Scored Patient-Generated Subjective Global Patient Identification Information

 
  Assessment (PG-SGA)
  History: Boxes 1 - 4 are designed to be completed by the patient.
  [Boxes 1-4 are referred to as the PG-SGA Short Form (SF)]
    2. Food intake: As compared to my normal intake, I would rate my
1. Weight (See Worksheet 1)
 
food intake during the past month as
 
In summary of my current and recent weight: unchanged (0)
 
  more than usual (0)
I currently weigh about _____kg
 
I am about _____ cm tall less than usual (1)
 
  I am now taking
 
One month ago I weighed about _____ kg normal food but less than normal amount (1)
  Six months ago I weighed about _____ kg little solid food (2)
 
only liquids (3)
  During the past two weeks my weight has:
  only nutritional supplements (3)
decreased (1) not changed (0) increased (0)
  very little of anything (4)
 
  Box 1 only tube feedings or only nutrition by vein (0) Box 2
 
  3. Symptoms: I have had the following problems that have kept me 4. Activities and Function:
  from eating enough during the past two weeks (check all that apply) Over the past month, I would generally rate my activity as:
  no problems eating (0)
  normal with no limitations (0)
no appetite, just did not feel like eating (3) vomiting (3)
  not my normal self, but able to be up and about with fairly
  nausea (1) diarrhea (3) normal activities (1)
  constipation (1) dry mouth (1) not feeling up to most things, but in bed or chair less than
  half the day (2)
  mouth sores (2) smells bother me (1)
  things taste funny or have no taste (1) feel full quickly (1) able to do little activity and spend most of the day in bed or
  chair (3)
problems swallowing (2) fatigue (1)
 
pain; where? (3) _________________ pretty much bed ridden, rarely out of bed (3)
 
  other (1)** _____________________
  **Examples: depression, money, or dental problems Box 3 Box 4
 
  The remainder of this form is to be completed by your doctor, nurse, dietitian, or therapist. Thank you.
                     Additive Score of Boxes 1-4 A
  ©FD Ottery 2005, 2006, 2015 v3.22.15
email: faithotterymdphd@aol.com or info@pt-global.org 
 
 
  Scored Patient-Generated Subjective Global Assessment (PG-SGA)
 
Worksheet 1 – Scoring Weight Loss                    Additive Score of Boxes 1-4 (See Side 1) A
  To determine score, use 1-month weight data if available. Use 6-month data only if there is no
  1-month weight data. Use points below to score weight change and add one extra point if 5. Worksheet 2 – Disease and its relation to nutritional requirements:
  patient has lost weight during the past 2 weeks. Enter total point score in Box 1 of PG-SGA. Score is derived by adding 1 point for each of the following conditions:
  Cancer Presence of decubitus, open wound or fistula
Weight loss in 1 month Points Weight loss in 6 months
  10% or greater 4 20% or greater AIDS Presence of trauma
  5-9.9% 3 10- 19.9%
Pulmonary or cardiac cachexia Age greater than 65
  3-4.9% 2 6- 9.9%
2-2.9% 1 2- 5.9% Chronic renal insufficiency
  0-1.9% 0 0- 1.9% Other relevant diagnoses (specify) _______________________________________
 
Primary disease staging (circle if known or appropriate) I II III IV Other ____
  Numerical score from Worksheet 1 Numerical score from Worksheet 2 B 
 
  6. Worksheet 3 – Metabolic Demand
  Score for metabolic stress is determined by a number of variables known to increase protein & caloric needs. Note: Score fever intensity or duration, whichever is greater. The score is additive so that a
patient who has a fever of 38.8 °C (3 points) for < 72 hrs (1 point) and who is on 10 mg of prednisone chronically (2 points) would have an additive score for this section of 5 points.
 
