Chapter 072. Malnutrition and Nutritional Assessment (Part 5)

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Nutritional History A nutritional history is directed toward identifying underlying mechanisms that put patients at risk for nutritional depletion or excess. These mechanisms include inadequate intake, impaired absorption, decreased utilization, increased losses, and increased requirements of nutrients. Individuals with the characteristics listed in Table 72-3 are at particular risk for nutritional deficiencies.

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Chapter 072. Malnutrition and Nutritional Assessment (Part 5) Nutritional History A nutritional history is directed toward identifying underlying mechanisms that put patients at risk for nutritional depletion or excess. These mechanisms include inadequate intake, impaired absorption, decreased utilization, increased losses, and increased requirements of nutrients. Individuals with the characteristics listed in Table 72-3 are at particular risk for nutritional deficiencies. Table 72-3 The High-Risk Patient
Underweight (body mass index
with the historic, anthropometric, and laboratory findings. For example, the finding of follicular hyperkeratosis on the back of the arms is a fairly common, normal finding. On the other hand, if it is widespread in a person who consumes little fruit and vegetables and smokes regularly (increasing ascorbic acid requirements), vitamin C deficiency is likely. Similarly, easily pluckable hair may be a consequence of chemotherapy, but in a hospitalized patient who has poorly healing surgical wounds and hypoalbuminemia, it suggests kwashiorkor. Table 72-4 Physical Findings of Nutritional Deficiencies Clinical Findings Possible Possible Deficiencya Excess Hair, Nails Corkscrew hairs and unemerged Vitamin C coiled hairs Easily pluckable hair Protein
Flag sign (transverse Protein depigmentation of hair) Sparse hair Protein, biotin, Vitamin A zinc Transverse ridging of nails Protein Skin Cellophane appearance Protein Cracking (flaky paint or crazy Protein pavement dermatosis) Follicular hyperkeratosis Vitamins A, C Petechiae (especially Vitamin C perifollicular)
Purpura Vitamins C, K Pigmentation, scaling of sun- Niacin exposed areas Poor wound healing, decubitus Protein, ulcers vitamin C, zinc Scaling Vitamin A, Vitamin A essential fatty acids, biotin Yellow pigmentation sparing Zinc Carotene sclerae (benign) (hyperpigmented) Eyes Night blindness Vitamin A Papilledema Vitamin A
Perioral Angular stomatitis Riboflavin, pyridoxine, niacin Cheilosis (dry, cracking, Riboflavin, ulcerated lips) pyridoxine, niacin Oral Atrophic lingual papillae (slick Riboflavin, tongue) niacin, folate, vitamin B12, protein, iron Glossitis (scarlet, raw tongue) Riboflavin, niacin, pyridoxine, folate, vitamin B12
Hypogeusesthesia, hyposmia Zinc Swollen, retracted, bleeding Vitamin C gums (if teeth present) Bones, Joints Beading of ribs, epiphyseal Vitamin D swelling, bowlegs Tenderness, subperiosteal Vitamin C hemorrhage in children Neurologic Confabulation, disorientation Thiamine (Korsakoff psychosis) Drowsiness, lethargy, vomiting Vitamin A
Dementia Niacin, vitamin B12, folate Headache Vitamin A Ophthalmoplegia Thiamine, phosphorus Peripheral neuropathy (e.g., Thiamine, Pyridoxine weakness, paresthesias, ataxia, foot drop, pyridoxine, vitamin and decreased tendon reflexes, fine B12 tactile sense, vibratory sense, and position sense) Tetany Calcium, magnesium Other
Edema Protein, thiamine Heart failure Thiamine ("wet" beriberi), phosphorus Hepatomegaly Protein Vitamin A Parotid enlargement Protein (consider also bulimia) Sudden heart failure, death Vitamin C a In this table, "protein deficiency" is used to signify kwashiorkor