1) The patient is a 16-year-old female with a 2-year history of anorexia nervosa who was admitted to the hospital due to bradycardia and electrolyte abnormalities.
2) On admission, her weight was 40.3 kg (70.6% of ideal body weight) with a BMI of 14.65 kg/m2. She had been losing weight over the past year.
3) During her hospital course, she was started on a refeeding protocol of 1400 kcal/day to gradually increase to 3400 kcal/day. Her electrolytes were closely monitored for refeeding syndrome.
This document provides a summary of assessment tools that can be used to quickly screen older adults for common medical issues during a geriatric assessment. It describes screens for dementia like the 3-item recall test, animal naming test, and clock drawing test. Physical performance is discussed and tests like the rapid gait and chair stand tests are described. Screens for depression, hearing, vision, incontinence and nutrition are also summarized. The document advocates using the "DEEP IN" mnemonic to systematically screen key areas in a quick office visit.
Challenges in rehabilitation of the elderly patientMarc Evans Abat
This document discusses rehabilitation in the elderly. It covers the prevalence of disability in the elderly, benefits of rehabilitation such as improved function and reduced risk of nursing home admission. Goals of rehabilitation include improving function and preventing further disability. Challenges include physiological changes like decreased muscle mass and strength, and geriatric syndromes like dementia, falls, and incontinence. Proper communication and addressing sensory issues are important in the rehabilitation of elderly patients. Tests like the timed up and go and functional reach can assess function.
This document summarizes research on obesity and serious mental illness. It finds that rates of obesity are 30-40% higher in men and 50-60% higher in women with serious mental illness. Obesity is associated with conditions like depression and bipolar disorder and can lead to longer episodes and poorer physical and mental health for those with bipolar disorder. Risk factors include poor diet, sedentary lifestyle, early life trauma, sleep disorders, and side effects of medications used to treat serious mental illness. Behavioral interventions and bariatric surgery can help treat obesity, but surgery may increase risks of alcohol dependency. Thorough psychological assessment is important before considering patients for bariatric surgery to determine suitability and provide support.
This document discusses connections between movement, mood, and memory. It explores mood disorders like depression and Alzheimer's disease, and how exercise can positively impact both. Regular exercise is suggested to reduce risks of many chronic diseases, as well as depression and Alzheimer's. The benefits of exercise are explained from psychological, neurogenic, and neurochemical perspectives. Goals and strategies for starting an exercise routine are also outlined.
This document discusses 5 case studies involving GI disorders in women. The first case involves a 32-year-old woman with 5 years of diarrhea and abdominal pain. The next best step is reassurance without further testing, as her symptoms are consistent with irritable bowel syndrome. The second case involves a 38-year-old woman with vomiting after gastric bypass surgery, where an internal hernia is the most likely cause. The third case involves a pregnant woman referred for irritable bowel syndrome, where testing her for celiac disease is the next best step. The fourth case involves constipation, where pelvic floor dysfunction is the most likely diagnosis given her exam findings. The fifth case involves a 58-year-old woman with diarrhea
WA eating disorders outreach and consultancy serviceSCGH ED CME
Miss S, a 17-year-old female, presented to the emergency department after nearly fainting at school with a low blood pressure and heart rate. Her body mass index was 14.8 and she had lost 12 kg in the past 6 months. There is currently a lack of public eating disorder services for patients over 16 in Western Australia, resulting in long wait times and inconsistent care. Initial treatment for severe eating disorders involves medical stabilization and nutrition rehabilitation to reverse the cognitive effects of starvation and address ambivalence about treatment.
1. Geriatric rehabilitation aims to help the elderly regain independence by recovering physical, psychological, or social skills lost due to aging or disability.
2. The key principles of geriatric rehab are addressing the variability in aging, preventing the effects of inactivity, and maintaining optimal health.
3. Interventions include a variety of exercises, assistive devices, and environmental adaptations delivered through different settings and providers.
This document provides a summary of assessment tools that can be used to quickly screen older adults for common medical issues during a geriatric assessment. It describes screens for dementia like the 3-item recall test, animal naming test, and clock drawing test. Physical performance is discussed and tests like the rapid gait and chair stand tests are described. Screens for depression, hearing, vision, incontinence and nutrition are also summarized. The document advocates using the "DEEP IN" mnemonic to systematically screen key areas in a quick office visit.
Challenges in rehabilitation of the elderly patientMarc Evans Abat
This document discusses rehabilitation in the elderly. It covers the prevalence of disability in the elderly, benefits of rehabilitation such as improved function and reduced risk of nursing home admission. Goals of rehabilitation include improving function and preventing further disability. Challenges include physiological changes like decreased muscle mass and strength, and geriatric syndromes like dementia, falls, and incontinence. Proper communication and addressing sensory issues are important in the rehabilitation of elderly patients. Tests like the timed up and go and functional reach can assess function.
This document summarizes research on obesity and serious mental illness. It finds that rates of obesity are 30-40% higher in men and 50-60% higher in women with serious mental illness. Obesity is associated with conditions like depression and bipolar disorder and can lead to longer episodes and poorer physical and mental health for those with bipolar disorder. Risk factors include poor diet, sedentary lifestyle, early life trauma, sleep disorders, and side effects of medications used to treat serious mental illness. Behavioral interventions and bariatric surgery can help treat obesity, but surgery may increase risks of alcohol dependency. Thorough psychological assessment is important before considering patients for bariatric surgery to determine suitability and provide support.
This document discusses connections between movement, mood, and memory. It explores mood disorders like depression and Alzheimer's disease, and how exercise can positively impact both. Regular exercise is suggested to reduce risks of many chronic diseases, as well as depression and Alzheimer's. The benefits of exercise are explained from psychological, neurogenic, and neurochemical perspectives. Goals and strategies for starting an exercise routine are also outlined.
This document discusses 5 case studies involving GI disorders in women. The first case involves a 32-year-old woman with 5 years of diarrhea and abdominal pain. The next best step is reassurance without further testing, as her symptoms are consistent with irritable bowel syndrome. The second case involves a 38-year-old woman with vomiting after gastric bypass surgery, where an internal hernia is the most likely cause. The third case involves a pregnant woman referred for irritable bowel syndrome, where testing her for celiac disease is the next best step. The fourth case involves constipation, where pelvic floor dysfunction is the most likely diagnosis given her exam findings. The fifth case involves a 58-year-old woman with diarrhea
WA eating disorders outreach and consultancy serviceSCGH ED CME
Miss S, a 17-year-old female, presented to the emergency department after nearly fainting at school with a low blood pressure and heart rate. Her body mass index was 14.8 and she had lost 12 kg in the past 6 months. There is currently a lack of public eating disorder services for patients over 16 in Western Australia, resulting in long wait times and inconsistent care. Initial treatment for severe eating disorders involves medical stabilization and nutrition rehabilitation to reverse the cognitive effects of starvation and address ambivalence about treatment.
1. Geriatric rehabilitation aims to help the elderly regain independence by recovering physical, psychological, or social skills lost due to aging or disability.
2. The key principles of geriatric rehab are addressing the variability in aging, preventing the effects of inactivity, and maintaining optimal health.
3. Interventions include a variety of exercises, assistive devices, and environmental adaptations delivered through different settings and providers.
Natural Treatments for ADHD - December 7th, 2016 - Saint Marys HospitalLouis Cady, MD
This lecture, presented December 7th, 2016 for the Parent Support Group for children with ADHD and Sensory Processing Disorders, was presented at Saint Marys Hospital in Evansville, Indiana. In this one hour presentation, Dr. Cady broke down some of the alternative treatments for ADHD, grounded in the peer-reviewed literature, that do not involve the prescription of typical psychiatric medication for ADHD. He emphasized, natural, holistic treatments to treat deficiencies and restore balance of nutrients and specific essential fatty acids.
this presentation will contains problem of old age, how can they affect the life of geriatric peoples, prevention and control of geriatric problems, national program for better health of old peoples, initiations done by private trusts to improve their health
This document discusses geriatric rehabilitation and provides information on:
- The components of geriatric rehabilitation including accommodation, prevention of disability/restoration of function, and medical treatment of impairments.
