Low BMI patient

[June11]

Just curious, if you had a 30yo patient present to you in family medicine for an establishing visit with abdominal pain for one year causing low appetite and a BMI of 14 what would you do? She presented somewhat paranoid but denies drug use. Notes depression with suicide attempt 5 years ago. Exam normal other than obviously underweight. No reported body image issues. Not on any medications, no known records, denies chronic conditions. Do you order imaging/labs then, send to ER, send to UC, direct admit? We’re in an underserved community with one hospital. Thoughts??

[SedRate]

Not FM, so this is more of a brain exercise for me. I apologize if this isn't extremely helpful. 

The first thing that comes to mind is cancer but unlikely in a young person. Any constitutional symptoms? Change in bowel habits? FH cancer? Exercise a lot? Does the pt look healthy or unhealthy/cachectic? Smoker? What do you mean by paranoid? 

What are her vitals? Is she able to maintain good fluid intake? 

If nothing alarming comes up, I'd start with a KUB, TSH/T3T4, CBC, and CMP.

Edited August 31, 2023 by SedRate

[June11]

3 minutes ago, SedRate said:

Not FM, so this is more of a brain exercise for me. I apologize if this isn't extremely helpful. 

The first thing that comes to mind is cancer but unlikely in a young person. Any constitutional symptoms? Change in bowel habits? FH cancer? Exercise a lot? Does the pt look healthy or unhealthy/cachectic? Smoker? What do you mean by paranoid? 

What are her vitals? Is she able to maintain good fluid intake? 

If nothing alarming comes up, I'd start with a KUB, TSH/T3T4, CBC, and CMP.

No other symptoms reported. HR 94, BP normal. Looks very unhealthy. Noticed she was extremely underweight before even looking at the vitals. No smoking history. 
As for paranoid- continuously looking around the room and not listening to my questions

[rev ronin]

With a BMI of 14, that woman likely needs inpatient care--as in, we don't deal with that low of BMI in residential or outpatient eating disorders care. BUT, assuming that's not something the patient will consent to and/or won't have a bed right away, let's think about stuff you can do outpatient to make the best referral.

And yes, an eating disorder should be high on your differential.  Administer and score an EAT-26 (https://www.eat-26.com/) and feel free to let me know what you find. Just because a patient denies body image issues doesn't rule out an ED--could very well still have AN and be lying about it (Remember Dr. House's rule...) or ARFID. It's also not clear from OP wording if you actually asked... or if patient didn't bring it up. Always, with a new patient, especially high or low BMI, use a one-question ED screen: "How is your emotional relationship with food?" and then if anything other than a reassuring answer, give 'em an EAT-26 or one of the other tools.

Administer orthostatic VS (lying x5m, vs, stand, 2m, vs) and see if there's anything going on.

I like the labs and imaging above, but would add Mag, Phos, and pre-albumin, as well as a UA+micro and UDS. Oh, and urine hCG. I'm sure she's probably not cycled in a year or more--did you cover that in your history?--but get one anyways.

Physical exam for self-injurious behavior--arms, thighs, belly for scratches, cuts, or burns, whether fresh or healed. WHERE is the abdominal pain? Generalized? I'd slap my POCUS on her in a heartbeat--on such a low BMI patient there's going to be nothing to obscure your view.  Also, get a 12-lead.

I strongly suspect the seeming paranoia is due to starved brain. Her prefrontal cortex is probably browned out, so she's thinking with reptile brain in charge. There's also probably co-occurring trauma, and quite possibly a PTSD diagnosis for a reason you don't yet understand, but you need to treat the nutritional status before mental health care makes sense.

DM me which state this is in, and I'll make a recommendation for closest, best inpatient for nutritionally challenged. MOST HOSPITAL DIETITIANS DO NOT KNOW HOW TO HANDLE THIS. So. San Diego and Denver are the two I would send people to here in the West... not sure about other places, but I can find out.

 

[June11]

8 hours ago, rev ronin said:

With a BMI of 14, that woman likely needs inpatient care--as in, we don't deal with that low of BMI in residential or outpatient eating disorders care. BUT, assuming that's not something the patient will consent to and/or won't have a bed right away, let's think about stuff you can do outpatient to make the best referral.

And yes, an eating disorder should be high on your differential.  Administer and score an EAT-26 (https://www.eat-26.com/) and feel free to let me know what you find. Just because a patient denies body image issues doesn't rule out an ED--could very well still have AN and be lying about it (Remember Dr. House's rule...) or ARFID. It's also not clear from OP wording if you actually asked... or if patient didn't bring it up. Always, with a new patient, especially high or low BMI, use a one-question ED screen: "How is your emotional relationship with food?" and then if anything other than a reassuring answer, give 'em an EAT-26 or one of the other tools.

Administer orthostatic VS (lying x5m, vs, stand, 2m, vs) and see if there's anything going on.

