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)
Pellagra
Clubbing
Koilonychia
Corneal arcus
Pale conjunctiva
Glossitis
Goitre
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
| 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!
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
