Clinical Commander

All dossiers
symptom.weight-loss.v1

Unintentional weight loss (outpatient symptom triage)

symptomchronicsubacuteundifferentiatedadultgeriatricpediatricoutpatientacute
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym wave-14 (2026-05-14) — symptom-workup template clones from symptom.constipation.v1 (wave-11), symptom.fuo.v1, symptom.anemia-workup.v1. Engine scope: unintentional weight loss (≥5% over 6 mo OR ≥10 lb) triage + cause stratification + screening workup + routing to disease-specific engines. Phenotypes covered (≥8): malignancy_dominant (~30%), psychiatric_depression_anxiety_substance (~20%), GI_malabsorption_IBD_celiac_pancreatic_insufficiency, hyperthyroidism, DM_uncontrolled_new, HIV_chronic_infection_TB, rheumatologic_RA_SLE, cardiac_cachexia_HF, COPD_cachexia, CKD_uremia, medication-induced, substance_use, eating_disorder, geriatric_FTT, pediatric_FTT, oral_dental_dysphagia. Bayesian linkage (LR+, LR−, pre-test priors by age/sex, calorie-energy thresholds, T_treat) lives in companion depth bundle _briefs/symptom.weight-loss.v1.depth.md. 6 sibling differentiation rows: endo.thyroid-storm + endo.dm2 + psych.depression + geriatrics.frailty-polypharmacy + gi.crohns + gi.ulcerative-colitis (all confirmed in ALL_DOSSIERS). 10 severity_triggers: malignancy_red_flag, refeeding_syndrome_risk, severe_thyrotoxicosis, new_dm_dka, severe_depression_si, eating_disorder_cardiac_instability, geriatric_FTT_severe, cardiac_cachexia, hiv_chronic_infection_tb, ckd_uremic_anorexia. KEY SAFETY RULES: thiamine BEFORE glucose (Wernicke); slow refeeding 10-20 kcal/kg/d if BMI <14; phosphorus / Mg / thiamine repletion BEFORE caloric load; psychiatric hold if SI; universal HIV screening; PHQ-9 ≥10 → psych routing. Calculators wired (0): schema-blocked at this layer — calc.mna_short_form, calc.snaq_screen, calc.cachexia_criteria_fearon, calc.phq9, calc.gds. Ticketed in shard-3 state file. Panels wired: panel.cbc + panel.renal + panel.lft + panel.thyroid + panel.inflammation + panel.lipid + panel.iron. Schema-blocked: workup.unintentional_weight_loss — NOT in clinical-tools-registry; manual application in setting playbook required_assessments. Regimen_axes intentionally empty — engine is triage-only. Stepwise pharmacologic ladder lives in setting_playbooks.outpatient.drug_actions. Setting playbooks: outpatient (primary) + ed (severe presentations — Hb <7, hypoglycemia, hypotension, BMI <14 refeeding-syndrome risk, severe thyrotoxicosis, DKA, suicidal ideation, eating-disorder cardiac instability). SCAFFOLDED status: no workup.unintentional_weight_loss in clinical-tools-registry; PRODUCTION audit would fail. Will promote once registry entries land.