I like the labs and imaging above, but would add Mag, Phos, and pre-albumin, as well as a UA+micro and UDS. Oh, and urine hCG. I'm sure she's probably not cycled in a year or more--did you cover that in your history?--but get one anyways.

Physical exam for self-injurious behavior--arms, thighs, belly for scratches, cuts, or burns, whether fresh or healed. WHERE is the abdominal pain? Generalized? I'd slap my POCUS on her in a heartbeat--on such a low BMI patient there's going to be nothing to obscure your view.  Also, get a 12-lead.

I strongly suspect the seeming paranoia is due to starved brain. Her prefrontal cortex is probably browned out, so she's thinking with reptile brain in charge. There's also probably co-occurring trauma, and quite possibly a PTSD diagnosis for a reason you don't yet understand, but you need to treat the nutritional status before mental health care makes sense.

DM me which state this is in, and I'll make a recommendation for closest, best inpatient for nutritionally challenged. MOST HOSPITAL DIETITIANS DO NOT KNOW HOW TO HANDLE THIS. So. San Diego and Denver are the two I would send people to here in the West... not sure about other places, but I can find out.

 

Thank you for such a detailed answer. I was putting this out there to see our role in primary care seeing such a malnourished patient. So basically I sent this patient to the ER with hopes she would be admitted or at least transferred…the ER basically told the patient this was an outpatient work up and they’d “do it” but really I should have done it. The patient then signed out AMA without workup. I’m bringing her back in to clinic next week for a traditional work up. But my thoughts were severe AN, HIV, or cancer requiring full workup and/or admission. Once I saw the notes from the ED I gave the patient a call and will be seeing them in clinic next week. She was a poor historian so there’s not much of a know history that she shared with me. When I’d ask a question I truly did get the bare minimum answer but she denied any disordered eating or poor relationship with food. Generalized abdominal pain, no diarrhea/blood in stool. Basically complained of severe lack of appetite. PE no scarring on arms, no needle marks, nothing I could see. My plan is blood work as above, UA/HCG, ECG, CT chest and CT abd/pelvis. I like the idea of the EAT-26 so I will likely do that. We’re on the west coast but decreased resources available in our county and I don’t believe the patient has very reliable transportation.

[Mayamom]

How alarming.   Could you directly admit skip the ER?  Other thoughts does she have enough $$ for food.  Maybe  social service consult is needed.   Can you get permission to speak with a family member to get more history?   Abuse situation?

[ventana]

Ct chest abd and pelvis with po and iv contrast 

general labs (cmp, cbc, celiac, esr?, tsh, t3, t4)

Psych eval 

consider gi consult, swallow study, gastrointestinal c emptying study 

 

 

fyi you were not wrong to do ER.  Could have done stat labs to maybe avoid. 
 

rule out life threats, get DDx, do basic work up then referr out.  Likely psych but this is a dx of exclusion. 

[rev ronin]

I agree psych referral might be helpful... if you have resources. Not sure about how well Psych NPs in general are educated on EDs, but at The Emily Program in Washington State, we have 2 MD psychiatrists, and about 6-8 Psych NPs. They're all awesome, but I can't guarantee that J. Random Psych ARNP will be.

Bottom line? This patient is SICK. It's been a slow sickness, but something is massively disrupting protein-calorie system here. Most homeless people don't struggle with maintaining BMI--the one thing they routinely get offered (if begging) is food. So, if not AN, ARFID, cancer, or drugs... I'm not sure what it might be, but I like the GI referral idea. HIV makes sense, but full-blown AIDS is so rare anymore, and I have genuinely never seen a case in outpatient/family med, it'd fallen off my differential.

If she has Medicaid, you can sic your hypothetical social worker on getting a single case agreement with one of the out of state inpatient eating disorders practices.  I know TEP will do a medical intake evaluation without regard to insurance status.

If she won't eat because she's full, you could try reglan. Extrapyramidal symptoms are not common in 30 year olds, but there's still an art to it and I certainly wouldn't be comfortable using that drug for appetite promotion for the first time based on some Internet advice.

Good luck...

[iconic]

I would involuntary commit the patient to psych. Crazy that ED let her go

Edited September 5, 2023 by iconic

[ventana]

33 minutes ago, iconic said:

I would involuntary commit the patient to psych. Crazy that ED let her go

nope

sounds like they are competent - think is she had some digestive issue that caused this.  you just wrongly sectioned a patient...... would be a mistake 

[iconic]

11 minutes ago, ventana said:

nope

sounds like they are competent - think is she had some digestive issue that caused this.  you just wrongly sectioned a patient...... would be a mistake 

Patient does not need to be incompetent (which btw is a global legal determination). They are likely anorexic and likely to deteriorate without treatment. If they are willing to go voluntary for treatment, then that would be the way to go. However, if there are no resources then that might be the only way for them to get into treatment. You don’t have the resources as an outpatient provider to figure out the treatment situation for the patient. 

