Name: Abd-Manaaf Bakere

Rotation 1: Surgery

Date: 01/25/2024

Rotation Location: Metropolitan Hospital.

Soap Notes 1-4

Bariatric Surgery Preoperative Visit

Chief Complaint –  I’m for preoperative evaluation for scheduled bariatric surgery

HPI

RM is a 62 y/o female with PMHx of HLD, HTN, CHF and severe obesity presents for a review of the consultations and pre-operative diet instructions for bariatric surgery. The patient’s health has been compromised by obesity. For these reasons, the patient is interested in bariatric surgery. She is pursuing the work-up in preparation of her scheduled laparoscopic sleeve gastrectomy. Pt admits exercising by walking 2 hours daily. admits unsuccessful attempt to lose weight by her own and with nutritionist. 24-hour recall includes Breakfast eggs and toast, skipped Lunch, and had baked chicken, potatoes, spinach for dinner. Pt denies any previous bariatric surgery.

Past Medical History

Hyperlipidemia

Hypertension

DM

Past Surgical History –

Cardiac catheterization, tubal ligation

Medications

amlodipine (NORVASC) 10 MG

Tablet atorvastatin (LIPITOR) 40 MG

Tablet carvedilol (COREG) 6.25 MG

Tablet empagliflozin (JARDIANCE) 25 MG

Tablet furosemide (LASIX) 80 MG tablet

Gabapentin (NEURONTIN) 300

Antiplatelet/Anticoagulants – none

PSHx: denies alcohol drinking and smoking

FMHx: None available

Objective

Vitals: on 01/22/24

BP: 163/83, Pulse: 82, Temp: 98.5 F/ 36.9 C, Sp02: 98%

BMI Readings from Last 4 Encounters:

01/22/24 -41.42 kg/m?

11/14/23- 40.60 kg/m

10/30/23- 40.68 kg/m

09/11/23- 41.67 kg/m?

General – appears well, well hydrated, ambulates normally Neurological – Alert, Oriented, No focal deficits.

Eyes – No pallor, anicteric

Abdomen – Scars -, Soft, Non-distended, Non-tender, No hernia Lower extremity – reports no pain or swelling. No edema note on exam in both lower extremities.

Psychiatric – Calm. Appropriate effect

Labs

HGBA1C: 9.6 H

Consultations

Cardiology -(not yet seen) –

Pulmonary – (7/19/23) – Recommend-

• No contraindication to surgery from pulmonary standpoint and no other optimization required

• Manage patient peri-op with the presumption that she has OSA.

She has been warned not to drive.

• Have albuterol available as needed PRN

• Would get cardiology clearance in view of h/o CHF and syncope

RV PRN – if patient still sleepy after weight loss Dietician – ( 10/30/23) – Optimized

EGD – (11/14/23) – Findings grossly normal:

Pathology: A STOMACH, ANTRUM RANDOM BIOPSY:

– CHRONIC GASTRITIS.

– NEGATIVE FOR INTESTINAL METAPLASIA.

– NEGATIVE FOR H. PYLORI (GIEMSA STAIN).

Assessment

RM is a 62 y/o female with PMHx of HLD, HTN, CHF and severe obesity presents for a review of the consultations and pre-operative diet instructions for bariatric surgery. The patient’s health has been compromised by obesity. For these reasons, the patient is interested in bariatric surgery. She is pursuing the work-up in preparation of her scheduled laparoscopic sleeve gastrectomy. Pt admits exercising by walking 2 hours daily. admits unsuccessful attempt to lose weight by her own and with nutritionist. 24-hour recall includes Breakfast eggs and toast, skipped Lunch, and had baked chicken, potatoes, spinach for dinner. Pt denies any previous bariatric surgery.

Plan

– Reviewed consultation reports and EGD findings – No contraindications to pursue planned surgery.

– Provided dietary instructions – Only liquid diet for 48 hours prior to surgery comprising protein drinks and other liquids in the list provided

– Provided educational materials about recovery in the postoperative period after surgery

– laparoscopic Sleeve Gastrectomy is scheduled on 2/12/24.

