Management of the healthy, post Roux-en-Y gastric bypass patient

History of present illness

Mrs. Smith is a 38-year-old female who comes to the clinic for a two-year follow-up visit after undergoing a non-complicated laparoscopic Roux-en-Y gastric bypass. She was last seen in the bariatric clinic one year ago. She has come to see her primary care provider, as she was instructed to follow up on a yearly basis.

Current concern related to bariatric surgery

The patient notes significant fatigue recently. She reports that she has been taking naps in the middle of the day and has been unable to run as often as she typically can. She has had heavy menses for the past four to five months.

Weight history

  • Baseline weight at the time of surgery: 122.1 kg
  • Weight at approximately one year post surgery: 83.4 kg
  • Weight at approximately two years post surgery (today): 87.6 kg

Current diet

The patient currently eats a regular, textured diet of typically three meals and two snacks per day. She reports intolerance to most dairy products (with the exception of cheese and yogurt) as she develops diarrhea with consumption of dairy. She consumes at least eight cups of fluids daily (water or unsweetened iced tea).  She reports an average consumption of at least 60 grams of protein per day, with protein sources of meat, Greek yogurt, cheese, and occasional protein bars. She consumes alcohol on a less than once per month basis.

Presence of GI symptoms

The patient reports a sensation of food blockage about once month, typically after eating too quickly or not chewing her food well. She often has to vomit to alleviate the pain from the blockage.

Exercise/activity program

The patient currently exercises three to four times per week for 30 to 60 minutes per session. Her main forms of exercise are running, walking, and weight training (at least 40-50 minutes/week). She has participated in several 5k races to help motivate herself to exercise.

Laboratory values

  • Hemoglobin: 9.6
  • Ferritin: 5
  • Vitamin B12: 543
  • Vitamin D: 31
  • Albumin: 4.1
  • Glucose: 89
  • HbA1c: 5.8%
  • Cholesterol: 129
  • Triglycerides: 46
  • HDL: 51
  • LDL: 77
  • Urine calcium: 144
  • Total 24-hour urine volume: 1950 ml

Current vitamin supplement regimen

  • Twice-daily Centrum vitamin
  • Twice-daily calcium 600 mg plus vitamin D 500 mg
  • Once-daily Vitron-C at bedtime
  • Once-monthly vitamin B12 1,000 mcg injection

Obesity-relevant past medical history

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