Edited September 5, 2023 by iconic

[ventana]

10 hours ago, iconic said:

Patient does not need to be incompetent (which btw is a global legal determination). They are likely anorexic and likely to deteriorate without treatment. If they are willing to go voluntary for treatment, then that would be the way to go. However, if there are no resources then that might be the only way for them to get into treatment. You don’t have the resources as an outpatient provider to figure out the treatment situation for the patient. 

Sectioning someone with out knowing the Dx is a minefield I would never ever walk into.  Early closure has you thinking anorexia, but what else is on DDx?   You can’t just pick one and run with it.   STAT labs to rule out life threats, if stable urgent out patient work up.  If not then ER—>admission.   
 

I would encourage you to reread original post.  New patient to family clinic.  Walked in on own, sectioning someone in the first 30-60 mins of a brand new appointment whom is not floridly psychotic, suicidal or homicidal who has a medical finding (bmi 14 with abd pain) would be impressive indeed.   This is not a patient I would want to defend my decision to section before medical board. “Why did I sectioned them instead of doing a prudent medical work up?”  
That’s just me though.   

[iconic]

1 hour ago, ventana said:

Sectioning someone with out knowing the Dx is a minefield I would never ever walk into.  Early closure has you thinking anorexia, but what else is on DDx?   You can’t just pick one and run with it.   STAT labs to rule out life threats, if stable urgent out patient work up.  If not then ER—>admission.   
 

I would encourage you to reread original post.  New patient to family clinic.  Walked in on own, sectioning someone in the first 30-60 mins of a brand new appointment whom is not floridly psychotic, suicidal or homicidal who has a medical finding (bmi 14 with abd pain) would be impressive indeed.   This is not a patient I would want to defend my decision to section before medical board. “Why did I sectioned them instead of doing a prudent medical work up?”  
That’s just me though.   

I must have a different perspective working in psychiatry. Patients are involuntary committed all the time for much less, and I am not aware of ANY board actions against medical providers for improperly committing someone (for one, if they are improperly committed, they will be promptly released on admission) . On the other hand, plenty of PAs/MDs have ended up in hot waters for not commiting someone who later ended up passing which could have been prevented with an inpatient admission. Someone with a BMI of 14 is likely cognitively impaired as evidenced by their paranoia, depressed mood, being an unreliable historian, not eating and signing out of a hospital AMA. Anorexia is the most deadly psychiatric disorder and a patient with such a low BMI may deteriorate very quickly. I would certainly not start trying to manage someone's severe anorexia as an outpatient psych provider, much less a PCP with no experience in eating disorders.

Edited September 6, 2023 by iconic

[ohiovolffemtp]

From the EM point of view:

• this is a chronic condition - reported as at least 1 year duration.  While the patient is clearly sick, it feels like more appropriate for an initial OP work-up then a direct admit.  
• some of diagnostics suggested: celiac, HIV, etc. are not done from the ED.
• ED mental health evals are focused on suicidality, homicidality, and acute psychosis.  Nothing that's been written so far would support a mental health hold.

My reco for OP workup would be labs: CMC, CMP, mag, thyroid, UA, UDS, urine HCG.  CT abd would depend on physical exam findings and whether the patient's kidney function would support IV contrast.  I'd do the same if this patient came to my ED.  Admission from ED would likely depend upon finding a critical lab abnormality or critical imaging abnormality.  OP referral to GI would be the likely path if there were no critical abnormalities.  Absent that, it's hard to make a case for IP over OP.

[iconic]

I've looked up involuntary criteria in CA which includes gravely disabled adults:
Definition: As a result of a mental disorder, the person is not able to provide or utilize food, clothing, or shelter.

FOOD: The person is malnourished and dehydrated; little or no food in house and person is unable to establish where or how he/she obtains meals; person has no realistic plan for obtaining meals; person has repeatedly stated he/she no longer intends to eat; person has been losing substantial weight without reasonable explanation; person repeatedly eats items not ordinarily considered fit for human consumption; refusal to leave jail cell for multiple days and refusing food/water due to depression resulting in dehydration

https://www.rcdmh.org/Portals/0/PDF/Inpatient/RUHS-BH 5150 Training Manual rev May 2018 (final) 30APR18.pdf?ver=2018-06-11-125124-863

[SedRate]

Interesting thread so far, appreciate the multiple perspectives. 

[June11]

5 hours ago, SedRate said:

Interesting thread so far, appreciate the multiple perspectives. 

Hi everyone! I haven’t seen the patient yet but hoping to have an update for you all this weekend. I really appreciate everyone’s perspectives. Goes to show that there are multiple approaches to this case and hopefully emphasizes the importance of collaboration. I’ll let you guys know what’s going on once I know! 

