Evaluation Note (Weight Regain After Bariatric Surgery)

Evaluation Note — Weight Regain After Bariatric Surgery

Encounter Context

Setting: [in-person / telehealth]  |  Clinician specialty: [Obesity Medicine / Bariatric Surgery / Primary Care / Endocrinology]  |  Referral source/reason: [Referral source and reason] (Only include if applicable.)  |  Interpreter or collateral historian: [Interpreter language / Collateral name and relationship] (Only include if present.)

Chief Concern

[Weight regain after specific bariatric procedure and timeframe] — [Patient goals in patient's own words] (Keep to 1–2 lines.)

Weight Trajectory and Bariatric History

(Always include this section when evaluating weight regain. If any key element is unknown, write "Unknown / not available" and document plan to obtain records.)

• Procedure: [RYGB / Sleeve / Band / DS / SADI / Revision / Unknown] — Date: [MM/YYYY / Unknown] — Surgeon/Center: [Name / Unknown] — Prior revisions or endoscopic interventions: [Details / None / Unknown]
• Pre-op weight: [value] (Date: [MM/YYYY / Unknown])
• Nadir weight: [value] (Date: [MM/YYYY / Unknown])
• Current weight: [value] (Date: [MM/DD/YYYY])
• Height: [value] — Current BMI: [calculated BMI]
• Regain calculations:
  • Absolute regain: [current weight − nadir weight]
  • Percent regain over nadir: [calculated value]
  • Rate of regain: [slope per month or year over specified time window] (Include if ≥2 weights available.)
• Obesity-related comorbidities (status since surgery):
  • T2DM: [remission / improved / stable / relapsed / not applicable]
  • HTN: [improved / stable / relapsed / not applicable]
  • OSA: [improved / on PAP adherent / on PAP nonadherent / relapsed / not applicable]
  • GERD: [improved / stable / worsened / not applicable]
  • Dyslipidemia: [improved / stable / relapsed / not applicable]
• Current anti-obesity medications: [List with doses and start dates / None]
• Supplement regimen and adherence: [Current supplements; adherence: consistent / intermittent / not taking] (If unknown, document plan to obtain medication list.)
• Safety flags: [Pregnancy or breastfeeding / severe vomiting or poor intake / hypoglycemia symptoms / concerning alcohol use / psychiatric instability] (Only include flags that are present.)
• Records status: [Operative report available / requested]; [Prior endoscopy or imaging available / requested] (If unavailable, document plan to obtain.)

History of Present Illness

[Narrative opening summarizing procedure, postoperative nadir, onset of regain, and timeframe] (State when regain began relative to surgery and nadir.)

[Pattern and triggers of regain] (Describe gradual vs rapid pattern; note potential triggers such as injury, pregnancy, medication changes, life stressors.)

[Symptoms suggesting complications] (Include GERD, regurgitation, dysphagia, vomiting, dumping, abdominal pain if present; specify timing and severity.)

Etiology-Focused History

(Address all three domains. If a domain is not contributory, state that it was assessed and no contributors identified.)

1) Behavioral and Nutritional Factors

• Eating pattern: [Meal timing and frequency, portion sizes, eating speed, estimated daily protein intake] (Use patient quotes if helpful.)
• Liquid calories and snacking: [Sugary beverages, alcohol, grazing episodes, binge episodes, night eating; triggers: stress, boredom, shift work, social factors]
• Supplement adherence: [Adherence description; barriers such as cost, side effects, access]
• Physical activity: [Baseline vs current activity; aerobic and resistance training; frequency, duration, intensity] — Barriers: [Pain, fatigue, depression, time, environment]

2) Medication and Metabolic Factors

• Weight-promoting medications: [Agents with start dates: psychotropics, insulin, sulfonylureas, steroids, anticonvulsants]
• Prior anti-obesity medication trials: [Agents, dose, duration, response, reason for discontinuation]
• Post-op medication constraints: [NSAID avoidance, extended-release formulation considerations] (Include only if relevant.)
• Contraindication screening: [Uncontrolled HTN / seizure history / pancreatitis history / gallbladder disease / pregnancy plans / other] (Include if pharmacotherapy anticipated.)
• Metabolic and endocrine contributors: [Hypothyroidism, PCOS, diabetes relapse, new disability affecting activity] (Link to regain pattern.)

3) Anatomic and Surgical Contributors

• Original surgical course: [Indication; immediate postop course; complications: leak, stricture, ulcer, internal hernia, GERD]
• Prior anatomic evaluations: [Endoscopy findings: pouch size, stoma diameter, ulcers, hiatal hernia; UGI findings; dates]
• Red-flag symptoms: [Progressive dysphagia / persistent vomiting / GI bleeding / severe reflux / severe abdominal pain] (Only include if present.)

