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Nutritional status examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent

General inspection

  • Patient: well/unwell, approximate BMI, alert, breathless, fever, portals of infection/wounds/drains, long lines (may be used for parenteral nutrition)
  • Around bed (if present look at quantity of fluids going in/coming out)
    • In: NG feed/parenteral nutrition, IV fluids, nutritional supplements, food/drink/NBM notes
    • Out: catheter, stoma, NG tube, vomit bowl
    • Charts: observations, fluid balance, drug chart 

Hands and arms

  • Nails: clubbing (cirrhosis, IBD, coeliac disease), leukonychia (hypoalbuminaemia), koilonychia (iron deficiency anaemia)
  • Palms: temperature, xanthomata (hypercholesterolaemia)
  • Pulse rate (tachycardia in dehydration)
  • Arms: bruising (coagulopathy in vitamin K deficiency), extensor rash (dermatitis herpetiformis in coeliac disease)
  • Blood pressure and postural drop (hypotension and postural drop in dehydration)

Head and neck

  • Eyes: sunken (dehydration), corneal arcus/xanthelasma (hypercholesterolaemia), xerophthalmia (vitamin A deficiency), conjunctival pallor (anaemia, e.g. due to bleeding or malabsorption)
  • Mouth/tongue: glossitis/stomatitis (iron/B12 deficiency anaemia), aphthous ulcers (Crohn’s disease)
  • JVP (heart failure in wet beriberi) and carotid pulse (volume and character)
  • Goitre (iodine deficiency)

Chest

  • Sternum: capillary refill, skin turgor (reduced in dehydration)

Abdomen

  • Ascites (hypoalbuminaemia, liver disease)
  • Adiposity
  • Loose skin/striae (rapid weight loss)

Legs

  • Pedal oedema (hypoalbuminaemia)
  • Bowed legs (rickets/osteomalacia)
  • Peripheral neuropathy (B12 deficiency, dry beriberi)

To complete

  • Thank patient 
  • ‘To complete my nutritional status assessment, I would take a full history, calculate BMI, check observations, look at the food and fluid balance charts, and take refeeding bloods (U&Es, Ca2+, Mg2+, PO43-).’ 
  • Summarise and suggest further investigations (e.g. OGD/colonoscopy for iron deficiency anaemia, anti-TTG for coeliac disease, parietal cell and intrinsic factor antibodies for B12 deficiency, dual energy X-ray absorptiometry (DEXA) scan)

Vitamin deficiencies

VitaminDeficiency
AXerophthalmia (dry conjunctiva); night blindness
DRickets/osteomalacia
EHaemolysis; neurological defects; retinopathy
KCoagulopathy (vitamin K required for factors II, VII, IX, X and protein C/S)
B1 (thiamine)Dry beriberi (peripheral neuropathy); wet beriberi (heart failure)
B1 (thiamine)Wernicke’s encephalopathy (ophthalmoplegia + ataxia + confusion)
B1 (thiamine)Korsakoff syndrome (amnesia, confabulation, apathy)
B3 (niacin)Pellagra (4Ds: Diarrhoea, Dermatitis, Dementia, Death)
B6 (pyridoxine)Dermatitis, glossitis, neuropathy, conjunctivitis 
B12Macrocytic anaemia; polyneuropathy; subacute combined degeneration of the cord; glossitis; pancytopenia 
CScurvy (listlessness, gingivitis, bleeding gums/hair follicles, rough dry scaly skin, anorexia, bruising)

Test yourself!

What is refeeding syndrome?

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Which electrolyte abnormalities are observed in refeeding syndrome and what is the reason for them?

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What are the normal requirements for energy, protein and fluid (per kg/day)?

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Photo references

Pellagra: Herbert L. Fred, MD, Hendrik A. van Dijk – book: Images of Memorable Cases – 50 years at the bedside ISBN 978-0-89263-000-4 http://cnx.org/content/m14940/latest/Case_2-pres1-1.jpg

Corneal arcus: Corneal arcus: 2008 Loren A Zech Jr and Jeffery M Hoeg; licensed under the Creative Commons Attribution 2.0 Generic license, edited

Glossitis: Glossitis: 2011. Grook Da Oger. Licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license

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