This document discusses a multidisciplinary conference for a 67-year-old female patient scheduled for elective gastric bypass surgery who is at high risk due to medical comorbidities. The patient has a history of obesity, hypertension, asthma, and is classified as ASA physical status 3. Preoperative evaluations found she has a dilated left ventricle, pneumonia, and episodes of low oxygen saturation. The conference aims to determine if surgery should proceed given her high anesthetic and surgical risks or be postponed until medical issues are optimized.

1. Departmental conference

2.  To discuss the case of a patient scheduled for elective surgery who was classified
as high risk with unmodifiable factors

3. SITUATION:
 T. T.
 67 years old, female
 Preoperative Diagnosis
 Metabolic syndrome , obese 3
 Proposed Operation
 Laparoscopic gastrectomy w/ reux en y bypass
 Problem:
 Patient is classified high risk endo, pulmo, cardio wise
Date of operation: Tentative

5.  T.T., 67 years old female, married, roman catholic, currently residing at alunahaw
st., navotas city, admitted for the first time at our institution last September 13,
2022 due to chief complaint of excessive wait gain.

6.  Excessive weight gain

7.  10 years prior to consult, patient was apparently well with medium built until
noticed increasing appetite and increase in food cravings. There was no change in
physical activities during this time.
 During the interim, there was noted weight gain. There was no food restriction, no
physical exercise.
 4 months prior to consult, patient started having difficulty in ambulation due to
increasing wait and increasing body mass, during this time, ambulation was
assisted and required support. There was also occasional dob, easy fatigability.
Consult at a clinic was done and was advised diet modification and increase in
physical exercise.

8.  Few days prior to consult, patient experienced pain at both knees during assisted
ambulation, consult was done at a private clinic and was prescribed unrecalled
medications.
 Persistence of symptoms prompted consult and subsequent admission to our
institution.

9.  Past medical history:
(+) Hypertension
(-+) Diabetes Mellitus
(+) bronchial asthma –last attack 1 month ago
 Family history:
hypertension – maternal side
Surgical history
unremarkable
 Personal and social history:
Non alchoholic
Non smoker
No illicit drug use

10.  General survey:
Conscious, coherent, not in cardiopulmonary distress, GCS 15
Wt. 105kgs
Bmi – 46.6kg/m2 – obese III
 Vital signs:
BP: 130/80mmhg, HR 64bpm, RR 24cpm, Temp 37.3C, 02 sat
98% on nasal cannula

11.  HEENT:
 Pink palpebral conjunctivae, anicteric sclerae, no naso-aural
discharge, no tonsillopharyngeal congestion, no cervical
lymphadenopathy
 mouth opening of 4cm, no limitation in Neck mobility, mallampati
classification 3, full dentition
 Short and thick neck
 Chest and Lungs:
 Symmetrical chest expansion, no retractions,
Crackles bilateral

12.  Cardiovascular:
Adynamic precordium, normal rate, regular rhythm, no
murmurs
 Abdomen:
Flabby, no tenderness noted
 Extremities:
No gross deformities, full and equal pulses, no cyanosis, no
edema

13. ANESTHETIC
ASSESSMENT AND
PLAN
 ASA Physical status 3
 Obese 3 – BMI of 46.6kg/m2
 Pneumonia-moderate risk
 Heart failure symptoms
 Aki secondary to infection
 Hypertension controlled
 Dm type 2 controlled

14.  IM Risk Strat: high risk
 IM Cardio: high risk
 Ecg – complete RBBB. 2d echo result of dilated left cavity
 IM Endo: high risk
 Cbg range of 68 to137, hba1c of 6.0
 IM pulmo : high risk
 Ongoing pneumonia, history if bronchial asthma, episode of desaturations
 RCRI class 3 – 2points
 dm not requiring insulin(0), hf symptoms (+1), type of surgery-intrabdominal (+1)
 Ariscat score: 66 – high risk
 67, episode of 90% o2sat (+8), recent respiratory infection (+17), upper abdominal sx (+15),
duration of more than 3 hrs, non emergency(+23)