PATIENT NEEDS TO COMPLETE HER REFERRALS PRIOR TO SURGERY

Post-operative visit scheduled on 2/19/24.

PATIENT 2

Chief complaint: Referral for evaluation of severe obesity

RD is a 62 y/o. female with PMHx of HTN, HLD presents for evaluation of severe obesity with BMI of 52.9. The patient has been obese for several years. She gradually started gaining weight after moving to NY in 2011. The patients tried numerous attempts at dieting and physical activity without durable success. She used to walk a lot, but her breathing becomes labored and admits cannot do a lot exercises. Obesity deteriorated patient’s health. The maximum weight she has being is 330 Ibs the minimum weight is 285 lb. She used to fast and only eats between noon and 4 pm. The maximum weight she has been able to lose on her own is 6 lb. For these reasons, the patient is interested in bariatric surgery. Admits walking few blocks a day and having liquid calories: water, coffee, green tea Coca Cola. Her 24-hour recall is Breakfast with coffee, Lunch with pasta and shrimp and dinner with peanut butter sandwich. She denies any previous bariatric surgery.

Review of systems

Constitutional – No significant unexplained weight loss/gain

Cardiac – No angina, exertional dyspnea, palpitations

Pulmonary – No cough, shortness of breath, hemoptysis

GI – No chronic diarrhea, constipation or bleeding per rectum

Joints – No back, shoulder, arm or leg pain.

Level of functioning – can walk 2 flights of stairs.

Obesity related Medical history – Hypertension and HLD

Past Medical History:

05/2019: Hepatitis A antibody positive

04/2019: Hepatitis C antibody positive in blood

05/2019: HTN (hypertension)

02/01/2023: OSA

2022: Ulcer

Medications

amlodipine (NORVASC) 5MG tablet

atorvastatin (LIPITOR) 20 MG tablet

hydrochlorothiazide (HYDRODIURIL) 12.5 MG tablet

mesalamine (ASACOL HD) 800 MG EC tablet

Valsartan ( DIOVAN) 320 MG tablet

Antiplatelet/Anticoagulants – No

oral contraceptives or hormone replacement therapy- yes

Past Surgical History

Appendectomy (2011);

Total abdominal hysterectomy (2004);

 EGD transoral biopsy single/multiple (N/A, 11/30/2021);

colonoscopy fix dx, 11/30/2021); and Hysterectomy.

Allergies – No Known Allergies

Social history – Former smoker,  Alcohol – Occasional,  Recreational drugs – No, Marijuana

Objective

Vitals: 01/15/24

BP: 132/81, Pulse: 81, Temp: 98.2 °F (36.8 °C), Sp02: 95%

BMI Readings from Last 4 Encounters:

01/22/24- 52.19 kg/m2

12/11/23- 52.31 kg/m2

11/02/23- 51.37 kg/m2

08/08/23- 50.90 kg/m2

Labs: HGBA1C: 5.6 , 07/27/2023

General – appears well, well hydrated, ambulates normally Neurological – Alert, Oriented, No focal deficits

Eyes – No pallor, anicteric

Abdomen – Scars +/-, Soft, Non-distended, Non-tender, No hernia

-extremities – Warm, No edema

Psychiatric – Calm. Appropriate effect

Cardiology requested – Yes

.

Assessment

RD, 62 y/o with PMHx of HTN, HLD with 52.19 BMI presents here for bariatric surgery. Patient has medical necessity for bariatric surgery for her morbid obesity and associated comorbidities. We recommend laparoscopic sleeve gastrectomy and went over the risks and benefits. Patient is provided with information about our bariatric seminars to further know about the surgery. Patient will under go the necessary preoperative work-up including cardiac and pulmonary assessment, EGD, nutrition evaluation, preoperative labs.

Plan

Recommended to stop using oral contraceptives (Estrogen based) for 1 month before and 3 months after surgery.