- Physiological changes that occur with normal aging like changes in body composition, posture, gait, neurological and skin functions, and cardiopulmonary and urological systems.
- Principles of geriatric rehabilitation including ascertaining the level of function, differentiating between delirium, dementia and depression, determining patient goals and motivation, and emphasizing function over diagnosis.
- Common impairments seen in geriatrics like fractures, arthritis, Parkinson's disease, and peripheral nerve impairments.
Dementia diagnosis, pharmacological and non-pharmacological interventionsanne spencer
The document discusses diagnosis and treatment of dementia. It covers:
- Diagnostic pathways including distinguishing between mild cognitive impairment and dementia. Screening tools like the Qmci are discussed.
- Pharmacological interventions for dementia including cholinesterase inhibitors like donepezil and memantine which can improve cognition but have small clinical benefits.
- Non-pharmacological interventions for dementia are also covered but not summarized here within the 3 sentence limit.
2015: Memory Changes Across the Spectrum of Brain Aging-GalaskoSDGWEP
Memory and cognition change with normal aging in several ways:
- Memory retrieval becomes less efficient although new learning is intact
- Slowing of cognition and motor skills occurs
- Executive function such as multitasking declines slightly
Mild Cognitive Impairment (MCI) involves memory decline with normal other cognition and minimal functional impairment, progressing to dementia in 8-15% per year. Brief cognitive screens plus informant reports can detect MCI and dementia so interventions can maintain function. Lifestyle factors like exercise, cognitive stimulation, and heart health may help preserve brain health in aging.
Complex eating disorder characterized by obsessive pursuit of thinness through dieting with extreme weight loss and disturbance of body image
Anorexia nervosa is typically characterized by
voluntary restriction of food intake ,distorted body image and fear of gaining weight
chronic kidney disease case presentationKamal Sharma
This document presents a case study of a 59-year-old female patient with chronic kidney disease (CKD) who was treated with Ayurvedic therapies including udwarthana, takradhara, and triphaladi lekhana basti. The patient had a history of hypertension, CKD, and urinary symptoms like burning sensation and frequency. Laboratory tests showed elevated creatinine and BUN levels. She was treated with various internal Ayurvedic medications and external therapies over a period of time, which resulted in reductions in her symptoms, fatigue, creatinine and BUN levels. The case study evaluates the effectiveness of the Ayurvedic treatment approach for managing this patient's CKD.
The Health Promotion of the Unsuspecting Individualheatheroleary
Lois is a 71-year-old woman with type 2 diabetes, hypertension, dyslipidemia, and coronary artery disease who lacks regular physical activity and adherence to blood glucose monitoring. The plan is to educate Lois on the implications of her current behaviors and risks to her health. The discussion focuses on increasing her physical activity through a walking plan and monitoring her blood glucose and carbohydrate intake more closely. Social support from friends and family is enlisted to help her adhere to the changes.
- Healthy brain aging is important due to the rising prevalence of age-related cognitive disorders like Alzheimer's disease.
- Brain aging is influenced by both modifiable and non-modifiable risk factors. Engaging in heart-healthy habits, cognitive activities, and social interaction may help promote healthy brain aging.
- When discussing brain health with older patients, physicians should evaluate risk factors and encourage lifestyle changes like exercise, a healthy diet, cognitive stimulation, and social engagement.
This document discusses the potential role of neuromodulation, specifically repetitive transcranial magnetic stimulation (rTMS), in the treatment of anorexia nervosa (AN). AN is characterized by abnormalities in brain regions involved in reward processing, decision making, and interoception. Preliminary evidence suggests rTMS targeting the dorsolateral prefrontal cortex may improve core AN symptoms, mood, and self-regulation. Several small studies and case reports provide initial support that rTMS is a safe, tolerable and may have therapeutic potential for AN, but more rigorous randomized controlled trials are still needed.
Saint Peter's launches a new concussion program led by Dr. Arlene Goodman. The program aims to educate about concussions which can occur from everyday play, not just sports, and provides treatment and recovery guidance. Dr. Goodman notes that while most high school athletes recover within 3 weeks, 20% take over a month and may need vestibular therapy or medication if symptoms persist beyond a month with headaches or vision issues. The program also provides information on recognizing danger signs that require immediate medical attention.
Here are the key points regarding contraceptive options for this obese adolescent patient:
- Combined hormonal contraceptives like the patch are generally safe for obese adolescents. However, progestin-only methods like the implant or IUD may be preferable due to a lower risk of venous thromboembolism.
- The US Medical Eligibility Criteria considers all contraceptive methods safe (Category 1 or 2) for obese adolescents regardless of weight. However, progestin-only methods are preferred over combined methods.
- DMPA is considered safe (Category 1) for obese adolescents by the US MEC. Its effectiveness is not reduced by obesity. Side effects like irregular bleeding may be more common but are generally
Healthy Brain Aging: Exercise, Nutrition, and Preventing ADDUKE
This document discusses ways to promote healthy brain aging and reduce the risk of Alzheimer's disease. It emphasizes controlling health conditions like diabetes and high blood pressure through diet and exercise. Regular mental and physical activity are also recommended, such as puzzles, games, and social engagement to exercise the brain and reduce stress. A healthy diet with fruits and vegetables can help protect the brain from oxidative stress and reduce risk of cardiovascular disease.
Our errors in diagnosing dizziness slidesBest Doctors
This document summarizes a webinar on diagnosing dizziness presented by Best Doctors. It includes:
1) Four case studies on misdiagnoses of dizziness presented by Drs. Samuels, Calkins, Megerian, and Derebery focusing on conditions like pheochromocytoma, postural orthostatic tachycardia syndrome, endolymphatic sac tumor, and migraine-associated vertigo.
2) A discussion by Dr. Derebery of the differential diagnosis of dizziness and approaches to diagnosis based on temporal patterns and urgency.
3) Details on ACCME accreditation and speaker disclosures for continuing education credits.
TAEM10: Common pitfalls in geriatric emergencytaem
Older adults frequently present unique challenges in the emergency department. They often present with atypical symptoms that can mask underlying medical issues. Common problems seen include falls, delirium, adverse drug reactions, and functional decline. A thorough history, physical exam, and medication review are important to identify potential precipitating factors and make an accurate diagnosis. Not following best practices for geriatric assessments can lead to missed or delayed diagnoses that negatively impact outcomes.
This document provides an overview of key considerations for emergency physicians in evaluating geriatric patients. It discusses how diseases often present atypically in older patients due to multiple organ system involvement. Common geriatric syndromes like falls, incontinence and delirium are described. The case study presented is of a 92-year-old woman who presents with increased sleeping; the initial impression is likely stroke or infection given her altered mental status and other chronic conditions. The document outlines the critical role of emergency physicians in caring for older patients and some common chief complaints like abdominal pain, confusion and electrolyte imbalances.
This document provides information on evaluating patients presenting with fatigue, weakness, and weight loss. It reviews common differential diagnoses and recommended initial laboratory tests. Four clinical cases are presented and discussed. The first case involves an 80-year-old woman who presented with hematemesis, confusion, and a 10kg weight loss over 4 months. Her initial workup revealed anemia and elevated ESR, suggesting a serious underlying condition needs to be investigated.
"Killer Drugs & The Supplement Hall of Fame" - IMMH Brazil, 2015Louis Cady, MD
In this presentation, the third of three lectures Dr. Cady delivered in São Paulo, Brazil, Dr. Cady reviews the critical patterns of interactions with numerous frequently prescribed psychotropic medications (and others). Emphasis is given on how not to commit an obvious drug-drug interaction as well as avoiding more subtle ones. The focus then shifts to supplements: which ones are the best, which ones have mental health benefits, and how to avoid interactions between conventionally used supplements and psychiatric medications.
This document provides an outline for creating an infographic on veganism, including sections for an infographic mood board, fact file mood board, font selections, titles and logos, and images.
