1500: Client is twelve weeks postoperative following gastric bypass surgery. The client's weight at this visit is 245 pounds (113.36 kilograms), a decrease of 6 pounds since the previous visit (2.72 kilograms) four weeks ago. She reports that she is starting to notice excess skin between her legs and upper arms. The client reports exercising regularly and eating solid foods with no reflux or nausea. Incision site appears fully healed with a minimal scar. The client reports no incisional pain. She reports feeling full much sooner compared to before the surgery. Denies abdominal pain, nausea, vomiting, and diarrhea. She reports symmetric paresthesias in both the upper and lower extremities. She endorses forgetfulness and fatigue. Physical exam normal with the exception of two oral ulcers.

• Diabetes mellitus, type II
• Gastric bypass surgery
• Irritable bowel syndrome

• Cyanocobalamin 1000 mcg intramuscular (IM) x 1 dose