Initial visit date
Seminar date
Patient demographics
Name
Date of birth
Medical record number
Gender
Race
Primary language
Height (cm, inches)
Weight at first patient contact (kg, lb) + date
BMI at first patient contact + date
Excess body weight (calculate from ideal body weight)
Smoking (current pack per day, pack/year history, or how long ago had the patient quit smoking)
Mobility status (if not fully mobile, document immobile, or mobility aids needed)
Previous abdominal surgery history
Obesity history
Overweight since what age
Highest weight
Most weight ever lost
Attempting to lose weight for how many years
Unsuccessful commercial diets/pills
Current exercise regimen
Previous weight loss operations (which one)
Obesity-related medical conditions
Diabetes mellitus
Type I/II
Controlled/uncontrolled
Controlled with diet, oral meds, or insulin
Diabetic complications (nerve, eye, kidney, skin)
Hemoglobin A1c and fasting blood sugar + date
Hypertension
Controlled/uncontrolled
Number of and class of medications
Hyperlipidemia
Gastroesophageal reflux disease
Medication treatment (PPI or H2 blocker)
Previous surgical or endoluminal therapy
Nonalcoholic steatohepatitis or cirrhosis
Obstructive sleep apnea (sleep study, STOPBang score, CPAP)
Other non-obesity-related medical conditions
Asthma
COPD (home oxygen requirement)
Coronary artery disease (h/o MI, PCTI, or CABG)
CHF (recent EF %)
Atrial fibrillation or PSVT
Pacemaker
Peripheral vascular disease
Peptic ulcer disease (Helicobacter pylori status)
Gallstones (present or history of cholecystectomy)
Stress incontinence
Renal failure (creatinine, dialysis, transplant patient/candidate)
Cirrhosis (cause, CTP class, MELD score, transplant patient/candidate)
DVT/PE (history, previous/current treatment)
Psychological (anxiety, depression, substance abuse, suicidal, bipolar, eating disorder)
Connective tissue disorder (which one?)
Bleeding disorder (which one?)
Table 2.
Preoperative H and P visit
Preoperative visit date |
Weight + BMI |
Planned procedure + date |
Labs/tests |
Anemia (hemoglobin) |
Arterial blood gas |
C-reactive protein |
Creatinine |
Coagulation panel (if necessary) |
Chest X-ray |
EKG |
Vitamin/micronutrient deficiency |
H. pylori (histology, serology, stool antigen, urea breath test, CLO test) |
Upper endoscopy |
Upper gastrointestinal series |
Table 3.
Operation
Procedure performed + date |
Approach (open, laparoscopic, converted to open) |
Procedure changed or aborted (+reason) |
OR procedure time (incision to closure) Additional OR procedures (cholecystectomy, hiatal hernia, liver biopsy, abdominal wall hernia) |
Intraoperative complications |
Procedure specifics |
Adjustable gastric band |
Band type |
Allergan LAP-BAND AP standard or large |
Ethicon REALIZE Band or REALIZE Band-C |
Gastro-gastric sutures placed? |
Gastric bypass |
Roux limb length (cm) |
Estimated pouch size (cc) |
Banded pouch
Related posts: Outcomes After Laparoscopic Gastric Bypass
Effects of Bariatric Surgery on Diabetes
 Developing a Successful Bariatric Surgery Program
 Gallbladder and Biliary Disease in Bariatric Surgery Patients
 Pathophysiology of Obesity Comorbidity: The Effects of Chronically Increased Intra-abdominal Pressure
 Laparoscopic Malabsorptive Procedures: Technique of Duodenal Switch
 Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
|