Qualitative research involves unstructured data from interviews and observations to understand audiences rather than gather facts. It explores underlying reasons, opinions, and motivations through exploratory research. Qualitative research is useful for studying a limited number of cases in depth and provides detailed individual case information, though findings cannot be generalized. Quantitative research involves structured data from surveys and experiments to quantify problems and uncover patterns through statistical analysis of factual information. It provides reliable population data but may lack detail. Focus groups observe small discussion groups to understand genuine opinions rather than single rehearsed answers.
Natural Treatments for ADHD - December 7th, 2016 - Saint Marys HospitalLouis Cady, MD
This lecture, presented December 7th, 2016 for the Parent Support Group for children with ADHD and Sensory Processing Disorders, was presented at Saint Marys Hospital in Evansville, Indiana. In this one hour presentation, Dr. Cady broke down some of the alternative treatments for ADHD, grounded in the peer-reviewed literature, that do not involve the prescription of typical psychiatric medication for ADHD. He emphasized, natural, holistic treatments to treat deficiencies and restore balance of nutrients and specific essential fatty acids.
this presentation will contains problem of old age, how can they affect the life of geriatric peoples, prevention and control of geriatric problems, national program for better health of old peoples, initiations done by private trusts to improve their health
This document discusses geriatric rehabilitation and provides information on:
- The components of geriatric rehabilitation including accommodation, prevention of disability/restoration of function, and medical treatment of impairments.
- Physiological changes that occur with normal aging like changes in body composition, posture, gait, neurological and skin functions, and cardiopulmonary and urological systems.
- Principles of geriatric rehabilitation including ascertaining the level of function, differentiating between delirium, dementia and depression, determining patient goals and motivation, and emphasizing function over diagnosis.
- Common impairments seen in geriatrics like fractures, arthritis, Parkinson's disease, and peripheral nerve impairments.
Dementia diagnosis, pharmacological and non-pharmacological interventionsanne spencer
The document discusses diagnosis and treatment of dementia. It covers:
- Diagnostic pathways including distinguishing between mild cognitive impairment and dementia. Screening tools like the Qmci are discussed.
- Pharmacological interventions for dementia including cholinesterase inhibitors like donepezil and memantine which can improve cognition but have small clinical benefits.
- Non-pharmacological interventions for dementia are also covered but not summarized here within the 3 sentence limit.
2015: Memory Changes Across the Spectrum of Brain Aging-GalaskoSDGWEP
Memory and cognition change with normal aging in several ways:
- Memory retrieval becomes less efficient although new learning is intact
- Slowing of cognition and motor skills occurs
- Executive function such as multitasking declines slightly
Mild Cognitive Impairment (MCI) involves memory decline with normal other cognition and minimal functional impairment, progressing to dementia in 8-15% per year. Brief cognitive screens plus informant reports can detect MCI and dementia so interventions can maintain function. Lifestyle factors like exercise, cognitive stimulation, and heart health may help preserve brain health in aging.
Complex eating disorder characterized by obsessive pursuit of thinness through dieting with extreme weight loss and disturbance of body image
Anorexia nervosa is typically characterized by
voluntary restriction of food intake ,distorted body image and fear of gaining weight
chronic kidney disease case presentationKamal Sharma
This document presents a case study of a 59-year-old female patient with chronic kidney disease (CKD) who was treated with Ayurvedic therapies including udwarthana, takradhara, and triphaladi lekhana basti. The patient had a history of hypertension, CKD, and urinary symptoms like burning sensation and frequency. Laboratory tests showed elevated creatinine and BUN levels. She was treated with various internal Ayurvedic medications and external therapies over a period of time, which resulted in reductions in her symptoms, fatigue, creatinine and BUN levels. The case study evaluates the effectiveness of the Ayurvedic treatment approach for managing this patient's CKD.
The Health Promotion of the Unsuspecting Individualheatheroleary
Lois is a 71-year-old woman with type 2 diabetes, hypertension, dyslipidemia, and coronary artery disease who lacks regular physical activity and adherence to blood glucose monitoring. The plan is to educate Lois on the implications of her current behaviors and risks to her health. The discussion focuses on increasing her physical activity through a walking plan and monitoring her blood glucose and carbohydrate intake more closely. Social support from friends and family is enlisted to help her adhere to the changes.
- Healthy brain aging is important due to the rising prevalence of age-related cognitive disorders like Alzheimer's disease.
- Brain aging is influenced by both modifiable and non-modifiable risk factors. Engaging in heart-healthy habits, cognitive activities, and social interaction may help promote healthy brain aging.
- When discussing brain health with older patients, physicians should evaluate risk factors and encourage lifestyle changes like exercise, a healthy diet, cognitive stimulation, and social engagement.
This document discusses the potential role of neuromodulation, specifically repetitive transcranial magnetic stimulation (rTMS), in the treatment of anorexia nervosa (AN). AN is characterized by abnormalities in brain regions involved in reward processing, decision making, and interoception. Preliminary evidence suggests rTMS targeting the dorsolateral prefrontal cortex may improve core AN symptoms, mood, and self-regulation. Several small studies and case reports provide initial support that rTMS is a safe, tolerable and may have therapeutic potential for AN, but more rigorous randomized controlled trials are still needed.
Saint Peter's launches a new concussion program led by Dr. Arlene Goodman. The program aims to educate about concussions which can occur from everyday play, not just sports, and provides treatment and recovery guidance. Dr. Goodman notes that while most high school athletes recover within 3 weeks, 20% take over a month and may need vestibular therapy or medication if symptoms persist beyond a month with headaches or vision issues. The program also provides information on recognizing danger signs that require immediate medical attention.
Here are the key points regarding contraceptive options for this obese adolescent patient:
- Combined hormonal contraceptives like the patch are generally safe for obese adolescents. However, progestin-only methods like the implant or IUD may be preferable due to a lower risk of venous thromboembolism.
- The US Medical Eligibility Criteria considers all contraceptive methods safe (Category 1 or 2) for obese adolescents regardless of weight. However, progestin-only methods are preferred over combined methods.
- DMPA is considered safe (Category 1) for obese adolescents by the US MEC. Its effectiveness is not reduced by obesity. Side effects like irregular bleeding may be more common but are generally
Healthy Brain Aging: Exercise, Nutrition, and Preventing ADDUKE
This document discusses ways to promote healthy brain aging and reduce the risk of Alzheimer's disease. It emphasizes controlling health conditions like diabetes and high blood pressure through diet and exercise. Regular mental and physical activity are also recommended, such as puzzles, games, and social engagement to exercise the brain and reduce stress. A healthy diet with fruits and vegetables can help protect the brain from oxidative stress and reduce risk of cardiovascular disease.
Our errors in diagnosing dizziness slidesBest Doctors
This document summarizes a webinar on diagnosing dizziness presented by Best Doctors. It includes:
1) Four case studies on misdiagnoses of dizziness presented by Drs. Samuels, Calkins, Megerian, and Derebery focusing on conditions like pheochromocytoma, postural orthostatic tachycardia syndrome, endolymphatic sac tumor, and migraine-associated vertigo.
2) A discussion by Dr. Derebery of the differential diagnosis of dizziness and approaches to diagnosis based on temporal patterns and urgency.
3) Details on ACCME accreditation and speaker disclosures for continuing education credits.
TAEM10: Common pitfalls in geriatric emergencytaem
Older adults frequently present unique challenges in the emergency department. They often present with atypical symptoms that can mask underlying medical issues. Common problems seen include falls, delirium, adverse drug reactions, and functional decline. A thorough history, physical exam, and medication review are important to identify potential precipitating factors and make an accurate diagnosis. Not following best practices for geriatric assessments can lead to missed or delayed diagnoses that negatively impact outcomes.
This document provides an overview of key considerations for emergency physicians in evaluating geriatric patients. It discusses how diseases often present atypically in older patients due to multiple organ system involvement. Common geriatric syndromes like falls, incontinence and delirium are described. The case study presented is of a 92-year-old woman who presents with increased sleeping; the initial impression is likely stroke or infection given her altered mental status and other chronic conditions. The document outlines the critical role of emergency physicians in caring for older patients and some common chief complaints like abdominal pain, confusion and electrolyte imbalances.
