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SUBJECTIVE:, This 23-year-old white female presents with complaint of allergies. | [
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She used to have allergies when she lived in Seattle but she thinks they are worse here. | [
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Both worked for short time but then seemed to lose effectiveness. | [
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She has used over-the-counter sprays but no prescription nasal sprays. | [
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She does have asthma but doest not require daily medication for this and does not think it is flaring up. | [
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,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra. | [
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,ALLERGIES: , She has no known medicine allergies. | [
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,OBJECTIVE:,Vitals: Weight was 130 pounds and blood pressure 124/78.,HEENT: Her throat was mildly erythematous without exudate. | [
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Nasal mucosa was erythematous and swollen. | [
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Only clear drainage was seen. | [
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,Neck: Supple without adenopathy. | [
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,ASSESSMENT:, Allergic rhinitis. | [
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Samples of Nasonex two sprays in each nostril given for three weeks. | [
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He has difficulty walking two blocks or five flights of stairs. | [
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Difficulty with snoring. | [
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He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling. | [
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He has gastroesophageal reflux disease. | [
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,PAST SURGICAL HISTORY:, Includes reconstructive surgery on his right hand 13 years ago. | [
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,SOCIAL HISTORY:, He is currently single. | [
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He had smoked significantly up until several months ago. | [
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,FAMILY HISTORY:, Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes. | [
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Denies obesity and hypertension in other family members. | [
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,ALLERGIES:, He is allergic to Penicillin. | [
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,MISCELLANEOUS/EATING HISTORY:, He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program. | [
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He likes big portions and carbohydrates. | [
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He currently weighs 312 pounds. | [
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Ideal body weight would be 170 pounds. | [
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He is 142 pounds overweight. | [
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If ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,REVIEW OF SYSTEMS: ,Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin. | [
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Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. | [
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},
{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.877851 | null |
Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis. | [
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"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.878430 | null |
,PHYSICAL EXAMINATION:, He is alert and oriented x 3. | [
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Cranial nerves II-XII are intact. | [
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} | Default | 2022-12-07T10:14:26.879015 | null |
He is a very pleasant gentleman who is 42 years old, 344 pounds. | [
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} | Default | 2022-12-07T10:14:26.887651 | null |
He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. | [
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He is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again. | [
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He wants to be able to exercise and play volleyball. | [
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When he loses weight he always regains it and he gains back more than he lost. | [
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} | Default | 2022-12-07T10:14:26.890464 | null |
His biggest weight loss is 25 pounds and it was three months before he gained it back. | [
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He did six months of not drinking alcohol and not taking in many calories. | [
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He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin's Diet for one month two years ago. | [
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,PAST MEDICAL HISTORY: , He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure. | [
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He has asthma and difficulty walking two blocks or going eight to ten steps. | [
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He has sleep apnea and snoring. | [
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He is a diabetic, on medication. | [
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He has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling. | [
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} | Default | 2022-12-07T10:14:26.893309 | null |
He has hemorrhoids. | [
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] | [
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"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.893621 | null |
,PAST SURGICAL HISTORY: , Includes orthopedic or knee surgery. | [
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,SOCIAL HISTORY: , He is currently single. | [
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} | Default | 2022-12-07T10:14:26.894319 | null |
He drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink. | [
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He smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks. | [
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,FAMILY HISTORY: , Obesity, heart disease, and diabetes. | [
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Family history is negative for hypertension and stroke. | [
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,MISCELLANEOUS/EATING HISTORY: ,He says a couple of friends of his have had heart attacks and have had died. | [
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He is on his second week of Chantix, which is a medication to come off smoking completely. | [
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Eating, he eats bad food. | [
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He is single. | [
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He eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m. He currently weighs 344 pounds and 5'9". | [
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His ideal body weight is 160 pounds. | [
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He is 184 pounds overweight. | [
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If he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,REVIEW OF SYSTEMS: , Negative for head, neck, heart, lungs, GI, GU, orthopedic, or skin. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.899764 | null |
He denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or CVA. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.900480 | null |
He denies venous insufficiency or thrombophlebitis. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.900811 | null |
Denies shortness of breath, COPD, or emphysema. | [
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"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.901116 | null |
Denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, GERD, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.901632 | null |
He denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis. | [
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} | Default | 2022-12-07T10:14:26.902049 | null |
,PHYSICAL EXAMINATION: ,He is alert and oriented x 3. | [
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Cranial nerves II-XII are intact. | [
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Neck is soft and supple. | [
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} | Default | 2022-12-07T10:14:26.902996 | null |
Lungs: He has positive wheezing bilaterally. | [
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Heart is regular rhythm and rate. | [
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His abdomen is soft. | [
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} | Default | 2022-12-07T10:14:26.903888 | null |
Extremities: He has 1+ pitting edema. | [
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"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:26.904316 | null |
,IMPRESSION/PLAN:, I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications. | [
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} | Default | 2022-12-07T10:14:26.904990 | null |
He wants to proceed with workup and evaluation for laparoscopic Roux-en-Y gastric bypass. | [
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} | Default | 2022-12-07T10:14:26.905715 | null |
He will need to get a letter of approval from Dr. XYZ. | [
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He will need to see a nutritionist and mental health worker. | [
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He will need an upper endoscopy by either Dr. XYZ. | [
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} | Default | 2022-12-07T10:14:26.906763 | null |
He will need to go to Dr. XYZ as he previously had a sleep study. | [
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We will need another sleep study. | [
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He will need H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar. | [
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} | Default | 2022-12-07T10:14:26.907843 | null |
After this is performed, we will submit him for insurance approval. | [
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} | Default | 2022-12-07T10:14:26.908220 | null |
Left atrial enlargement with left atrial diameter of 4.7 cm. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.909731 | null |
Normal size right and left ventricle. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.909981 | null |
Normal LV systolic function with left ventricular ejection fraction of 51%.,4. | [
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"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.910206 | null |
Normal LV diastolic function. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.910348 | null |
No pericardial effusion. | [
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"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.910523 | null |
Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.910756 | null |
PA systolic pressure is 36 mmHg. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.910967 | null |
Mild mitral and tricuspid regurgitation. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.911167 | null |
Trace aortic and pulmonary regurgitation. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.911355 | null |
The left ventricular cavity size and wall thickness appear normal. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.913980 | null |
The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. | [
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} | Default | 2022-12-07T10:14:26.914380 | null |
There is near-cavity obliteration seen. | [
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} | Default | 2022-12-07T10:14:26.914674 | null |
There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. | [
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} | Default | 2022-12-07T10:14:26.914975 | null |
There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.915260 | null |
The left atrium appears mildly dilated. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.915583 | null |
The right atrium and right ventricle appear normal. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.915880 | null |
The aortic root appears normal. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.916165 | null |
The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:14:26.916571 | null |