Paul, age 35, presents for a 4-year follow-up visit after undergoing a laparoscopic biliopancreatic diversion with a duodenal switch 4 years ago. He was last seen for a follow-up for bariatric surgery about 2 years ago.
He notes concerns with vision difficulty. Specifically, he has difficulty transitioning from light to dark and from dark to light. He often notices a yellow hue at sunset throughout his entire vision field. He denies any difficulty with driving at night but has not done it frequently. He has had to strain his eyes at work while working on the computer, so he has been wearing “cheater” glasses for the past few months. Recently, he noticed a possible blind spot in both eyes. He was seen by an ophthalmologist within the last month. He has a new mild refractive error and was given a prescription, but nothing else was noted of significance during that visit.
- Baseline weight: 166.8 kg
- Weight at the time of bariatric surgery: 141.8 kg
- Weight at approximately 1 year post-bariatric surgery: 76.6 kg
- Weight today: 85.3 kg
He typically consumes 3 meals with occasional snacks and between 70 and 75 g of protein daily. He plans to add a protein shake to get closer to 90 g of protein daily. He also consumes about 32 ounces of water per day.
Presence of GI symptoms
He notes having loose stools 3 to 4 times per day, typically 2 to 3 times in the morning, and up to 2 times in the evening. He also notes having gas, which is often more common at night.
Exercise and activity
He tries to walk as much as he can at work. He is also very active during the summer months doing yard work, housework, and paddleboarding on the weekends. Last winter he participated in a daily workout video course with his wife.
Preexisting weight-related comorbidities
- Impaired fasting glucose, which resolved within 3 months of bariatric surgery
- Obstructive sleep apnea—no longer requires CPAP.
He is not currently taking any multivitamins, calcium, or vitamin B12 and stopped all supplements one year ago.
- Hemoglobin 13.9 g/dL (reference range 13.5-17.0 g/dL)
- Ferritin 33 mcg/L (reference range 11-307 mcg/L)
- Vitamin D 22 ng/mL (reference range 20-50 ng/mL)
- Vitamin A 4.4 mcg/dL (reference range 32.5-78.0 mcg/dL)
- Vitamin E 4.2 mg/L (reference range 5.5-17 mg/L)
- Calcium 8.7 mg/dL (reference range 8.9-10.1 mg/dL)
- Albumin 4.1 g/dL (reference range 3.5-5 g/dL)
- Cholesterol 99 mg/dL (reference range <200 mg/dL is ideal)
- Triglycerides 42 mg/dL (reference range <150 mg/dL is ideal)
- HDL 45 mg/dL (reference range >40 mg/dL)
- LDL 46 mg/dL (reference range <100 mg/dL is ideal)
- Bone alkaline phosphatase 25 mcg/L (reference range 0-20 mcg/L)
- 24-hour urine calcium 123 mg/24 hours (reference range 80-200 mg/24 hours)
- 24-hour urine volume 2453 mL (reference range >1500 mL)