Entry points (16)

  • symptom
    Documented ≥5% body weight loss over 6 mo + no clear cause + age >50 + family hx OR alarm features (anemia, B-symptoms, new pain, mass, hematochezia) — malignancy dominant (~30% of unintentional WL >5%; lung / GI / pancreas / lymphoma / renal / hepatic top etiologies — Marton 1981, Wong 2014, Hernandez 2003)
    malignancy_dominant_unintentional_wl
  • symptom
    Weight loss + anhedonia / depressed mood / appetite loss / functional impairment / sleep disturbance + PHQ-9 ≥10 — depression / anxiety / substance use (~20% of unintentional WL; route psych.depression.core.v1)
    psychiatric_depression_anxiety_substance
  • symptom
    WL + diarrhea / steatorrhea / abdominal pain / iron-deficiency / B12 deficiency / hypoalbuminemia — GI malabsorption (celiac, IBD — route gi.crohns/UC, chronic pancreatitis with EPI, SIBO); evaluate with TTG-IgA, fecal calprotectin, fecal elastase, stool studies
    gi_malabsorption_IBD_celiac_pancreatic_insufficiency
  • symptom
    WL + heat intolerance + tachycardia + tremor + diarrhea + suppressed TSH — hyperthyroidism (Graves, toxic nodule, thyroiditis); severe (T >38.5, AMS, tachy, AF, HF) → route endo.thyroid-storm.core.v1
    hyperthyroidism_thyrotoxic_features
  • symptom
    WL + polyuria + polydipsia + blurred vision + glucose >200 / HbA1c >6.5% — uncontrolled / new diabetes (T1DM, T2DM decompensation); route endo.dm2.core.v1 (or T1DM if young + thin + DKA-prone)
    dm_uncontrolled_new_with_polyuria_polydipsia
  • symptom
    WL + night sweats + lymphadenopathy + risk factors (sexual, IDU, endemic exposure) + chronic cough — HIV / TB / chronic infection (~5-10% of WL; route id.hiv-initial.chronic.v1 if HIV-positive; TB IGRA + chest CT)
    hiv_chronic_infection_TB_endemic_exposure
  • symptom
    WL + arthralgia + morning stiffness + fatigue + serositis + rash / Raynaud + elevated CRP/ESR — rheumatologic (RA, SLE, vasculitis, PMR); ANA / RF / anti-CCP / ANCA workup
    rheumatologic_RA_SLE_inflammatory
  • symptom
    WL + dyspnea + orthopnea + LE edema + reduced EF + diuretic dependence — cardiac cachexia (advanced HFrEF); route cardio.acute-hf.core.v1 or cardio.hfref.core.v1 + GDMT + nutritional support
    cardiac_cachexia_hf_advanced
  • symptom
    WL + chronic dyspnea + hyperinflation on CXR + emphysematous phenotype + FEV1 <50% — COPD cachexia (advanced GOLD D); route pulm.copd.core.v1 + pulmonary rehab + nutritional support
    copd_cachexia_advanced_emphysema
  • symptom
    WL + advanced CKD (eGFR <30) + uremic symptoms (nausea, anorexia, fatigue, pruritus, restless legs) — uremic anorexia; route neph.ckd.core.v1 + dietary phosphorus + protein modulation
    ckd_uremic_anorexia
  • symptom
    WL + new medication within 6 mo (metformin, GLP-1 agonist, SGLT2i, methylphenidate, levothyroxine excess, topiramate, bupropion, sertraline, amphetamine, chemotherapy) — drug-induced; deprescribe or substitute when feasible
    medication_induced_weight_loss
  • symptom
    WL + alcohol use disorder OR stimulant use (cocaine, methamphetamine) + social / functional decline — substance-induced; route psych counseling + harm reduction; rule out withdrawal complications
    substance_use_alcohol_stimulant
  • symptom
    WL + body image distortion + restrictive eating / binge-purge + amenorrhea + BMI <18.5 — anorexia / bulimia nervosa; route psych / eating-disorder specialist; rule out refeeding-syndrome risk (phosphorus, magnesium, thiamine) if BMI <14 or rapid loss >15%
    eating_disorder_anorexia_bulimia
  • symptom
    Elderly (≥65) + WL + functional decline + decreased appetite + decreased social engagement + cognitive decline — geriatric failure-to-thrive; route geriatrics.frailty-polypharmacy.core.v1; comprehensive geriatric assessment; deprescribing review
    geriatric_failure_to_thrive
  • symptom
    Pediatric (<2 yr) + weight <3rd percentile or crossing 2 percentile lines downward — pediatric failure-to-thrive; nutritional + psychosocial + organic workup
