Guest guest Posted April 22, 2011 Report Share Posted April 22, 2011 Most docs usually just want what they want, and I have found few will listen once their minds are made up. Whenever I receive a request for consult to increase protein because, I work it so that the resident wins - after a comprehensive evaluation as you've done and covering all reasons why most probably PAB or ALB are low, then I do some form of short-term intervention with repeat labs. I always include calories when protein supplementation is required, so unless resident weight should not increase, I use a complete meal type of supplementation, either through food such as a half sandwich & milk, or a supplement such as a house-prepared pudding or shake, or a commercial supplement. This always seems to satisfy the docs more than a lecture in nutrition which they really don't want to know. I do use my time with them providing the training or retraining that you're suggesting below, but usually they'll listen better once they've been satisfied that their requests were honored. None have ever refused my approach to the intervention they seek, even though all consults of this type always state - " RD consult to increase protein bc of low ALB/ PAB " Goo luck! Digna From: rd-usa [mailto:rd-usa ] On Behalf Of Osowski Sent: Friday, April 22, 2011 7:11 AM To: rd-usa Subject: MD & prealbumin > I am in need of RD clinical judgement ammunition as to communicate effectively w an MD R/E interpreting prealbumin levels. > I am monitoring a SNF resident w IV sacral. Fro 1/11 to 3/11, wt increased (desired), wound healing, eating well, family aware of importance of protein, adequate kcals, fluids for wound healing support. Diet: NAS, arginaid, MVI, Vit C, ZNSO4, Procel 1 scoop TID (15 gm pro). March labs: all WNL chem 7, alb and prealbumin. > In April, new labs freaked out the MD: ESR sed rate 95, normal range 0-30, C reactive pro 142.8 normal range 0.0-1.0. prealbumin 16, now < NL. > MD wants more pro. I communicated that the prealbumin is not a tool for diagnosing adequacy of protein intake, and that the drop in prealbumin is likely related to the inflamation response evident by the elevated C reactive pro. > He wrote.... > " There was concern regarding markly elevated CRP. With the overall improved appearance and reduction in size of the ulcer do not believe the elevated CRP is related to inflammatory process of the ulcer and the elevated CRP maybe due to other inflammatory processes as the patient is experiencing inflammation in both knees. The elevated CRP could also be erroneous as there is no concomitant and elevation of the ESR. (actually, the ESR is >NL). " Protein supplement ProCel is not high protein (5 gm/scoop). Increase procel 2 scoops 4 x day (40 gm pro), in addition to Arginaid and repeat prealbumin in 5-7 days to determine response. " > Ugh. > I need a reference in hand prior to calling this doctor to discuss. > What script would you use, knowing I will likely have 60 seconds of his time. > Thanks for your help. O MS,RD,LD Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 23, 2011 Report Share Posted April 23, 2011 C reactive protein is a marker of inflammation either it is the patients knees or the ulcer. Any kind of inflammatory process leads to a drop in negative response acute phase proteins like prealbumin. ESR is not always elevated with inflammatory processes it is a test with very low sensitivity and specificity, in asymptomatic persons doesn't even appear elevated. I had several surgical patients with CRP of around 300 and ESR in normal rates. With suborn doctors, I usually use the approach of starting the sentence " as you know... " , then I throw them the guidelines or latest researches to explain what I want to do. Never got a negative response using that approach. > > > I am in need of RD clinical judgement ammunition as to communicate effectively w an MD R/E interpreting prealbumin levels. > > I am monitoring a SNF resident w IV sacral. Fro 1/11 to 3/11, wt increased (desired), wound healing, eating well, family aware of importance of protein, adequate kcals, fluids for wound healing support. Diet: NAS, arginaid, MVI, Vit C, ZNSO4, Procel 1 scoop TID (15 gm pro). March labs: all WNL chem 7, alb and prealbumin. > > In April, new labs freaked out the MD: ESR sed rate 95, normal range 0-30, C reactive pro 142.8 normal range 0.0-1.0. prealbumin 16, now < NL. > > MD wants more pro. I communicated that the prealbumin is not a tool for diagnosing adequacy of protein intake, and that the drop in prealbumin is likely related to the inflamation response evident by the elevated C reactive pro. > > He wrote.... > > " There was concern regarding markly elevated CRP. With the overall improved appearance and reduction in size of the ulcer do not believe the elevated CRP is related to inflammatory process of the ulcer and the elevated CRP maybe due to other inflammatory processes as the patient is experiencing inflammation in both knees. The elevated CRP could also be erroneous as there is no concomitant and elevation of the ESR. (actually, the ESR is >NL). " Protein supplement ProCel is not high protein (5 gm/scoop). Increase procel 2 scoops 4 x day (40 gm pro), in addition to Arginaid and repeat prealbumin in 5-7 days to determine response. " > > Ugh. > > I need a reference in hand prior to calling this doctor to discuss. > > What script would you use, knowing I will likely have 60 seconds of his time. > > Thanks for your help. > O MS,RD,LD > Quote Link to comment Share on other sites More sharing options...
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