Managment issues Flashcards
(13 cards)
What would you like to do about this patient’s obesity?
Management issues frame work:
GIS NPH
Id like to take a more detailed Hx and examination and confirm the diagnosis:
- Weight Hx, age of onset
- LOW attempts
- Diet and exercise interventions
- family Hx
- Previous pharm therapy
- Medication Hx
Confirm Dx
- BMI, Waist circ, weight diary, food diary
Id like to assess for secondary causes (ddx) or associations and investigate these:
- Endocrine: hypothalamic dysfunction, hypothyroisism, cushings, hypogonadism, PCOIS
- Drugs: BB, PNL, Insulin, Antipsychotics
- Other causes of weight gain: CKD / nepohrotic syndrome, cirrhosis, CCF
- Depression
Workup for causes:
- Cushings workup - low dose Dex sup test, 24hr urine cortisol, TSH, review meds
Id like to screen for secondary complications (with relevant investigations):
- DM
- HTN
- dyslipidaemia
- IHD
- OSA
- OA
- cholelithiasis
- Depression
- Infections
- NAFLD
Id set goals of management specific to the patient
- 10% body weight reduction over a 6 month period at a rate of 0.5-1kg / week
- Modification of vascular risk factors
Increased physical activity
Id commence non pharm amangment
- Exersise (150-250mins moderate exersise /week
- DIet (caloric restriction and goal setting, commercial weight loss programs, mediteranean diet
Id consider pharm and surgical therapies:
- Off lable GLP1 agionists
- Orlistat (flatulence, urgency, faecal incont)
- Phentermine (insomnia, aggitation, arrhythmias, HTN, PHT)
- Phentermine + toperimate
- Liraglutide
- Lorcaserin
- Barbaric surgery (indication BMI >40 or BMI ?35 and complications + MDT agree)
What would you like to do about this patient’s hypertension?
Id like to take a more detailed Hx and Examination and confirm the diagnosis.
- When Dx
- Usual BP and Highest BP
- ANy BP crisis, any symptomatic HTN
- Previous investigations and treatments
- other vascular RFs
- Diet and exercise
- FHx:
Examination:
- Fundoscopy, renal bruits, cushings exam, AAA, Cardiomyopathy, neurological exam and carotids
Confirm Dx:
- 24hr BP, 2 hr BP measuments
Id like to assess for secondary causes (ddx) or associations and investigate these:
- Endocrine: conns, cushings, phaeo, acro, hyper/hypothy
- Renal: CKD, renovascular disease, RAS, VUR, nephrotic
- Drugs - NSAIDs, OCP, steroids
- OSA
Workup for these causes
Id like to screen for secondary complications
- CVA / TIA
- Nephropathy
- Cardiomyopathy / Arrhythmia
- retinopathy
- Vascular disease (inc AAA)
Investigate for these complications
Id goal of managment specific top teh patient:
- General population <140/90
- High risk (IHD, CVA, DM, CKD, protinuria) <130/80
- If protinuria >1g/day then <125/75
“the best blood pressure is the lowest one a patient can tolerate” need to weigh against falls risk
Id commence non pharm therapies:
- Weight loss (1kg = 2mmHg)
- 30 mins moderate exersise 5x / week
- smoking cessation
- moderation of etoh
- No added salt, salt restriction
- Mediteranean died, low fat diet
- avoid NSAIDs
- Manage OSA with CPAP
Id consider pharm therapies:
- First line: CCB, ACEI/ARB, thiazide
-> Check RF and K prior to commencing
- Consider presence of RAS prior to commencing ACEi
- 2 agents usually required
- Beta blockers
- Central agents/ alpha blockers
What would you like to do about this patient’s dyslipidaemia?
