• 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?

• 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)

• 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

Downloads / Links

download pdf here

size: 265.29kb

Comments:

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,

Joel

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,

Joel

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

Make a Comment: