Bariatric Surgery Preoperative Medical Evaluation/Clearance Note

Bariatric Surgery Preoperative Medical Evaluation/Clearance

Date/Time: [Date and time of evaluation]
Author/Service: [Clinician name, credentials, and service]
Encounter Type: [in-person clinic / telehealth video / telephone]
Referring Surgeon/Program: [Referring surgeon and program name]; Referral Question: [Specific question to address]
Planned Procedure: [sleeve gastrectomy / Roux-en-Y gastric bypass / revision / other]; Approach: [laparoscopic / robotic / not yet determined]
Planned Surgery Date: [Date / not yet scheduled]
Data Sources: [patient interview / chart review / outside records / family input / bariatric program records] (List all sources used. If based solely on chart review, state explicitly and note limitations.)

Executive Summary for Surgical Team

• Current weight/BMI and key comorbidities: [Weight, height, BMI]; [Top 3–5 obesity-related comorbidities]
• Key perioperative risk drivers: [Risk factors present, e.g., OSA on PAP, insulin-treated diabetes, prior VTE, CAD/CHF, poor functional capacity, difficult airway history] (List only those present.)
• Optimization status: [Medically optimized—no additional medical testing recommended / Optimized with conditions—may proceed once items below are completed / Not optimized—recommend deferring surgery until items below completed]
• Hard-stop items: [Items present, e.g., uncontrolled diabetes, active tobacco/nicotine use, untreated severe OSA/OHS, unstable cardiac symptoms / No hard-stop items identified]
• Critical medication highlights: [Anticoagulants/antiplatelets]; [Insulin/oral diabetes agents]; [GLP-1 agents with risk mitigation plan]; [SGLT2 inhibitor hold plan]; [Chronic steroids] (Summarize perioperative holds/continues.)
• Pending requirements: [Item: status, owner] (If none, state "No pending medical items identified.")
• Communication: Recommendations communicated to bariatric team on [date] via [method].

Reason for Evaluation

[Consultation purpose and specific questions to address] (Limit to 1–2 sentences.)

History of Present Illness

[Reason for pursuing bariatric surgery and goals]. [Obesity duration and weight trajectory including highest and lowest adult weights with context]. [Current weight management efforts: nutrition/physical activity, prior or current anti-obesity medications including GLP-1/GIP agents with response/tolerance, prior bariatric or endoscopic procedures]. [Functional limitations attributable to obesity and/or related comorbidities]. [Bariatric program steps completed to date: nutrition classes, psychological evaluation, support groups]. [Relevant complication history: prior VTE, cardiovascular or cerebrovascular events, anesthesia or airway challenges, wound healing issues]. [Patient motivation/expectations with brief quote if meaningful]. (If based solely on chart review, state: "History obtained from chart review only; patient not interviewed—may not reflect current status.")

Medical History

• [Condition, e.g., Type 2 diabetes]: [Severity/control status]; Most recent marker: [Value and date]; Current regimen: [Medications and doses]; Perioperative status: [Optimized / Needs adjustment—brief plan]
• [OSA/OHS]: [Severity, AHI if known]; PAP settings/adherence: [Device type, pressure, average nightly use]; Perioperative status: [Optimized / Needs adherence improvement]
• [Cardiovascular disease]: [CAD/CHF/arrhythmia/HTN specifics, NYHA class if applicable]; Objective data: [BP trend, last ECG/echo/stress test with dates]; Therapies: [Medications and doses]; Perioperative status: [Optimized / Needs adjustment]
• [VTE history/thrombophilia]: [Event type/date, provoking factors, anticoagulation details]; Prophylaxis considerations: [Inpatient and post-discharge plan]; Perioperative status: [Optimized / Needs hematology input]
• [CKD/chronic liver disease/NAFLD/GERD/gallstones]: [Stage/severity, key labs/imaging with dates]; Therapies: [Current treatment]; Perioperative status: [Optimized / Needs adjustment]
• [Pulmonary disease]: [COPD/asthma severity, baseline O2]; PFTs: [Results and date if available]; Perioperative status: [Optimized / Needs adjustment]
• [Anemia/micronutrient deficiencies]: [Type and severity]; Recent labs: [Iron studies, B12, folate, vitamin D with date]; Repletion plan: [Oral/IV and timing]; Perioperative status: [Optimized / Needs repletion prior to surgery]
• [Psychiatric conditions/substance use]: [Diagnoses, stability, current treatments]; Perioperative considerations: [Medication continuity, relapse risk]; Perioperative status: [Optimized / Needs coordination]
• [Chronic pain/opioid therapy]: [Regimen and daily MME]; Risk mitigation: [Multimodal plan]; Perioperative status: [Optimized / Needs pain management coordination]

(Order problems by perioperative relevance; include only conditions present.)