Id like to take a more detailed Hx and Ex and confirm the Dx:
- Last lipids
- Family Hx
Examination:
- Erruptive xanthomas
- tendon xanthomatra
- Xantholasma
- Lipidaemia retinalis
Confirm Dx:
- Fasting LDL, HDL, triglycerides, cholesterol
Calculate risk:
- Framingham risk calculator - high, intermediate or low risk
Id like to assess for secondary causes or associations and investigate these:
- Familila hypercholesterolaemia
- Familial combined hyperlipidaemia
Causes of raised LDL:
- Hypothyroidism
- Nephrotic syndrome
- Cholestasis
- Anorexia nervosa
Causes of raised triglycerides:
- T2DM
- obesity
- renal impairment
- Smoking, alcohol, medications
Workup:
- thyroid exam + TSH
- Urinalysis + ACR and PCR
- LFTs and UECs
Id like to screen for secondary complications:
- IHD
- CVA
- PVD / PAD
- cerebrovascular disease
Workup:
- ECG, TTE
- renal dopplers
- CTB, USS neck
- Pod review, TP and vascular imaging legs
Id set patient specific managment goals:
- LDL <2.2 for primary prevention, <1.8 for secondary prevention
- All targets: LDL <2, HDL >1, Trig <2, total chole <4
- Modify overall vascular risk factors
Id commence non pharmacological therapies:
- reduction in saturated and trans fats
- Increase in soluble fiber
- Salt reduction
- Regular fish, legumes, vegetables
- Mediteranean diet (most effective)
- Exersise 30 mins 5x /week
- weight reduction
- alcohol moderation
Id consider pharmacological and surgical therapies:
- statins
- Ezetimibe
- Fibrates
- PCSK9 inhiubitors
Nicotinic acid
- Bile acid binding resins
If raised trigs:
- fibrates +/- fish oil, then can add nicotinic acid
What would you like to do about this patient’s smoking?
Id like to take a detailed Hx and Ex and confirm teh diagosis
- Hx via 5 A’s framework:
-> Ask: when started, reasons for smoking, prievious quit attempts, what worked, what barriers
-> Assess: level of dependance: High (sm during sleep or 5 mins after waking), moderate (within 30 mins of waking), low- mod (not within 30 mins waking). Stages of change (precontemplative, contewmplative, preparing, acting, relasping)
-> Advice: benfits of quitting, comorbid conditions
-> Assist (pharm and non pharm)
-> Arrange follow up
- Examination:
-> General examination, nicotine staining
Id like to assess for secondary causes or association and investigate these:
- Depression, anxiety
- Significant stressors
- OCD
- Loneliness
Workup
- DASS / K10
Id like to screen for secondary complications:
- H and N tumours, lymphadenopathy
- Resp: COPD, cancer
- CV: IHD, CCF, AAA
- Neuro: carotids, CVA/TIA
- Vascular disease (ie legs)
Workup:
- CXR, ECG, carotid USS + CTB, Abdo USS
Id like to set patient specific managment goals:
- Quit smoking
- Harm minimisation
- Adress other vascular RFs
- prevent morbidity and mortality
May not be completely feasible to quit smoking but this should be encouraged. Set realistic goals for pt in front of you (ie limit number of cigarettes, switch out some smokes for replacement puffers)
Id like to commence non pharmacological therapies:
- Councelling, CBT, Hypnotherpay
- Regular exersise
- Diet planning
- Avoid triggers such as etoh
- Family support, inform friends and work collegues about attempt
- Stress balls, figget spinners
- Quitline, quitting apps on phone
Best results achieved when pharm and non pharm are combined with counseling and support
Id consider pharmacological and surgical therapies:
- Recomended for moderate to high nicotine dependance
- NRT, Varenicline, Bupropion, Nortriptaline
Arrange follow up
What would you like to do about this patient’s alcohol misuse?
I would like to take a detailed Hx and Ex and confirm the diagnosis:
- CAGE quesioning: have you ever felt teh need to CUT down on your drinking? Have people ANNOYED you by critisising your drinking? Have you ever felt GUILTY about drinking? Have you ever felt the need for an EYE OPENER drink in the morning to steady your nerves or get rid of a hangover?
