Weight Loss Established

Clinician's specialty: Obesity Medicine History of Present Illness Patient reports increased energy levels and improved sleep quality since the last visit. No new complaints. Her primary goal remains sustainable weight loss and better metabolic control. Status of comorbidities: 1. Type 2 Diabetes Mellitus (E11.9): HbA1c 6.5% (down from 6.8%). Currently on Metformin 1000mg BID. Adherent to medication. Blood glucose readings are within target range. BP: 128/82 mmHg. 2. Hypertension (I10): Controlled on Lisinopril 20mg daily. Adherent to medication. BP: 128/82 mmHg. 3. Dyslipidaemia (E78.5): On Atorvastatin 20mg daily. Adherent. LDL-C 2.2 mmol/L (improved from 2.8 mmol/L). HR: 72 bpm. Weight loss update: Patient has successfully maintained a steady weight loss of 1.5 kg since her last visit. She is currently taking Phentermine 37.5mg daily, which she perceives as moderately effective in suppressing her appetite and reducing cravings. She notes improved satiety after meals. She has experienced mild dry mouth, but no other significant side effects. *Due on PinPoint: All PinPoint requirements are up to date and completed. Dietary History: Patient continues to follow a low-carbohydrate, high-protein diet. She reports eating three structured meals a day with one planned snack. Cravings for sugary foods have significantly decreased. She actively tracks her food intake using a mobile application and has been consistent with her dietary recommendations. She avoids processed foods and sugary drinks, focusing on whole, unprocessed options. Physical Activity History: Patient engages in regular physical activity, including 30 minutes of brisk walking five times a week and two sessions of strength training per week. She reports increased stamina and less joint pain during exercise. No significant barriers to activity reported, other than occasional work-related travel which can disrupt her routine, but she makes efforts to walk during these periods. Active Problems * Obesity (E66.9) - Resolved Date: N/A, Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova * Type 2 Diabetes Mellitus (E11.9) - Resolved Date: N/A, Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova * Hypertension (I10) - Resolved Date: N/A, Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova * Dyslipidaemia (E78.5) - Resolved Date: N/A, Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova Social History * Exercise habits: Brisk walking 5x/week, strength training 2x/week. * Smoking status: Never smoked. * Drug use: Denies recreational drug use. * Sexual activity: Stable relationship, denies new concerns. * Caffeine consumption: One cup of coffee daily. * Relationship status: Married. * Reported abuse: Denies history of abuse. Family History * Mother: Type 2 Diabetes, Hypertension. * Father: Myocardial Infarction at 60, Hypertension. * Paternal Aunt: Obesity. * No pertinent negative history mentioned. Surgical History 1. Cholecystectomy - 10 years ago 2. Appendectomy - 25 years ago Vitals Vital Signs Recorded: 1 November 2024 10:30 AM Height: 165 cm Weight: 92 kg BMI Calculated: 33.8 kg/m² BSA Calculated: 2.1 m² Blood Pressure: 128/82 mmHg Heart Rate: 72 bpm O2 Saturation: 98% on room air FiO2 Flow Rate: N/A Results/Data BMI BMI is 33.8 kg/m², categorised as Obesity Class I. Physical Exam General constitutional: Alert and oriented x3, well-nourished, no acute distress. Appears comfortable and cooperative. Eyes Conjunctivae pink, sclerae anicteric. Eyelids without oedema or lesions. Pupils equal, round, and reactive to light bilaterally. Ears, Nose, Mouth, and Throat External ears normal appearance, no tenderness. Nares patent, no discharge. Oral mucosa moist, pharynx clear. No dental caries noted. Pulmonary Respiratory effort unlaboured. Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Musculoskeletal Gait steady and coordinated. Station erect. Full range of motion in all major joints without pain or limitation. No oedema or erythema. Neurologic Motor exam: Strength 5/5 in all four extremities. Sensation intact to light touch. Deep tendon reflexes 2+ and symmetrical bilaterally. Psychiatric Orientation to person, place, and time intact. Speech clear and coherent. Comprehension excellent. Mood reported as positive, affect euthymic and congruent. Assessment * Obesity (E66.9) - Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova * Type 2 Diabetes Mellitus (E11.9) - Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova * Hypertension (I10) - Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova * Dyslipidaemia (E78.5) - Last Assessed: 1 November 2024, Assessing Provider: Dr. Elena Petrova Plan Goals until next visit: Diet: * Continue low-carbohydrate, high-protein diet. * Focus on increasing vegetable intake at each meal. * Limit processed snacks to one per day. * Attend group nutrition session next month. Exercise: * Achieve 10,000 steps daily. * Increase strength training sessions to three times per week. * Consider incorporating swimming once a week for variety. Behavioral: * Continue daily food logging. * Practice mindful eating techniques. * Ensure adequate sleep (7-8 hours per night). GOAL WEIGHT-- 70 kg Status of co-morbid conditions 1. Type 2 Diabetes Mellitus: Continue Metformin 1000mg BID. Monitor HbA1c in 3 months. Discuss potential for dose reduction if weight loss continues. 2. Hypertension: Continue Lisinopril 20mg daily. Home blood pressure monitoring encouraged. Re-evaluate medication at next visit if BP remains stable. 3. Dyslipidaemia: Continue Atorvastatin 20mg daily. Lipid panel to be repeated in 6 months. Weight Loss Plan Visit: 4 Starting weight 105 kg. Current Weight 92 kg. Down 1.5 kg since last visit, Down 13 kg total Starting BMI 38.5 kg/m² Current BMI 33.8 kg/m². Weight loss promoting medications: Phentermine 37.5mg, started 3 months ago; Orlistat 120mg, started 6 months ago. Patient's questions were thoroughly answered. Body Composition History Start: Date 1 May 2024, 105 kg, 38.5 BMI, 1 May 2024. BF% 42%. BFMO 44.1 kg. FFM 60.9 kg. WL UPDATE: Patient continues on Phentermine 37.5mg daily. Review effectiveness at next visit. Follow-up with Dr. Petrova in 6 weeks. Provider and Scribe Attestations: "I, the undersigned scribe, attest to performing the scribing services for and in the presence of the undersigned provider." "I, the undersigned provider, attest to personally performing the services documented and scribed by the undersigned scribe and the documentation is both accurate and complete." Follow-up with Dr. Elena Petrova in 6 weeks for reassessment and ongoing management.