What level would you choose? This is a nutrition follow up for Surgery. Thank you.
Patient with history of medically complicated obesity, currently undergoing a physician supervised weight loss program, is presenting for follow-up. Diet journals are consistent with improved eating habits and the patient is following an exercise program. She is doing really well with weight loss.
Reports moderate to severe fatigue of few years duration that interferes with optimal performance of daily activities. It is not alleviated by anything; but has improved since starting the weight loss program.
.eg
Current medication g3
Medication List Reconciled.
Atorvastatin 80 mg tablet take 1 tablet by Oral route 1 time per day at night.
Klor-Con M20 20 mEq tablet,ER particles/crystals take 1 tablet by Oral route with food 2 times per day.
Niaspan Extended-Release 1,000 mg tablet extended release 24 hr take 1 tablet (1,000 mg) by oral route once daily at bedtime after a low-fat snack.
Celebrex 200 mg capsule 1 capsule by Oral route 2 times per day.
Hydrochlorothiazide 25 mg tablet 1 tablet by Oral route 1 time per day.
Allopurinol 100 mg tablet 1 tablet by Oral route 1 time per day.
Paxil 30 mg tablet take 1 tablet by Oral route 1 time per day.
Lisinopril 20 mg tablet 1 tablet by Oral route 1 time per day.
Plavix 75 mg tablet 1 tablet by Oral route 1 time per day.
Metformin 500 mg tablet extended release 24 hr take 2 tablets (1,000 mg) by oral route once daily with the evening meal.
Nitrostat 0.4 mg tablet, sublingual 1 tab by Sublingual route . . for Chest Pain. Every 5 minutes if needed. If 3rd dose seek help.
Protonix 40 mg tablet,delayed release (DR/EC) take 1 tablet by Oral route 2 times per day.
Test Strips ///// Strip 2 times per day dx 250.00, FREE STYLE LITE.
Potassium chloride 20 mEq tablet,ER particles/crystals 1 tablet by Oral route 1 time per day.
Osphena 60 mg tablet take 1 tablet (60 mg) by oral route once daily with food.
Magnesium oxide 400 mg tablet 1 tablet by Oral route 2 times per day.
Lancets - Needle 4 times per day Freestyle use as directed dx 790.29.
TraZODONE 50 mg tablet take 2 tablets (100 mg) by oral route once daily at bedtime.
Glucometer Device dx 790.29.eg
Past medical/surgical history g4
Reported:
Surgical / Procedural: Knee replacement.
Diagnoses:
Acute myocardial infarction
Hypertension.
Esophageal reflux (GERD).
Hyperlipidemia.
Obesity.
Type 2 diabetes mellitus.
Stroke syndrome.
Depression
Procedural:
? Complete colonoscopy 2002
Surgical:
? Tonsillectomy
? Thyroid surgery
? Shoulder surgeryeg
Personal history g5
Behavioral: Never a smoker.eg
Review of systems g16
Systemic: Feeling tired or poorly. No fever and no chills.
Otolaryngeal: No nasal passage blockage (stuffiness) -Congestion.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: No shortness of breath. No cough.
Gastrointestinal: No dysphagia and no heartburn. No nausea, no vomiting, no diarrhea, and no constipation.
Hematologic: Easy bleeding and a tendency for easy bruising.
Musculoskeletal: Limb pain.
Arthralgias. No soft tissue swelling. Stiffness localized to one or more joints.eg
Physical findings g8
Vital Signs:
Vital Signs/Measurements Value Date
Oral temperature 98 9/23/2015
RR 16 per min 9/23/2015
PR 70 bpm 9/23/2015
Blood pressure 130/80 mmHg 9/23/2015
Pain level by numeric rating scale 0 9/23/2015
Weight 246 lbs 9/23/2015
Body mass index 38.5 kg/m2 9/23/2015
Height 67 in 9/23/2015
Standard Measurements:
Standard Measurements: Value Date
Body surface area 2.3 9/23/2015
Laboratory Studies:
Pulmonary Tests: Value Date
Oxygen saturation 98% percent 9/23/2015
Standard Measurements:
Patient was observed to be obese.
General Appearance:
Alert.
Eyes:
General/bilateral:
Eyes: 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.
Orthopedic Disorder:
Backache.eg
Assessment g11
? Lethargy was observed
? Morbid obesity due to excess calories
Patient with medically complicated obesity despite multiple attempts of weight loss with conventional methods. The patient is a good candidate for bariatric surgery. The patient's fatigue has improved since the start of the program and the patient is compliant with the recommended lifestyle changes.eg
Allergies and Adverse Reactions g24
No Known Allergies.
Allergies Reviewed.eg
Plan g13
? Follow-up visit 1 month(s)
? Niaspan Extended-Release 1,000 mg tablet extended release 24 hr. take 1 tablet (1,000 mg) by oral route once daily at bedtime after a low-fat snack. Dispense: 90 tablet(s). Refill: 3. REASON: Course Complete
1) 1200 Calorie Diet
2) Exercise Program
.eg
Other g15
Barriers to care addressed: None identified.eg
Patient with history of medically complicated obesity, currently undergoing a physician supervised weight loss program, is presenting for follow-up. Diet journals are consistent with improved eating habits and the patient is following an exercise program. She is doing really well with weight loss.
