Assessment of The Nutritional State
Assessment of the nutritional state of a patient is an important part of the clinical examination. While gross malnutrition is usually easy to recognize, lesser degrees of the body tissue depletion my be difficult to detect, particularly if oedema is also present, as in hypoalbuminanaemia associated with severe protein loss, severe malabsorption, or kwashiorkor. Malnutrition may be due to starvation, to maldigestion of food or to malabsorption of the products of the process of digestion.
There are several ways to assess the nutritional state. The most important are the clinical history, including dietary history, and the physical examination, including anthropometric measurements. Other more subtle indices of malnutrition include muscle function tests and evaluation of creatinine excretion and serum, levels of albumin. Transferrin and retinol binding protein measurements are usually reserved for research studies.
History
If starvation is excluded, patients likely to be at risk of the malnutrition are those with reduced intake due to poor appetite or inability to eat. Malnutrition may also develop in patients with gastrointestinal failure and when metabolic needs exceed energy intake, as in hypeerthyroidism.
Depressed appetite may accompany any severe illness, particullarly malignancy and chronic renal or cardiac failure, in which nausea is often an accompanying problem. Chronic drug abuse is an other pointer to poor food intake. Drug addicts may spend all their available income on drugs and neglect food. Alcoholics obtain calories from their drink but often develop protein and vitamins malnutrition syndromes. Malnutrition due to inability to eat (dysphagia) may occur in patients with neurological disturbances such as strokes, and in patients with oropharyngeal disease. A history of diarrhoea or steatorrhoea which progress weight loss despite a good appetite should lead to consideration of alimentary disorders such as coeliac disease, bacterial overgrowth syndromes, or inflammatory bowel disease.
Increased metabolic needs arise in severely ill patients, particularly those with fever, burns, or cancers, or following major trauma, including surgery. Hyperthyroidism must also be remembered as a cause of weight loss despite good appetite.
Dietary History
A simple evaluation of a patient's diet is valuable in the assessment of patient and is mandatory in all patients who appear malnourished. General question about frequency of meals, types of food eaten, and methods of food preparation give a clue to dietary habits but are occasionally misleading of patients are elderly or impoverished. Recent changes in appetite or dietary pattern should be noted.
It is important to enquire whether the patient avoid certain foodstuffs for any reason. Strict vegatarians (vegans) may become vitamins B12 deficient while avoidance of specific foods to relieve gastrointestinal symptoms may provide a clue to the nature of the underlying disease, e.g, milk avoidancein intestinal lactase deficiency.
Physical Examination
In the general assessment of nutritional status careful attention must be given to the presence and distribution of body fat, the muscle bulk and presence of oedema.
Loss of facial muscle mass is common in malnutrition. A wasting of temporal muscles produces the characteristic gaunt appearance of the starved. Additional clues to poor nutrition are a dry cracked skin, loss of hair and poor wound healing.
Deficiency of specific vitamins produces characteristic manifestation, e.g. pellagra and scurvy.
There are several ways to assess the nutritional state. The most important are the clinical history, including dietary history, and the physical examination, including anthropometric measurements. Other more subtle indices of malnutrition include muscle function tests and evaluation of creatinine excretion and serum, levels of albumin. Transferrin and retinol binding protein measurements are usually reserved for research studies.
History
If starvation is excluded, patients likely to be at risk of the malnutrition are those with reduced intake due to poor appetite or inability to eat. Malnutrition may also develop in patients with gastrointestinal failure and when metabolic needs exceed energy intake, as in hypeerthyroidism.
Depressed appetite may accompany any severe illness, particullarly malignancy and chronic renal or cardiac failure, in which nausea is often an accompanying problem. Chronic drug abuse is an other pointer to poor food intake. Drug addicts may spend all their available income on drugs and neglect food. Alcoholics obtain calories from their drink but often develop protein and vitamins malnutrition syndromes. Malnutrition due to inability to eat (dysphagia) may occur in patients with neurological disturbances such as strokes, and in patients with oropharyngeal disease. A history of diarrhoea or steatorrhoea which progress weight loss despite a good appetite should lead to consideration of alimentary disorders such as coeliac disease, bacterial overgrowth syndromes, or inflammatory bowel disease.
Increased metabolic needs arise in severely ill patients, particularly those with fever, burns, or cancers, or following major trauma, including surgery. Hyperthyroidism must also be remembered as a cause of weight loss despite good appetite.
Dietary History
A simple evaluation of a patient's diet is valuable in the assessment of patient and is mandatory in all patients who appear malnourished. General question about frequency of meals, types of food eaten, and methods of food preparation give a clue to dietary habits but are occasionally misleading of patients are elderly or impoverished. Recent changes in appetite or dietary pattern should be noted.
It is important to enquire whether the patient avoid certain foodstuffs for any reason. Strict vegatarians (vegans) may become vitamins B12 deficient while avoidance of specific foods to relieve gastrointestinal symptoms may provide a clue to the nature of the underlying disease, e.g, milk avoidancein intestinal lactase deficiency.
Physical Examination
In the general assessment of nutritional status careful attention must be given to the presence and distribution of body fat, the muscle bulk and presence of oedema.
Loss of facial muscle mass is common in malnutrition. A wasting of temporal muscles produces the characteristic gaunt appearance of the starved. Additional clues to poor nutrition are a dry cracked skin, loss of hair and poor wound healing.
Deficiency of specific vitamins produces characteristic manifestation, e.g. pellagra and scurvy.
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