Stress none (0) low (1) moderate (2) high (3)
  Fever no fever > 37.2 and < 38.3 ≥ 38.3 and < 38.8 ≥ 38.8 °C
  Fever duration no fever < 72 hours 72 hours > 72 hours
  Corticosteroids no corticosteroids low dose moderate dose high dose
(< 10 mg prednisone (≥ 10 and < 30 mg (≥ 30 mg prednisone
  equivalents/day) prednisone equivalents/day) equivalents/day)  Numerical score from Worksheet 3 C
 
  7. Worksheet 4 – Physical Exam
  Exam includes a subjective evaluation of 3 aspects of body composition: fat, muscle, & fluid. Since this is subjective, each aspect of the exam is rated for degree. Muscle deficit/loss impacts point score more than fat deficit/loss.
Definition of categories: 0 = no abnormality, 1+ = mild, 2+ = moderate, 3+ = severe. Rating in these categories is not additive but are used to clinically assess the degree of deficit (or presence of excess fluid).
 
Muscle Status Fat Stores Point score for the physical exam is determined by the overall subjective rating of the
  temples (temporalis muscle) 0 1+ 2+ 3+ orbital fat pads 0 1+ 2+ 3+ total body deficit. No deficit score = 0 points
clavicles (pectoralis & deltoids) 0 1+ 2+ 3+ triceps skin fold 0 1+ 2+ 3+ Mild deficit score = 1 point Again, muscle deficit/loss
shoulders (deltoids) 0 1+ 2+ 3+ fat overlying lower ribs 0 1+ 2+ 3+ Moderate deficit score = 2 points takes precedence over fat
interosseous muscles 0 1+ 2+ 3+ Global fat deficit rating 0 1+ 2+ 3+ Severe deficit score = 3 points loss or fluid excess.
scapula (latissimus dorsi, trapezius, deltoids) 0 1+ 2+ 3+ Fluid status
thigh (quadriceps) 0 1+ 2+ 3+ ankle edema 0 1+ 2+ 3+
calf (gastrocnemius) 0 1+ 2+ 3+ sacral edema 0 1+ 2+ 3+ Numerical Score for Worksheet 4 D
Global muscle status rating 0 1+ 2+ 3+ ascites 0 1+ 2+ 3+
Global fluid status rating 0 1+ 2+ 3+ Total PG-SGA Score (Total numerical score of A+B+C+D)
 
Clinician Signature ________________________________________RD RN PA MD DO Other _________ Date ________________ Global PG-SGA Category Rating (Stage A, Stage B or Stage C)

Worksheet 5 – PG-SGA Global Assessment Categories Nutritional Triage Recommendations: Additive score is used to define specific nutritional interventions including
Stage A Stage B Stage C patient & family education, symptom management including pharmacologic intervention, and appropriate nutrient intervention (food,
Category Well-nourished Moderate/suspected malnutrition Severely malnourished
Weight No weight loss ≤ 5% loss in 1 month (≤10% in 6 months) > 5% loss in 1 month (>10% in 6 months) nutritional supplements, enteral, or parenteral triage).
OR recent non-fluid wt gain OR Progressive weight loss OR Progressive weight loss First line nutrition intervention includes optimal symptom management.
Nutrient intake No deficit OR Significant Definite decrease in intake Severe deficit in intake
recent improvement
Triage based on PG-SGA point score
Nutrition Impact None Presence of NIS (Box 3 of PG-SGA) Presence of NIS (Box 3 of PG-SGA) 0-1 No intervention required at this time. Re-assessment on routine and regular basis during treatment.
Symptoms (NIS) OR significant recent 2-3 Patient & family education by dietitian, nurse, or other clinician with pharmacologic intervention as
improvement allowing indicated by symptom survey (Box 3) and lab values as appropriate.
adequate intake 4-8 Requires intervention by dietitian, in conjunction with nurse or physician as indicated by symptoms (Box 3).
Functioning No deficit OR Significant Moderate functional deficit Severe functional deficit
recent improvement OR Recent deterioration OR Recent significant deterioration     ≥ 9 Indicates a critical need for improved symptom management and/or nutrient intervention options.
Physical Exam No deficit OR chronic Evidence of mild to moderate loss Obvious signs of malnutrition ©FD Ottery 2005, 2006, 2015 v3.22.15
deficit but with recent of muscle mass &/or muscle tone on (e.g., severe loss muscle, fat,
clinical improvement palpation &/or loss of SQ fat possible edema) email: faithotterymdphd@aol.com or info@pt-global.org