GP Clinic

Face to face consultation to: Dr. Anya Sharma (Dietitian), Mr. John Smith (Patient), Mrs. Sarah Smith (Patient's daughter). Consent obtained. Reason for referral: Unintentional weight loss of 5kg over the past 3 months, poor appetite, and concerns regarding nutritional intake due to recent bereavement and reduced mobility. Dietetic Background: Patient previously seen by community dietitian 2 years ago for general healthy eating advice following a cardiac event. No specific dietetic input related to weight loss previously. Anthropometry: Weight: 62 kg Height: 165 cm BMI: 22.8 kg/m² Weight history: Stable weight of 67kg for several years, recent decline to 62kg over 3 months. Reports difficulty maintaining weight due to poor appetite. Impression: Patient has experienced 7.5% weight loss over 3 months, indicating significant involuntary weight loss. MUST: 2 (Medium Risk). Biochemistry: Recent blood tests (15/10/2024) show Hb 11.2 g/dL (mild anaemia), Albumin 3.0 g/dL (mild hypoalbuminaemia), U&Es WNL. B12 and Folate WNL. Clinical: 78-year-old male, recently bereaved (wife passed 4 months ago), living alone. Reports reduced mobility due to osteoarthritis in knees, making food preparation difficult. Complains of fatigue and occasional dizziness. No dysphagia or new GI symptoms. PMHx: Osteoarthritis, Hypertension, Atrial Fibrillation, Mild Cognitive Impairment, History of Myocardial Infarction (2 years ago). Relevant Medications: Ramipril 5mg OD, Bisoprolol 2.5mg OD, Apixaban 5mg BD, Paracetamol PRN. Multivitamin supplement (self-prescribed). Nutritional Supplements: None currently prescribed. SALT IDDSI recommendations (20/09/2024): Level 0 Thin fluids and Level 7 Regular diet. No additional SALT recommendations. Bowels: Reports bowel movements every 2-3 days, soft and formed. No reported concerns like constipation or diarrhoea. Clinical symptoms affecting intake: Poor appetite, early satiety, fatigue, reduced motivation to cook, mild depression related to bereavement. SHx: Lives alone in a two-bedroom house. Daughter (Mrs. Sarah Smith) visits twice a week and helps with grocery shopping and some meal preparation. Limited social interaction outside family. Access to financial resources is adequate. Physical activity level: Sedentary. Walks short distances within the house with aid of a stick. No regular exercise. Dietary recall: B – One slice of toast with jam, cup of tea. L – Sandwich (cheese or ham) with a packet of crisps, glass of water. EM – Small portion of pre-made meal (e.g., ready meal or soup), often skips dessert. Snacks: Occasionally a biscuit or piece of fruit. Supper: None. Fluid (including alcohol): Approximately 1 litre of water/tea/coffee per day. No alcohol intake. Allergies: Penicillin (rash), no known food allergies. Diet summary: Overall dietary intake is inadequate in both energy and protein, consistent with reported weight loss. Limited variety in meals, insufficient portion sizes, and infrequent snacking. Fluid intake appears borderline. Estimated protein and energy intake from diet history: 1200 kcal and 45 g protein Daily estimated nutritional requirements based on 62 kg kg: Energy: 30 kcal/kg x 1.0 PAL = 1860 kcal Protein: 1.2 g/kg = 74.4 g Fluid: 35 ml/kg = 2170 ml Consultation summary: Patient presents with significant unintentional weight loss. Contributing factors include bereavement, reduced appetite, limited mobility impacting food preparation, and potentially mild depression. Nutritional assessment confirms inadequate energy and protein intake against estimated requirements. Patient and daughter are motivated to improve nutritional status. PASS statement: Inadequate oral intake related to poor appetite and reduced ability to prepare meals as evidenced by 7.5% weight loss over 3 months, low BMI, and reported fatigue. Aim of intervention: To stabilise weight and prevent further decline, improve nutritional intake, and enhance overall well-being. Plan: 1. Increase meal frequency and portion sizes: Encourage 3 small meals and 2-3 nutritious snacks daily. Provide examples of high-calorie, high-protein snacks. 2. Recommend oral nutritional supplements: Prescribe two Fortisip Compact Protein daily to be taken between meals. Review tolerance and effectiveness at next appointment. 3. Explore practical solutions for meal preparation: Discuss options such as frozen ready meals, community meal delivery services, and increased support from daughter. Consideration for next appointment: Review compliance and tolerance of ONS. Monitor weight and symptoms. Discuss mental health support options if depression continues to impact intake. Patient booked for telephone review on 1 November 2024 at 10:00 AM.