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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Malnourishment, Adult
Allan S. Detsky, Philip S. Smalley, Jose Chang
3. Presence of Significant Gastrointestinal Symptoms: Anorexia, Nausea, Vomiting, and Diarrhea

Topics Discussed: ascites, diagnostic process, diarrhea, edema, malnutrition, nausea, nutrition assessment, subjective global assessment, vomiting, weight reduction

Excerpt: "This article primarily describes features of the medical history and physical examination for assessing overall nutritional status.A weight loss of less than 5% is considered small. A weight loss between 5% and 10% is considered potentially significant, and a weight loss of more than 10% is considered definitely significant. In addition to considering the amount of weight loss, it is important to note the pattern of the weight loss. For example, suppose a patient lost 12% of his or her weight in the 6 months to 1 month before the examination and then regained half of that weight in the subsequent month, resulting in a net loss of 6% for the entire period. This patient would be considered better nourished than a patient who had lost 6% progressively in the 6 months, with continued weight loss in the recent weeks, before the examination. Patients can be considered well nourished despite significant proportions of weight loss if there has been a recent stabilization or increase in weight. In eliciting the history of weight pattern from patients, we recommend asking the patient what his or her maximum weight was and what it was 1 year ago, 6 months ago, 1 month ago, and at present. If patients report substantial weight loss that we cannot confirm with prior records, we ask for confirming history of a change in clothing size or whether their clothes now fit very loosely. Finally, we ask for the pattern of the weight loss during the past few weeks (continued loss, stabilization, or gain).There are several locations where one can look for loss of subcutaneous fat, and the best are the triceps region of the arms, the midaxillary line at the costal margin, the interosseous and palmar areas of the hand, and the deltoid regions of the shoulder (Figures 28-1 and 28-2). Positive findings are loss of fullness or 1 or more areas where the skin fits too loosely over the deeper tissues; this latter sign may be falsely positive in elderly individuals who may appear to have lost subcutaneous tissue without being clinically malnourished...."
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