CICM SAQ 2010.2 Q20

History and physical examination:

• Indicators of malnutrition – recent involuntary weight loss, changes in appetite or bowel habit, presence of persistent GI symptoms, muscle wasting, signs of specific micro-nutrient deficiency e.g. glossitis, angular stomatitis, anaemia, bleeding gums, skin/hair/nail condition.

Ancillary blood tests:

• serum hepatic protein levels are linked to nutritional status and severity of illness.
• Serum albumin and pre-albumin levels. ( Albumin will be a better indicator of chronic nutritional status and pre-albumin serves more as a marker of changes in current nutritional status).
• Transferrin and coagulation factors: Useful but may more reflect the poor synthetic function of the liver in this case than nutritional deficiency per se.
• Fat-soluble vitamin deficiency levels of vitamins A, D and E should be checked. Water-soluble vitamin deficiency, (thiamine), is common in alcoholic liver disease and therefore levels of thiamine and other treatable vitamins e.g. zinc, selenium, Vit B12 and folate should also be checked.
• Other
  (1) delayed hypersensitivity skin testing
  (2) total lymphocyte count
  (3) anthropometric measurements e.g. mid-arm muscle circumference and skin-fold thickness
  (4) indirect calorimetry to measure energy expenditure – metabolic cart, VO2, VCO2,
  (6) nitrogen balance – but calculations inaccurate in liver and renal failure.