Clinical impression

• Height: about 174 cm
• Waist: about 180 cm, giving waist-to-height ratio 1.03. A ratio above 0.5 indicates increased cardiometabolic risk.
• The handwritten note appears to record BMI around 103 kg/m², but the exact current weight should be reconfirmed.
• Gradual weight gain began in adult life, more pronounced over the past 10 years.
• No diabetes, hypertension, or documented insulin resistance at present.
• Likely physical complications already present: bilateral edema, osteoarthritis or mobility limitation, and possible respiratory/sleep-related complication.
• STOP-BANG score 6/8 and neck circumference around 62 cm indicate a very high probability of obstructive sleep apnea.

Priority concerns

1. Obstructive sleep apnea and obesity hypoventilation syndrome
   • With severe obesity, high STOP-BANG, large neck circumference, edema, and any breathlessness or daytime somnolence, assess urgently for OSA and OHS.
   • OHS is obesity plus awake carbon-dioxide retention and sleep-disordered breathing. It can lead to pulmonary hypertension, right-heart failure, and worsening edema.
   • Obtain resting SpO₂, serum bicarbonate, ABG or arterialised capillary blood gas if bicarbonate is raised or clinical suspicion is high, and arrange sleep study or respiratory polygraphy. The NICE OHS guidance recommends awake blood-gas testing when OHS is suspected and notes that bicarbonate below 27 mmol/L makes OHS less likely in low-probability settings.
2. Hepatomegaly plus splenomegaly
   • The note appears to state hepatomegaly 18 cm and splenomegaly 16 cm.
   • Simple obesity can cause MASLD, previously called fatty liver disease, but splenomegaly is not something to dismiss as uncomplicated obesity. It needs evaluation for advanced liver disease/portal hypertension, congestive hepatopathy from right-sided cardiac strain, hematologic disease, and infection depending on symptoms.
   • Do abdominal ultrasound with Doppler, liver stiffness assessment if available, CBC with peripheral smear, LFTs, albumin, PT/INR, bilirubin, viral hepatitis tests, and renal profile.
3. Edema
   • Clarify pitting vs non-pitting, onset, symmetry, dyspnea, orthopnea, reduced urine output, and medication history.
   • Evaluate cardiac, renal, hepatic, venous/lymphatic causes, and OHS-related pulmonary hypertension.
   • ECG, echocardiography, urine protein/albumin-creatinine ratio, creatinine/eGFR, serum albumin, LFTs, and chest assessment are appropriate.
4. Very low HDL reported as 5 mg/dL
   • This requires repeat fasting lipid profile with LDL-C, non-HDL-C, ApoB, and preferably direct HDL measurement.
   • If HDL truly is 5 mg/dL with triglycerides only 125 mg/dL, consider laboratory error first, then secondary causes or rare inherited severe HDL disorders. Isolated low HDL with otherwise normal triglycerides can warrant consideration of primary genetic or specific secondary causes.
   • Confirm the units and whether HDL may have been recorded as 35 rather than 5.
5. Thyroid results
   • TSH 0.35 with low FT3 is not a typical pattern for primary hypothyroidism causing obesity.
   • Repeat TSH, FT4, FT3 when clinically stable. Interpret with medication history and systemic illness; do not start thyroid hormone solely to treat obesity without confirming a thyroid disorder.

Working problem list

1. Extreme central obesity, likely severe adiposity-based chronic disease
2. High risk OSA, rule out OHS
3. Peripheral edema, evaluate for right-heart strain/pulmonary hypertension, renal, hepatic, venous, and lymphatic causes
4. Hepatomegaly with splenomegaly, rule out advanced MASLD/portal hypertension and hematologic causes
5. Severe mobility impairment and osteoarthritis
6. Extremely low HDL value needing verification
7. Need to exclude secondary contributors to weight gain, especially medications, Cushing syndrome only if clinical features are present, hypogonadism/PCOS where relevant, and sleep-related worsening of weight and function

Focused evaluation plan

• Snoring, witnessed apneas, unrefreshing sleep, daytime sleepiness, morning headache
• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, chest symptoms
• Diet pattern, binge eating, alcohol, steroid or antipsychotic exposure, previous weight-loss attempts
• Menstrual history, infertility, acne/hirsutism if female
• Symptoms of Cushing syndrome: proximal muscle weakness, easy bruising, wide purple striae, facial plethora
• Family history of dyslipidemia, liver disease, early vascular disease

