一二三院合堂-2017五年制医学英语assessment of nutritional status

AssessmentofNutritionalStatus

吉林大学中日联谊医院风湿免疫科马翠丽Onemusteattolive,andnotlivetoeat.

JeanBaptisteMoliere1622-1673

Nutritionisoneofthemostimportantfactorsaffectinganindividual’shealthanddiseasebecauseitaffectsalmosteverysystem.IthasbeenshownthatdietaryhabitscontributeimportantlytothepathogenesisofmanyofthemajorcausesofdeathintheUnitedStates.词语辨析affect

vt.影响、（疾病）侵袭

n.感情、情感bluntedaffect情感迟钝

flataffect情感淡漠effect

vt.产生、招致、实现

n.结果、效应、作用、影响beofnoeffect无效；takeeffect生效sideeffect副作用TwomainnutritionalproblemsintheUnitedStates:1.Obesity肥胖

Obesityisoneofthemostchallengingnutritionalproblems.Obesityisariskfactorformanydiseases,includinghypertension,coronaryarterydisease,diabetes,osteoarthritis,cancersofthebreastandendometrium,andhepato-biliarydisease.2.Malnutrition营养不良

Malnutritionisaproblemthattargetsanumberofspecificpopulations,includingtheelderlywholivealone,chronicallyillpatients,adolescentswhoeatanddieterratically,andrecentlydiagnosedpatientswithcancer,becausechemotherapeuticandradiationtherapeuticprotocolsmaypromotenutritionalproblems.相关词缀mal-不良

malnourishment营养不良maldevelopment发育不良dys-

不良、困难、障碍

dysaudia听力障碍；dysdipsia饮水困难；dysfunction功能不良a-

不、无、缺

abacterial无菌的相关词缀hyper-

过多、超过、过度、上、高、重hyperabsorption吸收过多hyperglycemia高血糖hypo-下、低、少、减退、迟、不足、次hypoactivity活动减退hypolipemia血脂过少Apatient’sabilitytorecoverfromanillnessorfromsurgeryfrequentlydependsonhisorherpastandpresentnutritionalstatus.Therefore,knowingwhatpatientseat,thenutritionaladequacyoftheirdiets,andtheirclinicalnutritionalstatusisanecessarycomponentofphysicaldiagnosis.Thischapterfocusesonthoseaspectsofthehistoryandphysicalexaminationthatconstituteanutritionalassessment.Atpresent,thereisnostandardizedsetofdietaryhistoryquestionsormethodforassessingnutritionalstatus.Rather,nutritionalassessmentrequirestheintegrationofinformationobtainedfromthemedicalhistoryandphysicalexamination.Throughoutthischapter,nutritionallyfocusedquestionsandexamplesofdiet-relateddiseasesareprovidedtoassistinbuildinghistory-takingandphysicalexaminationskills.MedicalHistoryChiefComplaintHistoryofPresentIllnessBodyWeightHistoryPastMedicalHistoryPastSurgicalHistoryMedicationsAllergiesandIntolerancesSocialHistoryLifestyleHabitsDietaryHistoryPhysicalActivityReviewofSystemsChiefComplaint

Thechiefcomplaintisdirectlyrelatedtothepatient’snutrition,whichmayaffecttreatmentandprognosis.Themostcommonvoice:

“lossofappetite”,“weightloss”,“weakness”.ChiefComplaint

Changesindietaryintakeandinweightareamongtheearliestsignsofmedicalproblems.Thesecomplainsshouldpromptadetailedinquiryaboutdietandrelatedsymptomsinthehistoryofpresentillness.HistoryofPresentIllness

Afteraskingthepatienttodescribethesymptomsormedicalproblemthatcausedhimorhertoseekmedicalattention,begintoexploreanydiet-diseaserelationshipthatmayexist.Thefollowingself-directedquestionsshouldguideyourinquiry:HistoryofPresentIllness

Doesnutritioncontributetothecause,severity,ortreatmentoftheillness?Howhastheillnessaffectedthepatient’sdietandnutritionalstatus?Doesthepatientseearelationshipbetweendietanddisease?HistoryofPresentIllness

Wasthepatienteveradvisedtofollowaspecialdietoruseothernutritionaltherapy,suchasdefinedformulasupplements,tubefeedings,orintravenousnutrition?Whatweretheparticularaspectsofthistherapy?Whatwasthepatient’sunderstandingofitspotentialefficacy?BodyWeightHistory