Pertinent Medical and Surgical History

• Psychiatric history: [Depression, anxiety, ADHD, SUD, eating disorder history] (Note implications for medication choices.)
• Chronic pain or mobility limitations: [Conditions impacting activity]
• Prior bariatric procedures: [List with dates]
• Other relevant surgeries: [Cholecystectomy, hernia repairs, others]
• Allergies: [Drug and food allergies relevant to planning]

Objective

• Vital signs: BP [value], HR [value], RR [value], Temp [value], SpO2 [value]
• Anthropometrics: Height [value], Weight [value], BMI [calculated]
• Physical exam (problem-focused):
  • General: [Appearance, distress, hydration]
  • Abdomen: [Scars, tenderness, masses, hernias]
  • Nutrient deficiency signs: [Alopecia, glossitis, cheilosis, neuropathy, pallor, bruising, edema] (Include if present.)
  • Endocrine findings: [Thyroid exam, Cushingoid features] (Include if indicated.)
• Data reviewed today: (Include dates and key results.)
  • Bariatric labs: [CBC, iron panel, ferritin, B12, folate, vitamin D, calcium, PTH] (If missing: "No recent bariatric labs available.")
  • Metabolic labs: [A1c, fasting glucose, lipids, TSH]
  • Imaging and procedures: [UGI results, CT findings, endoscopy findings including pouch size, stoma diameter, ulcers, hiatal hernia]
  • Weight trend: [Prior weights with dates and sources]
• Data ordered today: [Tests ordered with clinical question for each] (Also list in Orders section.)

Assessment

[One-sentence summary: Weight regain after (procedure) characterized as (severity) with key contributors including (brief list).]

• Regain severity metrics: [Absolute regain] | [Percent over nadir] | [Percent of maximum weight lost regained] | [Rate of regain] (If using severity classification, define thresholds.)
• Differential — Behavioral/Nutritional: [Grazing / liquid calories / loss of meal structure / night eating / reduced activity] (Link to specific history findings.)
• Differential — Medication/Metabolic: [Weight-promoting medications / diabetes treatment intensification / depression relapse / hypothyroidism] (Link to specific findings.)
• Differential — Anatomic/Surgical: [Dilated pouch or anastomosis / gastrogastric fistula / hiatal hernia / GERD / stricture / band slippage] (Link to specific findings.)
• Secondary diagnoses requiring assessment: [Nutrient deficiency risk / GERD worsening / postprandial hypoglycemia / comorbidity relapse / behavioral health concerns]

Plan

1) Weight Regain After Bariatric Surgery

Diagnostics

• Records to obtain: [Operative report, prior endoscopy, weight records] (State who will request and timeframe.)
• Laboratory evaluation: [CBC, iron panel, ferritin, B12, folate, vitamin D, calcium, PTH, CMP, A1c, lipids, TSH] — Clinical question: [Nutrient deficiency? Metabolic drivers? Endocrine contributors?]
• Anatomic evaluation: [EGD / UGI] — Clinical question: [Assess for dilated anastomosis, ulcer, fistula, hiatal hernia] (Include if indicated.)

Treatment — Stepwise Escalation

• Step 1: Nutrition and behavioral intervention
  • [Referral to bariatric-experienced dietitian / In-visit counseling provided]
  • Targets: [Structured meals, protein-forward eating with daily goal, eliminate liquid calories, mindful pacing] (Tailor to identified behaviors.)
  • Barriers addressed: [Cost, schedule, stress triggers, food environment] — [Specific solutions]
  • Supplement plan: [Regimen and adherence strategy]
• Step 2: Physical activity prescription
  • [Aerobic plan: type, minutes per week, intensity] | [Resistance plan: days per week, progression]
  • [Address limiting factors: PT referral, pain management, sleep optimization]
• Step 3: Anti-obesity pharmacotherapy (Include if indicated.)
  • Indication and goals: [Weight and BMI thresholds, comorbidities, expected response and timeframe]
  • Agent selection and rationale: [Medication] because [comorbidity fit, prior response, contraindication avoidance]
  • Baseline safety checks: [BP, HR, pregnancy test if applicable, relevant labs]
  • Dose and titration: [Starting dose → target dose; schedule]
  • Monitoring and counseling: [Side effects, adherence strategies, stopping rules]
• Step 4: Endoscopic or surgical escalation (Include if indicated.)
  • Indication: [Suspected or confirmed anatomic abnormality / refractory regain]
  • Referral: [Bariatric surgeon / therapeutic endoscopist] — Rationale: [Suspected abnormality and supporting evidence]

Follow-up

• Interval: [2–4 weeks / 6–8 weeks / 3 months] (Tie to regain severity and interventions initiated.)
• Assess at next visit: [Medication tolerance, weight trend, food and activity logs, lab results, procedure results]
• Patient tasks before next visit: [Complete labs, schedule procedures, food log, activity tracking, RD or behavioral health appointments]
• Return precautions: [Persistent vomiting, inability to tolerate oral intake, GI bleeding, severe abdominal pain, syncope, hypoglycemia] (Include only if relevant.)

2) Secondary Problems

(Create brief assessment and plan for each secondary issue identified.)

• Nutrient deficiency: [Risk factors or abnormal labs]. Plan: [Supplementation regimen, recheck interval].
• GERD: [Symptom characterization]. Plan: [PPI trial, EGD if alarm features, lifestyle measures].
• Postprandial hypoglycemia: [Symptoms and timing]. Plan: [Dietary modification, glucose monitoring, referral if severe].
• Comorbidity relapse: [T2DM, HTN, OSA status]. Plan: [Medication adjustments, device adherence, referrals].
• Behavioral health: [Screening results]. Plan: [Therapy referral, medication coordination].

Orders and Care Coordination

• Labs ordered: [List] — Clinical question: [For each]
• Imaging and endoscopy referrals: [UGI / EGD] — Clinical question: [Anatomic concerns]
• Referrals: [Dietitian / Behavioral health / Physical therapy / Bariatric surgery / Endocrinology]
• Medications prescribed: [Name, dose, titration plan, quantity, refills]
• Care coordination: [Communication to bariatric surgeon or PCP]; [Insurance authorization status for medications or procedures]