- Other substance use and complications
- Mental health problems, forensic Hx
- Reasons for drinking, barriers to stopping drinking
- Previous quit attempts
- Assess level of dependence
- Assess readiness to change (stages of change)
Examination for complications:
Id like to assess secondary cusses and associations and investigate these:
- Depression, anxiety, OCD
- Lonliness, social isolation, circumstance
Id like to screen for secondary complications:
- GI - Chronic liver disease ( Alcoholic fatty liver, steatohepatits, acute alc hep, liver cirrhosis), esophagitis, gastritis, UGI bleeds / varicies, eahd and neck cacners, pancreatitis, chronic panc insuf, diarrhoea
- CV: Dilated CM, arrh thmia, HT
- CNS: Cerebella degeneration, sensorimotor peripheral neuropathy, dementia, myopathy, autonomic dysfunciton
- Nutritional: wernickes, micronutrient def, niacin def
- Haem: megaloblastosis, anaemia, hypersplenism, thrombocytopenia
- Endo - impotence, infertility, hypogonadism
- Injury - MVA, accidents, fractures, falls, ICB
- Forensic - DUI
Workup:
- Full bloods, nutritional screen inc micronutrients, DT review, CTB, MCS, ECG, TTE, amylase elastase
Id set patient specific management goals:
- 2 std per day, no more than 4 std in any one given day
- std drink contains 10g etoh, eq 1 shot 40% spirit or 285ml full strength beer, 100ml wine, 60ml fortefied wine
- accept that decreasing is better than nothing
- reduce etoh consumption
- prevent medical sequelae from etoh missue
- prevent functional and social sequelae from etoh missue
- Maintain organ function and prevent further injuries
Address underlying cause
Id like to commence non pharmacological therapies:
- Group or individual support and councelling programs form the basis of long term managment (ie AA)
- Avoidance of precipitating factors
- Inform friends and family, engage local doctor
- Encourage other activities to keep busy (ie exersise)
- address underlying psychological issues
- Brief interventions
Id consider commencing pharm and surigcal therapies:
- Acute etoh withdrawal - THiamine 300mg IV TDS + multivitamin + diaz loading and 5-20mg PRN per AWS. If liver dysfunction then oxaz
- Chronic etoh use - Disulfuram (cannot drink any eoth -> aldehyde reaction), acamprosate (6 tabs per day), Naltrexone (fewer craving, good for binge drinking but can affect opioids)
What would you like to do about this patient’s gout?
Id like to take a more detailed Hx and Examination and confirm the diagnosis:
- First diagnosis: mono or polyarticular gout, tophi present, previous symptoms, Ix and Rx. Previous complications including secondary OA
Examination:
- Signs of renal failure
- Tophaceous vs non tophaceous
Confirm Dx:
- Urate level
- XR hands (punched out lesions woith sclerotic margins, overhanging edges, diffuse soft tissue calcification and focal soft tissue tophi, joint space usually well preserved, juxtaarticular osteopenia absent
- Joint aspirate: negatively birefringant uric acid needle shappoed crystals intercellular
- DECT scan
Id like to assess for secondary causes or associations and investigate these:
- Increased production (increased cell turnover eg burns, cancer)
- decreased clearance: renal failure, medications metabolic syndrome
Risk factors:
- Hyperuricaemia, HTN, Obesity, etoh, low dose aspirin use, diuretic use, insulin resitance, increased trigs, OA, post meno women
Work up:
- FBE, Blood film, UEC, Uric acid
Id like to screen for secondary complications:
- Urate nephropathy
- Uric acid calculi
- Secondary OA
Ix:
- XR, Urine uric acid and UEC
Gout is often a marker of metabolic syndrome so pay attn to this
Id set patient specific management goals:
- reduce freq episodes
- prevent joint destruction
- maintain QoL
- Improve joint dysfunction
- Treat underlying Cause
Aim <0.36 is non tophi, or <0.3 if tophi
Id like to commence non pharm therapies:
- Diet modification: decreased purines, beer, high fructose foods
- exersise: regular exersise
- Optimise renal function
- Lose weight
- fluid restrict rather than diuretic use if possible
Id consider pharmacological or surgical therapies:
- Commence if hyperuricaemia and gouty arthritis + any one of the following:
-> tophi
-> errosions on XR
-> >2 attacks per year
->< urate nephropathy or renal insuf
-> urate calculi
Dont treat asymp uricaemia. Dont stop urate lowering therpy if attack just cover with colchicine or PNL
- Allopurinol - start low go slow, dose increase every 6 weeks (screen HLA B5801 Han chinese)
- Febuxostat - no dose reduction in RF
- Uricase agents - rasburicase (mainly in TLS)
- Uricosuric agents (medications that increase excretion of uric acid) inc amlodipine, atorva, fenofibrate, probenicid
What would you like to do about this patient’s depression?