Bodyweightisaglobalindicatorforoverallhealth.Askingapatientwhetherheorshehasexperiencedanyweightlossisagoodgeneralindicationoftheseverityorsystemicnatureofthepresentingsymptoms,whethertheyareacuteorchronic.BodyWeightHistory

Theunderlyingreasonsfortheweightchangeshouldbeexploredandtheamountofweightlossclearlydefined.Informativequestionsincludethefollowing:“Hasyourweightchanged,eitherupordown,overthepastseveralweeksormonths?”Ifso,“Inwhatway?”BodyWeightHistory

“Howmuchweightdidyouloseorgain?”“Whatwasyourweightbeforethesymptomsstarted?”“Overwhatperiodoftimedidyouexperiencetheweightlossorgain?”“Howwasyourappetiteoverthistime?”“Doyouknowwhatmayhavecontributedtoyourchangeinweight?”BodyWeightHistory

Rapidweightgainisoftenanindicatoroffluidretentionandmaybepaniedbyedemaorascites.Commondiseasesassociatedwithrapidweightgainincludecongestiveheartfailure,liverdisease,andrenaldisease.BodyWeightHistory

Rapidweightlossusuallysignifieslossofbodytissue,unlessthepatienthasbeenundergoingtherapeuticdiuresis(increasedurination)orisexperiencingdehydration(decreasedfluidingestion,drymouth,weakness,anddizziness).%weightchange=[(usualweight-currentweight)/usualweight]×100相关词缀in-

内、在内、向、朝

innervation神经支配de-

脱、去、除、离、解除deaminase脱氨酶decerebrate去脑degeneration退变denervation去神经支配BodyWeightHistory

Fourphysiologiccategoriesforweightloss:(1)decreasedcaloricintake,(2)malabsorptionormaldigestion,(3)impairedmetabolismorincreasedrequirements,(4)increasedlossesorexcretion.PastMedicalHistory

Aspatientslisttheirpastillness,askthefollowingquestions:

(1)Howwastheillnessdiagnosedandwhattreatmentwasrendered?(2)Whetherdidheorshereceivedietarycounselingoralterhisorherdietinresponsetothediagnosis?PastSurgicalHistory

Inthissection,shouldrecord:(1)allsurgicalprocedures,(2)serioussurgicalcomplications.Thesecomplications(suchasdrainingfistulas,abscesses,openwounds,andchronicbloodloss)oftenleadtomalnutritionandtheneedforspecializednutritionalsupport,includingenteralandparenteralfeedings.相关词缀par-

类、副、拟、旁、周、错乱、异常parenteral肠胃外的、非肠道的parepigastric上腹旁的post-

在后、后postdigestive消化后的postrenal肾后的MedicationsThemedicationhistoryshouldincludebothprescriptionandover-the-countermedications.Suggestedquestionsare:“Areyoutakinganyvitamins,minerals,herbs,orotherdietarysupplements,eitherprescriptionorover-the-counter?”Ifso,“Whatisthedosage?”Medications

“Whatisthereasonyouaretakingthesupplement?”“Haveyouexperiencedanysideeffectsorbenefitsfromthesupplements?”“Isanybodymonitoringyou,suchasyourdoctor,nutritionist,orherbalist?”“Whatisyourconsumptionofgrapefruitandgrapefruitjuice?”MedicationsDrugsandnutrientsinteractinmanywaystoaffectbothnutritionalstatusandtheeffectivenessofdrugtherapy.Drugsmayinfluencenutritionalstatusbyseveralphysiologicmechanisms:alteringfoodintakeproducingmalabsorptionmodifyingexcretionAllergiesandIntolerancesInadditiontoaskingaboutallergiestomedicationsandenvironmentalallergens,inquireaboutallergiesandintolerancestofood.Themostcommonallergenicfoodsamongadultsarepeanuts,treenuts,shellfish,fish,eggs,soy,wheat,andmilk.AllergiesandIntolerancesAllergicsymptomsmayaffecttherespiratorytract,skin,orGItract.Afoodallergyneedstobedifferentiatedfromfoodintolerance.SymptomsoffoodintoleranceareusuallyconfinedtotheGItractandmaybeacuteorchronic.SocialHistoryMultiplesocialfactorsaffectthedietaryandnutritionalstatusofpatients.Forexample,lowsocioeconomicstatus,lowfixede,homelessness,orlackofaccesstoavarietyoffoodchoicesmaycontributetonutritionaldeficiencies.Religiousobservances,alsodetermineeatingpatternsandtheselectionoravoidanceofspecificfoods.LifestyleHabitsThelifestylehabitssectionofthemedicalhistoryincludesthedietaryhistory,physicalactivityhistory,alcoholuse,andsmokinghistory.DietaryHistoryThedietaryhistoryprovidesinformationaboutthepatient’sfoodhabits,diet,andanycounselingheorshemayhavereceived.Therearethreemethodscommonlyused:

a24-hourintakerecall,atypicalday,andfoodfrequency.DietaryHistoryA24-hourintakerecall,questions:Iwouldliketoknowwhatyouhadtoeatanddrinkfortheentiredayyesterday.Couldyoustartwiththefirstitemyouhadtoeatordrinkandbringmethroughtheentireday?Iwouldalsoliketoknowthetimesyouateandtheamounts.DietaryHistoryAtypicalday,questions:Iwouldliketoknowaboutyourusualortypicaldiet.Canyoubringmethroughatypicalday,startingwiththefirstitemyoueatordrink?Iwouldalsoliketoknowthetimesyoueatandtheamounts.DietaryHistoryFoodfrequency,questions:Howoftendoyoueatfruitsandvegetables-daily,everyfewdays,weekly,orrarely?Whenyoueatthem,howmanyservingsdoyouchoose?DietaryHistoryOtherinformativequestions:“Whatareyourfavoritefoodsandsnacks?”“Areyoufollowinganyspecialdiet?”Ifso,“Whatdoesthisdietentail?”“Howoftenaremealshomecooked?Whopreparesthemeals?”DietaryHistoryOtherinformativequestions:“Whatsortoffatsoroilsdoyouuseincooking?”“Howoftendoyoueatoutororderfoodin?”“Howisfoodusuallyprepared?”DietaryHistoryTheInstituteofMedicinemendsthatthefollowingguidelinesbeusedforachievingahealthfuldiet:Carbohydrates:45%to65%ofcaloriesFat:20%to35%(<10%saturatedfat)Protein:10%to35%ofcaloriesSodium:1.5g(3.8gofsalt)eachdayCholesterol:lessthan300mgeachdayPhysicalActivityBothnutritionandregularphysicalactivityplayanimportantroleintheoverallhealthoftheindividual.Itismendedthatalladultshaveatleast30minutesofphysicalactivitydaily.PhysicalActivitySomehelpfulquestions:“Whatisthemostphysicallyactivethingyoudointhecourseoftheday?”“Howdoyouspendyourworkingdayandleisuretime?”“Whattypesofphysicalactivitydoyouenjoy?Howoftendoyoudothem?”“Doyouexerciseregularly?”Ifso,“Whatexercisesdoyoudoregularly?Howoften?”PhysicalActivity“Whatgetsinthewayofyouconsistentlydoingphysicalactivity?”“HowmanyhoursofTVdoyouwatcheveryday?”“Howmanyhoursareyouatacomputerordeskeveryday?”“Doyoubelongto(andattend)ahealthcluborexerciseclasses?”ReviewofSystemsThereviewofsystemssectionisareexaminationofthepatient’shistorybyorgansystem.Thissectionshouldincludeageneralstatementaboutthepatient’sbodyweighthistoryandappetiteifnotincludedinthehistoryofpresentillnessorpastmedicalhistory.PhysicalExaminationVitalSignsheartratepulsebloodpressuretemperatureheightweightVitalSignsHeightandweightprovidesignificantinformationaboutthepatient’soverallhealthstatusandarefrequentlyusedformedicationdosing.VitalSignsThenutritionalstatusofthepatientbasedonheightandweightisinterpretedbythebodymassindex(BMI).BMIisaninternationaldesignationofrelativeweightforstatureandisamorereliableindexofobesitythanaretheolderheight-weighttables.BMI=weight(kg)/height(meters)2,orBMI=weight(pounds)/height(inches)2×703VitalSignsBMIunderweight:lessthan18.5kg/m2healthyweight:between18.5and25.0overweight:between25.1and29.9obese:30andaboveAppearanceAdescriptionofthepatient’sgeneralappearanceisalwaysfoundatthebeginningofthephysicalexaminationreport.Forexample,“Onexamination,Ms.B.isawell-developed,thin,whitefemale.”AppearanceOthernutritionallydescriptivetermsare:Emaciated瘦弱Cachectic恶病质Malnourished营养不良Thin/slim苗条Underweight低体重Normalweight正常体重Fit适合Overweight超重Obese肥胖Edematous水肿性AppearanceNutrition-orientedaspectsofthephysicalexaminationfocusontheshin,eyes,mouth,skeletalmuscle,andfatstores.SpecialPopulationsObesepatientsMalnourishedpatientsElderlypatientsObesePatientsWhencalorieintakecontinuouslyexceedsrequirements,obesityresults.Lessthan1%ofallcasesofobesityarerelatedtoneuroendocrinecauses,andtheseconditionsrarelycausemassiveobesity.Obesity-FocusedHistoryAnobesity-focusedhistoryshouldincludeachronologichistoryofthepatient’sweight,identifyingageatonset,descriptionofweightgain,andincitingevents.Thefollowingquestionsshouldbeconsideredpartofanobesity-focusedhistory:“Whendidyoufirstconsideryourselfoverweightorhaveaweightproblem?”Obesity-FocusedHistory“Doyourememberwhatyouweighedwhenyouwereinhighschool?College?Your20s,30s,etc.?”“Whatwasyourlowestweightasanadult?”“Whatwasyourhighestweightasanadult?”“Werethereanyparticularlifeeventsthatcausedyoutogainweight,suchaspregnancy,stoppingsmoking,changingjobs,gettingadivorce,etc.?”“Didyouexperienceweightgainaftertakinganymedication?”Ifso,“Whichmedication,andhowmuchweightdidyougain?”Obesity-FocusedHistoryItisimportanttoappreciatewhatimpacttheobesityhashadonthepatient.Thisinformationcanbeobtainedwiththefollowingquestions:“Howdoesyourbodyweightaffectyou?”“Isthereanythingthatyoucannotdobecauseofyourweight?”“Doesyourweightaffectyourownsenseofself-worth?”“Haveyouparticipatedinanyweightmanagementprogramsinthepast?”Ifso,“Whatwerethey,andhowdidyourespond?”Obesity-FocusedPhysicalExaminationAssessmentofriskstatusduetooverweightandobesityisbasedonthepatient’sBMI,waistcircumference,andexistenceofcomorbidconditions.Obesity-FocusedPhysicalExaminationThemeasurementofwaistcircumference:Ahorizontalmarkisdrawnjustabovetheuppermostlateralborderoftheiliaccrest.Aclothormetaltapeisthenplacedinahorizontalplanearoundtheabdomenatthelevelofthemark.Themeasurementismadeatanormalminimalrespiration.MalnourishedPatientsMalnutritionisassociatedwithslowerwoundhealing,increasedcomplications,longerlengthofhospitalstay,higherhealth-carecosts,andincreasedmortality.TheSubjectiveGlobalAssessment(SGA)providesanintegrationofhistoricalandphysicalexaminationdatatoarriveatanevaluationofthepatient’snutritionalstatus.MalnourishedPatientsFivefeaturesofthehistoryandeightfeaturesofthephysicalexaminationarecombinedtoassessrisk.Thehistoricalfeaturesareweightloss,changesindietaryintake,significantGIsymptoms,functionalstatusorenergylevel,andmetabolicdemandofthepatient’sunderlyingdiseasestate.MalnourishedPatientsPhysicalfindingsarescoredasnormal(0),mild(1+),moderate(2+),orsevere(3+),andincludedepletionofsubcutaneousfatinthechestandtriceps,musclewastinginthequadricepsanddeltoidmuscles,andthepresenceofedemaorascites.MalnourishedPatientsBasedonthehistoryandphysicalexaminationfindings,patientsarerankedaccordingtothefollowingthreecategories:A,goodnutrition;B,moderateorsuspectedmalnutrition;C,severemalnutrition.ElderlyPatientsThefollowingriskfactorsassociatedwithpoornutritionalstatusinolderAmericans:inappropriatefoodintake,poverty,socialisolation,dependency,ordisability,acuteorchronicdiseasesorconditions,andchronicmedicationuse.ElderlyPatientsThesefactorshavebeenincorporatedintoariskfactorchecklistusingtheacronymDETERMINE,whichidentifiesseveralwarningsignsforindividualsatriskforpoornutritionalstatus.Disease,Eatingpoorly,Toothlossormouthpain,Economichardship,Redu