Anorexia Nervosa Flashcards
They can restrict calorie intake. How else may they try to lose weight? - 3
Diagnostic Criteria:
1st:
- What percentage of predicted weight have they lost?
- Under what BMI?
2nd:
- Their thoughts? - 1
- Behaviour - 1
3rd:
- Thoughts - 1
- Endocrine changes in men and women
Vomiting Intense exercise Laxative use ------------------------------- 85% <17.5 - 14 is severe
Fear of weight gain, or becoming fat, with persistent behaviour that interferes with weight gain
Feeling fat when thin
Amenorrhoea for 3 months, or low libido in men.
Other features:
Mental state:
- Main symptom without food
- Why is cognition impaired?
- Sleep
Sensations:
- What sensation are they sensitive to?
- One more
CVD:
- Why do you get arrhythmias? What may it lead to?
Sexual - 2
GI - 1
Skin:
- What happens to the skin?
- You get lanugo. What is it?
Bone:
- Lack of Vit D
- Teeth
OBS - 3
Fatigue
Due to cerebral atrophy
Altered sleep
Cold sensitive
Dizzy
Arrhythmias due to hypokalaemia LEADING to heart failure.
Amenorrhoea
Reduced lipido
Constipation
Dry skin
Fine body hair all over
Osteoporosis
Dental caries - tooth decay
Low temperature, BP and HR
Risk factors:
What sex is it more common in?
Co-morbid conditions? - 4
Personality traits? - 2
Social pressures? - 2
FH
4x commoner in women
Depression
Anxiety
OCD
Substance abuse
Low self-esteem
Perfectionism
TV watching
Image-aware work
Differentials diagnosis:
Psychiatric - 3
GI - 2
Endocrine - 2
Eating disorders
Depression
OCD
IBD
Coeliac
Thyrotoxicosis
Hypothalamic tumour
Investigations:
What screening tool is used?
What needs to be measured?
Bloods and why? - 4
SCOFF screening tool
TFT - hypothyroidism
FBC - low blood cells
LFT - mildly raised
Sex hormones reduced - effects of AN
Investigations:
ECG findings?
What scan should be done if amenorrheic?
Long QT intervals
DEXA scan - osteopenia and osteoporosis
Investigations - Metabolic effects:
- What causes hypokalaemia? - 2
- Why do you get alkalosis?
- Why do you get acidosis?
- How do you get raised urea and creatinine?
- What electrolytes should be measured?
Vomiting or laxatives
Vomiting
Laxatives
Dehydration
Magnesium
Phosphate
Calcium
Management:
How much weight gain do you aim for per wk?
What should be avoided as much as possible?
0.5kg
Admission unless severe
Management - Biological:
What should be monitored regularly and why?
What antidepressant can be used if there is a co-morbid depression or OCD?
Physical health - weighing
Fluoxetine
Management - Psychological:
1st line
Who needs to be involved?
Enhanced CBT (CBT-E) can be used. What is the aim?
What type of therapy should be used for children?
Psychoeducation
Dietician - structured eating plan
To establish regular eating habits
Then to identify and address harmful ideas about body size and eating
As well as triggers and stressors
Family therapy
Management - Social:
What can be done for families?
Self-help and support groups
Management - Inpatient care - Admission:
BMI needed for admission?
You must refeed them with dietician input. How do you start?
How much do you increase their caloric intake by and how often?
<14
Start on current intake
Increase by 200 calories every 2 days
0.5 - 1.0 kg/week
Management - Inpatient care - Admission:
What may be needed if they are unable to eat orally?
When is the only time TPN should be used?
Why is 1 to 1 observation needed?
What must be used if they want to leave the ward?
NG tube
If there is GI dysfunction
To prevent micro exercise (e.g. fidgeting).
Monitoring during meals to ensure food is not hidden.
A wheelchair
Management - Inpatient care - Admission:
What electrolyte usually needs to be replaced?
What can be added to this as well just to make sure?
What can be used instead of laxatives for constipation as laxatives can be used for weight loss?
What is important to remember?
Potassium
Multivitamins
Stool softeners
Getting the weight back prevents short-term complications, but remember that this doesn’t;t fix the underlying problem.
Management - Inpatient care - Admission:
Monitoring:
What is an emergency that should be looked out for?
How should their weight be monitored? - 4
What daily blood should be done?
What bedside test should also be done daily?
Re-feeding syndrome
Same scales
Same clothing
Jewellery removed
Ensure no fluid loading before hand
FBC, LFT, U&E, phosphate, calcium, magnesium, CK, TSH
ECG
Management - Inpatient care - Admission:
What sections of the MHA can be used for compulsory Rx?
Below what BMI are they thought to lack capacity and need to be treated in their best interest?
What about when their weight increases again?
Section 2/3
<12.5
The legal framework needs to be reviewed and they may need to be sectioned.
Re-feeding syndrome:
What can it happen after?
How long after re-feeding does it tend to happen?
What electrolyte drops?
What else happens leading to multiorgan problems?
Re-feeding for anorexia Rx
Malnutrition
GI disease or surgery
5 days
Phosphate + Fluid shifts
Re-feeding syndrome:
S+S:
What does low phosphate levels lead to?:
- muscles
- heart
- lungs
- neurological
What 2 other electrolytes can also drop?
Rhabdomyolysis
Respiratory or CV failure, Low BP
Delirium, seizures and coma
Potassium and magnesium
Re-feeding syndrome:
Monitoring required?
How can it be prevented?
Bloods - looking for drop-in phosphate, magnesium and potassium.
Gradual re-feeding and correction of electrolyte imbalances
https://www.youtube.com/watch?v=HlFr7in3_S8
SCOFF screening tool:
What does each one start?
It is used to diagnose eating disorders
> 2
*One point for every “yes”; a score of ≥2 indicates a likely case of anorexia nervosa or bulimia
Sick - do you make yourself feel sick because you feel full?
Control - worry you have lost control over how much you eat?
One - have you lost a stone in the last 3 months
Fat - do you believe you’re fat when others say you are thin?
Food - does it dominate your life
What score can be used to assess for malnutrition?
MUST SCORE:
BMI:
- Clinical impression – thin, acceptable weight, overweight.
- Obvious wasting (very thin) and obesity (very overweight) can also be noted.
Unplanned weight loss:
- Clothes and/or jewellery have become loose fitting (weight loss).
- History of decreased food intake, reduced appetite or swallowing problems over 3-6 months and underlying disease or psycho-social/physical disabilities likely to cause weight loss.
Acute disease effect:
- Acutely ill AND no nutritional intake or likelihood of no intake for more than 5 days.
- If the subject is currently affected by an acute patho-physiological or psychological condition, and there has been no nutritional intake or likelihood of no intake for more than 5 days, they are likely to be at nutritional risk.
- Such patients include those who are critically ill, those who have swallowing difficulties (e.g. after stroke), or head injuries or are undergoing gastrointestinal surgery.
Determine overall risk of malnutrition:
On the basis of estimated BMI category, unplanned weight loss, and Acute Disease Effect, select the appropriate risk category.