This document provides information on evaluating patients presenting with fatigue, weakness, and weight loss. It reviews common differential diagnoses and recommended initial laboratory tests. Four clinical cases are presented and discussed. The first case involves an 80-year-old woman who presented with hematemesis, confusion, and a 10kg weight loss over 4 months. Her initial workup revealed anemia and elevated ESR, suggesting a serious underlying condition needs to be investigated.
"Killer Drugs & The Supplement Hall of Fame" - IMMH Brazil, 2015Louis Cady, MD
In this presentation, the third of three lectures Dr. Cady delivered in São Paulo, Brazil, Dr. Cady reviews the critical patterns of interactions with numerous frequently prescribed psychotropic medications (and others). Emphasis is given on how not to commit an obvious drug-drug interaction as well as avoiding more subtle ones. The focus then shifts to supplements: which ones are the best, which ones have mental health benefits, and how to avoid interactions between conventionally used supplements and psychiatric medications.
This document provides an outline for creating an infographic on veganism, including sections for an infographic mood board, fact file mood board, font selections, titles and logos, and images.
Qualitative research involves unstructured data from interviews and observations to understand audiences rather than gather facts. It explores underlying reasons, opinions, and motivations through exploratory research. Qualitative research is useful for studying a limited number of cases in depth and provides detailed individual case information, though findings cannot be generalized. Quantitative research involves structured data from surveys and experiments to quantify problems and uncover patterns through statistical analysis of factual information. It provides reliable population data but may lack detail. Focus groups observe small discussion groups to understand genuine opinions rather than single rehearsed answers.
Qualitative research involves unstructured data from interviews and observations to understand audiences rather than gather facts. It explores underlying reasons, opinions, and motivations. Advantages are it provides detailed case information, but disadvantages are it cannot make predictions or generalizations. Quantitative research uses structured data from surveys to quantify attitudes and prove information. It provides factual data but responses may not be honest. Audience profiles consider demographics like age, gender, socioeconomic status, and psychographics to understand lifestyle values. This helps target advertising effectively.
- Unpaid HECS (Higher Education Contribution Scheme) student loan debt in Australia is predicted to exceed $70 billion by 2017, with 25% expected to never be repaid. The growing debt poses economic issues for Australia.
- Current measures aim to increase repayment rates, such as requiring Australians living overseas to register with the tax office and repay loans. However, there is no penalty for failing to register.
- The author proposes several solutions to reduce HECS debt, such as offering higher voluntary repayment bonuses, recovering debt from deceased estates, lowering the repayment threshold, and reducing loans offered to underperforming degrees. These solutions remain controversial and politically difficult.
Este documento trata sobre la comunicación. Define la comunicación como un proceso de intercambio de información entre un emisor y receptor a través de un canal y código. Explica los siete elementos de la comunicación, los niveles de comunicación (intrapersonal, interpersonal y masiva), y las barreras a la comunicación como semánticas, físicas, fisiológicas y psicológicas. Finalmente, describe brevemente cada tipo de nivel y barrera de la comunicación.
This document summarizes the key findings from a survey about veganism. The survey found that most respondents knew a little about veganism and wanted to know more about the health, environmental, and animal welfare reasons for being vegan. Common barriers to adopting a vegan diet included not knowing alternative foods and finding it difficult to give up meat. Most respondents said social media and word of mouth were effective ways to learn about veganism and indicated they would try a vegan diet for one month. The survey results will help focus the content in an informational booklet about veganism to potentially increase interest in adopting a vegan lifestyle.
The document discusses probiotics as a potential new treatment for irritable bowel syndrome (IBS). It summarizes five studies that examined the effects of various probiotic supplements on IBS symptoms like constipation. The studies showed mixed results, with some finding probiotics improved constipation and overall IBS symptoms, while others found no significant improvement. The document concludes that probiotics may help IBS, but further research is needed to determine which species, dosages, and IBS subtypes are most effective.
This document is from an Escuela de Formacion de Soldados or School for Soldier Training called "Vencedores del Cenepa". It discusses environmental issues like recycling, contamination, felling of trees, trash, and contaminated rivers. It encourages not burning garbage and quotes that "The earth is our refuge, we help protect and care since it depends the future of many generations."
This project charter outlines a research project that will analyze how to best backup and secure data on servers for ABC Corporation. The project aims to reduce costs and risks around data interruptions. Key stakeholders include the project sponsor, manager, and leads from various departments. The project will deliver a business continuation plan by analyzing backup strategies and securing data on servers, but will not include data on user systems. Major risks are a steep learning curve using new technology and potential changes in federal regulations. The project requires staff time from developers, analysts, and testers and has a first year estimated total cost of $XXX with projected benefits of $YYY.
Este documento describe los propósitos y aspectos más importantes de la comunicación oral, incluyendo conocer exactamente lo que se quiere comunicar, decirlo con el tono adecuado para que sea aceptado por el receptor, y hablar de manera que el receptor entienda. También cubre cualidades como claridad, concisión, coherencia y sencillez. Además, explica técnicas de discusión en grupo como el panel, simposium, mesa redonda y debate, y destaca la importancia de las ayudas audiovisuales para transmitir un mensaje con mayor compre
Anorexia nervosa and bulimia nervosa are eating disorders that involve disturbances in eating behavior and thoughts about body weight and shape. Anorexia nervosa is characterized by self-starvation and excessive weight loss, while bulimia nervosa involves binge eating and compensatory behaviors to prevent weight gain such as forced vomiting. Both disorders are classified in the DSM-5 and involve biological, psychological, and social factors. Treatment involves hospitalization, psychotherapy such as CBT, and sometimes pharmacotherapy to address medical complications, disordered thoughts and behaviors, and associated psychiatric conditions. Prognosis varies but early intervention tends to lead to better long-term outcomes.
Case study presentation on DM-II (1).pptxHozanBurhan
This document presents a case study of a 45-year-old Asian male diagnosed with type 2 diabetes mellitus. It discusses the epidemiology, pathophysiology, risk factors, signs and symptoms, diagnostics, and therapeutic interventions for diabetes. It also provides details of the patient's history, medications, physical exam findings, assessment, and treatment plan. The patient was started on metformin and lifestyle changes including diet, exercise, and quitting smoking. Herbal supplements like fenugreek and bitter gourd juice were also recommended. The goal is to control his blood glucose and prevent diabetes complications through proper management.
Bulimia nervosa and anorexia nervosa are eating disorders characterized by disturbed eating behaviors and thoughts. Bulimia nervosa involves recurrent binge eating and compensatory behaviors like purging to prevent weight gain, while anorexia nervosa involves self-starvation and intense fear of weight gain. Both can have medical complications and are more common in females. Treatments include cognitive behavioral therapy, family-based therapy for younger patients, and hospitalization to address medical instability.
[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)Alex J Mitchell
This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
This document discusses anorexia nervosa and refeeding syndrome. It provides details on a case of a 19 year old girl admitted with severe anorexia and a BMI of 12. The document outlines her physical condition, initial treatment plan involving gradual feeding and electrolyte replacement, and progress over her hospital stay including the need for brief assisted feeding via NG tube. It also discusses the risks, pathophysiology, and management of refeeding syndrome.
The document provides a summary of a patient case involving a 22-year-old female admitted for increasing depression symptoms. She has a history of eating disorder, depression, anxiety, and insomnia. On examination, she has a low BMI and recent weight loss. Laboratory tests show normal results. The patient is taking several psychotropic medications and has been followed by an eating disorder dietitian. The document discusses recommendations for her diet and omega-3 supplementation to support her mental health conditions.
After this presentation, you should be able to:
Critically evaluate the scientific rationale regarding dietary Na+, P, K+, and fluid restrictions in HD patients, and why these restrictions may be misguided.
Better communicate with HD patients and clinic staff the nuances of these dietary restrictions.
Promote efficacious physical activity programs for hemodialysis patients.
