Medical Weight Loss

OVERALL_INSTRUCTIONS

Chief Complaint

Medical Weight Loss

Template

Thank you for referring [name], a [age] year old [gender], who was seen on [date], for assessment of weight management. Consent: I obtained consent from the patient for use of an AI scribe software. I explained that [company] saves a copy of our conversation on their website for the purpose of generating a note, and that this software is FDA approved. Weight history: Weight gain began around age: [age] Pattern of weight gain: [slow and steady/fluctuating] Therapies previously tried: Goal weight: Current Diet: [diet] Diets previously tried: Current Exercise: [exercise] Exercise regimens previously tried: Symptoms of eating disorder: [binge eating/purging] Endocrine review of systems: Symptoms of Hypothyroidism: Symptoms of Cushing's syndrome: Symptoms of PCOS: Symptoms of Menopause: Symptoms of Acromegaly: Other medical history: [medical_history] (List numerically with each having its own line) Current medications: [medications] (List numerically with each having its own line) Allergies: [allergies] (List numerically with each having its own line) Social history: Work: [work] Extended coverage: [coverage] Alcohol: [alcohol] Cigarettes: [cigarettes] Drugs: [drugs] Family history: [family_history] No known family history of medullary thyroid cancer. Exam: [general exam, weight, height, vitals, cardiac exam, pulmonary exam] Weight: [weight] Height: [height] BMI: [bmi] Blood pressure: [blood_pressure] Heart rate: [heart_rate] Investigations: [investigations] Impression and Plan: [name] is a [age] [gender] who wants to pursue medical weight loss with a goal weight of [weight]. 1. Weight management: (Use first person tone, such as "I have ordered...") [- I have prescribed [drug_name] [dosage] SC weekly, with a plan to titrate to [dosage] SC weekly, as tolerated. I discussed the risks and benefits of [drug_name] with the patient, as well as its cost.] 2. Disease prevention: [- I have initiated metformin [dosage] PO daily to reduce the patient's risk of diabetes] [- I have initiated [atorvastatin/rosuvastatin] [dosage] daily to reduce the patient's risk of cardiovascular disease and stroke] [- I have recommended that the patient take vitamin D 2000 IU daily and a multivitamin daily] 3. Hormone screening: [- I have provided the patient with a lab requisition to screen for endocrine causes of weight gain] 4. Follow-up: - Patient Counseling: I counseled the patient on the side effects of GLP1 receptor agonists, including nausea and vomiting, which occurs in the majority of patients and tends to improve with repeated exposure to the medication, as well as the risk of pancreatitis and gallbladder disease, and what symptoms to expect if they were to occur. We also discussed the theoretical risk of medullary thyroid carcinoma in rodent studies, but this has not been demonstrated in humans. I also informed [pronoun] of the need to hold the medication for 3 weeks prior to surgery or procedures requiring general anesthesia. Thank you for involving me in the care of this pleasant patient. Please do not hesitate to contact me with any questions or concerns. Dr. Leo Hu, MD, FRCPC Forward Care Medical Clinic