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⁺, PO₄^3-).’ 
• 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

Vitamin	Deficiency
A	Xerophthalmia (dry conjunctiva); night blindness
D	Rickets/osteomalacia
E	Haemolysis; neurological defects; retinopathy
K	Coagulopathy (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
B12	Macrocytic anaemia; polyneuropathy; subacute combined degeneration of the cord; glossitis; pancytopenia
C	Scurvy (listlessness, gingivitis, bleeding gums/hair follicles, rough dry scaly skin, anorexia, bruising)

Test yourself!

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