NACCHO 2018 National Conference – Too Deadly for DiabetesNACCHOpresentations
This document summarizes Ray Kelly's experience and research on reversing chronic disease through lifestyle interventions for Indigenous populations. It acknowledges the traditional owners of the land and introduces Ray Kelly's qualifications. It then discusses the rising rates of diabetes and heart disease, especially in Western Sydney and young Indigenous populations. Several research studies are summarized that show Indigenous peoples respond well to lifestyle programs and diabetes and cardiovascular disease can be reversed through weight loss and improved lifestyle. The document calls for more effective lifestyle programs in Aboriginal Community Controlled Health Organizations to help address chronic disease in these communities.
The document discusses the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) in India. It notes that non-communicable diseases are emerging as a leading cause of death in India. The NPCDCS was initiated in 2010 to prevent and control common NCDs through lifestyle changes, early diagnosis, treatment, and capacity building. The program aims to reduce mortality from heart disease, stroke, cancer and other NCDs. It operates in 100 districts across 21 states using strategies like health promotion, screening, affordable diagnosis and treatment, and monitoring/evaluation.
The document discusses a presentation on lifestyle medicine and exercise prescription, including goals of providing knowledge on foundational muscle physiology concepts, exploring exercise as medicine, and developing skills to write exercise prescriptions and motivate patients to change habits. Barriers to counseling patients on exercise are reviewed, along with efficacy evidence of physician counseling, and the need to better train medical students on exercise as preventive medicine.
Dr. Colin Depp, Associate Professor of Psychiatry at the University of California, San Diego and CREST.BD member, describes research on the changes, including positive ones, that occur as people grow older with bipolar disorder. He shares evidence and considerations for treatments for bipolar disorder in older adults, as well as an overview of the lifestyle and behavioral determinants of healthy aging. He also presents new research on the importance of these factors in aging well with bipolar disorder.
Colin Depp, Ph.D. is an Associate Professor of Psychiatry at the University of California, San Diego. He is also Associate Director of Research Education and Training Division of the San Diego Clinical Translational Science Institute and psychologist at the Veterans Administration Healthcare System in San Diego. His research focuses on psychosocial interventions for bipolar disorder, use of technology for behavioral change, and the determinants of successful aging in people with mental illnesses. Dr. Depp is a principal investigator or co-investigator on multiple studies and he on the Editorial Board of Bipolar Disorders.
Lifestyle Medicine: The Power of Personal Choices, North American Vegetarian...EsserHealth
Lifestyle Medicine focuses on applying behavioral and environmental principles to managing lifestyle-related health problems. Chronic diseases now account for 75% of healthcare costs in the US, many of which are strongly associated with diet and physical inactivity. While genetics play a role, the rise of these "lifestyle diseases" correlates with changes in American diets and exercise patterns over recent decades. Prospective randomized studies demonstrate that organized lifestyle interventions can significantly reduce disease incidence and healthcare costs compared to prescription medications. Lifestyle Medicine aims to educate and empower individuals to make personal choices that can transform health outcomes on both individual and societal levels.
This document discusses eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder. It provides information on the epidemiology, underlying causes, signs and symptoms, medical complications, diagnostic criteria, screening tools, treatment options, and the role of primary care providers in managing these conditions. Eating disorders typically have an onset during adolescence or young adulthood and disproportionately affect females. Treatment involves a multidisciplinary team approach including medical monitoring, nutritional counseling, and psychological therapies like CBT.
Healthy aging is a multidimensional process influenced by genetics, lifestyle, environment and healthcare factors. It involves maintaining physical and cognitive function to allow well-being in older age. Key aspects of healthy aging include regular health assessments, nutrition, exercise, managing chronic conditions, mental health, vaccination, sleep, and injury prevention. Geriatric assessments evaluate multiple health domains. Nutrition, exercise, stress management and preventing smoking and excessive drinking promote healthy aging. Public health policies also play a role by supporting factors like financial security, housing, mobility and social connections in older adults.
DrRic Using Food Choices to Control Inflammation (slide share edition)DrRic Saguil
1. The document discusses using food choices to control inflammation in the body and reduce the risk of chronic diseases like heart disease and cancer.
2. It recommends following an anti-inflammatory diet like the Mediterranean diet, which is high in vegetables, fruits, whole grains, fish and healthy fats.
3. Research studies have shown that following a Mediterranean diet is associated with reduced risk of death from all causes as well as specific diseases.
Satish K. Gupta, Ramesh C. Sawhney, Lajpat Rai , V. D. Chavan, Sameer Dani, Ramesh C. Arora,
W. Selvamurthy, H. K. Chopra, Navin C. Nanda
Indian Heart Journal 2011; 63:461-469
My STSH Scholary Article about TREATMENT of PRE-DIABETES with SSDDDr. Sutanu Patra
I had done research on "Scope of Individualistic treatment with Serially Succussed and Diluted Drugs in treating Pre-diabetic condition: an Open-label Exploratory trial – in search of Prevention of Diabetes" and this was got awarded in Short Term Studentship in Homeopathy (STSH) 2014 by Central Council for Research in Homeopathy (CCRH), Ministry of AYUSH, Govt. of India.
3. Introduction
What is Anorexia Nervosa?
Anorexia nervosa is a serious, potentially
life-threatening eating disorder characterized
by self-starvation and excessive weight loss.
90-95% are women
0.5-1% of women are affected
https://www.nationaleatingdisorders.org/anorexia-nervosa
5-20% will die from disorder
Typically appears in early-mid adolescence
6. Introduction - Pathophysiology
Multi-causal
• Genetic
• Body dissatisfaction
• Adverse life event
• Difficulty with negative emotions
• Troubled relationships
https://www.nationaleatingdisorders.org/factors-may-contribute-eating-disorders
7. Introduction - Diagnosis
Diagnostic and Statistical Manual of Mental
Disorders DSM 5
A. Restriction of energy intake relative to
requirements
B. Intense fear of gaining weight or becoming fat
C. Disturbance in the way in which one’s body
weight or shape is experienced
D. Undue influence of body weight or shape on
self-evaluation, or denial of the seriousness of
the current low body weight
Mahan, L. Kathleen (2011-08-24). Krause's Food & the Nutrition Care Process (Food, Nutrition & Diet Therapy (Krause's)) (Page 490). Elsevier Health. Kindle Edition.
8. Introduction - Diagnosis
DSM 5
• Restricting Type
• Binge-eating, purging Type
Mahan, L. Kathleen (2011-08-24). Krause's Food & the Nutrition Care Process (Food, Nutrition & Diet Therapy (Krause's)) (Page 490). Elsevier Health. Kindle Edition.
10. Introduction - Signs and Symptoms
Pediatrics
•Failure to maintain normal
development trajectory
•Delayed puberty
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596..
11. Introduction - Signs and Symptoms
Bradycardia Hypothermia
Osteopenia,
osteoporosis
Muscle/fat
wasting
Weakness
Dry hair, skin;
hair loss; lanugo,
carotenemia
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596.
12. 12
Introduction - Signs and Symptoms
https://www.urmc.rochester.edu/childrens-hospital/adolescent/eating-disorders/look-for.aspx
14. Introduction - Signs and Symptoms
food rules, excessive
chewing, moving food
around, excuses not to
eat, rigid exercise
regimen
esophagitis, GER,
vomiting, bloating,
abdominal pain,
constipation
stress, anxiety, OCD,
social withdrawal,
substance abuse,
suicide
amenorrhea, atrophic
breasts, atrophic
vaginitis
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596.
15. Introduction – Treatment & Prognosis
Options
Inpatient vs. Outpatient
Maudsley Therapy
Day treatment
Pharmaceutical
15
Ozier AD, Henry BW. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-41.
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
Multi-disciplinary care
Medical
Psychology
Social work
Nutrition
Standard Treatment
16. Introduction – Treatment & Prognosis
Research
Repetitive transcranial
magnetic stimulation
(rTMS)
Telemedicine
16Ozier AD, Henry BW. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-41.