• Accurate weight, height, BMI, waist circumference, BP, resting and walking SpO₂
• Signs of fluid overload/right-heart failure
• Acanthosis nigricans, Cushingoid features, thyroid signs
• Confirm liver and spleen enlargement
• Lower-limb venous insufficiency, lymphedema, cellulitis, skin-fold complications

• CBC, peripheral smear, ESR/CRP if indicated
• CMP: electrolytes, creatinine/eGFR, AST/ALT, ALP, GGT, bilirubin, albumin
• PT/INR
• Fasting glucose and HbA1c, fasting insulin only if it will alter management
• Repeat fasting lipid panel, LDL-C, ApoB, non-HDL-C
• TSH, FT4, FT3
• Urine routine and urine albumin-creatinine ratio
• ECG and echocardiography
• ABG/capillary gas plus serum bicarbonate, sleep study
• USG abdomen with portal/hepatic Doppler, liver stiffness assessment where available

Management direction

• Respiratory/sleep specialist review urgently if somnolence, low SpO₂, morning headache, breathlessness, or edema are present.
• Dietitian-led, high-protein calorie-deficit plan adapted to mobility and financial constraints.
• Physiotherapy focused on bed-based or chair-based activity initially, then progressive ambulation.
• Treat OSA/OHS with CPAP or NIV if confirmed, before considering surgery.
• Evaluate anti-obesity pharmacotherapy after contraindications and affordability are reviewed.
• Given the apparent BMI near 100 kg/m² and substantial functional/respiratory burden, refer early to a high-volume bariatric/metabolic surgery center. Surgery assessment requires optimization of respiratory, cardiac, hepatic, nutritional, mobility, and psychological risks first.

Urgent referral or emergency assessment now if

• Resting SpO₂ low, cyanosis, confusion, excessive sleepiness, or morning headaches
• New/worsening breathlessness, orthopnea, chest pain, syncope
• Rapidly increasing edema or reduced urine output
• Fever/red painful swollen leg, leg ulceration, or suspected cellulitis
• Abdominal pain, jaundice, GI bleeding, or rapidly increasing abdominal distension

Bariatric surgery preoperative assessment plan

1. Confirm baseline anthropometry and surgical eligibility

2. Multidisciplinary bariatric team assessment

• Bariatric surgeon
• Bariatric anesthetist
• Physician/endocrinologist or obesity-medicine specialist
• Dietitian experienced in bariatric nutrition
• Clinical psychologist/psychiatrist
• Respiratory physician or sleep specialist
• Physiotherapist and rehabilitation team
• Cardiologist if abnormal symptoms, ECG/echo, edema, or poor functional capacity
• Hepatologist/gastroenterologist because of hepatomegaly and splenomegaly
• Social worker/case coordinator if finances, caregiver support, transport, equipment, or long-term follow-up are barriers

3. Respiratory and sleep assessment: highest immediate priority

Clinical screening

• Loud snoring, witnessed apnea, choking at night
• Excessive daytime sleepiness, morning headache, poor concentration
• Dyspnea at rest or exertion, orthopnea, PND
• Resting and exertional SpO₂
• STOP-BANG score. Current score reportedly 6/8, which indicates high OSA probability.
• Neck circumference, current note approximately 62 cm
• Smoking/vaping history, asthma/COPD, previous ventilation or ICU admission

Investigations

1. Sleep study or respiratory polygraphy before surgery.
2. Serum bicarbonate.
3. Awake ABG or arterialised capillary blood gas if bicarbonate is elevated, resting hypoxemia exists, daytime somnolence/morning headache is present, or clinical probability of OHS is high.
4. Chest X-ray if symptoms/signs warrant it.
5. Spirometry/PFTs if respiratory symptoms, suspected COPD/restrictive disease, or anesthesia team requests it.

Optimization required before surgery

• Initiate and document adherence to CPAP for OSA or NIV/BiPAP for OHS if confirmed.
• Bring personal CPAP/NIV device to hospital.
• Do not proceed electively with untreated suspected OHS, resting hypoxemia, or unexplained hypercapnia.
• Plan post-op monitored bed, likely HDU/ICU-level observation depending on gas exchange and OSA/OHS severity.

4. Cardiac, edema, and peri-anesthetic assessment

Key concern

• Pulmonary hypertension
• Right ventricular dysfunction/cor pulmonale
• Heart failure with preserved ejection fraction
• Venous insufficiency or lymphedema
• Renal disease
• Liver disease with hypoalbuminemia or portal hypertension

Evaluation

• BP on repeated visits, pulse, resting SpO₂
• ECG
• Transthoracic echocardiography: LV/RV function, pulmonary pressures, valvular disease, volume status clues
• Cardiology review if abnormal ECG/echo, chest pain, heart-failure symptoms, poor functional capacity, or suspected pulmonary hypertension
• BNP/NT-proBNP if heart failure is clinically suspected
• Review any prior DVT/PE, thrombophilia, immobility, venous ulcers, and family VTE history
• Lower-limb venous Doppler only if asymmetric edema, prior VTE, acute pain, or clinical suspicion of DVT

Anesthesia review

• Difficult mask ventilation/intubation risk
• Airway examination: Mallampati, mouth opening, neck movement, dentition, neck circumference
• Bariatric operating table, imaging, transfer equipment, cuffs, beds, wheelchairs, hoists, and appropriately sized compression devices
• Planned postoperative location and airway/ventilation strategy
• Medication allergies, prior anesthetic issues, aspiration risk, reflux symptoms

5. Hepatomegaly and splenomegaly: complete before clearance

Tests

• CBC with platelet count and peripheral smear
• LFT: AST, ALT, ALP, GGT, bilirubin
• Serum albumin and total protein
• PT/INR
• Creatinine/eGFR and electrolytes
• Hepatitis B surface antigen and hepatitis C antibody, with further viral testing as indicated
• Ferritin and transferrin saturation
• Abdominal ultrasound with liver, spleen, portal vein, hepatic veins, and Doppler
• Liver stiffness measurement/FibroScan if feasible
• Hepatology review if splenomegaly, thrombocytopenia, abnormal synthetic function, portal-vein abnormality, advanced fibrosis, or cirrhosis is suspected

Surgical implication

• Significant portal hypertension, decompensated cirrhosis, major coagulopathy, or unexplained splenomegaly requires specialist decision-making and may defer or change the surgical approach.

6. Metabolic and endocrine work-up

Core laboratory panel

• Fasting plasma glucose and HbA1c
• Fasting lipid profile: total cholesterol, LDL-C, HDL-C, triglycerides, non-HDL-C
• ApoB if available
• CBC
• Renal function, electrolytes, liver panel, albumin
• Urine routine and urine albumin-creatinine ratio
• TSH and free T4. Repeat FT3 only if endocrinology considers it clinically useful.

HDL issue

• Repeat fasting lipid profile at a reliable lab
• Check units and transcription accuracy
• If HDL remains extremely low with normal triglycerides, assess for secondary causes and consider lipid specialist input for rare genetic hypoalphalipoproteinemia

Screen for secondary obesity only if clinically indicated

• Medication-induced weight gain: steroids, antipsychotics, antidepressants, antiepileptics, insulin/sulfonylureas, etc.
• Cushing syndrome testing only if there are suggestive features such as proximal muscle weakness, easy bruising, wide violaceous striae, facial plethora, unexplained osteoporosis, or early/severe hypertension/diabetes
• PCOS assessment if relevant: menstrual irregularity, acne, hirsutism, infertility
• Hypogonadism assessment if symptoms suggest it

7. Nutritional assessment and correction

Dietitian assessment

• Meal frequency, portion size, liquid calories, refined carbohydrates, eating outside home
• Binge eating, grazing, night eating, emotional eating
• Protein intake and hydration
• Food insecurity, affordability, cultural eating pattern
• Understanding of lifelong diet stages, supplementation, follow-up, and alcohol risks after surgery

Baseline nutritional tests

• CBC, ferritin, iron, TIBC/transferrin saturation
• Vitamin B12 and folate
• 25-OH vitamin D, calcium, phosphate, PTH
• Thiamine if vomiting, poor intake, or high nutritional risk
• Albumin
• Consider vitamin A, zinc, copper, and selenium based on planned procedure, nutritional risk, or local protocol

Optimization

• Correct iron, B12, folate, vitamin D/calcium, thiamine, and protein deficiencies before surgery.
• Start the bariatric program’s prescribed multivitamin/mineral regimen.
• Begin a supervised preoperative liver-reduction diet, usually a short low-calorie or very-low-calorie protocol, individualized by the bariatric team.
• A 2025 systematic review found that VLCD-based preoperative programs may reduce perioperative complications, although certainty of evidence was low (systematic review).