Surgical and Anesthesia History

• [Procedure name], [Year]—[Indication]; Complications: [None / details] (Highlight prior abdominal surgeries and any bariatric/endoscopic procedures.)
• Anesthesia history: [Difficult airway / prolonged ventilation / severe PONV / malignant hyperthermia concern / no complications]

Medications

• [Medication name]: [Indication]; [Dose and frequency]; Perioperative plan: [continue / hold]; [Stop timing and restart timing if held]

High-risk agents requiring explicit plans:

• Anticoagulants/antiplatelets: [Agent and dose]; Bridging: [yes with plan / no]; Stop [timing], restart [timing] (Coordinate with surgeon/cardiology as applicable.)
• Insulin and sulfonylureas: [Current regimen]; Night-before: [adjustment]; Day-of: [adjustment]; Hypoglycemia plan: [instructions]
• SGLT2 inhibitors: [Agent]—hold 3–4 days preoperatively; restart when eating normally and hemodynamically stable
• GLP-1/GIP agents: [Agent and dosing interval]; Risk stratification: [low / elevated concern for delayed gastric emptying]; Mitigation: [dosing adjustment and/or preoperative liquid diet per protocol; aspiration precautions]
• Chronic steroids: [Dose and duration]; Stress-dose plan: [indicated with regimen / not indicated]

Allergies

• [Allergen]—[Reaction type and severity]

Social History

• Tobacco/nicotine: [never / former, quit date / current, amount per day]; Verification: [biochemical testing status if program requires]
• Alcohol: [Quantity and frequency]; Misuse history: [yes with details / no]
• Recreational drugs: [None / type and frequency]; Treatment: [if applicable]
• Postoperative support: [Caregiver availability and transportation plan]
• Functional baseline: [Mobility status, assistive devices, ADL independence]

Physical Examination

• Vitals: BP [value], HR [value], RR [value], Temp [value], SpO2 [value] on [room air / supplemental O2], Weight [value], Height [value], BMI [calculated value]
• General/Mobility: [Body habitus, distress level, gait, use of assistive devices]
• Airway: [Mallampati class if assessed, neck circumference, mouth opening, neck mobility]
• Cardiac: [Rate, rhythm, murmurs, JVP, peripheral edema]
• Lungs: [Work of breathing, breath sounds, wheezes/crackles]
• Abdomen: [Surgical scars, hernias, tenderness, organomegaly]
• Extremities: [Edema, varicosities, venous stasis changes]

(For telehealth encounters, document exam limitations and reference objective data sources.)

Data Review

• Labs: CBC [date]: [values]; CMP [date]: [values]; A1c [date]: [value]; Lipids [date]: [values]; Coagulation [date]: [values if indicated]; Nutrient panel [date]: iron studies [value], B12 [value], folate [value], vitamin D [value]
• Cardiac testing: ECG [date]: [findings]; Echo [date]: [LVEF, key findings]; Stress test [date]: [modality, result]
• Sleep/Pulmonary: Sleep study [date]: AHI [value], severity [mild/moderate/severe]; PAP prescription: [device, settings]; PFTs [date]: [key values if obtained]
• Other studies: Endoscopy [date]: [findings]; H. pylori: [positive/negative/not tested, date]; Abdominal imaging [date]: [findings]; Behavioral health clearance: [complete/pending, date]; Nutrition evaluation: [complete/pending, date]

(For missing critical data, document as "not available—requested" and include in Pending Requirements.)

