This is a young man in his 20’s who is a quadraplegic and suffered a bowel obstruction about 6 months before this photograph was taken. The midline abdominal wound is granulated, but still hasn’t epithelialized. Why? There’s no pressure over this area and it doesn’t appear heavily colonized. I will give you a hint. I’m screening all my patients with the Nestle Mininutritional Assessment tool, and his MNA score is only 7 which indicates that he is malnourished. To make screening easier, we built the MNA into the electronic health record (EHR) and there’s a clinical practice suggestion in the EHR that reminds me to do it. Nutritional screening of patients with non-healing wounds is also a CMS-recognized quality measure.

Perhaps not surprising for a patient who stays inside all the time, his Vitamin D level is only 22.7. Levels less than 30 are associated with poor healing. Yes, it’s also vitamin D Groundhog day. He’s going to be another one of the many patients who has had a non-healing wound for months, but which will be fixed with low-cost and simple nutritional interventions. I will provide Vitamin D3 supplementation, L-arginine, and a lot more calories.

The saddest part of this story is that he’s been malnourished for months, has seen a LOT of different doctors and has been hospitalized several times. Why is it so hard to do the right thing about nutrition?

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