Counseled on the need for lifelong vitamin and mineral supplementation after surgery Encouraged to increase physical activity (Between 5000-8000 steps), take protein rich diet (Chicken, Turkey, Beans, Protein powder/drinks), avoid carbohydrates (rice, bread, pasta),

Please buy a digital weighing scale and record your weight 2 times per week

Labs for new patient – CBC, BMP, LFT, PT/partial thromboplastin time, HbA1c, Lipid panel,

EKG, Urine Pregnancy test (for females), Type and Screen, TSH Consultations – PCP, Pulmonary, EGD, Dietician, Psychiatry, Cardiology.

Consultations – PCP, Pulmonary, EGD, Dietician, Psychiatry, Cardiology. Patient will be followed by clinic and Nutritionist for about 6 months.

RTC in one month

Patients 3 SOAP Notes 3

Chief Complaint: “ I have abdominal pain and hernia at umbilicus for 2 years”

SC is a 48 y/o. male with past medical history of cirrhosis with moderate ascites who presents with umbilical hernia. Hernia has been there for 2 years. Worse with cough or heavy lifting. When at rest it is self-reducing. Pain at umbilicus with exertion (6/10).  Pts tolerates food and drink without issue. Denies nausea and vomiting, black or bloody stool, constipation.

Past Medical History:

Diagnosis

• Alcoholic cirrhosis (HCC)

• Diabetes (HCC)

• Hepatic encephalopathy (HCC)

• Hypertension

• Psoriasis vulgaris

Past Surgical History:

Colonoscopy flx dx w/collj spec when left

Esophagogastroduodenoscopy (EGD) with transoral biopsy

No Known Allergies

Medications

carvedilol (COREG) 6.25 mg

clobetasol (TEMOVATE) 0.05 % ointment, 2 times a day

FeroSul 325 mg

furosemide (LASIX). 40mg

Ixekizumab (TALTZ) 80 MG/ML Solution Auto-injector 2pens

Januvia 50mg

lactulose (ENULOSE), 10g

Nutritional Supplements (GLUCERNA) Liquid 2 bottles

rifaximin (XIFAXAN), 550mg

spironolactone (ALDACTONE) 100mg

triamcinolone acetonide (KENALOG) 0.1 % ointment, 2 times a day

Social Hx: no smoking, former heavy drinker.

Family Hx: cirrhosis – sister

Objective

No Vital sign not taken.

Physical Exam

General Appearance: awake, alert, oriented, in no acute distress

Skin: + psoriatic changes on abdomen, sides, hands bilaterally + Caput medusa + Jaundice.

Head/Face: Normal Cephalic, atraumatic.

Eyes: +Icteric sclera

Mouth/Throat: Mucosa moist, no lesions; pharynx without erythema, edema or exudate.

Neck: supple, no mass, non-tender

Lungs: Normal expansion. No distress on room air

Heart: Regular rate and rhythm. Normal pulses

Abdomen: Soft, non-tender, distended. Chronic Umbilical hernia not fully reducible.

Nontender. Psoriatic changes. Small inferior to hernia skin break. Cleaned with peroxide and bacitracin applied.

Extremities: Extremities warm to touch, pink, with no edema.

Musculoskeletal: Range of motion normal in extremities

Labs

CMP: Within Normal range

CMP:   BUN 8.0, Creatinine 0.6 (L), Glucose: 102, Calcium: 8.3 (L), Anion Gap: 10.0, Osmolality Calc: 277, eGFR(cr): 119.1, Magnesium:1.8, Lipase: 23, Albumin: 2.7 (L), Total Protein: 7.2, Total Bilirubin: 0.6, Direct Bilirubin: 0.3, ALK PHOS: 257 (H), ALT (SGPT):20, AST (SGOT): 26.

Imaging:

Echo 11/21/23

Left ventricular size is normal. Mild left ventricular hypertrophy. EF evaluated by visual assessment. LV ejection fraction is 55% – 60%. The left ventricular systolic function is normal. Unable to assess diastolic function.

