Class 4 Flashcards
At risk anorexia
female, young, depression, medical comorbidities
at risk bulimia
change in weight, bulimia, anxiety, vital signs, medical comorbidities
at risk BED
not as young, increase in weight, male or female, anxiety, impulsivity, depression, GI problems, mestrual prb, metabolic syndrome
What to ask screening
- Are you trying to lose weight, have you lost weight, are you still losing weight?
- What are you doing to lose weight?
- Do you ever lose control over how much you eat?
- Would you say that food dominates your life?
- Body image question
Worrisome sx
loss of consciousness convulsions weakness: get out of chair BMI ≤ 15 Weight loss ≥ 1 kg /week x 3 months Pregnancy Type 1 diabetes Weakness or syncope Sodium < 130 Potassium < 3.0 Abnormal liver function tests Bradycardia < 45; Prolonged QTc Orthostatic changes : BP drops by ≥ 20; Pulse increases by ≥ 20 Hypothermia (≤ 35.0°C) Contact us: Medical risk management
basic labs to do
CBC Albumin, Total Protein Glucose Random Creatinine Sodium, Potassium, Chloride, Bicarbonate ALT (Alanine aminotransaminase); AST (Aspartate aminotransaminase) if alcoholic CK (Creatinine kinase) Calcium, Magnesium, Phosphate B12 HbA1c (if diabetic) TSH Other recommended tests Electrocardiogram (ECG)
Elevated CK
intense exercise
potassium low, increase Cl and CO2
induced vomiting
increased ALT
liver damage because malnourished
WBC low
bone marrow suppression in the case of chronic under eating. Not more prone to illness
Physical consequences
Arrhythmia Bradycardia Osteoporosis Amenorrhea Hypokalemia Hypothermia Hypophosphatemia Hypotension
Starvation leads to
energy conservation: decrease in temperature, pulse, BP, turn off reproductive factors
dehydration: water conservation mechanisms turn on: decrease BP increase pulse
Starvation uses up
reserves: fat, muscle and bone, other tissues
Effect of vo
Teeth Throat Salivary glands Stomach Blood in vomit
Effect of laxatives
Cramps
Bloating
Diarrhea
Blood in stool
Most common s/symptoms: or purging
dizziness and poor concentration Gastroesophageal reflux (heartburn); dental problems, parotid gland enlargement Elevated amylase (normal lipase); metabolic alkalosis (elevated CO2)
when weight decreases, what increases
compulsivity and hyperactivity
PRIORITY 3
Normal weight
No daily bingeing or purging
No medical complications
PRIORITY 2
BMI: 15-18 (women); 16 -19 (men) or sign of medical instability
With at least one symptom
Syncope Laxatives > 10 co./day Hypokalemia < 2.8 mmol/L Fasting > 2 days/week Multiple purging episodes per day
PRIORITY 1
BMI: < 15 (women); < 16 (men) or Drastic weight loss
1 kg/week x 3 months
Significant medical instability i.e. syncope, bradycardia, ↓↓ potassium
Fasting : 2 days/week
Pregnancy
type 1 db
transfer from adolescent services
Proposed criteria to send patient to ER
BMI < 12 (female) <13 (male) or rapid and drastic weight loss.
•Plus at least one or more of the following:
–Ongoing weight loss
–Syncope
–Weakness
–Bradycardia HR< 40 bpm or HR > 110 bpm
–Hypothermia <34.8 C
–Hyponatremia <120 mmol/L or <125 mmol/L and symptomatic
Regardless of weight:
–Hypokalemia < 2.8 mmol/L or hypokalemia with abnormal EKG and/or significant metabolic alkalosis (CO2 >38 mmol/L)
–Signs and symptoms of severe dehydration
To ignore labs
- Low T3 (metabolic compensation)
* High cholesterol
pharmaco bulimia
SSRIs and other antidepressants are useful.
pharmaco BED
SSRIs, SNRIs, and medications associated with appetite and weight reduction, such as the stimulant LDX (Vyvanse), work.
pharmaco anorexia
Olanzapine appears to have a small but significant effect on weight gain, but should not be used as a stand-alone treatment
pharmaco arfid
Mirtazapine and Olanzapine are worth a try
Not recommended: pharmaco
Tricyclics (cardiac risk; prolonged QTc interval), Paroxetine(weight gain), Mirtazapine (increased appetite), Bupropion (increased seizure risk)
What doesn’t work pharmaco
- Manipulating appetite (↑ or ↓)
- Trying to decrease or stop bingeing and purging when a person is underweight
- Taking your medication and then throwing up
K 3-3.5
a banana per day
if lower: give supplement, ask tonight in bed (less chance of purging)
sx of low k:
cramps, fatigue, palpitations thirst, novo, thirst, partial or total paralysis, tingling of the extremities, fingertips, around the mouth and nostrils
complications of hypok
arythmie, slowing of the heart, cardiac arrest
Refeeding
•Increasing your intake can be painful
–Expect physical and psychological discomfort
–Bloating, early satiety, nausea, feeling uncomfortably full, gas, constipation…
•Refeeding syndrome is rare and only seen in hospitalized patients
osteoporosis give
Ca and vit D:
Weight loss: Common symptoms and signs
Sx:Cold intolerance; dizziness; hair loss; poor concentration, fatigue; insomnia ; early satiety (fullness); bloating; heartburn; amenorrhea; loss of libido
Signs: Metabolic profile different from other types of starvation (Normal protein and albumin); Sick euthyroid (normal TSH/T4; low T3; increased rT3); Anemia (~40%) often normochromic, normocytic but may be microcytic if iron deficient; low white count (~30%); high cholesterol (up to 75%)
Hyponatremia
Low sodium: suspect water loading (<130 mmol/L high risk) or occult chest infection with associated SIADH
Hypoglycemia:
- blood glucose <3 mmol/L (if present, suspect occult infection, especially with low albumin or raised C-reactive protein)
- Also seen in refeeding usually post-prandial (insulin surge in context of low glycogen stores in liver to offset). Treat only if patient is symptomatic
Normal weight Bulimia: Common s/sx
Symptoms: Dizziness, Palpitations, Fatigue, Heartburn; Bloating
Signs: Dental caries, enamel erosion, loss of teeth, gingivitis, enlarged salivary glands, callous on the back of the hand (Russell’s Sign)
Normal weight Bulimia: Worrisome
Orthostatic changes in blood pressure+ pulse:
BP decreases by≥ 20/Pulse increases by ≥ 20
Hypokalemia (potassium < 3.0); Pseudo-Bartter’s syndrome (hypochloremic hypokalemic metabolic alkalosis). CO2 > 38
Hyponatremia
Pancreatitis
Hematemesis (Mallory-Weiss tear)
Incontinent (severe laxative abuse)