Id like to take a detailed Hx and examination and confirm the Dx:
- PHQ4 - score each q 0-3. >9 severe, 6-8 moderate
-> In last 2 week, feeling nervous anxious or on edge?
-> Not being able to stop or control worrying?
-> feeling down, depressed or hopeless?
-> Little interest or pleasure in doing things?
- Other screening tools: DASS 21 or 42, K10, GDS (older pts)
Examination:
- Full MSE
- Suicide Hx and risk screening
Confirm Dx:
- DSM 5 criteria
Id like to assess for secondary causes or associations and investigate these:
- Endocrine - cushings, hypothyroidism, addisions
- Neuro - dementia, huntingtons, parkinsons, MS, apathetic delirium, B12 def
- Chronic diseases - CCF, cancer, any disease
- OSA
- Medications - steroids, propanolol, interferons
- Substance abuse - etoh, meth, withdrawal
DDx Depression:
- Organic disroder above
- Bipolar vs unipolar dysthymia
- Adjustment disorder
Screening investigations:
- FBE, UEC, B12, folate, TSH, AM cortisol. COnsider CTB and EEG
Id like to screen for secondary complications:
- Non compliance with therapy
- Anxiety
- Harm to self / suicide
- Social isolation
- sleep and diet disturbance
- Substance use, sm
Suicide risk screen:
- Ideation, plan, intent, plausible, completion, any protective factors
I would set patient specific managment goals:
- Improve function, improve outlook and depression
- Prevent deterioration
- Prevent sequelae including suicide
- Ensure adequate health care delivery
Id commence non pharm therapies:
- psychotherapy + supportive psychotherapy
- CBT
- ACT
- Mental health action plan
- Regular exersise, yoga
- Meditation
- Support groups
- smoking cessation, decrease caffine, decrease etoh (D+A support)
- sleep hygine
- Diet improvement with DT input
- Lifeline number, crisis number
-address social determinant of health
Consider specialist referral if severe, failure to respond to Rx, risk of harm to self or others, unclear Dx, consideration of ECT
Id consider pharmacological or surgical therapies:
- SSRI first line for dep and anx
- SNRIs
- TCAs
- tetracyclines
- Agomelatine
- Dopamine NA re uptake inhibitors
Consider low dose adjunct ANtipsychotics
COndier ECT if severe refractory
What would you like to do about this patient’s anxiety?
Id like to take a detailed history and examination and confirm the diagnosis:
- PHQ4 scores:
-> In the last 2 weeks have you been feeling nervous, anxious or on edge?
-> Have you been unable to control or stop worry?
-> Feeling down, hopeless or depressed?
->< Little interest in pleasurable activities?
