Preoperative Bariatric Nutrition Followup Sample Report #1

LAST SEEN BY REGISTERED DIETITIAN: MM/DD/YYYY.

DIAGNOSIS: Morbid obesity with surgical preference for the lap band. Surgery is not booked.

INITIAL WEIGHT: 243 pounds.

WEIGHT LOSS GOAL: 15 to 20 pounds.

PRESENT WEIGHT: 246 pounds with an increase of about 2 pounds since last meeting.

HEIGHT: 64.5 inches.

BMI: 41.5.

BEHAVIOR SKILLS GROUPS: Enrolled.

EXERCISE: No structured exercise; however, she does have a treadmill at home and stated she is going to start today. We reviewed the importance of a goal of the eventual 30 minutes 5 days a week.

CHANGES IDENTIFIED: The patient reports really making no changes since last nutrition visit and having a difficult time during the holidays, eating cookies and other “junk” food.

FLUIDS: Reports drinking 1 coffee in the morning with cream and Splenda, water and Crystal Light. We reviewed the importance of staying adequately hydrated and drinking 64 ounces daily.

FOOD RECALL: Note that the patient reports eating “junk” all day and being “bad” around the holidays. She is very vague in her food recall. She reports not eating breakfast, sometimes not eating lunch or having a bagel, sandwich or pizza. Dinnertime is generally protein, a vegetable or takeout subs. Snacking in the evening is her difficult time, and she tends to eat crackers, popcorn and chocolate. We discussed this at length.

ASSESSMENT: The patient is a (XX)-year-old morbidly obese female who present today for a preoperative bariatric nutrition followup. Overall, the patient appears to be struggling since initial consultation.

She reports having a hard time around the holidays and really not making any changes since last meeting. We reviewed the importance of eating 3 meals per day, prioritizing protein and then balancing the protein foods with fruits and vegetables.

She tells me today that she wants to start a low-carbohydrate diet and is somewhat resistant to eat fruits, vegetables and whole grains. We reviewed the importance of an overall healthy diet, including fruits, vegetables and healthy carbohydrates. The patient has not had her eating disorder evaluation as discussed last time with the nurse practitioner, and she was encouraged to have this evaluation done prior to meeting with the nurse practitioner in March.

We encouraged her to begin structured exercise and she is aware of her 30 minutes 5 days a week goal. She will also increase her fluid intake to about 64 ounces. Upon fully reviewing all of the diet and exercise goals discussed at the last nutrition visit, it is apparent that the patient is struggling to make lifestyle changes consistent with postop success such as meal structure, menu planning, behavior modification and consistent cardiovascular exercise. The patient may further benefit from completion of the goals listed below as she continues to prepare for gastric banding surgery.

GOALS:
1. Consume 3 meals a day, 7 days a week, spaced 4 to 6 hours apart.
2. Measure and weigh protein to a goal of 20 grams or 3 ounces at every meal.
3. Prioritize protein at all meals.
4. Continue to wean off of high sugar foods such as cookies, cakes, etc.
5. Snack only when physically hungry and choose only a fruit or protein.
6. Format meals as 20 grams/3-4 ounces of protein plus fruit and/or vegetable and minimal amounts of starch.
7. Practice waiting between meals to consume fluids.
8. Increase fluids to a minimum of 64 ounces daily, noncaloric, noncarbonated, and noncaffeinated.
9. Begin structured exercise working up to a goal of 30 minutes 5 days a week.
10. Work on preop weight loss goal of 15 to 20 pounds prior to surgery.
11. Meet with eating disorder specialist prior to meeting with nurse practitioner in March.
12. Work on eating slowly, cutting food into bites and chewing food well.
13. Call with any questions or concerns between now and next nutrition visit.

FOLLOWUP: Appointment booked for March.

TIME SPENT: 30 minutes.

Preoperative Bariatric Nutrition Followup Sample Report #2

LAST SEEN BY REGISTERED DIETITIAN: MM/DD/YYYY.

DIAGNOSIS: Morbid obesity with surgical preference for the gastric bypass. Her surgery is not booked at this point.

