is married. He has 4 children, all of whom are well. He does not currently smoke, drink alcohol or use recreational drugs, not currently exercising.

REVIEW OF SYSTEMS:
RESPIRATORY:  Intermittent dyspnea on exertion.
CARDIOVASCULAR:  See history of present illness and past medical history for cardiac history.
Remainder of comprehensive review of systems is negative.

PHYSICAL EXAMINATION:
GENERAL:  Morbidly obese (XX)-year-old Hispanic man sitting in exam chair, in no obvious distress.
VITAL SIGNS:  Pulse 64, respirations 16, blood pressure 132/88. Height 5 feet 6 inches. Weight 268 pounds. BMI 43.30. Using body mass index of 23, ideal body weight is 143 pounds with an excess body weight of 125 pounds.
HEENT:  Pupils are equal, round and reactive to light and accommodation. Sclerae anicteric. Oral cavity moist and pink. Tongue protrudes midline.
NECK:  Supple. No JVD, adenopathy, thyromegaly.
LUNGS:  Clear to bases bilaterally with distant breath sounds but no adventitious sounds.
CARDIOVASCULAR:  Regular rate and rhythm. No S3, S4, murmurs or carotid bruits.
ABDOMEN:  Centrally obese, semi-firm, positive bowel sounds in all quadrants. Healed midline sternal scar extending to mid abdomen consistent with cardiovascular surgery with large sternal dehiscence with hernia. No tenderness. HSM not appreciated secondary to body habitus. No masses or rebound.
RECTAL:  Exam deferred.
PERIPHERAL VASCULAR:  Extremities warm and dry. Healed scarring consistent with cardiovascular surgical history.
MUSCULOSKELETAL:  Near full ROM of all the major joints.

ASSESSMENT AND PLAN:
The patient is a (XX)-year-old morbidly obese man with significant comorbid conditions including moderately severe coronary artery disease, diabetes, sleep apnea amongst others. The patient is interested in surgical weight loss, particularly adjustable gastric band surgery. The patient meets the criteria for adjustable gastric band surgery as defined by the American Society for Metabolic and Bariatric Surgery using NIH guidelines. However, in my opinion, he is not a candidate for gastric bypass surgery due to his extensive medical/surgical history. Laparoscopic adjustable gastric band surgical procedure, benefits, risks, expectations of weight loss and limitations were reviewed. Risks reviewed included, but were not limited to, the risk of general anesthesia, national statistics of death following lap band surgery, infection, bleeding, postoperative blood clots or pulmonary embolism, band or port dislodgment, leakage along the system or band erosion, failure to lose weight. Lifelong schedule of visits, lab studies and vitamins and minerals were also discussed along with the increased risk of occurrences of certain cancers as related to obesity and encouragement to continue health surveillance with his primary care physician. The patient wishes to proceed with presurgical preparation and agrees to do the following:
1.  Lose 20-25 pounds prior to surgery. We will send him to Endocrinology for evaluation of his diabetes management and consideration of possible HMR diet for presurgical weight loss.
2.  He must stay on CPAP therapy every night.
3.  Pulmonary consultation for evaluation of his recent pleural effusion.
4.  Attend mandatory presurgical skill sessions.
5.  Meet with bariatric surgeon, John Doe, MD, within 1-3 weeks for evaluation from a surgeon’s standpoint on his candidacy for bariatric surgery.
6.  Return to bariatric nutritionist for a progress check in 8-9 weeks.
7.  Start regular exercise, start slow and increase as tolerated for cardiovascular and pulmonary reconditioning as well as reconditioning of the muscles.
8.  Return in 4-5 weeks for progress check.


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HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female being seen today for 6-month followup after laparoscopic gastric bypass surgery. Overall, she is feeling well and has no physical complaints. Following the postoperative bypass protocol without difficulty. Please refer to gastric bypass followup sheet for complete details of postoperative protocol adherence.

MEDICATIONS:
1.  Tramadol.
2.  Percocet as needed for severe pain.
3.  Omeprazole.
4.  Ursodiol.
5.  Lorazepam.
6.  Cymbalta.

ALLERGIES:  NKDA.

REVIEW OF SYSTEMS:  Essentially negative. The patient continues to see her psychiatric counselor every week and her psychiatric medical provider every 4 weeks and feels quite stable from a psychosocial aspect.

PHYSICAL EXAMINATION:
GENERAL:  Obese (XX)-year-old female sitting in exam chair, in no apparent distress.
VITAL SIGNS:  Blood pressure 136/82. Height 5 feet 4 inches. Preoperative weight 264 pounds. Today's weight 199 pounds. Today's BMI 34.2.
LUNGS:  Clear.
HEART:  RRR.
ABDOMEN:  Essentially rotund with pear-shaped configuration, soft. No tenderness, masses or rebound.

LABORATORY DATA:  Six-month postoperative nonfasting labs completed today, results pending at the time of this dictation.

