Sample Type / Medical Specialty: Bariatrics

Sample Name: Bariatric Consult - Surgical Weight Loss - 1

Description: Evaluation for elective surgical weight loss via the gastric bypass
as opposed to Lap-Band.
(Medical Transcription Sample Report)
ABC was seen in my office for evaluation for elective surgical weight loss on Oc
tober 6, 2008. ABC is a 34-year-old female with a BMI of 43. She is 5'6" tall an
d weighs 267 pounds. She is motivated to attempt surgical weight loss because sh
e has been overweight for over 20 years and wants to have more energy and improv
e her self-image. She is not only affected physically, but also socially by her
weight. When she loses weight she always regains it and she always gains back mo
re weight than she has lost. At one time, she lost 100 pounds and gained the wei
ght back within a year. She has tried numerous commercial weight loss programs i
ncluding Weight Watcher's for four months in 1992 with 15-pound weight loss, RS
for two months in 1990 with six-pound weight loss, Slim Fast for six weeks in 20
04 with eight-pound weight loss, an exercise program for two months in 2007 with
a five-pound weight loss, Atkin's Diet for three months in 2008 with a ten-poun
d weight loss, and Dexatrim for one month in 2005 with a five-pound weight loss.
She has also tried numerous fat reduction or fad diets. She was on Redux for ni
ne months with a 100-pound weight loss.
PAST MEDICAL HISTORY: She has a history of hypertension and shortness of breath.
PAST SURGICAL HISTORY: Pertinent for cholecystectomy.
PSYCHOLOGICAL HISTORY: Negative.
SOCIAL HISTORY: She is single. She drinks alcohol once a week. She does not smok
e.
FAMILY HISTORY: Pertinent for obesity and hypertension.
MEDICATIONS: Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abil
ify 5 mg daily, Motrin 800 mg daily, and a multivitamin.
ALLERGIES: She has no known drug allergies.
REVIEW OF SYSTEMS: Negative.
PHYSICAL EXAM: This is a pleasant female in no acute distress. Alert and oriente
d x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric
sclerae. Chest is clear to auscultation bilaterally. Cardiovascular is normal si
nus rhythm. Abdomen is obese, soft, nontender and nondistended. Extremities show
no edema, clubbing or cyanosis.
ASSESSMENT/PLAN: This is a 34-year-old female with a BMI of 43 who is interested
in surgical weight via the gastric bypass as opposed to Lap-Band. ABC will be a
sking for a letter of medical necessity from Dr. XYZ. She will also see my nutri
tionist and social worker and have an upper endoscopy. Once this is completed, w
e will submit her to her insurance company for approval.
Keywords: bariatrics, elective surgical weight loss, surgical weight loss, weigh
t loss, loss, weight, bmi, surgical, pounds,