Pending Requirements

• Nutrition evaluation: [complete / pending / not indicated], Owner: [responsible party]
• Psychosocial evaluation: [complete / pending / not indicated], Owner: [responsible party]
• Sleep study and PAP plan: [complete / pending / not indicated], Owner: [responsible party]
• Cardiac evaluation: [complete / pending / not indicated], Owner: [responsible party]
• Required labs: [complete / pending / not indicated], Owner: [responsible party]
• Tobacco cessation verification: [complete / pending / not indicated], Owner: [responsible party]
• Pregnancy test: [complete / pending / not applicable], Owner: [responsible party]
• Age-appropriate cancer screening: [complete / pending / not indicated], Owner: [responsible party]
• Endoscopy/H. pylori: [complete / pending / not indicated], Owner: [responsible party]

Risk Assessment

• Functional capacity: [Estimated METs or practical descriptor]; Red-flag symptoms: Exertional chest pain [present / absent], syncope [present / absent], HF symptoms [present / absent]
• Risk tool results: [Tool name: score/result] (Include only if used and informed management.)
• Testing rationale: [For tests ordered: clinical question and how results will change management. For tests not ordered: rationale based on risk level, functional capacity, and symptom status.]

Assessment and Plan

Obesity and Surgical Candidacy

[Statement of surgical indication based on BMI and metabolic disease burden]. [Readiness status and program adherence]. [Contraindications or conditions requiring stabilization if any].

• Optimization actions: [Weight management steps, nutrition/behavioral requirements]
• Day-of-surgery considerations: [Positioning, airway, aspiration risk, equipment needs]
• Owner: [Responsible clinician/service]

Diabetes/Prediabetes

[A1c trend with dates]; [Glycemic variability and hypoglycemia risk assessment].

• Perioperative medication plan: [Specific hold/adjustment instructions for each diabetes agent with restart timing]
• Monitoring: [Glucose targets and monitoring frequency]
• Owner: [Endocrinology / PCP / preop clinic]

OSA/OHS

• PAP adherence: [Status]; Instructions: Bring device on day of surgery
• Inpatient monitoring: [Level of care, supplemental O2, PAP use plan]
• Owner: [Sleep medicine / anesthesia]

Cardiovascular

• Optimization: [BP targets and medication adjustments]
• Antiplatelet/anticoagulant management: [Plan with timing and bridging decision]
• Owner: [Cardiology / PCP / anesthesia]

VTE Risk

• Risk factors: [History, BMI, immobility, OSA, estrogen use, thrombophilia]
• Prophylaxis recommendation: [Mechanical and chemoprophylaxis regimen; extended post-discharge prophylaxis if high risk]
• Owner: [Surgical team with input from medicine/hematology]

Other Active Problems

• Pulmonary disease: [Optimization and inhaler plan; day-of bronchodilator timing]
• Renal/hepatic: [Medication dosing adjustments, fluid/electrolyte considerations]
• GERD/ulcer risk: [PPI plan, H. pylori treatment status]
• Micronutrient deficiencies: [Repletion plan and timing relative to surgery]
• Psychiatric: [Medication continuation plan, perioperative risks]
• Tobacco/alcohol: [Status relative to program requirements, verification plan]
• Reproductive health: [Pregnancy testing, contraception counseling if applicable]

(Include only problems that are active and relevant.)

Recommendation

Optimization status: [No additional medical optimization recommended at this time / Medically appropriate to proceed once the following are completed / Recommend deferring surgery until the following are addressed]

• Conditions/contingencies: [Measurable criteria, e.g., A1c ≤ target, SGLT2 inhibitor held ≥72 hours, PAP adherence verified, nicotine testing negative]

Communication: Recommendations sent to [bariatric surgery, anesthesia, PCP, other consultants] on [date] via [method].

Coordination and Follow-up

• Counseling provided: [Topics discussed: risks, medication plan, preoperative diet, NPO instructions, PAP use, VTE prophylaxis, activity expectations]
• Communications: [Teams contacted, dates, methods, responses received]
• Patient next steps: [Labs to complete, studies to schedule, program requirements, cessation plan adherence]
• Return precautions: [Concerning symptoms warranting earlier contact]

(For high-stakes variables—planned procedure, anticoagulant use, diabetes regimen, OSA/PAP status, active nicotine use, prior VTE, exertional symptoms—explicitly document when unknown with last known information and whether data were requested. Do not leave blanks that could be mistaken for real data.)