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 <18.5) and/or recent loss of
≥10% of usual
body weight
Poor intake: anorexia, food avoidance (e.g., psychiatric condition), or NPO
status for more than about 5 days
Protracted nutrient losses: malabsorption, enteric fistulae
, draining
abscesses or wounds, renal dialysis
Hypermetabolic states: sepsis, protracted fever, extensive trauma or burns
Alcohol abuse or use of drugs with antinutrient or catabolic properties:
steroids, antimetabolites (e.g., methotrexate), immunosuppr
essants, antitumor
agents
Impoverishment, isolation, advanced age
Physical Examination
Physical findings that suggest vitamin, mineral, and protein-energy
deficiencies and excesses are outlined in Table 72-4. Most of the physical findings
are not specific for individual nutrient deficiencies, and they must be integrated
with the historic, anthropometric, and laboratory findings. For example, the

Skin
Cellophane appearance Protein

Cracking (flaky paint or crazy
pavement dermatosis)
Protein
Follicular hyperkeratosis Vitamins A, C

Petechiae (especially
perifollicular)
Vitamin C
Purpura Vitamins C, K
Pigmentation, scaling of sun-
exposed areas
Niacin
Poor
wound healing, decubitus
ulcers
Protein,
vitamin C, zinc

Scaling
Vitamin A,
essential fatty acids,
biotin
Vitamin AYellow pigmentation sparing
sclerae (benign)

folate, vitamin B
12
Hypogeusesthesia, hyposmia Zinc

Swollen, retracted, bleeding
gums (if teeth present)
Vitamin C
Bones, Joints

Beading of ribs, epiphyseal
swelling, bowlegs
Vitamin D

Tenderness, subperiosteal
hemorrhage in children
Vitamin C
Neurologic
Confabulation, disorientation Thiamine
(Korsakoff psychosis) Drowsiness, lethargy, vomiting Vitamin A

Dementia
Niacin, vitamin
B
12

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