What components should be included in a History of Present Illness (HPI) for a patient with severe protein calorie malnutrition?

Components of HPI for Severe Protein Calorie Malnutrition

When documenting a History of Present Illness for severe protein calorie malnutrition, you must capture specific quantitative weight loss data, dietary intake patterns, functional decline, and underlying disease burden to establish both the severity and etiology of malnutrition.

Essential Weight Loss Documentation

• Document precise weight loss percentage and timeframe: Severe PCM is defined as >10% weight loss within the past 6 months or >20% weight loss beyond 6 months 1, 2.
• Record the patient's usual body weight, current weight, and the specific time period over which the loss occurred 3.
• Note whether weight measurements are accurate or confounded by fluid retention (ascites, edema), as this can mask the true severity of muscle and fat loss 3, 2.
• In patients with fluid overload (liver disease, kidney disease, heart failure), document clinical signs of muscle wasting independent of weight, particularly around shoulders and gluteal muscles 3.

Dietary Intake Assessment

• Quantify recent caloric intake as a percentage of estimated requirements: Severe malnutrition is characterized by ≤50% of energy requirements for >1 week, while moderate malnutrition involves any reduction below requirements for >2 weeks 1, 2.
• Document the duration of reduced intake in specific timeframes (days, weeks, months) 3, 2.
• Record specific barriers to adequate intake: anorexia, early satiety, nausea, vomiting, diarrhea, pain with eating, dysphagia, or dental problems 3.
• Note any dietary restrictions (prescribed or self-imposed) that may have contributed to malnutrition 1.

Functional Status Changes

• Document specific functional decline using validated scales: Use WHO or Karnofsky performance status to quantify the degree of functional impairment 1, 2.
• Record whether the patient is bedridden or has significantly reduced functional capacity, as this indicates severe PCM 4.
• Note muscle weakness, fatigue, and inability to perform activities of daily living 3.
• Document handgrip strength if measured, as this provides objective functional assessment 1.

Disease Burden and Inflammatory State

• Identify the underlying acute or chronic disease driving malnutrition: This includes acute illness, chronic disease-related inflammation, or metabolic stress 1, 2.
• Document specific comorbidities known to cause malnutrition: cancer, end-stage liver disease (present in 65-90% of cases), chronic kidney disease, chronic pancreatitis, or gastrointestinal disorders 3, 5, 2.
• Record recent hospitalizations, surgeries, infections, or other acute metabolic stresses 3.
• Note symptoms of systemic inflammation: fever, ongoing infection, or inflammatory conditions 1.

Physical Examination Findings

• Document visible signs of muscle wasting and fat loss: Obvious significant muscle wasting in temporal areas, shoulders, ribs, scapulae, gluteal muscles, and extremities indicates severe PCM 3, 4.
• Record loss of subcutaneous fat in triceps, lower ribs, and orbital areas 4.
• Note skin changes, hair loss, or other signs of micronutrient deficiencies that may accompany PCM 6.
• Document presence of edema or ascites that may mask weight loss 3, 2.

Associated Symptoms and Complications

• Document gastrointestinal symptoms: diarrhea, malabsorption, vomiting, or bowel dysfunction 3.
• Record neurological symptoms if present, particularly in patients with liver disease where malnutrition increases risk of hepatic encephalopathy 3.
• Note any signs of refeeding risk: prolonged starvation, recent minimal intake, or electrolyte abnormalities 3.
• Document alcohol intake history, as chronic alcohol abuse is a major contributor to malnutrition, particularly in liver and pancreatic disease 3.

Psychosocial and Economic Factors

• Record socioeconomic barriers to adequate nutrition: food insecurity, inability to shop or prepare meals, social isolation 3.
• Document psychiatric conditions affecting intake: depression, anxiety, dementia, or organic brain disease 3.
• Note living situation and available support systems 3.

Critical Pitfalls to Avoid

• Do not rely solely on BMI in patients with fluid retention, as this dramatically underestimates the severity of malnutrition in liver disease, kidney disease, and heart failure 3, 2.
• Do not delay documentation while awaiting laboratory results, as the clinical history establishes the diagnosis and severity of PCM 3.
• Do not overlook rapid weight loss even if absolute weight appears normal, as a 2% loss in 1 week, 5% in 1 month, or 7.5% in 3 months indicates severe malnutrition regardless of starting weight 4.