US Abd 11/20/23

IMPRESSION:

1. No portal vein thrombus.

2. Small/moderate ascites adjacent to the liver.

3. Cirrhosis.

4. Mobile cholelithiasis.

Assessment

48 y/o male with history of cirrhosis presents with moderate ascites with umbilical hernia. Hernia has been there for 2 years. Worse with cough or heavy lifting. When at rest it is self-reducing. Pain at umbilicus with exertion (6/10).  Pts tolerates food and drink without issue. Denies nausea and vomiting, black or bloody stool, constipation. Abdominal US confirms Small/moderate ascites adjacent to the liver, Cirrhosis, mobile cholelithiasis.

Plan

Medical optimization of liver disease and skin disease.

CT abdomen A/P with IV contrast

GI EGD scheduled on 02/15/2024

Return after studies and EGD and labs and can potentially schedule for repair.

Patient 4 Soap Notes.

Chief Complaint: “I have right groin pain for 3months”

HPI:

LG is a 62 y/o. male with history of gout, asthma, HTN and OA who presents with right groin hernia pain. He noticed a bulge about 3 months ago. Worse with standing long periods of time, better with lying flat. Eating and drinking without issue. Pain radiates to medial thigh when standing for long periods of time. Works at a counter standing all day. Lifts heavy things rarely. Denies nausea and vomiting, constipation, diarrhea or bloody or black stool.

Past Medical History:

Diagnosis

• Acute respiratory failure due to pneumonia due to COVID-19 virus

• Asthma

• Gout

• History of 2019 (COVID-19)

• Hypertension

• Osteoarthritis of knees, bilateral

Past Surgical History:

• APPENDECTOMY

• LEFT HERNIA REPAIR

No Known Allergies

Home Meds:

Current Outpatient Medications

Medication

• aspirin (BAYER), 81 mg

• atorvastatin (LIPITOR), 10mg

• clobetasol (TEMOVATE) 0.05 % cream, 2 times a day

• colchicine (COLCRYS), 0.6mg

• diclofenac (VOLTAREN), 2 g, 2 times daily

• lisinopril (ZESTRIL), 10mg

• polyvinyl alcohol 1.4% (LIQUIFILM TEARS) 1.4% ophthalmic solution,

• prednisone (DELTASONE) 20 MG tablet, one tablet a day for week

Social History: no smoking. No drinking

Family History: cancer in brother.

Physical Exam:

Vital: none

General Appearance: awake, alert, oriented, in no acute distress

Skin: there are no suspicious lesions or rashes of concern

Head/Face: Normal Cephalic, atraumatic.

Eyes: No gross abnormalities.

Mouth/Throat: Mucosa moist, no lesions; pharynx without erythema, edema or exudate.

Neck: neck- supple, no mass, non-tender

Lungs: Normal expansion. No distress on room air Heart: Regular rate and rhythm. Normal pulses

Abdomen: Soft, non-tender, Right inguinal hernia present. Reducible. Nontender. No left hernia appreciated. Scar from open Appy present RLQ.

Extremities: Extremities warm to touch, pink, with no edema.

Musculoskeletal: Range of motion normal in extremities.

Labs: pending

Imaging: none

Assessment and Plan:

LG is a 62 y/o. male with history of gout, asthma, HTN, OA who presents with mildly symptomatic right inguinal hernia. Noticed a right groin a bulge about 3 months ago. Worse with standing long periods of time, better with lying flat. No Nausea and vomiting bloody or black BM. Eating and drinking without issue. Pain 5/10 radiates to medial thigh when standing for long periods of time. Patients has request to postpone surgery until summertime. Pt admits appendectomy few years back.

Plan

Diet: encouraged fiber diet.

Educate pt to return clinic or go to ER if skin changes or notice increase pain in the area.

Revisit prior to surgery to schedule closer to time desired. Follow up in 3 months.