16. Cbc 8/26/22
Hgb 129
hct 38.5
platelets 297
wbc 6.8
Blood chemistry 8/26/22
na 140.9
k 3.5
crea 85.9
bun 2.69
fbs 5.7
hba1c 6.7
ast 17.8
alt 11.46

17. Bleeding parameters 8/26/22
pt 12.2
ptt 33.5
inr 0.95
% activity 94.5
Lipid profile 8/26/22
HDL 1.43
LDL 3.15
VLDL 0.52
TRIGLYCERIDE 1.15
TOTAL CHOLESTEROL 5.10

18.  2d echo results
 Dilated left ventricular cavity, with adequate wall motion and contractility
 Mild mitral and pulmonary regurgitation
 Aortic sclerosis
 Ejection fraction of 69%

19. Chest xray
Pneumonia, bilateral

21. 9/13/22
-patient was admitted by the surgery
department
Admitting labs requested
Medications started – omeprazole 40mg OD,
cefuroxime 750mg q8, paracetamol 300mg tiv
prn
Surgical plan of laparoscopic gastrectomy reu
en y bybass
Monitor vs q4
Monitor i/o q shift
For im, pulmo, cardio, endo clearance

22. 9/14/22
Requested ABG
Started ceftriaxone 2g tiv OD
Started azithromycin 500mg tiv OD
Assessment
Cap –MR
Metabolic syndrome
Obese type III
Dm type 2 – controlled
Hypertension st. 2, controlled
Risk stratification – high risk

23. 9/14/22c
Requested ABG
Started ceftriaxone 2g tiv OD
Started azithromycin 500mg tiv OD
For cbg TID premeals
Tx.
Insulin HR 10 u SC for cbg > 100mg/dl
D5050 if cbg <80mg/dl
Risk stratification – high risk

24. 9/15/22
Bp 140/80, hr 74, rr 20, o2 sat 96%
2d echo – dilated left ventricular cavity qith
adequate contractility and wall motion, EF 69%
Continue amlodipine 10mg od
Carvedilol 6.25mg bid
Atorvastatin 40mg tab odhs
Risk stratification – high risk

25. 9/17/22 – cardio notes
Bp 130/80, hr 80, rr 20, o2 sat 98%
2d echo – dilated left ventricular cavity qith
adequate contractility and wall motion, EF 69%
Ideally for sestamibi scan and myocardial
perfusion imaging
9/17/22 – gen surgery notes
Bp 130/80, hr 80, rr 20, o2 sat 98% Still for laparoscopic gastrectomy w/
gastrojejunostomy and jejuno-jejunostomy

26. 9/18/22 – IM notes
Noted an episode of desaturation
O2 sat of 92%
No dob, sob , chest pain, headache, n/v
Abg result
Ph 7.56 pco2 33.6, p02 65.5, hco3 29.6, be 7.4,
o2sat 94.5
K 3.1
For abg now
For cbc na k, bun, crea
Hook to nasal cannula at 3-4 lpms
9/19/22 – gen surgery notes
Stable vs
No dob, sob, chestpain
For re-strat of clearances prior to OR

27. 9/20/22 – IM notes
Noted hypoglycemic episode
Cbg 60mg/dl
No dob sob chestpain n/v
Bp 130/70
Hr 86
rr 20
02sat 98
Pls refer to dietary department for patient
education regarding dietary modification
Pls refer to psych department for evaluation of
eating disorder

28. 9/24/22 – 2pm Anesthesia preop
Proposed as semi urgent with scheduled or date Patient seen and examined
History, labs chart reviewed
Main service verbalized possible family
conference prior to scheduled OR
Awaiting proposed schedule of family and
interdepartmental conference
COD updated
9/24/22 – 6pm Anesthesia preop
Cod informed
Pls schedule multidisciplinary conference prior
to family conference
OR schedule to follow based on the outcome of
said conferences.

29. 9/26/22 – 7 am – gen surgery notes
May we suggest to do per department
grandrounds with other services, if not, we will
have zoom meeting with other consultants
Suggest also to discharge the patiuent for now
and re admit once final clearance is given
9/26/22 – 10am – gen surgery notes
May go home anytime
Pls inquire with all services if any laboratory or
workup needed for preoperativr preparations
Will coordinate with family regarding schedule
of family conference