ASSESSMENT AND PLAN:
Doing well 6 months following gastric bypass surgery. No obvious complications today. Advised further as follows:
1.  Continue all efforts at postoperative gastric bypass protocol adherence.
2.  Return for a 9-month postoperative check with bariatric nutritionist with monitoring labs at that time.
3.  Continue all medications, vitamins and minerals as listed above.
4.  Return for 1-year postoperative bypass check with fasting annual labs at that time with either bariatric surgeon, John Doe, MD, or the nurse practitioner.
5.  Keep followup with all other providers for ongoing routine healthcare as scheduled.
6.  Call with problems, questions or concerns between now and next visit.


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REASON FOR CONSULTATION:  Preoperative evaluation for bariatric surgery.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old gentleman with multiple medical problems including hypertension, diabetes and dyslipidemia. He has been overweight most of his life. The patient was considering bariatric surgery and he is planning to go for a lap band procedure. He says that snoring is not a very common complaint of his wife. He snores mainly when he drinks; otherwise, it could be soft snoring or sometimes no snoring at all. There was no mention of witnessed apneas. He does not wake himself up choking or gasping for air. He is a very quiet sleeper with not much tossing and turning. He wakes up feeling refreshed for the most part, unless he sleeps for 5 hours or so. He goes on with his day with no difficulty as far as excessive daytime sleepiness or fatigue. He is only tired if he had a really busy long day. His Epworth sleepiness score today was between 5 and 6. He has never fallen asleep behind the wheel or got himself in an accident. His weight has been steady. He has been overweight since he was 15 years old. He never had any symptoms suggestive of cataplexy, sleep paralysis or hypnagogic or hypnopompic hallucinations. He denies any symptoms of restless legs. No symptoms of parasomnia. No sleep onset or sleep maintenance insomnia.

ALLERGIES:  No known drug allergies.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Dyslipidemia.
3.  Diabetes.

PAST SURGICAL HISTORY:
1.  Deviated septum repair.
2.  Bilateral knee arthroscopies.
3.  Pilonidal cyst removal.

MEDICATIONS:
1.  Lipitor.
2.  Metformin.
3.  Hyzaar.
4.  Carvedilol.
5.  Amlodipine.
6.  Aspirin 81 mg daily.

SOCIAL HISTORY:  The patient smoked 1 pack a day for 15 years, but quit 6 years ago. He drinks about 3 glasses of wine 4 times a week. He has 3 cups of coffee on an average twice a day. He exercises 4 times a week as much as he can. He is married and he has 3 children.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  The patient does have seasonal nasal congestion, possibly related to allergies. His weight has been steady as mentioned before. No hypothyroidism symptoms. No memory, attention or concentration problems. No depression. No impotence. No wheezing. No seizures. No tremors. No cough. He does have occasional GERD, no parasomnia. Review of systems otherwise is entirely negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 174/102, pulse 90, O2 saturation 98% on room air. His weight was 236 pounds. BMI of 41.
GENERAL APPEARANCE:  Obese man, in no respiratory distress.
HEENT:  Swollen inferior turbinates, right more than left. Oral exam with Mallampati class III, enlarged tonsils, enlarged tongue and crowded oropharynx.
NECK:  No JVD, no lymphadenopathy. Neck circumference is 18 inches.
LUNGS:  Good air entry bilaterally. No wheezing, no rhonchi, no crackles.
CARDIOVASCULAR:  Regular rate and rhythm. S1, S2 audible.
ABDOMEN:  Soft, no tenderness, no distention.
EXTREMITIES:  No edema.
NEUROLOGIC:  Grossly nonfocal.

STUDIES:  No recent sleep studies available for review. His most recent exercise stress test showed just nonspecific ST changes.

LABORATORY DATA:  The patient’s most recent thyroid-stimulating hormone level was 0.9. 

ASSESSMENT AND PLAN:
This is a (XX)-year-old gentleman with multiple medical problems as mentioned above, here for evaluation.
1.  Even though he does not have any of the cardinal symptoms of obstructive sleep apnea including snoring, witnessed apneas or excessive daytime sleepiness, he does have physical features that increase the risk for sleep apnea including obesity, large neck circumference, crowded airway with a high Mallampati class, as well as his multiple associated cardiovascular and metabolic disorders including hypertension that is not very well controlled on different blood pressure medicines, diabetes and dyslipidemia.
2.  We had a long discussion with the patient today about the need for a sleep study to rule out obstructive sleep apnea, even though he does not have the classic symptoms. We also explained to him the risks in the perioperative period for patients with obstructive sleep apnea that has not been treated. At this point, he wants to wait and think about it as well as talk it over with the bariatric surgery team. He does not think he has sleep apnea. He does not think he would be able to perform the sleep study, as he will have a hard time sleeping outside his house.
3.  We explained to him the risks involved with untreated moderate to severe obstructive sleep apnea including worsening cardiovascular disease, arrhythmias, risk of stroke and increased overall mortality.
4.  We also mentioned to him that there is a possibility of doing a portable sleep study at home if that would be something he is willing to pursue.
5.  In the meantime, he should continue to lose weight, avoid alcohol and sedatives, exercise routinely and avoid driving if drowsy.
6.  We will follow up with him as needed if he is willing to pursue that further.




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