Audio_Soap_9

SUBJECTIVE: Seeing patient back for preoperative visit prior to undergoing laparoscopic gastric bypass surgery. The patient has been through our multidisciplinary preoperative education and workup and has been deemed to be a good candidate for surgery. Since our last visit, he has been diagnosed with obstructive sleep apnea and was prescribed a device for better oral placement as opposed to a CPAP. Otherwise, there have been no changes to his medical problems or medications.

SURGICAL HISTORY: He has had a thyroidectomy for benign tumors, he says. He takes Synthroid. He has had his gallbladder out through a laparotomy.

MEDICATIONS: Include:
1. Verapamil extended release 240 mg.
2. Diclofenac 75 mg 2 b.i.d. for hip pain.
3. Lexapro 20 mg a day for anxiety.
4. Levoxyl 0.1 mg a day for thyroid replacement.

FAMILY HISTORY: An aunt and grandmother had diabetes. Obesity runs throughout his family, especially his aunts and his cousins. Four of his cousins had gastric bypass surgery. His mother was not obese. One sister is obese.

SOCIAL HISTORY: He does not smoke. He does not drink alcohol. He is not employed.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

REVIEW OF SYSTEMS: Constitutional: He has fatigue and exercise intolerance and weakness. Eyes: He has blurry vision but no loss of vision or halos. Ear, nose and throat: Hayfever and runny nose. He has a lump in throat sometimes on laying down. No loss of balance. Respiratory: He has occasional cough, gets out of breath with exertion. No bronchitis or emphysema. Cardiovascular: He has told me he has had a heart murmur before. No angina, squeezing in chest or heart attack. Gastrointestinal: Heartburn and hemorrhoids. No cramps or abdominal pain. Genitourinary: He leaks urine. No kidney stones, bladder stones or kidney failure. Endocrine: He has a low thyroid from a thyroidectomy. No adrenal problems or diabetes problems. Musculoskeletal: Severe back pain and hip pain. No knee pain. Neurologic: No convulsions, loss of consciousness or tremor. Psychologic: He has anxiety. He has had psychologic treatment in the past.

OBJECTIVE: Body weight is 288 pounds. BMI is 48.3. Temperature is 37.1. Blood pressure is 102/80. Pulse is 48. In general, patient is a well-appearing male in no acute distress. Heart: Regular rate and rhythm. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Abdomen is soft, nondistended, nontender. Costal margin is palpable. He has some upper abdominal obesity as well as weight centered around his hips. Extremities: No clubbing, cyanosis, or edema.

LABORATORY: Labs reviewed.

ASSESSMENT: The patient is a 51-year-old male with medically complicated obesity including a presenting BMI of 51, excess body weight of 178 pounds, and an actual body weight of 278 pounds. He has lost 24 pounds and now weighs 288 pounds with a BMI of 48. His weight-related comorbidities include obstructive sleep apnea, osteoarthritis, major depression, previous breast biopsies, and chronic headaches.

PLAN: The patient has been thoroughly evaluated and been through our comprehensive program and has been deemed an excellent candidate for gastric bypass surgery. He has lost 25 pounds preoperative weight, which is an excellent result; and he is very motivated to have the surgery. I once again discussed in detail the rationale, risks, benefits, alternatives, and potential complications of laparoscopic Roux-en-Y gastric bypass including special emphasis on potential for mortality, infection, leak, need for re-intervention, obstruction, bleeding, thrombosis, and postoperative lifestyle changes. He expressed understanding, had all questions answered, and desires to proceed. He has been scheduled for surgery next week.