Malnutrition, Weight Loss and Eating Disorders Clinical Pathway — ICU and Inpatient

History and Physical

Review of systems and physical exam will guide the differential diagnosis and the estimate of the degree of malnutrition and management.

Evaluate for signs of weight loss caused by infection, GI illness, thyroid disease or inadequate caloric intake as well as signs of refeeding syndrome.

History

Weight Loss	Amount of weight loss and time period Does patient report intentional weight loss? Does the patient have a goal of desired weight?
Food Intake	Recent typical 24-hour food recall This can be helpful to determine at what caloric prescription it is safe to initiate the protocol Eating/diet rules Vegetarianism Veganism Food groups avoided Skipping meals, etc.
Behaviors	Purging Bingeing Diet pills Laxatives
Exercising	Amount of exercising Sports Obsessive repetitive activities (always standing, etc.)
SHADESS	Assess for behavioral co-morbidities

Review of Systems — Malnutrition Related

Constitutional	Fatigue Sleepiness Stamina during sports
Lungs	Chest pain Shortness of breath
Cardiovascular	Chest pain
Endocrine	Menarche, last menstrual cycle Oral contraceptive pill use Feeling cold or hot
GI	Abdominal pain Constipation, diarrhea Reflux, hematemesis
GU	Dark urine
Musculoskeletal	Weakness
Neurologic	Dizziness Headache
Skin	Cold intolerance Easy bruising Hair loss Scars
Psychiatric	Mood changes Ability to concentrate Withdrawn from friends and social activities Suicidal thinking or risk
Hematologic	Easy bruising
Allergic	Food allergies (confirm)

Physical Exam

Skin	Dryness Lanugo Scars Bruises Edema or acrocyanosis
CVS	Low heart rate Hypotension Arrhythmias Orthostatic changes
Oral	Enamel decay Parotid enlargement
Affect	Flat Anxious Withdrawn Agitated

Complications — Every Organ System Can be Affected

Constitutional	Cachexia Fatigue Hypothermia
Cardiovascular	Bradycardia ECG changes such as prolonged QTc Increased PR interval and other arrhythmias (due to electrolyte abnormalities) Pericardial effusion (due to refeeding syndrome) Mitral valve prolapse Hypotension Orthostatic changes
Gastrointestinal	Dyspepsia GERD Delayed gastric emptying Constipation Rectal prolapse Superior mesenteric artery syndrome
Endocrine	Amenorrhea Low testosterone level Euthyroid sick syndrome Decreased libido Puberty delay Growth retardation/stunting Elevated cortisol level Poor diabetes control
Bone	Osteopenia/osteoporosis Stress fractures
Renal	Dehydrationazotemia Renal failure Pseudo Barter’s (when purging behaviors) kidney stones Impaired urine concentration
Skin	Acrocyanosis Lanugo Hair loss Edema (refeeding syndrome) Orange skin discoloration (carotenoderma) Poor wound healing
Neurologic	Seizures (hyponatremia) Cognitive decline Decreased attention span Dizziness Peripheral neuropathy Cerebral atrophy
Mental health	Depression Anxiety Obsessive-compulsive disorder
Hematologic	Bone marrow atrophy Anemia Neutropenia Thrombocytopenia Easy bruising
Fluids/Electrolytes	Hypo or hypernatremia Hypokalemia Hypophosphatemia Metabolic alkalosis Hypoglycemia Refeeding syndrome
Hepatic, Pancreas	Elevated transaminases Elevated amylase Elevated lipase Gallstones
Muscular	Muscle wasting Weakness
Pulmonary	Spontaneous pneumomediastinum/pneumothorax Pulmonary muscle wasting

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Malnutrition, Weight Loss and Eating Disorders Clinical Pathway — ICU and Inpatient

History and Physical

History

Review of Systems — Malnutrition Related

Physical Exam

Complications — Every Organ System Can be Affected

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Innovation and your child

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Malnutrition, Weight Loss and Eating Disorders — History and Physical Examination — Clinical Pathway: ICU and Inpatient

Malnutrition, Weight Loss and Eating Disorders Clinical Pathway — ICU and Inpatient

History and Physical

History

Review of Systems — Malnutrition Related

Physical Exam

Complications — Every Organ System Can be Affected