    pediatric_failure_to_thrive
  • symptom
    WL + oral / dental disease + dysphagia + odynophagia + decreased PO intake — mechanical / oropharyngeal; route ENT / GI / dental; barium swallow / EGD
    oral_dental_swallowing_dysphagia

Required inputs (38)

  • agerequired
    demographic • used at CONTEXT
    Age shifts priors: pediatric → FTT; adult → infection / GI / endocrine / psychiatric / malignancy; elderly (≥65) → malignancy / geriatric FTT / medication; new WL >50 raises malignancy prior (Marton 1981; Hernandez 2003)
  • sexrequired
    demographic • used at CONTEXT
    Sex shifts cancer priors (prostate vs ovarian / breast); eating-disorder prevalence higher in young women; alcohol use higher in men
  • weightrequired
    vital • used at FRAME
    Document current weight; calculate % loss from baseline (≥5% over 6 mo or ≥10 lb defines unintentional WL); serial weights for trajectory
  • heightrequired
    vital • used at FRAME
    BMI calculation; identify low-BMI threshold for refeeding-syndrome risk (BMI <14 or BMI <16 + rapid loss); pediatric percentile growth chart
  • duration_and_magnitude_of_lossrequired
    symptom • used at FRAME
    Unintentional ≥5% over 6 mo OR ≥10 lb in 6 mo is the operational threshold (Marton 1981 PMID 24450891 — anchor); rapid loss >15% in 6 mo raises malignancy + organic disease prior
  • appetite_anorexia_early_satietyrequired
    symptom • used at ENTRY
    Anorexia (reduced appetite) suggests systemic illness, cancer cachexia, depression, geriatric FTT; early satiety suggests gastric malignancy, gastroparesis
  • gi_symptoms_pain_diarrhea_steatorrhea_dysphagiarequired
    symptom • used at ENTRY
    GI symptoms guide workup: dysphagia → EGD/barium swallow; steatorrhea → fecal elastase; chronic diarrhea → celiac / IBD / SIBO; abdominal pain → CT abdomen / pancreatitis
  • b_symptoms_fever_night_sweatsrequired
    symptom • used at ENTRY
    B-symptoms (fever, drenching night sweats, ≥10% WL) → lymphoma; TB; HIV (NEJM B12 2013 PMID 22106456 alone NOT a marker — but combined screen)
  • mood_anhedonia_sleep_disturbancerequired
    symptom • used at ENTRY
    PHQ-9 ≥10 + anhedonia + sleep / energy disturbance → depression (~20% of unintentional WL; route psych.depression.core.v1)
  • medication_review_glp1_sglt2_metformin_methylphenidate_topiramate_bupropionrequired
    history • used at CONTEXT
    GLP-1 agonist, SGLT2i, metformin, methylphenidate, levothyroxine excess, topiramate, bupropion, sertraline, amphetamine, chemotherapy → drug-induced; deprescribe or substitute (Wong 2014; geriatric weight loss 2018 PMID 30025927)
  • substance_use_alcohol_stimulant_cocaine_methrequired
    history • used at CONTEXT
    Alcohol use disorder + stimulant (cocaine, methamphetamine) → substance-induced; functional decline; rule out withdrawal complications (DTs, Wernicke); thiamine before glucose if alcohol use
  • endocrine_thyroid_dm_adrenal_hyperparathyroidrequired
    history • used at CONTEXT
    Hyperthyroidism (Graves, toxic nodule, thyroiditis); uncontrolled DM (T1DM, T2DM with polyuria/polydipsia); adrenal insufficiency (orthostasis, hyperpigmentation, fatigue); hyperparathyroidism (Ca >10.5)
  • cardiac_pulmonary_renal_chronic_diseaserequired
    history • used at CONTEXT
    Advanced HFrEF → cardiac cachexia; COPD → pulmonary cachexia; advanced CKD → uremic anorexia; routing to disease-specific engine
  • infection_history_hiv_tb_exposurerequired
    history • used at CONTEXT
    HIV risk (sexual, IDU); TB endemic exposure / family contact; chronic infection screen (HBV, HCV, syphilis); route id.hiv-initial.chronic.v1 if HIV+
  • oncologic_history_family_screening_statusrequired
    history • used at CONTEXT
    Family hx CRC / breast / ovarian / prostate / pancreatic → earlier screening; smoking → lung; alcohol → hepatic / pancreatic / oral; HBV/HCV → HCC