Van den eynde F, Guillaume S, Broadbent H, Campbell IC, Schmidt U. Repetitive transcranial magnetic stimulation in anorexia nervosa: a pilot study. Eur Psychiatry. 2013;28(2):98-101.
Alternative Treatments
Biofeedback
Acupuncture
Yoga
Stress management
Spirituality
Innovative Treatment
17. Repetitive transcranial magnetic
stimulation (rTMS)
Targeted magnetic pulses to induce neuronal activity
Noninvasive
FDA approved for depression
17
http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml
18. Introduction – Treatment & Prognosis
18
Prognosis: ~50% achieve full recovery
Zipfel S, Löwe B, Reas DL, Deter HC, Herzog W. Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study. Lancet (London, England). 2000;355(9205):721–2.
19. Introduction – Admission Criteria
AFCH Admission Criteria
Weight < 75% IBW (BMI < 15.99 in adults)
Rapid wt. loss
Arrested growth and development
Temperature Hypothermia (< 96 F or 35.6 C)
Cardiovascular HR < 50 bpm (day) or < 45 bpm (night)
decreases in SBP > 20 mmHg or DBP > 10 mmHg
or increase in HR > 20 bpm
Arrhythmia, chest pain
Lab Abnormal electrolytes, anemia
Malnutrition (BUN, Creat. , Alb, BG)
Females: FSH, LH, Prl, Urine beta-hcg
Additional
Symptoms
Acute medical complications e.g. seizures
Acute food refusal, uncontrolled binge-purge
Failure of outpatient therapy
20. Introduction – Refeeding Syndrome
#1
Nutrient repletion
Insulin secretion
#4
Arrhythmia
Heart failure
Death
#2 Increase intracellular
PO4, Mg 2+, thiamine,
K+, water
#3 Depletes serum
levels
Electrolyte
imbalance
Guarda AS, Redgrave G. Chapter 228. Eating Disorders. In: McKean SC, Ross JJ, Dressler DD,
Brotman DJ, Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York,
NY: McGraw-Hill; 2012.
21. History and Physical
SS: Demographic, social, prior medical history
• 16 year old Caucasian female, high school student,
tennis & soccer player
• Recently lost classmate in motor vehicle accident
• PMH: eating disorder 2 years ago after father diagnosed
with DM
Physical Exam and Review of Systems
Vitals
Diagnostic procedures
22. History and Physical
Physical Exam and Review of Systems
• General: awake, alert, no acute distress, appears
cachectic.
• Cardiovascular: bradycardic, normal S1 and S2, no
murmurs, gallops, or rubs, 2+ peripheral pulses, <2 second
capillary refill
• Extremities: cool and mottled appearing but with good
capillary refill, no cyanosis or clubbing, no deformities, no
edema
23. History and Physical
Physical Exam and Review of Systems
• Skin: no rashes or lesions noted, lanugo noted on arms
• NFPE: dark circles around her eyes, prominent clavicle,
square shoulders with bones prominent, and very little
muscle definition in her quads with prominent patella.
24. History and Physical
SS: Demographic, social, prior medical history
Physical Exam and Review of Systems
Vitals
• Bradycardia: sitting pulse 43, standing pulse 60
• BP: 100/69 mmHg
• Actual Weight: 40.279 kg (88 lb 12.8 oz)
• Height: 166 cm (5' 5.35")
• BMI (Calculated): 14.65 kg/m2
Diagnostic procedures: none
25. Introduction – Admission Criteria
✔
✔
✔
✔
70.6% IBW
sitting pulse 43,
standing pulse 60
BUN 22 H
Glucose 84 H
Magnesium 2.6 H
Inability to
maintain growth
trajectory
AFCH Admission Criteria
Weight < 75% IBW (BMI < 15.99 in adults)
Rapid wt. loss
Arrested growth and development
Temperature Hypothermia (< 96 F or 35.6 C)
Cardiovascular HR < 50 bpm (day) or < 45 bpm (night)
BP decreases in SBP >20 mmHg or Diastolic
BP > 20mmHg or increase in HR > 20 bpm
Arrhythmia, chest pain
Lab Abnormal electrolytes, anemia
Malnutrition (BUN, Creat. , Alb, BG)
Females: FSH, LH, Prl, Urine beta-hcg
Additional
Symptoms
Acute medical complications e.g. seizures
Acute food refusal, uncontrolled binge-purge
Failure of ambulatory/outpatient therapy
27. Hospital Course
Anthropometrics
• Height: 166 cm (5' 5.35") (69%ile, Z = 0.65)
• Admission Weight: 40.279 kg (0.78 %ile, Z = -2.42)
• BMI-for-age: 14.62 kg/m2 (0.03 %ile, Z = -3.46)
• IBW: 57 kg (based on BMI-for-age at the 50th %ile) -
70.6% IBW
Total loss of 7.439 kg (15.6%) over ~1 year.
31. Hospital Course
Nutrition History
• Working with outpatient MD and RD to manage her
anorexia for 2 years.
• Interest in food increased
• Gradually restricted her intake to only “healthy” foods;
eliminated simple carbs, bread/cereals, fried foods,
butter/oils, desserts.
32. Hospital Course
Nutrition History
• Portion sizes decreased; only small bites of meals; very
small plates/bowls.
• Previous goal was 3000-3600 kcal/d and to eat 3 meals
with 3 snacks daily. She is not counting calories.
33. Hospital Course
Dietary intake, ~2-4 weeks PTA:
• Breakfast: yogurt, granola, OJ/AJ, and fruit
• AM Snack: Carnation Instant Breakfast with whole milk
(school days)
• Lunch: Peanut butter or hummus with crackers and
mixed vegetables or apples with peanut butter and
cheese. 8-10 oz Kefir shake and a granola bar on most
days (Kind, Lara, or Clif bars)
• PM Snack: handful of nuts
34. Hospital Course
Dietary intake, ~2-4 weeks PTA:
• Dinner: Last night had chicken, quinoa, broccoli, and
cheese casserole. 1/2-1 cup portion. 1 cup milk and a
side of fruit
• HS Snack: 1 can Ensure or Teddy Grahams with
applesauce or banana
• Fluids: Does not drink much water and did not recall a
fluid goal.
35. Hospital Course
Physical assessment
Chronic (>3 months), Severe Calorie-Protein Malnutrition
• Intake <25-50% of needs to support weight restoration
• BMI-for-age z-score of -3.46 with a change of 2.22 over 1
year.
• Total weight loss of 7.439 kg (15.6%) over 1 year
Bradycardia resting heart rate in 30-40's
Amenorrhea (LMP ~2 years PTA)
36. Hospital Course
Estimated needs based on 40.3 kg
• Initiate at 1400 kcal/day and gradually advance by 200 to
400 kcal/d to goal of 3400 kcal/day
• 1 to 2 g/kg/day protein
• 1900 to 2860 mL/day fluid - (1.0 - 1.5 x maintenance
fluids) using Holiday-Segar Method
Diet order: General, RS-2
37. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Basic Chem
Magnesium
Phosphorus
GI/Liver
CBC
Anemia (B12 + Iron)
Urinalysis
38. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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39. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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40. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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41. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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42. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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43. Hospital Course – Lab Data
Day 1-3: every 12 hours to monitor for refeeding syndrome
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Carbon
Dioxide
mmol/L 30 H 28 28 25 30 H 24 27 26 27
Anion Gap
mEq/L 7 6 L 6 L 9 6 L 9 7 7 8
BUN
mg/dL 22 H 20
Mg mg/dL 2.6 H 2.3 H 2.3 H 2.3 H 2.3 H 2.2 2.3 H 2.1 2.4 H
Phosphate
mg/dL 3.6 3.7 3.5 3.7 3.4 4 4.2 3.8 3.4
Protein,
total g/dL 3.9 L 6.5
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45. Hospital Course
Nutritional Diagnosis: Malnutrition related to disordered
eating patterns with a history of anorexia nervosa as
evidenced by total weight loss of 15.6% over 1 year,
change in BMI-for-age Z-score of 2.22, bradycardia with
resting heart rate in the 40's and amenorrhea.