[ventana]

12 hours ago, iconic said:

I've looked up involuntary criteria in CA which includes gravely disabled adults:
Definition: As a result of a mental disorder, the person is not able to provide or utilize food, clothing, or shelter.

FOOD: The person is malnourished and dehydrated; little or no food in house and person is unable to establish where or how he/she obtains meals; person has no realistic plan for obtaining meals; person has repeatedly stated he/she no longer intends to eat; person has been losing substantial weight without reasonable explanation; person repeatedly eats items not ordinarily considered fit for human consumption; refusal to leave jail cell for multiple days and refusing food/water due to depression resulting in dehydration

https://www.rcdmh.org/Portals/0/PDF/Inpatient/RUHS-BH 5150 Training Manual rev May 2018 (final) 30APR18.pdf?ver=2018-06-11-125124-863

Classic premature closure 

 

you are defending the decision instead of taking a step back and looking at DDx   You have a selection bias by working in psych   I have had a number of patients in my career that were labeled wrongly with a psych dx (ie addiction with discitis) because someone jumped to a conclusion   You must be able to reasonable state it is a mental health emergency   In this case a generalist(pcp or er) needs to start the work up    Do the CT and labs, talk to here, look at dentition, and get psych eval if appropriate    It is inappropriate to label this as a psych dx when cancer, absorptive, infectious or autoimmune cause has not been considered   

Granted this sounds like an eating d/o but let’s give the patient the work up and consideration she deserves.  Please remember she is walking into a family practice on her own willpower.  It would not be conducive to strip away the last bit of control of her life with involuntary commitment (planting the seed of distrust and watering it fair amount too) by taking away her autonomy.  Building raptor, exceptionally close follow up (I would likely put her on a daily call list and see in person at least weekly). 
 

two decades of primary care have taught me to talk to the patient   Listen to the patient (they likely have a pretty good idea of the etiology)    Then building a path forward WITH them   Not taking a paternalistic “we are forcing you to do this” and in effect destroying any faith they may have had in the system  

 

in the perfect world   
stat labs

urgent CT chest abd pelvis (ideally with contrast but with miniscule lean muscle mass be cautious with lab interpretation of renal function)

consult with GI and ID and other specialist (I would be on phone same or next day after labs resulted )

having a follow up in office visit in 1-2 days to go over findings and plan   At this would have a solid 2-3 days of interactions with patient, labs and possibly imaging   Now we could start to develop a dx and treatment plan   
 

this is the art of primary care (and it is time and energy intensive-I would likely have 5+ hrs into this one patient in the first week)

 

 

[rev ronin]

On 9/5/2023 at 7:45 PM, iconic said:

Anorexia is the most deadly psychiatric disorder

Actually, it's fallen to #2, specifically anorexia binge/purge type. Opioid use disorder took the crown a few years back.

[SedRate]

On 9/6/2023 at 9:46 PM, ventana said:

two decades of primary care have taught me to talk to the patient   Listen to the patient (they likely have a pretty good idea of the etiology)    Then building a path forward WITH them   Not taking a paternalistic “we are forcing you to do this” and in effect destroying any faith they may have had in the system

[polarbebe]

Interesting thread and far from my field of practice, so don’t have anything much to add besides if the patient was admitted or otherwise suddenly has a dramatic increase in caloric intake would be at risk for refeeding syndrome which can be fatal.  

Agree with the above workup that mentioned CMP, Mg and phos.  We usually check two or three times a day in the ICU for repletion if concerned for refeeding.  

[rev ronin]

15 hours ago, polarbebe said:

Agree with the above workup that mentioned CMP, Mg and phos.  We usually check two or three times a day in the ICU for repletion if concerned for refeeding.  

Yep, refeeding is why I was requesting mag and phos--if there's any nutritional compromise, it doesn't hurt to get baselines... but they aren't going to show up on a CMP. In outpatient ED care, we don't do them more than once a week, and in residential care not more than twice a week. Of course, you probably give thiamine more often than I do in the outpatient world, too.  The one other thing that I like to get once to check for longer term issues is pre-albumin. Isn't going to change my treatment plan if it's low, but it is something nice to demonstrate has raised to an appropriate level after refeeding has been managed. This is often more for the patient's benefit--there is no lack of denial among patients with EDs--than for insurance justification.

[UGoLong]

Really good thread.

[June11]

So far all lab work has come back negative, imaging still pending. She was much more lucid last time I saw her which was reassuring and actually gained 6lbs! Putting her bmi to almost 16. Still denies body image issues and attributes lack of appetite to GI issues BUT I found out through other ER notes that there is a question about schizophrenia. We’ll see what the imaging says for other pathology. Thanks everyone for making this such an informative thread! 

[June11]

Additionally, systolic murmur heard on PE