What should I document during an initial visit for a patient interested in weight loss medications, such as orlistat (Xenical), phentermine-topiramate (Qsymia), and liraglutide (Victoza), including medical history, vital signs like blood pressure (BP), blood glucose, and lipid profiles, and other relevant information?

Documentation Requirements for Initial Visit of Patients Seeking Weight Loss Medications

A comprehensive initial assessment for patients interested in weight loss medications should include detailed documentation of obesity-related health risks, anthropometric measurements, laboratory tests, and readiness for weight loss treatment to guide appropriate medication selection and management. 1

Patient History Documentation

Medical History

• Document obesity-related comorbidities:
  • Type 2 diabetes/prediabetes
  • Hypertension
  • Hyperlipidemia
  • Sleep apnea
  • Gastroesophageal reflux disease
  • Nonalcoholic fatty liver disease
  • Osteoarthritis
  • Respiratory diseases 1

Weight History

• Document:
  • Weight trajectory over time
  • Previous weight loss attempts and outcomes
  • Maximum weight achieved
  • Previous weight loss medications tried and responses
  • Family history of obesity 1

Behavioral Assessment

• Document:
  • Eating patterns and behaviors
  • Physical activity habits
  • Sleep patterns
  • Stress management techniques
  • Alcohol consumption 1

Readiness Assessment

• Document patient's:
  • Motivation for weight loss
  • Current life stressors that might impact treatment
  • Presence of psychiatric conditions (depression, anxiety, binge eating disorder)
  • Time availability for weight management activities
  • Weight loss goals and expectations 1

Social Determinants of Health

• Document:
  • Housing situation
  • Food security status
  • Educational background
  • Neighborhood environment 1

Physical Examination Documentation

Anthropometric Measurements

• Document:
  • Current weight (kg)
  • Height (cm)
  • Body Mass Index (BMI) calculation
  • Waist circumference (cm)
  • Hip circumference (optional)
  • Waist-to-hip ratio (optional) 1

Vital Signs

• Document:
  • Blood pressure (seated, both arms at initial visit)
  • Heart rate
  • Respiratory rate
  • Temperature 1

Laboratory Testing Documentation

Metabolic Parameters

• Document:
  • Fasting plasma glucose
  • HbA1c
  • Lipid panel (total cholesterol, HDL-C, LDL-C, triglycerides)
  • Liver function tests
  • Consider Fibrosis-4 Index if fatty liver suspected 1

Additional Testing Based on Medication Considerations

• Document:
  • Thyroid function tests
  • Renal function tests
  • Pregnancy test for women of childbearing potential
  • Electrocardiogram if cardiovascular risk factors present 1

Treatment Planning Documentation

Medication Selection Considerations

• Document:
  • Appropriateness for pharmacotherapy (BMI ≥30 kg/m² or BMI ≥27 kg/m² with comorbidities)
  • Contraindications to specific medications
  • Potential drug interactions with current medications
  • Patient preferences regarding side effect profiles 1

Weight Loss Goals

• Document:
  • Short-term weight loss goals (5-10% of initial weight)
  • Rate of expected weight loss (1-2 lbs/week)
  • Timeframe for evaluation (typically 3-6 months)
  • Non-weight outcomes important to patient 1

Behavioral Intervention Plan

• Document:
  • Dietary approach (caloric deficit of 500-1000 kcal/day)
  • Physical activity recommendations (aim for 230 minutes/week)
  • Behavioral strategies 1

Follow-up Plan Documentation

• Document:
  • Frequency of follow-up visits
  • Parameters to monitor at follow-up
  • Criteria for medication adjustment or discontinuation
  • Plan for addressing potential side effects 1

Common Pitfalls to Avoid

1. Inadequate comorbidity screening: Ensure comprehensive screening for all obesity-related conditions as they may influence medication selection.

2. Insufficient laboratory testing: Baseline labs are essential for monitoring medication effects and safety.

3. Unrealistic expectations: Document discussion about realistic weight loss goals (5-10% with behavioral interventions, 8-21% with medications) 1.

4. Medication-specific considerations: Document discussion of medication-specific side effects (e.g., gastrointestinal effects with orlistat) 2, 3.

5. Failure to document readiness: Initial weight loss success is the strongest predictor of long-term success, so documenting readiness factors is critical 4.

6. Missing follow-up plans: Document clear follow-up schedule and criteria for assessing medication efficacy (typically 5% weight loss within 3-6 months) 1.

By thoroughly documenting these elements during the initial visit, you'll establish a comprehensive baseline for monitoring treatment progress and make informed decisions about appropriate weight loss medication selection and management.