  • oral_dental_dysphagia_swallowing
    history • used at CONTEXT
    Oral / dental disease, ill-fitting dentures, dysphagia, odynophagia → mechanical PO; ENT / GI / dental referral; barium swallow if dysphagia
  • social_isolation_food_insecurity_socioeconomic
    history • used at CONTEXT
    Social isolation + food insecurity + socioeconomic stress → particularly in elderly; geriatrics.frailty-polypharmacy.core.v1 routing; social work referral
  • severity_red_flags_hypoglycemia_hypotension_severe_anemiarequired
    symptom • used at RED_FLAGS
    Hypoglycemia + AMS + hypotension + severe anemia (Hb <7) + tachycardia + dehydration → ED for stabilization; refeeding-syndrome risk if BMI <14 or rapid loss >15%
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Anemia (iron-deficiency → GI workup; macrocytic → B12/folate; pancytopenia → marrow failure / lymphoma); leukocytosis (infection); lymphocytosis (lymphoma / pertussis / CLL)
  • bmp_glucose_electrolytesrequired
    lab • used at INITIAL_WORKUP
    Glucose (DM screen); electrolytes (hyponatremia → SIADH / Addison; hyperkalemia → Addison / CKD); BUN/Cr (uremia); calcium (hyperPTH, malignancy); phosphorus (refeeding-syndrome screen if BMI <14)
  • lft_albumin_prealbuminrequired
    lab • used at INITIAL_WORKUP
    LFT (hepatic disease, malignancy, alcohol); albumin (chronic malnutrition / inflammation); prealbumin (acute nutritional status); hypoalbuminemia <3.0 → severe malnutrition / inflammation
  • tsh_t4_freerequired
    lab • used at INITIAL_WORKUP
    TSH (suppressed → hyperthyroid screen → severe → route endo.thyroid-storm.core.v1; elevated → hypothyroid — paradoxical WL rare but possible)
  • hba1c_fasting_glucoserequired
    lab • used at INITIAL_WORKUP
    HbA1c ≥6.5% or fasting glucose ≥126 → DM screen (route endo.dm2.core.v1); type-stratify (T1DM in young + DKA-prone)
  • crp_esr_inflammationrequired
    lab • used at INITIAL_WORKUP
    CRP / ESR — inflammatory screen (IBD, vasculitis, malignancy, infection); ESR >100 nonspecific but raises concern for malignancy / infection / vasculitis
  • hiv_test_universalrequired
    lab • used at INITIAL_WORKUP
    Universal HIV screening (CDC, USPSTF) — route id.hiv-initial.chronic.v1 if positive; B-symptoms + risk factors → priority screen
  • tb_igra_quantiferon
    lab • used at INITIAL_WORKUP
    TB IGRA / Quantiferon — endemic exposure, B-symptoms, chronic cough; co-route to TB engine if positive + clinical suspicion
  • ttg_iga_celiac_screen
    lab • used at BRANCHING_WORKUP
    Tissue-transglutaminase IgA + total IgA — celiac screen if iron-deficiency, B12 deficiency, hypoalbuminemia, diarrhea; positive → confirm with EGD biopsy
  • b12_folate_iron_studiesrequired
    lab • used at BRANCHING_WORKUP
    B12 (NEJM 2013 PMID 22106456) — neuro-psych deficiency; folate; iron studies (ferritin, transferrin, saturation); guides malabsorption workup
  • phq9_geriatric_depression_scalerequired
    lab • used at CONTEXT
    PHQ-9 ≥10 (depression screen); Geriatric Depression Scale (GDS) for ≥65 — high prior for depression as cause of WL (~20%)
  • fecal_elastase_calprotectin_stool
    lab • used at BRANCHING_WORKUP
    Fecal elastase <200 µg/g → exocrine pancreatic insufficiency (chronic pancreatitis); fecal calprotectin (IBD screen); stool studies + occult blood
  • cortisol_acth_low_morning
    lab • used at BRANCHING_WORKUP
    Adrenal insufficiency (Addison) — low morning cortisol (<5 µg/dL) + elevated ACTH; orthostasis + hyperkalemia + hyponatremia + hyperpigmentation + fatigue
  • spep_upep_serum_free_light_chains
    lab • used at BRANCHING_WORKUP
    SPEP / UPEP / sFLC — monoclonal gammopathy (multiple myeloma, MGUS); especially if anemia, hypercalcemia, renal failure, bone pain (CRAB criteria)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    UA — hematuria (renal malignancy); proteinuria (renal disease, paraprotein cast nephropathy); glucose (DM)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    CXR — lung mass, TB, COPD emphysematous changes, HF (cardiomegaly, congestion); first-line lung screen; raises lung-cancer prior in smoker + WL