- Other screening tools include DASS 21 or 42, and K10
Examination:
- MSE
Confirm Dx:
- Consult DSM for diagnostic criteria for GAD or panic disorder
Id like to asses for secondary causes or association and investigate these:
- CV - post MI, arrhythmia, CCF, PE
- Resp - asthma, COPD, hyperventilation
- Endo - hyperthyroid, phaeo, increased PTH, hypoglycemia
- Metabolic - B12 def, porphyria
- Neuro - neoplasm, vestibular dysfunction, encephalitis, paraneoplastic, autoimmune
- Substance - intoxication or withdrawal
DDx for anxiety:
- Organic causes as above
- Panic disorder (with or without agoraphobia)
- GAD
- Phobic disorders (specific or social)
- OCD
- PTSD
- Acute stress reaction, acute stress disorder
- Personalization syndrome
Workup:
- FBE, UEC, CMP
- TSH, PTH, phaeo workup, cortisol
- ECG and TTE
- UDS
Id like to screen for secondary complications:
- Depression, and suicide
- SCZ
- PTSD
- substance use
- functional decline, social isolation
Risk assessment for suicide
Id like to set patient specific goals:
- Improve function
- prevent deterioration
- prevent sequelae including suicide
- improve outlook and depression
- ensure adequate delivery of health care
Id like to commence non pharmacological therapies:
- Same as depression
Id consider pharma and surgical therapies:
- SSRIs
- low dose anipsychotics
- Agomelatine (used for concurrent poor sleep)
- Benzos (used for acute setting)
- BB for somatic symptoms ie tachycardia
What would you like to do about this patient’s peripheral vascular disease?
I would like to take a detailed Hx and Ex and confirm the diagnosis:
- History: 2x distinct clinical identities with lower limb ischemia: chronic ischemia with intermitent caludication, vs critial limb ischemia, vs acute limb ischemia
- Vascular risk factors
- Previous surgeries
- Site of claudication: Foot = tibial or peroneal, Buttocks and hips = aortoiliac disease, Thigh = aortoiliac or common femoral, upper 2/3 of calf = superficial femoral, lower 1/3 calf = popliteal artery
Examination:
- 6 Ps for threatened limb: perishingly cold, pulsless, pain, pallor, paras
Confirm the Dx:
- ABPI
- Vascular USS
- Angiography
I would like to assess the secondary causes or associations and investigate these
- Non modifiable - age, male, non caucasian, FHx
- Modifiable - Diabetes (HBa1c and BSLs), HT (24hr amb BP), dyslipidaemia (lipids), smoking (diary), Vascular disorders
I would like to screen for secondary complications:
- Local complications
-> Ulcers inc marjoplins ulcer
-> wound breakdown
-> amputations
-> Gangrene / infection -> OM, sepsis
- Investigations for PAD:
-> ABI <0.9 abn, <0.4 critical
-> CT angiography
-> USS
-> Angiography
-> Wound swabs / bone Bx
- Systemic complications:
-> CVA/TIA
-> IHD
- Investigaitons:
-> Carotid dopplers, TTE, ECG, CTB
I would set patient specific management goals:
- Maintain function (prevent progressive claudication)
- Increase QoL
- Increase Walking distance
- Prevent deterioration (inc ulcers and infection)
- Overall CVD mortality
I would commence non pharmacological management:
- Exersise: graded exersise - graduated walking program
- Weight loss
- Diet
- Smoking cessation - pursue aggressively
- High risk foot clinic referral (if ulcers)
- regular podiatry input, consider orthotics
- Lipids and BP control
I would consider pharmacological and surgical therapies:
- Intermitent claudication:
-> Aspirin or clopidogrel monotherapy, nil evidence for DAPT
-> ACEI improves walking distance
-> Aggressive lipid, HTN, and DM control
- Critical limb ischemia - surgery, IV prostanoid infusions
- Acute limb ischemia - surgery, amputation.
What would you like to do about this patient’s steroid use?