Reports moderate to severe fatigue of few years duration that interferes with optimal performance of daily activities. It is not alleviated by anything; but has improved since starting the weight loss program.
.eg
Current medication g3
Medication List Reconciled.
Atorvastatin 80 mg tablet take 1 tablet by Oral route 1 time per day at night.
Klor-Con M20 20 mEq tablet,ER particles/crystals take 1 tablet by Oral route with food 2 times per day.
Niaspan Extended-Release 1,000 mg tablet extended release 24 hr take 1 tablet (1,000 mg) by oral route once daily at bedtime after a low-fat snack.
Celebrex 200 mg capsule 1 capsule by Oral route 2 times per day.
Hydrochlorothiazide 25 mg tablet 1 tablet by Oral route 1 time per day.
Allopurinol 100 mg tablet 1 tablet by Oral route 1 time per day.
Paxil 30 mg tablet take 1 tablet by Oral route 1 time per day.
Lisinopril 20 mg tablet 1 tablet by Oral route 1 time per day.
Plavix 75 mg tablet 1 tablet by Oral route 1 time per day.
Metformin 500 mg tablet extended release 24 hr take 2 tablets (1,000 mg) by oral route once daily with the evening meal.
Nitrostat 0.4 mg tablet, sublingual 1 tab by Sublingual route . . for Chest Pain. Every 5 minutes if needed. If 3rd dose seek help.
Protonix 40 mg tablet,delayed release (DR/EC) take 1 tablet by Oral route 2 times per day.
Test Strips ///// Strip 2 times per day dx 250.00, FREE STYLE LITE.
Potassium chloride 20 mEq tablet,ER particles/crystals 1 tablet by Oral route 1 time per day.
Osphena 60 mg tablet take 1 tablet (60 mg) by oral route once daily with food.
Magnesium oxide 400 mg tablet 1 tablet by Oral route 2 times per day.
Lancets - Needle 4 times per day Freestyle use as directed dx 790.29.
TraZODONE 50 mg tablet take 2 tablets (100 mg) by oral route once daily at bedtime.
Glucometer Device dx 790.29.eg
Past medical/surgical history g4
Reported:
Surgical / Procedural: Knee replacement.
Diagnoses:
Acute myocardial infarction
Hypertension.
Esophageal reflux (GERD).
Hyperlipidemia.
Obesity.
Type 2 diabetes mellitus.
Stroke syndrome.
Depression
Procedural:
? Complete colonoscopy 2002
Surgical:
? Tonsillectomy
? Thyroid surgery
? Shoulder surgeryeg
Personal history g5
Behavioral: Never a smoker.eg
Review of systems g16
Systemic: Feeling tired or poorly. No fever and no chills.
Otolaryngeal: No nasal passage blockage (stuffiness) -Congestion.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: No shortness of breath. No cough.
Gastrointestinal: No dysphagia and no heartburn. No nausea, no vomiting, no diarrhea, and no constipation.
Hematologic: Easy bleeding and a tendency for easy bruising.
Musculoskeletal: Limb pain.
Arthralgias. No soft tissue swelling. Stiffness localized to one or more joints.eg
Physical findings g8
Vital Signs:
Vital Signs/Measurements Value Date
Oral temperature 98 9/23/2015
RR 16 per min 9/23/2015
PR 70 bpm 9/23/2015
Blood pressure 130/80 mmHg 9/23/2015
Pain level by numeric rating scale 0 9/23/2015
Weight 246 lbs 9/23/2015
Body mass index 38.5 kg/m2 9/23/2015
Height 67 in 9/23/2015
Standard Measurements:
Standard Measurements: Value Date
Body surface area 2.3 9/23/2015
Laboratory Studies:
Pulmonary Tests: Value Date
Oxygen saturation 98% percent 9/23/2015
Standard Measurements:
Patient was observed to be obese.
General Appearance:
Alert.
Eyes:
General/bilateral:
Eyes: 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.
Orthopedic Disorder:
Backache.eg
Assessment g11
? Lethargy was observed
? Morbid obesity due to excess calories
Patient with medically complicated obesity despite multiple attempts of weight loss with conventional methods. The patient is a good candidate for bariatric surgery. The patient's fatigue has improved since the start of the program and the patient is compliant with the recommended lifestyle changes.eg
Allergies and Adverse Reactions g24
No Known Allergies.
Allergies Reviewed.eg
Plan g13
? Follow-up visit 1 month(s)
? Niaspan Extended-Release 1,000 mg tablet extended release 24 hr. take 1 tablet (1,000 mg) by oral route once daily at bedtime after a low-fat snack. Dispense: 90 tablet(s). Refill: 3. REASON: Course Complete
1) 1200 Calorie Diet
2) Exercise Program
.eg
Other g15
Barriers to care addressed: None identified.eg