46. Hospital Course
Intervention: Eating Disorder Protocol
Monitoring/Evaluation: Calorie counts, labs,
anthropometrics, meal plan compliance, liberalization of
activity restrictions
47.
48. Clinical Practice Guidelines
Treatment plan = Eating Disorder Protocol
• Admission Criteria
• Initial discussion – matter of fact, no bargaining, avoid trigger
words “calories or weight”, continuous supervision
• Health care team – meet within 24-48 hrs of admission, rounds
• Vital signs and monitoring – every 4-8 hrs, risk for refeeding
syndrome
49. Clinical Practice Guidelines
Treatment plan = Eating Disorder Protocol
• Activity Restriction
• Bed rest sit up (bed, chair) wheel chair walk
• Constant supervision
• Fluids, meds – IVF, I/O q 4H, multivitamin, Miralax
• Lab tests – EKG, CBC, CMP, Mg, Phos, UA
• Meal planning – Initiate slowly, pt. identifies 3 likes, 3 dislikes
• Meal and snack procedures – 3 meals, 0-3 snacks, eat 100%
within 30 minutes
52. Hospital Course – Milestones
Day 1
•Initial Assessment, likes/dislikes, overview of treatment
•Initiate at 1400 kcal
•Physical Activity: none
•PhosNaK 2x/day
Day 2
•Goal: advanced to 1600 kcal, 3 meals + PM snack
•Physical Activity: none
•PhosNaK 2x/day
Day 3
•Goal: advanced to 1800 kcal, added AM snack
•Mg slightly elevated, Phos & K WNL
Day 4
•Goal: advanced to 2200 kcal
•Phos low PhosNaK 3x/day
Day 5
•Goal: advanced to 2600 kcal
•Labs WNL
53. Hospital Course – Milestones
Day 6
•Goal: advanced to 3000 kcal
•Labs WNL
•Physical activity: 30 m in chair
Day 7
•Goal: remained at 3000 kcal
•Physical Activity: used wheel chair today
Day 8
•Reassessment
•Goal: advanced to 3400 kcal – goal met
•Physical activity: 1 lap around unit + wheelchair ride today
•Sitter during meals, video rest of time
Day 9
•Goal: 3400 kcal
•Labs WNL
•Physical activity: 2 laps around unit
54. Hospital Course – Milestones
Day 10
•Goal 3400 kcal
•Physical activity: 3 laps around unit
Day 11
•Goal 3400 kcal
•Physical Activity: 4 laps around unit, continued until DC
Day 12
•Goal 3400 kcal
•Sitter not needed, discontinued 24-hour supervision
•Discontinued daily labs
Day 13
•Discharge to Rogers Memorial Hospital: inpatient eating disorder
treatment for children and teens
56. Hospital Course
Discharge planning and criteria
Required 72 hours prior to DC
• Resolution of orthostatic symptoms
• HR > 40 for 24 hours
• Stable labs
• Disposition (inpatient vs outpatient)
• Weight stabilization or weight > 75%
IBW
Appointments with PCP, Outpatient RD,
Eating disorder MD, Behavioral Health
Day 12
• HR: 64 bpm
• Resp: 16 breaths per min.
• BP: 103/57 mmHg
• Temp: 36.8 ºC (98.3 ºF)
• Weight: 43.092 kg (95 lb)
75.6% IBW
57. Hospital Course
Patient outcome
• Discharge to inpatient eating disorder facility
• Continue 3400 kcal meal plan per eating disorder
protocol.
• Continue collaboration with outpatient PCP and
behavioral health
58. Application to Practice
Signs of disordered eating
• Diet mentality
• Strict food “rules”
• Compensatory behaviors
Communicate with health care team
Request referrals to behavioral health
Resources…learn more
• Academy Position Statement
• Life Without Ed by Jenni Schaefer
• Intuitive Eating by Eveleyn Tribole, RD and Elyse Resch
RD
60. References
60
1. National Eating Disorders Association: Anorexia Nervosa. https://www.nationaleatingdisorders.org/anorexia-nervosa.
Accessed March 1, 2016.
2. Mahan, L. Kathleen (2011-08-24). Krause's Food & the Nutrition Care Process (Food, Nutrition & Diet Therapy
(Krause's)) (Page 490). Elsevier Health. Kindle Edition.
3. Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics.
2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.
4. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013.
doi:10.1176/appi.books.9780890425596.
5. Ozier AD, Henry BW. Position of the American Dietetic Association: nutrition intervention in the treatment of eating
disorders. J Am Diet Assoc. 2011;111(8):1236-41.
6. Van den eynde F, Guillaume S, Broadbent H, Campbell IC, Schmidt U. Repetitive transcranial magnetic stimulation
in anorexia nervosa: a pilot study. Eur Psychiatry. 2013;28(2):98-101.
7. Zipfel S, Löwe B, Reas DL, Deter HC, Herzog W. Long-term prognosis in anorexia nervosa: lessons from a 21-year
follow-up study. Lancet (London, England). 2000;355(9205):721–2.
8. Guarda AS, Redgrave G. Chapter 228. Eating Disorders. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ,
Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York, NY: McGraw-Hill; 2012.
http://accessmedicine.mhmedical.com.ezproxy.library.wisc.edu/content.aspx?bookid=496&Sectionid=41304219.
Accessed March 11, 2016.
9. Heimburger DC. Malnutrition and Nutritional Assessment. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J,
Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015.
http://accessmedicine.mhmedical.com.ezproxy.library.wisc.edu/content.aspx?bookid=1130&Sectionid=63653604.
Accessed March 11, 2016.
Editor's Notes
Hi my name is Anita and I’m going to be going over the nutritional management of anorexia nervosa. My preceptors are Laura Bodine and Rachel Parks
Here is an overview of my talk today. I will be giving you an introduction to anorexia and going over research trends in treatment options. Then I’ll dive into the case study starting with the HP, hospital course and lastly application to practice
What is Anorexia Nervosa? It is serious, potentially life threatening eating disorder characterized by self-starvation and excessive weight loss.
The majority of people with anorexia are women, ~90%, and it effects about 1% of all women.
Onset is typically in early to mid adolescence.
5-20% mortality rate
We all know what anorexia looks like on the outside, but what about the disordered thoughts and behaviors that drive it?
The following 2 slides are screen shots of blogs I’ve found detailing some of the ”commandments” or tips to the pro ana or anorexia lifestyle
https://theproanalifestyleforever.wordpress.com
https://missanamia.wordpress.com/tips-pro-ana/
So what causes anorexia?
Anorexia can develop from many things.
It can be genetic in that there’s a disruption in the normal hunger/satiety signaling. Some patients report always feeling full or never feeling hungry
Body dissatisfaction/thin-ideal internalization commonly observed in people who engage in activities like wrestling, gymnastics or ballet where body weight is associated with performance
Inability to deal with adverse life event
Difficulty expressing negative emotions depression, anxiety, anger, stress, loneliness
Difficulty with troubled relationships
As dietitians we can identify disordered eating, but diagnosis is done by a physician.
Here is the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) set by the American Psychiatric Association
Restriction of energy intake relative to energy requirements for normal growth and body processes.
Intense fear of gaining weight or of becoming fat
Disturbance in the perception of one’s body weight or shape, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
In the adult population, severity is categorized by BMI
In the pediatric population, eating disorder are marked by the inability to maintain normal growth trajectory or development and puberty
Here is a picture of lanugo, fine body hair growth in attempt to conserve body heat
This picture also illustrates a common area of muscle wasting seen in malnutrition
The picture on the left illustrates carotenemia which is caused by a defective conversion of carotene to vitamin A
Behavioral signs include
GI signs
Psychologal signs
And hormonal signs
Here is an outline of standard treatment options.
Inpatient or outpatient therapy is determined by the medical stability of the patient.
Maudsley Therapy is a family-based interventions in which parents with the help of a therapist take the responsibility of weight and growth restoration while the patient undergoes therapy to address root causes of the eating disorder developing a healthy identity. As weight recovery progresses, the adolescent is tasked with gradually assuming responsibility for eating again.
