Examination: Nutritional Status

  • Wash hands
  • Introduce self
  • Permission - ask to examine patient
  • Expose down to underwear
  • Reposition lying flat

General inspection:
  • Around the patient for:
    • Nutritional supplements
    • 'Nil by mouth' (NBM) signs
  • Patient as a whole
    • Comfortable?
    • General body habitas/body mass index (BMI)
    • Is there food at the bedside? Are meals unfinished?
    • Do they have nutrition supplements on their table?
    • Do they have a naso-gastric (NG) tube in situ
    • Do they have 'Total Parenteral Nutrition' (TPN) running - usually a covered plastic bag on a drip stand, running through a long line (PICC line/Hickman line/central line)
    • Do they have intravenous fluids running?

Specific inspection:
  • Hands:
    • Nails, for:
      • Clubbing (could be in keeping with Cystic Fibrosis, Crohns Disease, or causes of cachexia such as malignancy or tuberculosis)
      • Koilonychia (iron deficiency)
      • Leukonychia (low albumin)
      • Xanthomata (hypercholesterolaemia)
  • Arms, for:
    • Loose skin over upper arms suggestive of rapid weight loss?
    • An erythematous rash (patches, blisters, excoriation marks) over extensor aspects (elbows, knees, buttocks) in keeping with 'dermatitis herpetiformis' (Coeliac Disease)
  • Face, for:
    • Hair
      • Rough and wirey?
    • Eyes, for:
      • Corneal arcus (hypercholesterolaemia)
      • Xanthelasma (hypercholesterolaemia)
      • Xerophthalmia - reduced tear formation. May be due to vitamin A deficiency
      • Conjunctival pallor (anaemia)
      • Icterus/jaundice (liver malfunction, associated with alcoholic liver disease/autoimmune liver disease)
    • Mouth
      • Angular stomatitis (vitamin deficiency)
      • Glossitis (vitamin/mineral deficiency)
      • Apthous ulcers (in keeping with Crohns Disease)
      • Gums
        • Gingivitis?
  • Neck
    • Goitre?
      • May be caused by Iodine deficiency
  • Abdomen
    • Thin patient?
    • Palpate for ascites (which can be due to low albumin states, such as malnutrition or liver failure)
  • Legs
    • Bowing of the legs (low Calcium or Vitamin D)
    • Pitting leg oedema (due to low albumin)

To conclude the examination:
  • Calculate the patient's Body Mass Index = (mass in kg)/(height in metres)2
  • Check the patient's food chart and fluid balance chart
  • Examine the patient's hydration state
  • Thank the patient and offer to help them get dressed
  • If there is evidence of a specific nutritional deficiency then you could offer to further investigate as appropriate:
    • Iron deficiency (depending on other factors): oesophagogastroduodenoscopy (OGD) and colonoscopy
    • Vitamin B12 deficiency: Shilling test
    • Mixed deficiency: Coeliac serology
  • If there is evidence of a specific nutritional deficiency then investigate for consequences of this, e.g:
    • Full blood count and haematinic blood tests (Iron, Vitamin B12, Folate)
    • Bone radiographs or DEXA scan for osteomalacia

written by: celine_lakra; joel_cunningham, first posted on: 8/03/12, 19:32

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3570prj says...
maybe also:
Clubbing: CF
apthous ulcers (IBD)
dermatitis herpetiformis (Coeliacs)
conjunctival pallor
signs of jaundice (alcoholism, psc, pbc)
If time rapid check for opthalmoplegia (B1 deficiency) neuropathy (b6 and 12 deficiency)
POSTED ON: 26/05/12, 09:47
ASIL2014 says...
very helpfule
POSTED ON: 22/10/16, 13:39
Joel_cunningham says...
Hi 3570PRJ,

Thanks for these additions - we've added a few of them in to the examination! Checking for ophthalmoplegia and neuropathy shows very good understanding of the more advanced consequences of malnutrition. I haven't added these two in to our standard examination guide, as they would take a lot of time in a short 5 minute station, but they're great to volunteer at the end of the examination if an examiner asks for 'next steps'.

Best wishes,

POSTED ON: 28/12/16, 11:28
Joel_cunningham says...
Hi ASIL2014,

Thanks for the comment - always good to hear when our resources are useful. Feel free to ask any questions in the comment boxes - we're more than happy to get back to you about it.

Best wishes,

POSTED ON: 28/12/16, 11:30

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