Id like to take a more detailed Hx and examination and confirm the diagnosis:
- Indication for steroid use
- Duration of steroids use and what dose
- Addisonian symptoms
- Symptoms on past withdrawal of steroids
- Past steroid sparing agents
- Steroid complications
Examination:
- Cushings vs obesity
-> THin skin, purple striae >1cm
-> facial plethora
-> central weight gain (lemon on sticks)
-> proximal myopathy
May want to discuss with GP or pharm re duration and dose of steroids to confirm
Id like to asses teh secondary causes or associations and investigate these:
- Exacerbating factors for obesity and for bone disease
Id like to screen for secondary complications:
- Skin - bruising, purpura, acne, hirsutism, acanthosis
- Bones - OP, fractures, Osteonecrosis (AVN hip)
- Eyes - cateracts, glaucoma
- Myopathy
- GI - ulcers bleeding, NAFLD, obesity
- CV - HTN, IHD, CCF, CVA, dyslipidaemia, peripheral oedema
- ENdo - DM, wt gain, adrenal suppresion, erections, Na / K dysreguylation, growth distirbance
- CNS - mood, depression
- Sleep
- Infection - PJP, TB reactivation,. Fungal infection, bacterial infections
Id set patient specific management goals:
- Limit complications
- Reduce steroid use to lowest effective dose
- Consider steroid sparing agents
Id commence non pharm therapies:
- SKin - limiting further skin dmg, limit UV light, skin kealth / moisturisers
- Bone - Diet high in Ca and vit D, resistance training and exersise
- Eyes - sunglasses, smoking cease
- Myopathy - PT, OT, exersise
- GI - small freq meals, avoid NSAIDs, limit etoh
- CV - agresive RF modification, medi diet, exersise, wt loss
- Endo - stress dosing plan documented
- SLeep hydgine
- monitor mood
Id consider pharm and surgical therapies:
- Boens - Ca and vit D sups, BPs if T score <1.5 if PNL >7.5mg for >3 months
- AVN Ix and surgical intervention
- Eyes - cateract surgery, glaucoma injections and medical managment
- GI - acid suppression with PPI
- CV - BP control, lipid control
What would you like to do about this patient’s osteoporosis?
Id like to take a more detailed Hx and examination and confirm the diagnosis
- History of possible secondary causes of OP (malabsorption, endocrinopathies, CT disease, drugs)
- Falls Hx
- Prievious fractures
Exam:
- Vertebral body height, change in height
- Tenderness over bony prominence
- Hip tenderness
Confirm:
- DEXA scan
- previous minimal trauma fractures
Fracture risk stratification:
- FRAX tool
- WHO fracture risk calculator
Id like to assess for secondary causes or associations and investigation these:
- Malabsorption - Coieliacs disease, UC / crohns, eating disorders
- Endocrine - hypogonadism, sex hormone def, cushings, DM, hyperparathyroidism, hyperthyroidism , acromegally
- Connective tissue diseases
- Chronic inflammation
- Chronic organ failure - renal, heart, liver
- Drugs - Steroids, anticonvulsants, long term heparin, excess thyroid, LHRH agonists, anastrazole / letrazole
- Prolongued immobilization - neuro conditions, musc conditions
Modifiable RFs
- smoking
- high caffine, etoh
- low Ca, vit D
- Physical incactivity,
Id screen for secondary complications:
- Fractures
- loss of function / disability
- sarcopenia and frailty
- pain
DEXA scan if >50 and RFs
Id set patient specific management goals:
- Prevent fractures
- reduce injuries from falls
- mortality benefit
- stop resultant functional disability and frailty
Id commence non pharm therapies:
- Exersise: balance, strength, weight bearing
- Smoking cease, decrease etoh
- diet modification high Ca and Vit D
- maintain adequate food intake and ideal body weight
- Falls prevention program (consider PT, OT input)
- Treat underlying conditions
- revioew medictions:
I would consider pharm and surgical therapies:
- Adequate Ca intake (600mg/day) if diet insuf
- Vit D replete
- Consider HRT for women
- Anti resorptive therapies - BPs, DMAB, teri, romo
- surgical therapies for ONJ if refractory or impending AFF
What would you like to do about this patient’s falls and balance?
I would like to take a more detailed Hx and Ex and confirm the diagnosis:
- Hx re mechanism and contributing fractrures, cerebellar distirbance or vetigo, neuropathy, myopathy, arrhythmia, fluid disturbance
Exam:
- Cerebellar syndrome
- myopathy, inc proximal myopathy
- poor knee extension / OA
- Cognition
- AS, arrhythmias
Confirm Dx:
- falls diary
- collateral from family, witnesses
Id like to assess for secondary causes or associations and investigate these:
- Biggest RFs are medications and cognitive deficits
- CV: arrhythmias, valvular disease, pHTN / orthostasis (DM)
- ENdo: hypothyroidism, hypoglycaemia, hypercalcaemia
- Medications: polypharm, diuretics, central acting, SSRis, ACEI, psychotropics
- Sensory defecit - vision / glasses, depth perception
- Resp - hypoxia (ie ILD)
- Neuro - knee extension, myopathy, sensory motor neuroapthy, proprioception, ceerebellar dysfunction, NPH
- Cognitive decline
Investigations:
- TTE, ECG, 24 BP and holter, med rec, Baseline bloods, inc TSH, CTB, geriatric screen
Id like to screen for secondary complications:
- Vertebral and hip tenderness
- other fractures
- Chronic subdural haematoma
- Soft tissue injuries
- Fear of falling or functional disability
Id like to set patient specific management goals:
- prevent falls
- prevent injury from falls
- prevent decline
- ensure good bone health
- prevent fear of falling
Id like to commence non pharm therapies:
- Strength and balance training - exersises in the community
- Falls and balance multidiciplinary clinic
- MDT with PT and OT, pharm and GP
- Home saftey modification
- Quad strengthening exersise
- Re-evaluate mobility aids and daily living aids
- Improve vission / optimise vision
- Call bell, regular checkups
- ENlist fam or neightbour supports
Id consider pharm and surgical therapies:
- Sup vit D and Ca
- Antiresorptive therapies
- medication reconsiliation
- Test and medications for postural HTN or specific causes
What would you like to do about this patient’s malnutrition?
Id take a more detailed Hx and Ex and confirm Dx:
- Protein intake, fat intake, CHO intake, dietary Hx, weight loss Hx
Exam:
- Micronutrient def: mouth and skin, glossitis, ulcers, xerosis, hyperkeretosis, koilonychia, eyes, bleeding
- Macronutrient def - temperalis wasting, forsal interosei wasting
Confirm Dx:
- BMI, waist circ
- Estimate calory intake
- Food diary, collateral Hx
Id like to assess for secondary causes or associations and investigate these:
- Almost every disease can be a risk factor for malnutrition. Also thing about functional and cognitive barriers to food, as well as psycho social barriers
- Look for elements of food consumption that could be contributing:
-> poor vision
-> poor hand use
-> cog changes
-> poopr cerebellar syfunction
-> Dysphagia
Investigations:
- FBE, UEC, CMP, LFTs, Vit D, vitamins, albumin, pre albumin, iron, B12, folate, others as indicated (ADEK)
Id like to screen for secondary complications:
- Cachexia and wasting of muscles
- Vascular changes
- Hypoalbuminaemia
- Anaemia
- Oral and dental changes
- Peripheral neuropathy, myopathies
- Night blindness
- Cognition
- Wernickes, korsekoffs
- Diarrhoea
- OP
- bleeding disorders
Id would set patient specific managment goals:
- Prevent end organ damage
- Adress frailty syndrome
- Bolster physiological reserve
- Improve aerobic capacity
Id commence non pharm therapies:
- DIet - based on specific clinical situation and co-morbiditeis
- Key micronutrients
- DT input
Id consider pharm and surgical therapies:
- Supplements - high in macro and micronutrients
- renal failure diet
- liver failure diet (HEHP)
-Vitamin and mineral sups, thiamine and B12
- Monitor and treat refeeding syndrome
- Appetite stimulants (steroids in cancer, medical marajuana)
- Consider alternative modes of food delivery (ie PEG/PEJ, NG, NJ, TPN)