Day treatment – 8-10 hours at facility with meals and therapy.
There are no FDA approved medications for anorexia, but meds like SSRI’s are prescribed to address comorbidities e.g. anxiety, stress
No matter what setting is used, are is usually multi-discplinary involving a physician, psychology, social work and nutrition
In addition to standard treatment, here are some emerging and alternative treatment options
rTMS, type of non-invasive brain stimulation therapy in which a patient receives targeted magnetic pulses to the prefontal cortex to induce neuronal activity. It’s FDA approved to treat depression, but researchers are looking into its application in eating disorders. In a study published in 2013 by European Psychiatry, rTMS was observed to induce significant decreases in anxiety and feelings of fullness or fatness.
Telemedicine is a growing avenue in healthcare as technology and internet access increase. In the treatment of eating disorders, patients and families meet with therapists via video chat and communicate via phone or secure messaging.
Alternative medicine can be explored when standard treatment alone is not successful. Some examples of alternative treatments are biofeedback, acupuncture, yoga, stress management, spirituality, religion
What is the prognosis for anorexia? It’s expected that only 50% achieve full recovery
This is the AFCH criteria for admission
Admission is recommended for patients who meet at least 1 of the following
Lastly, I want to review refeeding syndrome as it’s one of the main reasons why we admit for medical stabilization.
Nutrient repletion stimulates insulin secretion for fat, protein and glycogen synthesis.
The increased cellular activity requires an influx of phosphate, mg, k, thiamine and water into cells.
But in doing so, serum levels (which are already low) become depleted
And can cause electrolyte imbalances which can lead to arrhythmia, heart failure and subsequently, death.
DM diagnosis – all family paying attention to what they were eating
Family decided to manage at home
Note abnormalities, otherwise normal ROS
Vitals…
no lines, lab studies or radiology on admission
Lanugo – fine body hair growth
NFPE not officially done, but she did present with the following characteristics
Note abnormalities, otherwise normal ROS
Vitals…
no lines, lab studies or radiology on admission
This is how SS’s disposition met admission criteria
SS has been working with outside MD and clinical nutrition in the ambulatory setting to manage her anorexia since 1/2014. Parents recall at that time SS's interest in food increased and she had a desire to eat a healthier diet. Gradually over time SS has restricted her intake to only perceived healthy foods by eliminating simple carbohydrates, bread/cereals, fried foods, butter/oils, and desserts. Portion sizes over time have also decreased and she will take only small bites of meals and use very small plates/bowls
SS has been working with outside MD and clinical nutrition in the ambulatory setting to manage her anorexia since 1/2014. Parents recall at that time SS's interest in food increased and she had a desire to eat a healthier diet. Gradually over time SS has restricted her intake to only perceived healthy foods by eliminating simple carbohydrates, bread/cereals, fried foods, butter/oils, and desserts. Portion sizes over time have also decreased and she will take only small bites of meals and use very small plates/bowls
Notice the emphasis on ”healthy” foods
Often didn’t drink CIB, would leave in locker too long
Bradycardia with resting heart rate during nutrition interview in 30-40's
Initial intake goal based on current intake
RS-2 – all meals planned by nutrition techs, patient not allowed to select meals as part of protocol
Tests: Basic Chem, GI/Liver, CBC, Anemia (B12 + Iron), Urinalysis
Abnormal Values:
CO2: consistent with bradycardia? – respiratory acidosis, resolved by end of treatment
Anion gap:
BUN: slightly elevated, stress on kidneys r/t heart; nut implications: kidney damage
Mg: refeeding? Trend to run high due to supplementation
Pro, total: inflammation, stressed state; resolved once protocol started
Tests: Basic Chem, GI/Liver, CBC, Anemia (B12 + Iron), Urinalysis
Abnormal Values
CO2: consistent with bradycardia
Anion gap: respiratory acidosis
BUN: slightly elevated, stress on kidneys r/t heart; nut implications: kidney damage, malnutrition
Mg: dehydration, kidney issues. Continued to trend high due to supplementation
Pro, total: inflammation, malnutrition; resolved once protocol started
Tests: Basic Chem, GI/Liver, CBC, Anemia (B12 + Iron), Urinalysis
Abnormal Values
CO2: consistent with bradycardia
Anion gap: respiratory acidosis
BUN: slightly elevated, stress on kidneys r/t heart; nut implications: kidney damage, malnutrition
Mg: dehydration, kidney issues. Continued to trend high due to supplementation
Pro, total: inflammation, malnutrition; resolved once protocol started
Tests: Basic Chem, GI/Liver, CBC, Anemia (B12 + Iron), Urinalysis
Abnormal Values
CO2: consistent with bradycardia
Anion gap: respiratory acidosis
BUN: slightly elevated, stress on kidneys r/t heart; nut implications: kidney damage, malnutrition
Mg: dehydration, kidney issues. Continued to trend high due to supplementation
Pro, total: inflammation, malnutrition; resolved once protocol started
Tests: Basic Chem, GI/Liver, CBC, Anemia (B12 + Iron), Urinalysis
Abnormal Values
CO2: consistent with bradycardia
Anion gap: respiratory acidosis
BUN: slightly elevated, stress on kidneys r/t heart; nut implications: kidney damage, malnutrition
Mg: dehydration, kidney issues. Continued to trend high due to supplementation
Pro, total: inflammation, malnutrition; resolved once protocol started
Tests: Basic Chem, GI/Liver, CBC, Anemia (B12 + Iron), Urinalysis
Abnormal Values
CO2: consistent with bradycardia
Anion gap: respiratory acidosis
BUN: slightly elevated, stress on kidneys r/t heart; nut implications: kidney damage, malnutrition
Mg: dehydration, kidney issues. Continued to trend high due to supplementation
Pro, total: inflammation, malnutrition; resolved once protocol started
Tests: Basic Chem, GI/Liver, CBC, Anemia (B12 + Iron), Urinalysis
Abnormal Values
CO2: consistent with bradycardia
Anion gap: respiratory acidosis
BUN: slightly elevated, stress on kidneys r/t heart; nut implications: kidney damage, malnutrition
Mg: dehydration, kidney issues. Continued to trend high due to supplementation
Pro, total: inflammation, malnutrition; resolved once protocol started
Mostly supplements to prevent refeeding and address deficiencies
PhosNaK – risk for refeeding
Multivitamin – address nutrient deficiencies
Polyethylene glycol – anticipate constipation
Evidenced-based practice guide is put together by an interdisciplinary work group comprised of nutrition, psych, nursing, pharmacy and physicians
This practice guidelines is reviewed every 2 years
Initial discussion: avoid “food, calories or weight”. Treatment = medicine, nourishment, energy. Child psych
Meal planning: increase by 200-400 kcal/day
If meal not eaten, patient must drink Ensure or Ensure via NG
Thiamine supplement in adults
RD/DTR plans all meals, no meal replacements or sharing food
Set meal and snack times to minimize anxiety over meals
20 min for snacks
This is the meal replacement guideline.
Weight, lab changes, phosnak supplement changes
Weight, lab changes, phosnak supplement changes
Weight, lab changes, phosnak supplement changes
Conclusion and application to clinical practice
What should we take away from this case? My key takeaway is the importance of eating behaviors in nutrition i.e. how we eat (behaviors, beliefs) is just as important as what we eat. Even though we may not diagnose or treat eating disorders, we should be able to recognize disordered eating and potential for eating disorder. Some signs of disordered eating include:
When we find disordered eating, communicate with health care team, request referrals to behavioral health
I also wanted to point out some resources to learn more…
Position statement describes role of RD in treatment of ED
Life without ed – written by a women who details her journey of recovery, interesting as she likens her ED to an abusive relationship or “Ed voice”
Intuitive eating – written by two dietitians who are considered leaders in mindful eating
Sources:
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.books.9780890425596.
Rosen DS. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2010;126(6):1240–1253. doi:10.1542/peds.2010-2821.