SUBJECTIVE: The patient is a (XX)-year-old woman who was admitted two weeks ago with dehydration. She had dysphagia for solid foods for several months. She was able to tolerate liquids. Her band was emptied, but she still had the same problem. She was admitted with dehydration and had an upper endoscopy and ESD done. ESD showed the band in good position with a small amount of stomach above the band without evidence of slip or a hiatal hernia. She had a rapid transit of barium through the band, which she did have a wide channel. She had an upper endoscopy performed and that showed a small food bezoar above the band. This was removed. She was discharged but still has not progressed her diet beyond liquids. She said she has mostly chicken broth. Medications include trazodone and Klonopin.
OBJECTIVE: The patient appears well. She is 5 feet 3 inches, 182 pounds. Blood pressure 122/72, heart rate 72, respirations 18. She is anicteric. Lungs are clear. Abdomen: Soft, obese, and nontender. No organomegaly, no tenderness. Extremities: Well perfused without edema. Also her upper GI from March has been reviewed with the findings as above.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old woman who, for unclear reason, has worsening dysphagia to solid foods. It is unclear if she has a primary problem of esophageal dysmotility. She is able to tolerate liquids well. We told her to maintain herself on a diet supplemented by 60 grams of protein, take supplements such as Glucerna or other whey-based protein supplements. We would like her to come back and see us in two weeks after getting esophageal motility study. If she does have esophageal dysmotility, think we can just take the band out. We think she would not tolerate a band in the future either. Alternatively, we could revise her to a larger band, perhaps placed higher at the stomach if she has good esophageal motility. We will tentatively schedule the surgery in mid April, and we will have her obtain an esophageal motility study next week. The patient will make sure she has adequate protein supplementation.
SUBJECTIVE: The patient is a (XX)-year-old woman considering bariatric surgery. She was seen in October, and at that time, she was 330 pounds down from her high of 360 pounds. Through diet and exercise, she is now down to 306 pounds. BMI is 54.2. She is 5 feet 3 inches tall. Past medical history is significant for a recent diagnosis of sleep apnea, just beginning CPAP treatment, hypertension, history of atrial fibrillation, lower extremity swelling, dyspnea on exertion, GERD, status post cholecystectomy, stress incontinence, hypothyroidism, and depression. Medications include hydrochlorothiazide, Lexapro, Synthroid, Vasotec, Celebrex, Prevacid, and multivitamins.
OBJECTIVE: The patient is a morbidly obese woman in no apparent distress. She is 5 feet 3 inches, 306 pounds. Her BMI is 54.2. Blood pressure is 142/72, heart rate 72, and respiratory rate 18. HEENT: Normocephalic and atraumatic. Extraocular motions are intact. Pupils are equal, round, and reactive to light and accommodation. Neck: No JVD. No carotid bruits. Trachea is midline. No thyromegaly. Lungs: Clear to auscultation and percussion. Heart: Regular. Abdomen is firm. No organomegaly is noted. No hernias are noted. Extremities: Warm and well perfused. There is 2+ edema bilaterally. Strength and sensation normal bilaterally. Affect appropriate.
ASSESSMENT AND PLAN: This is a super morbidly obese woman considering bariatric surgery. She would like to have a laparoscopic adjustable gastric band. Meets NIH criteria for this with a BMI of greater than 40, sleep apnea, and other health problems. Risks and benefits were discussed including, but not limited to, bleeding, infection, band slippage, band erosion, poor weight loss, weight regain, need for band removal. All questions were answered, and the patient wishes to proceed. Prior to surgery, the patient will go on a liquid HMR 500 diet, and we will do this for about three months. We told her that she see her primary care physician in two weeks and get a metabolic profile. The patient will get some lab tests today, and she will call for the results on Tuesday. We will also get an ESD to evaluate the size of the hiatal hernia preoperatively, and we will see her again preoperatively.
