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 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 Deficiency a Possible Excess Hair, Nails Corkscrew hairs and une merged coiled hairs Vitamin C Easily pluckable hair Protein Flag sign (transverse depigmentation of hair) Protein Sparse hair Protein, biotin, zinc Vitamin A Transverse ridging of nails Protein 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 A Yellow pigmentation sparing sclerae (benign) Zinc (hyperpigmented) Carotene Eyes Night blindness Vitamin A Papilledema Vitamin A Perioral Angular stomatitis Riboflavin, pyridoxine, niacin Cheilosis (dry, cracking, ulcerated lips) Riboflavin, pyridoxine, niacin Oral Atrophic lingual papillae (slick tongue) Riboflavin, niacin, folate, vitamin B 12 , protein, iron Glossitis (scarlet, raw tongue) Riboflavin, niacin, pyridoxine, 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 , folate Headache Vitamin A Ophthalmoplegia Thiamine, phosphorus Peripheral neuropathy (e.g., weakness, paresthesias, ataxia, foot drop, and decreased tendon reflexes, fine tactile sense, vibratory sense, and position sense) Thiamine, pyridoxine, vi tamin B 12 Pyridoxine 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 . Chapter 072. Malnutrition and Nutritional Assessment (Part 5) Nutritional History A nutritional history is directed toward identifying. 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. 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