Key clinical processes in LM Flashcards
LM history and and physical examination involves: Vital signs risk factor assessment Physical examination Lab work and interpretation diagnosis and management collaborative care and referrals.
vital signs: PA, diet, stress, sleep, emotional well being, tobacco use, alcohol consumption and BMI.
Only BMI, PA and AUDIT-C are validated at this time.
PA vital sign
its an aspect of daily total energy expenditure (TEE)
which people have control. rest and thermic effect from food can change with increased muscle mass or types of food buy may longer to see or have a smaller impact.
TEE= Resting energy expenditure+ PA+ Diet induced Thermogenesis TEE= 60-75% of TEE+15->30% of TEE+10% of TEE
two item exercise vital sign
- how many days a week do you engage in moderate to strenuous exercise such as brisk walking.
2.on average how many minutes per day do you exercise at this level.
based on PA guideline a person can be Inactive/ Insufficiently active/ sufficiently active.
This provide info about CV exercise not strength and resistance exercises, balance or flexibility exercises.
advantages of strength
question to ask: how many days a week do you engage in strength training or resistance exercises?
training increase resting energy expenditure
improves activities of daily living, reduce the risk of falls especially in elderly.
diet vital sign
based on US department of agriculture dietary guidelines for Americans 2020-2025. Its better to assess for whole foods or eating patterns rather than isolated nutrients. looking at specific nutrients is complicated and misleading
Question to ask: how many serving s of Veg do you have in a day? repeat the question with Fruit, Whole grains, Beans, Legumes, nuts, seeds, herbs and spices then low fat diary products.
typical shortfall nutrients are
Vitamin A,D, E, C, folate, calcium, magnesium, Fiber and potassium they are found in veg fruit, whole grains, beans, legumes and low fat diary products.
its helpful to understand what food and food components are over-consumed.
question to ask
how many sugar sweetened beverages do you have in a day. repeat questions with other foods/food components. dietitian can be more helpful getting detailed information or try to get information on separate visit.
added sugars including high fructose corn syrup, cholesterol, refined grains, sodium, sat fats, trans fat.
they are found in sugar sweetened beverages, processed and packaged foods with added fat, sugar and salt, fried foods, animal products including high fat dairy products ( milk and cheese), meat and eggs.
National institute of health had validated tools.
A
1.dietary screener questionnaire in the National health and nutritional examination survey (NHANES)
2.Dietary screener in National Health Interview Survey (NHIS) Cancer control Survey (CCS)
3. Dietary screeners in the California health interview survey (CHIS)
4.Fruit and vegetables intake screeners in Eating at Americas Table Study (EATS)
5. Percentage of energy from fat screener.
6.Multifactor screener in observing protein and energy nutrition (OPEN) study.
B
The Mediterranean DASH diet intervention for neurodegenerative delay (MIND) diet score is a dietary screening tool. A positive score is associated with slower decline in global cognitive score, but findings needs to replicate in an intervention trial.
C.
The SOS free ( Salt/oil/sugar free) diet screener from T Colin Campbell centre for nutrition studies
Food included: vegetables 10-30 + servings per day
fruit 4-10+ servings per day, Whole grains 0-10+ servings per day, Legumes 0-5+ servings per day, Nuts and seeds 1 ounce per day.
food not included: animal products, added sugar, salt and oil, refined grains, other processed foods.
D.
A short form food frequency questionnaire (SFFFQ) for primary care patient but didnt show significant agreement with a 24 hours telephone based diet recall.
Stress vital sign
important to assess as 70% on primary care visits as linked to stress and these patient are more less likely to engage in healthy habits.
Perceived stress scale assessment
10 item questionnaire scale 0- never to 4- very often over the last one month
1. upset because of something happened unexpectedly.
2. unable to control the important things in your life.
3.Felt nervous and stressed.
4. Felt confident about your ability to handle your personal problems.
5. felt that things were going your way.
6.could not cope with the things that you had to do.
7.able to control irritations in your life
8.felt that you were on top of things.
9.angered because of things that happened that were outside of your control.
10. felt that difficulties were pilling up so high that you could not overcome them.
Negatively phrased questions: 1,2,3,6,9,10
never =0
almost never=1
sometimes=2
fairly often=3
very often=4
Positively Phrased: 4,5,7,8
Never=4
almost never=3
sometimes =2
fairly often=1
very often=0
higher the score more perceived stress one is under.
The Dundee stress state questionnaire is a short stress state questionnaire
24 item assessing 3 aspects: task engagement, distress, worry
Sleep Vital sign
mini sleep assessment ask 1.typical weekend hours of sleep 2.typical weekend hours of sleep 3.perceived sleep quality Epworth sleepiness scale (ESS) 8 question assessment for daytime sleepiness. high scores consistent with moderate to severe excessive day time sleepiness.
Emotional well being vital sign
ask scale 1= lowest to 5= highest
1.in most ways my life is close to my ideal
2.i am satisfied with my life.
these two questions are from satisfied with life scale (SWLS) total 5 questions.
older age, higher education and higher income associated with greater subjective well being.
lower satisfaction= not being white, black and hispanic, lowest level of education and lower household income.
Tobacco use vital sign
current, past or never used.
cigarettes cigars, chew and e cigarettes amount and years
Alcohol consumption vital sign
screen at every visit if regular drinker otherwise annually.
AUDIT-C The Alcohol Use disorders Identification Test-Concise 3 items 0= never low number of occurrences to 4=often high number of occurrences.
1. how often do you have drink containing alcohol.
2.how many drinks containing alcohol do you have on a typical day when you’re drinking?
3. how often do you have six or more drinks on one occasion?
BMI vital Sign
BMI= weight in Kg/ (height in metres)2
imperial (weight in pounds/ (height in inches)2) x703
underweight <18.5 normal 18.5-24.9 (18-22 lowest risk) overweight 25-29.9 obese class 1 30-34.9 class 2 35-39.9 class 3 >= 40
asians 18.5-22.9= normal
23-24.9= overweight
>=25 =obese
Risk Factor Measurement
1 Screening tools are helpful to start early discussion of lifestyle factors/intervention.
2. CVD
1.life’s simple 7 questionnaire
2.ASCVD ( Atherosclerotic CVD) risk estimator plus by the American college of cardiology.
*the assessment indicates the patient’s risk of MI in the next 10 years.
*20-79 years age without heart disease
* non hispanic white and african americans
underestimate risk = in American indian, some asian american of south asian ancestary and some hispanic ( Puerto ricans)
overestimate risk in = Asian americans of east asian ancestary and some hispanics ( Mexican Americans)
* age, gender, total cholesterol, HDL-C, LDL-C, Smoking status, Diabetes history, Treatment for HT, such as use of aspirin and or statin therapy.
* low risk, borderline risk, intermediate risk and high risk
2015 MESA ( multi ethnic study of atherosclerosis) look at coronary calcium score
10 year coronary heart disease risk in multiethnic study
39% non hispanic whites, 12% chinese americans, 28% african americans 22% hispanic americans.
Reynolds risk score for women
considers family history and high sensitivity CRP which predicts risk of global CVD.
