Patient with a history of medically complicated obesity and multiple comorbidities, including stroke on Pradaxa, presenting for weight loss surgery evaluation. Patient has failed multiple attempts of weight loss using conventional methods: dieting, exercising, and commercial weight loss programs. Current diet is consistent of high calorie count food rich in carbohydrates and fat and reports minimal exercise.
Reports moderate to severe fatigue of few years duration that interferes with optimal performance of daily activities. Fatigue has been worsening with weight regain. It is not alleviated by any factors.
Stroke workup 3 years ago included Carotid duplex which did not show any significant stenosis.
Current medication
Medication List Reconciled.
Trilipix 135 mg capsule,delayed release(DR/EC) take 1 capsule (135 mg) by oral route once daily.
Amlodipine 5 mg tablet take 1 tablet (5 mg) by oral route once daily.
Quinapril 40mg 1 time per day.
Pradaxa 150 mg capsule take 1 capsule (150 mg) by oral route 2 times per day.
Pravastatin 40 mg tablet take 1 tablet (40 mg) by oral route once daily.
Toprol XL 50 mg tablet extended release 24 hr take 2 tablets (100 mg) by oral route once daily.
Meloxicam 15 mg tablet 1 Tablet by Oral route 1 time per day.
Amlodipine 10 mg tablet take 1 tablet (10 mg) by oral route once daily.
Lantus Solostar 100 unit/mL (3 mL) insulin pen inject 60 units by Subcutaneous route as per insulin protocol 2 times per day DX; 250.90.
Humalog KwikPen 100 unit/mL insulin pen inject 9-12 units by Subcutaneous route 3 times per day.
BD Pen Needle Mini 31g x 3/16" ///// Needle INJECT 1 Needle by Subcutaneous route 6 times per day.
Free Style Light Test . Strips test 1 Strip by Subcutaneous route 4 times per day as directed.
Toprol XL 100 mg tablet extended release 24 hr take 1 tablet by Oral route 1 time per day.
Past medical/surgical history
Reported:
Medical: Previous hospitalizations.
Diagnoses:
Hypertension.
Hyperlipidemia.
Obesity.
Type 2 diabetes mellitus.
Stroke syndrome
Personal history
Lives alone.
Behavioral: Caffeine use and never a smoker.
Alcohol: Not using alcohol.
Drug Use: Not using drugs.
Work: Retired from work.
Family history
Paternal:
Heart disease
Hypertension
Maternal:
Brain cancer
Stroke syndrome.
Review of systems
Systemic: Feeling tired or poorly. No fever and no chills.
Head: No headache.
Neck: No swollen glands in the neck.
Eyes: Vision problems decreased vision right eye and blurred vision.
Otolaryngeal: No nasal passage blockage (stuffiness) -Congestion, no snoring, and no sore throat.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: Shortness of breath. No cough.
Gastrointestinal: No dysphagia, no jaundice, no change in stool, no bright red blood per rectum, no fecal incontinence, and no polyphagia. Heartburn. No nausea, no vomiting, no diarrhea, and no constipation.
Genitourinary: No inguinal swelling and no increase in urinary frequency. No dysuria.
Endocrine: No polydipsia, no temperature intolerance, and no hot flashes.
Hematologic: Easy bleeding and a tendency for easy bruising.
Musculoskeletal: No muscle aches, no soft tissue stiffness -muscle stiffness, and no limb pain.
No arthralgias, no soft tissue swelling, and no localized joint stiffness.
Neurological: No memory lapses or loss, no dizziness, and no sensory disturbances.
Psychological: No anxiety, no depression, and no sleep disturbances.
Skin: No pruritus and no rash.
Urinary System: Bladder incontinence was not demonstrated.
Physical findings
Vital Signs:
Vital Signs/Measurements Value Date
Oral temperature 98 6/15/2015
RR 16 per min 6/15/2015
PR 100 bpm 6/15/2015
Blood pressure 130/70 mmHg 6/15/2015
Pain level by numeric rating scale 0 6/15/2015
Weight 268.4 lbs 6/15/2015
Body mass index 39.6 kg/m2 6/15/2015
Height 69 in 6/15/2015
Standard Measurements:
Standard Measurements: Value Date
Body surface area 2.4 6/15/2015
Laboratory Studies:
Pulmonary Tests: Value Date
Oxygen saturation 96% percent 6/15/2015
Standard Measurements:
Patient was observed to be obese.
General Appearance:
Alert.
Neck:
Neck: normal.
Trachea: The trachea showed no abnormalities.
Eyes:
General/bilateral:
Eyes:
Lungs:
Respiration rhythm and depth was normal, the lungs were clear to auscultation, no wheezing was heard, no rhonchi were heard, and no rales/crackles were heard.
Cardiovascular:
Heart Rate And Rhythm: Heart rate and rhythm normal.
Heart Sounds: Heart sounds normal S1 & S2.
Murmurs: No murmurs were heard.
Carotid Arteries: The carotid arteries were normal.
Arterial Pulses: Arterial pulses were equal bilaterally and normal.
Abdomen:
Visual Inspection: The abdomen was normal on visual inspection and the abdomen was not distended.
Palpation: No ascites, the abdomen was soft, abdominal non-tender, and no abdominal mass was palpated.
Liver: The liver was not enlarged.
Neurological:
Oriented to time, place, and person.
Psychiatric:
Mood: The mood was not depressed and was not anxious.
Skin:
The skin showed no generalized erythema. No skin lesions.
Cardiovascular Disorder:
No lymphedema.
Gastrointestinal Disorder:
No hernia.
Assessment
? Fatigue
? Benign essential hypertension
? Esophageal reflux
? Morbid obesity
? Type 2 diabetes mellitus
? Chronic kidney disease, stage 3
? Ischemic embolic stroke
Patient with medically complicated obesity despite multiple attempts of weight loss with conventional methods. Based on the NIH criteria, the patient is a good candidate for bariatric surgery; however, his comorbidities put him at a higher risk than average. After discussing all the different types of procedures, the patient would like to proceed with a laparoscopic vertical sleeve gastrectomy.
.
Allergies and Adverse Reactions
No Known Allergies.
Allergies Reviewed.
Plan
? An automated urinalysis with microscopic exam
? Hemogram with platelet count
? Serum ferritin level
? Serum iron level
? Prothrombin time
? Basic metabolic panel with total calcium
? A hepatic function panel
? Serum vitamin B12 (Cyanocobalamin)
? Serum vitamin D3 (cholecalciferol)
? Serum vitamin levels - folate
? Serum TSH level
? Serum albumin level
? Thiamine (B-1) level
? Follow-up visit 3 month(s)
? Request consultation by specialist Consult Mental Health
? Request consultation by specialist Cardiology.
? Request consultation by specialist Program Support Group
1) High Fiber/Protein Diet Limited to 1200 calories per day
2) Exercise Program
3) Dietitian Consult
4) Psychiatric Evaluation
5) Cardiology Evaluation
6) 3 month bariatrician visit