  • ct_chest_abdomen_pelvis_with_contrast
    imaging • used at BRANCHING_WORKUP
    CT C/A/P — occult malignancy (lung, GI, pancreas, lymphoma, renal, hepatic, ovarian); use in age >50 + alarm features + workup-negative; alternative low-dose lung CT for smokers per USPSTF
  • colonoscopy_egd_screen_age_appropriate
    imaging • used at BRANCHING_WORKUP
    Colonoscopy (CRC) + EGD (gastric, esophageal, celiac biopsy) — age >50 OR alarm features (iron-deficiency anemia, hematochezia, dysphagia, melena); risk-stratified
  • mammogram_age_screen
    imaging • used at BRANCHING_WORKUP
    Mammogram (USPSTF: 50-74 q2y or 40-74 individualized) — breast cancer screen in WL workup for women
  • echocardiogram_if_cardiac_features
    imaging • used at BRANCHING_WORKUP
    TTE — reduced EF → cardiac cachexia (route cardio.hfref.core.v1); valvular disease; pericardial effusion (malignancy, TB)

12-phase flow (12)

  1. 1FRAME
    Document ≥5% unintentional body weight loss over 6 mo (or ≥10 lb) — Marton 1981 PMID 24450891 anchor; baseline weight + serial weights; BMI calculation; rule out intentional loss
    inputs: weight, height, duration_and_magnitude_of_loss
    advance: Unintentional ≥5% / 6 mo confirmed + BMI documented
  2. 2ENTRY
    Phenotype-defining features: appetite / early satiety / GI symptoms / B-symptoms / mood / cognitive — anchor the entry phenotype (malignancy / psychiatric / GI malabsorption / endocrine / infection / cardiac / pulmonary / renal / medication / substance / eating disorder / geriatric FTT / pediatric FTT)
    inputs: appetite_anorexia_early_satiety, gi_symptoms_pain_diarrhea_steatorrhea_dysphagia, b_symptoms_fever_night_sweats, mood_anhedonia_sleep_disturbance
    advance: Phenotype tentative
  3. 3CONTEXT
    Age + sex + comprehensive medication review (GLP-1, SGLT2i, metformin, methylphenidate, levothyroxine excess, topiramate, bupropion, chemo) + substance use + endocrine hx + cardiac/pulm/renal + infection risk + oncologic + family hx + social
    inputs: age, sex, medication_review_glp1_sglt2_metformin_methylphenidate_topiramate_bupropion, substance_use_alcohol_stimulant_cocaine_meth, endocrine_thyroid_dm_adrenal_hyperparathyroid, cardiac_pulmonary_renal_chronic_disease, infection_history_hiv_tb_exposure, oncologic_history_family_screening_status, oral_dental_dysphagia_swallowing, social_isolation_food_insecurity_socioeconomic, phq9_geriatric_depression_scale
    advance: Context comprehensive + medication audit complete
  4. 4RED_FLAGS
    Severe presentations → ED: Hb <7, hypoglycemia + AMS, hypotension, dehydration with tachycardia, severe anemia / GI bleed, suspected refeeding-syndrome risk (BMI <14 or rapid loss >15% in 6 mo — phosphorus / magnesium / thiamine repletion needed), severe thyrotoxicosis (route endo.thyroid-storm), DKA in new DM (route endo.dka)
    inputs: severity_red_flags_hypoglycemia_hypotension_severe_anemia
    advance: Severe features ruled out OR ED routing
  5. 5INITIAL_WORKUP
    CBC + diff (anemia, leukocytosis, pancytopenia); BMP + glucose + Ca + Mg + PO4 (DM, hyperPTH, refeeding screen); LFT + albumin / prealbumin (malnutrition, hepatic); TSH + T4 (hyperthyroid); HbA1c (DM); CRP / ESR (inflammation); HIV (universal); UA; CXR; PHQ-9 / GDS (depression)
    inputs: cbc_with_diff, bmp_glucose_electrolytes, lft_albumin_prealbumin, tsh_t4_free, hba1c_fasting_glucose, crp_esr_inflammation, hiv_test_universal, urinalysis, cxr
    actions: panel.cbc, panel.renal, panel.lft, panel.thyroid, panel.inflammation, panel.lipid
    advance: Tier 1 returned + cause stratification preliminary
  6. 6BRANCHING_WORKUP
