KK Presint 18 • Weight Management

Template klinik (auto-generate note)

KLINIK KESIHATAN PUTRAJAYA PRESINT 18

Multidisciplinary Integrated Management of Obesity

1. PATIENT DETAILS

Name

IC No.

Date

2. VITAL SIGN & ANTHROPOMETRY

Weight (kg)

Height (cm)

BMI: -

Waist Circ. (cm)

BP (mmHg)

Pulse (bpm)

Pain Score

Body Fat (%)

Skeletal Muscle (kg)

Body Fat Mass (kg)

3. MEDICATION

Medication group

List of medication

Choose medication

Add adittional medication

Tip: Klik ubat untuk tambah, klik “×” pada tag untuk buang.

4. COMORBID

Hypertension T2DM Prediabetes Metabolic Syndrome Dyslipidaemia Obs. Sleep Apnea OA / Back Pain MAFLD GERD Cancer

5, 6, 7. GOALS & COMPLICATIONS

Patient Goals

Barriers

Complications for Adiposity (tick + tulis detail bawah)

Metabolic

eg: dysglycaemia, NAFLD, dyslipidaemia, etc

Mental

eg: depression, anxiety, binge eating, etc

Mechanical

eg: OA knee, back pain, OSA symptoms, etc

Social

eg: stigma, work limitation, family stress, etc

8. DISEASE SEVERITY

9. PHYSICAL EXAMINATION

Head and Neck Neck circ, Mallampati, Thyroid, Cushing's sign (moon facies), PCOS (acanthosis/hirsutism)

Cardiorespiratory Heart rate/rhythm, Signs of heart failure

Gastrointestinal Liver span, Hernias (umbilical/incisional), Liver stigmata

Musculoskeletal OA nodes, Weight-bearing joints, Gout, Gait exam

Skin Candida, intertrigo, tags, psoriasis, AN, deficiencies, striae

Lower Limbs Lymphedema, Lipoedema, Venous insufficiency/ulcers

10. INVESTIGATIONS (Auto-Grouped)

1. Paste Result Here: 2. Simplified version:

11. MANAGEMENT

Diet advice (monitor MyNutriDiari) Exercise advice (monitor steps) Refer OT (Stress mgmt/Behavioural therapy) Refer Dietitian Refer Physiotherapy Refer KBM Clinic Pharmacotherapy: Blood Invest: To see back (TCA)