INITIAL WEIGHT: 294 pounds.

WEIGHT LOSS GOAL PRIOR TO SURGERY: 20 pounds.

PRESENT WEIGHT: 286 pounds with a weight loss since initial consult of 8 pounds. Per Dr. John Doe, he would like her to get down to 250 pounds prior to surgery, which is a total weight loss of about 36 pounds.

HEIGHT: 63.4 inches.

BMI: 49.9.

BEHAVIOR SKILLS GROUPS: Completed per patient.

EXERCISE: No structured exercise at this point. We reviewed the importance of working up and doing what she can comfortably tolerate as she does say she has asthma and atrial fibrillation, which limits her exercise during the day. We did discuss, also, a goal of 30 minutes 5 days a week and working up to this as tolerated.

CHANGES IDENTIFIED: The patient reports trying to watch her portions, trying to increase vegetables and decrease carbohydrates.

FOOD RECALL:
Breakfast: Either skips or has raisin bran with a piece of wheat toast and apple juice. On the weekends, she will occasionally have eggs or Egg Beaters with a light toast and apple juice.
Lunch: Tuna with light mayonnaise on a sandwich or, if she is at work, she will have meat, vegetable and trying to stay away from potatoes and starches, or she will have tomato soup and a grilled cheese.
Snack: Yogurt or string cheese.
Dinner: Pork, chicken, beef, prime rib, with applesauce and green beans.
Snack: Yogurt or cheese stick.

FLUIDS: She drinks Crystal Light Lemonade and iced tea about 2 quarts per day. She does drink coffee in the morning with cream and sugar and does drink apple juice as well.

HMR liquid diet, per Dr. John Doe. The patient will start this today and is going to be doing 5 HMR shakes 500 daily.

ASSESSMENT: The patient is a (XX)-year-old morbidly obese female who presents today for a progress check prior to bariatric surgery. She has completed her behavior skills classes and now she just needs to get some weight off prior to surgery. She has done a good job since last nutrition visit, losing about 8.3 pounds. However, per Dr. John Doe, she is to start HMR to get off about 36 pounds prior to surgery.

We talked about the HMR liquid diet in detail today. The patient is going to do the HMR 500, 5 shakes a day. We reviewed the importance of drinking adequate fluids, and she is going to consume greater than 64 ounces of her noncaloric, noncarbonated and noncaffeinated fluids.

We discussed the extreme importance of exercise and working up as tolerated to a goal of 30 minutes 5 days a week. We also talked about after surgery planning meals and trying to choose leaner proteins, more fruits and vegetables, limiting her starch intake. The patient was given HMR liquid diet materials and recipe ideas as well as information about ordering it online and ordering it from the pharmacy.

Upon fully reviewing all the diet and exercise goals set at last nutrition visit, it is apparent the patient is slowly trying to make lifestyle changes consistent with postoperative success such as meal structure, menu planning, behavior modification and consistent cardiovascular exercise. The patient may further benefit from completion of goals listed below as she continues to prepare for her gastric bypass surgery.

PATIENT GOALS:
1. Consume 5 HMR shakes daily.
2. Consume greater than 64 ounces of noncaloric, noncarbonated and noncaffeinated fluids.
3. Try to avoid solid foods in general. If hungry, have 1 extra shake.
4. Complete lab work with primary care physician in 2 weeks and have a followup appointment in 4 weeks, and she will also complete lab work at that point.
5. Increase exercise to a minimum of 30 minutes 5 days a week.
6. Work towards preoperative weight loss goal of about 36 pounds prior to surgery.
7. Call with questions or concerns between now and next nutrition visit.

Followup: Return visit with registered dietitian in 4 weeks for HMR followup. Also, follow up with primary care and have lab work completed there for initial HMR labs.

TIME SPENT: 30 minutes.

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Bariatric Weight Loss Medical Transcription Sample Report #1

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.

Bariatric Weight Loss Medical Transcription Sample Report #2

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.

Bariatric Weight Loss Medical Transcription Sample Report #3

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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