    Cause-anchored next steps: malignancy concern → CT C/A/P + age-appropriate cancer screen (colonoscopy, mammogram, EGD); GI symptoms → fecal elastase / calprotectin / TTG-IgA / EGD / colonoscopy; rheumatologic → ANA / RF / anti-CCP / ANCA; endocrine → adrenal cortisol, hyperPTH; B12/folate; SPEP/UPEP if elderly + anemia + hyperPTH (myeloma); echocardiogram if cardiac features; PET-CT if all negative + age >50 + persistent WL
    inputs: ttg_iga_celiac_screen, b12_folate_iron_studies, fecal_elastase_calprotectin_stool, cortisol_acth_low_morning, spep_upep_serum_free_light_chains, ct_chest_abdomen_pelvis_with_contrast, colonoscopy_egd_screen_age_appropriate, mammogram_age_screen, echocardiogram_if_cardiac_features, tb_igra_quantiferon
    advance: Targeted workup complete or routed to specific engine
  7. 7DIFFERENTIAL
    Malignancy (~30%) — lung / GI / pancreas / lymphoma / renal / hepatic / ovarian / prostate; Psychiatric (~20%) — depression / anxiety / substance / eating disorder; GI malabsorption (~15%) — celiac, IBD, EPI, SIBO; Endocrine (~10%) — hyperthyroid, DM, adrenal, hyperPTH; Infection (~5%) — HIV, TB, occult; Cardiac/Pulmonary/Renal cachexia (~5%); Medication / substance (~5%); Geriatric FTT (~5% — elderly); Eating disorder (variable); Undiagnosed (~5-10% self-resolve or chronic — Marton 1981; Wong 2014)
    advance: Differential ranked
  8. 8RISK_STRATIFICATION
    Severity by % WL + BMI (BMI <14 or rapid loss >15% → refeeding-syndrome risk → inpatient + slow refeeding + phosphorus/Mg/thiamine); cancer-screening risk by age + family hx + smoking + alcohol; depression risk by PHQ-9; geriatric FTT by frailty score; cachexia risk by underlying disease (cachexia mechanisms — Fearon 2011 PMID 25060842 verify)
    advance: Risk-stratified disposition documented
  9. 9TREATMENT
    Cause-directed: malignancy → onc routing; psychiatric → SSRI / psychotherapy / eating-disorder specialist; GI malabsorption → cause-specific (gluten-free, IBD therapy, pancreatic enzyme replacement); endocrine → methimazole / radioactive iodine / surgery for hyperthyroid; insulin / oral hypoglycemic / GLP-1 for DM (cautious in WL); HIV → ART; TB → RIPE; cardiac cachexia → GDMT optimization + nutritional support; COPD cachexia → pulm rehab + nutritional support; CKD → dialysis planning / dietary; medication-induced → deprescribe; substance → counseling / detox; eating disorder → multidisciplinary; geriatric FTT → CGA + deprescribing + social support + nutritional counseling. Megestrol acetate, mirtazapine, dronabinol — appetite stimulants (low-grade evidence; thromboembolism risk with megestrol)
    inputs: medication_review_glp1_sglt2_metformin_methylphenidate_topiramate_bupropion
    advance: Treatment initiated or routing complete
  10. 10DISPOSITION
    Home (most): outpatient with stepwise workup + return precautions; outpatient subspecialty referral: GI / endocrine / onc / psych / dietitian; ED: severe anemia + hypoglycemia + hypotension + refeeding-syndrome risk + severe thyrotoxicosis / DKA; inpatient: severe malnutrition (BMI <14 with slow refeeding), severe electrolyte derangement, geriatric FTT failing outpatient, eating disorder with cardiac instability
    advance: Disposition assigned
  11. 11MONITORING
    Serial weights monthly until trajectory established; repeat CBC + BMP + albumin / prealbumin at 1-3 mo; depression response to SSRI at 4-6 wk + PHQ-9 trend; TSH at 6 wk after thyroid therapy; HbA1c at 3 mo after DM tx; colonoscopy result follow-up; CT findings follow-up; geriatric CGA reassessment q3-6 mo
    advance: Monitoring plan in place
  12. 12FOLLOWUP
    Lifestyle counseling (caloric supplementation, oral nutrition supplements, swallowing assessment); deprescribing review; chronic disease optimization; cancer screening intervals; psych follow-up (CBT, SSRI); eating-disorder multidisciplinary; geriatric long-term planning (advance directives, GOC); pediatric NASPGHAN FTT pathway
    advance: Long-term plan documented + follow-up scheduled