Sample Type / Medical Specialty: Bariatrics

Sample Name: Laparoscopic Gastric Bypass Consult - 2

Description: Consult for laparoscopic gastric bypass.
(Medical Transcription Sample Report)
He is a 22-year-old male who is 312 pounds, 6 feet tall, and a BMI of 42. He has
been overweight for 15 years since the age of 8, at his highest 330 pounds, at
his lowest 200. He is attempting surgical weight loss because most of his childh
ood and entire life, he has been overweight. He had some initial success with di
ets, but results are not long lasting and he gains the weight back. His goal is
to have a Lap-Band surgery as a tool to help him to more healthy life and to hel
p resolve his poor eating habits. He feels that the weight adversely affects his
life physically. Most days he has back, knee, and ankle pain and makes walking
upstairs quite difficult. When he loses weight he always regains it and he gains
more than he lost. His biggest weight loss was 45 pounds and it was two months
before he gained it back. He was on the Atkin's Diet when he was 16-years-old. H
e lost the 45 pounds in two months. He saw quick results. It was unsuccessful be
cause it was just a diet as soon as he reintroduced carbs he gained the weight b
ack. He has participated in multiple commercial weight loss programs, Weight Wat
cher's for four months in 2004 and lost 35 pounds over one to two months, Weight
Watcher's for two months in 2007 and lost 20 pounds over one month, Atkin's Die
t for three months in 2002 and lost 45 pounds over two months, Slim Fast for two
months in 2003 and lost ten pounds over two months, Nutri-Systems for two month
s in 2005 and lost five pounds over one month, New York Sports Club exercising f
or seven years in 2001 to present and no weight loss, and personal trainer 25 se
ssions in 2007 and 2008 and no weight loss. He has tried multiple calorie and fa
t reduction diets including Atkin's, South Beach, and various fad diet books and
magazines. He has been on medically supervised weight loss programs.
PAST MEDICAL HISTORY: He has difficulty climbing stairs,
seats, tying shoes, used to public seating, and lifting
He exercises three times a week at home and does cardio.
ng two blocks or five flights of stairs. Difficulty with
and joint pains including knee pain, back pain, foot and
g. He has gastroesophageal reflux disease.

difficulty with airline

objects off the floor.
He has difficulty walki
snoring. He has muscle
ankle pain, and swellin

PAST SURGICAL HISTORY: Includes reconstructive surgery on his right hand 13 year
s ago.
SOCIAL HISTORY: He is currently single. He has about ten drinks a year. He had s
moked significantly up until several months ago. He now smokes less than three c
igarettes a day.
FAMILY HISTORY: Heart disease in both grandfathers, grandmother with stroke, and
a grandmother with diabetes. Denies obesity and hypertension in other family me
mbers.
CURRENT MEDICATIONS: None.
ALLERGIES: He is allergic to Penicillin.
MISCELLANEOUS/EATING HISTORY: He has been going to support groups for seven mont
hs with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he f
eels that we are the appropriate program. He had a poor experience with the Gree
nwich program. Eating history, he is not an emotional eater. Does not like sweet
s. He likes big portions and carbohydrates. He likes chicken and not steak. He c
urrently weighs 312 pounds. Ideal body weight would be 170 pounds. He is 142 pou
nds overweight. If
he lost 60% of his excess body weight that would be 84 pounds and he should weig

h about 228.
REVIEW OF SYSTEMS: Negative for head, neck, heart, lungs, GI, GU, orthopedic, an
d skin. Specifically denies chest pain, heart attack, coronary artery disease, c
ongestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high choles
terol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, throm
bophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes
, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, pe
ptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver,
hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary
stress incontinence, or cancer. Denies cellulitis, pseudotumor cerebri, meningi
tis, or encephalitis.
PHYSICAL EXAMINATION: He is alert and oriented x 3. Cranial nerves II-XII are in
tact. Afebrile. Vital Signs are stable. Neck is soft and supple. Lungs clear to
auscultation. Heart is regular rhythm and rate. His abdomen is soft and nontende
r. He has no palpable herniations. Extremities are nonedematous.
IMPRESSION/PLAN: I have explained to him the risks and potential complications o
f laparoscopic gastric banding in detail including bleeding, infection, deep ven
ous thrombosis, pulmonary embolism, slippage of the band, erosion of the band, e
sophageal dilatation, injury to the band, port, or tubing necessitating replacem
ent of the band, port, or tubing, injury to the esophagus, stomach, small intest
ine, large intestine, spleen, or liver, and possible mortality in 1 to 2000 pati
ents. He understands. He is going to see Dr. XYZ and receive a letter of recomme
ndation from him. He will see Lynn Holmberg, mental health evaluation Mary Zille
r, and pulmonary clearance by Dr. XYZ. He will have upper GI, ultrasound for gal
lstones, H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobi
n, and fasting blood sugar. After these are performed, we will submit him for in
surance approval.
Keywords: bariatrics, laparoscopic gastric bypass, weight loss programs, gastric
bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weig
ht loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lo
st,