8. Psychological and behavioral assessment

• Capacity for informed consent
• Understanding that surgery is a tool, not a cure
• Expectations for weight loss, body image, mobility, and social changes
• Depression, anxiety, bipolar disorder, psychosis, suicidality
• Binge-eating disorder, bulimia, night-eating syndrome
• Cognitive impairment or low health literacy
• Active alcohol, tobacco, opioid, or other substance use
• Current psychiatric treatment and stability
• Caregiver support, adherence history, financial capacity for lifelong supplements and follow-up

9. Gastrointestinal and procedure-specific assessment

• Ask specifically about GERD, dysphagia, vomiting, peptic ulcer disease, NSAID use, prior abdominal surgery, gallstone symptoms, and GI bleeding.
• Upper GI endoscopy if reflux, dysphagia, anemia, persistent upper-GI symptoms, NSAID use, suspected ulcer disease, planned revisional surgery, or as required by local bariatric protocol.
• Test/treat H. pylori according to local program policy.
• Gallbladder ultrasound if biliary symptoms or local preoperative protocol indicates.
• If significant reflux/Barrett’s esophagus is present, procedure selection needs surgeon and GI input because sleeve gastrectomy may worsen reflux in some patients.

10. Venous thromboembolism plan

Preoperative VTE checklist

• Previous DVT/PE
• Family thrombosis history
• Known thrombophilia
• Chronic venous insufficiency, leg ulcer, immobility
• Estrogen therapy, pregnancy possibility, malignancy
• Platelet count, renal function, bleeding history
• Current anticoagulants/antiplatelets and a documented perioperative plan

Perioperative plan

• Mechanical prophylaxis: intermittent pneumatic compression, appropriately sized
• Pharmacologic prophylaxis adjusted for body weight and renal function
• Early mobilization and respiratory physiotherapy
• Whether extended prophylaxis after discharge is indicated
• Avoidance of routine prophylactic IVC filter unless a specific specialist indication exists

11. Preoperative medication plan

• Antihypertensives, diuretics, insulin/oral antidiabetic drugs
• GLP-1 receptor agonists or dual incretin drugs
• Anticoagulants and antiplatelets
• Steroids and immunosuppressants
• NSAIDs
• Sedatives, opioids, psychiatric medicines
• Herbal/over-the-counter products

12. Prehabilitation and logistics

• Respiratory physiotherapy and incentive spirometry teaching
• Chair-based or bed-based exercise progressing to supervised walking as tolerated
• Resistance training where feasible to preserve muscle mass
• Skin-fold care, pressure injury prevention, and treatment of fungal intertrigo/cellulitis
• Edema management after cardiac/renal/hepatic causes are assessed
• Smoking cessation, if applicable, with nicotine testing per program policy
• Confirm home support, transport, bariatric equipment, CPAP/NIV access, and ability to attend frequent follow-ups
• Discuss staged surgery if technical/anesthetic risk is excessive

Clearance checklist before proceeding

• Accurate weight, height, BMI, waist, functional assessment documented
• Bariatric surgeon, anesthetist, dietitian, psychologist, and physician assessment completed
• Sleep study completed and OSA/OHS treated or perioperative plan documented
• ABG/capillary blood gas reviewed if OHS suspected
• Echocardiogram and cardiology review completed if edema, low functional capacity, abnormal ECG, or cardiopulmonary symptoms
• Edema cause assessed and optimized
• Hepatosplenomegaly evaluated with imaging, CBC/platelets, liver synthetic function, and hepatology input where needed
• Nutritional deficiencies corrected or active replacement started
• Repeat fasting lipid profile completed, particularly to verify HDL 5 mg/dL
• VTE and anticoagulation plan documented
• Psychological readiness, adherence capacity, and social support confirmed
• Procedure-specific GI work-up completed
• Preoperative diet and postoperative lifelong supplementation/follow-up plan understood
• Appropriate bariatric theatre, equipment, postoperative monitoring, and ICU/HDU contingency confirmed