To investigate Malnutrition and Micronutrient Deficiencies
Roshina RabailM.Phil Human Nutrition and Dietetics
GENERAL PHYSICAL EXAMINATION
General Physical Examination• The signs and symptoms of severe nutritional disorders can be readily recognized.
• Milder nutritional deficiencies may be more difficult to identify.
• Many of the signs are nonspecific and may be due to a combination of nutrient deficiencies.
• The physical examination can provide clues to the existence of a deficiency .
• To identify further the specific nutrient(s) involved, however, the physical findings must be viewed in the context of the diet history, associated symptoms, and laboratory findings
Nutrition Focussed Physical Exam (NFPE)• Assessment of Macro and Micronutrient Deficiencies• How to Do It?• Techniques of the Physical Exam
• Inspection• Broad observation• Critical evaluation• Symmetry• Palpation• Examining body structures - touch
Components of GPE• Posture/Stature• Body Type• Vital Signs
• BP, Respiration rate, pulse rate
• Head to toe physical Exam:• Skin• Nails• Hair• Head and Neck• Eyes• Nose• Mouth• Neck
•Skeletal Exam:• Upper Body• Clavicles, Shoulders• Scapulas, Deltoids• Ribs• Hands
• Lower Body• Quadriceps, Calves• feet/ankles
•Abdomen•Exam is systematic: Head to Toe
General Physical Exam for Muscle wasting MALNUTRITION
Orbital Region (orbital fat pads)
Exam areas
Tips Severe Malnutrition
Mild-Moderate Malnutrition
Well Nourished
Orbital Region – Fat Pad Surrounding the Eye FAT
View patient when standing directly in front of them, touch above cheekbone
Hollow look, depressions, dark circles, loose skin
Slightly dark circles, somewhat hollow look
Slightly bulged fat pads. Fluid retention may mask loss
Temples (temporalis muscle)
Exam areas
Tips Severe Malnutrition
Mild-Moderate Malnutrition
Well Nourished
Temple Region - Temporalis Muscle MUSCLE
View patient when standing directly in front of them, ask patient to turn head side to side
Hollowing, scooping, depression
Slight depression
Can see/feel welldefined muscle
Clavicle Bone Region:Exam areas
Tips Severe Malnutrition
Mild-Moderate Malnutrition
Well Nourished
Clavicle Bone Region – MUSCLE
Look for prominent bone. Make sure patient is not hunched forward
Protruding, prominent bone
Visible in male, some protrusion in female
Not visible in male, visible but not prominent in female
Clavicle and Acromion Bone Region Exam areas
Tips Severe Malnutrition
Mild-Moderate Malnutrition
Well Nourished
Clavicle and Acromion Bone Region Deltoid Muscle MUSCLE
Patient arms at side; observe shape
Shoulder to arm joint looks square. Bones prominent Acromion protrusion very prominent
Acromion process may slightly protrude
Rounded, curves at arm/shoulder/neck
Upper Arm Region Triceps/biceps FATTips Severe
Malnutrition
Mild-Moderate Malnutrition
Well Nourished
Upper Arm RegionTriceps/biceps FAT
Arm bent, roll skin between fingers, do not include muscle in pinch
Very little space between folds, fingers touch
Some depth pinch, but not ample
Ample fat tissue obvious between folds of skin
Posterior Calf Region Exam area Tips Severe
Malnutrition
Mild-Moderate Malnutrition
Well Nourished
Posterior Calf Region
Grasp the calf muscle to determine amount of tissue
Thin, minimal to no muscle definition
Not well developed
Well-developed bulb of muscle
Edema and Ascites • Excessive fluid in the interstitial compartment• Used as supportive evidence• Primarily found in dependent areas; –
• Ambulatory - ankles, feet• Bedridden - buttocks
Edema and Ascites: Causes • Increased capillary hydrostatic pressure
• Hypervolemia; kidney disease, pregnancy, CHF • Loss of plasma proteins
• Kidney disease, liver disease, burn victims, malabsorption, malnutrition
• Obstruction of lymphatic circulation • Obstructing tumor, infection, damages to the lymph nodes or
lymph node removal (cancers)• Increased Capillary permeability
• Usually from inflammatory response or response to infections
Nutrition Focused Physical Examination:MICRONUTRIENT DEFICIENCIES
Micronutrient deficiencies• Micronutrient deficiencies:
• supporting evidence of malnutrition• Correlate with other evidence of malnutrition
• diet history, intake, weight loss, lab values• Differentiate findings as nutrition-related vs non nutrition related
• Rapidly proliferating cells-skin, hair, nails• Use head to toe examination• Skin is examined throughout exam
Skin• Largest organ in body, examine throughout
• protective barrier, metabolism and temperature regulator • Inspect for color, lesions, rashes, edema, turgor, hygiene • Nutritional implications-vitamin/mineral deficiencies, hydration
Physical Findings Possible
Nutrient Deficiency
Non Nutritional Cause
Pallor; paleness Iron (anemia) Low volume or low perfusion states
Poor or delayed woundhealing
Protein, zinc,Vitamin A & C
PVD, arterial insufficiency
Xerosis: abnormal dryness
Vitamin A, EFA Hygiene, aging, hypothyroidism, uremia, ichthyosis
Follicular hyperkeratosis:plaques around hair follicle
Vitamin A & C, EFA
Infection of hair follicle,Darier disease, syphilis
Perifolliculosis: pigmentedplaques (usually upper legs, thorax, abdomen)
Vitamin C Diabetic dermopathy(usually lower legs, feet)
Dermatitis, generalized
Zinc, EFA Atopic dermatitis, allergy ormedication rash, psoriasis
hyper-pigmented patches
Protein
Hair• Assess for color, distribution, texture, loss, Shiny, smooth, and not easily plucked
• Poor hair quality• Protein, zinc, EFAD, biotin deficiency
• Lanugo (fine hairs) which become more fragile as• energy deficiency prevails
Eye•Examine for:•Inflammation of lid, margins or corners•Vitamin B12, B6, Niacin
•Bitot Spots•Vitamin A Deficiency
Oral Exam•Lips, teeth, tongue, oral cavity•Assess for
• moisture, swelling, color, lesions, dentition•Abnormalities associated with malnutrition,
• deficiency/excess vitamins and minerals,• infection, dehydration
Lips•Bilateral fissures (angular stomatitis)
• Vitamins B-2, B-6, niacin, or iron • Poor fitting dentures
•Cheilosis (dry, swollen, cracked) • Vitamins B-2, B-6, niacin, or iron • Environment • Herpes
Teeth•Teeth Exam•Dental Caries•Loss of enamel•Periodontal Disease/Vit. C deficiency
Tongue• Tongue
• Note any mouth sores which may impair ability to eat• Glossitis: inflammation of tongue, magenta color
• Vitamins B-2, B-6, B-12, niacin, folate, iron • Can be due to Crohn’s, uremia, infection, malignancy, anticancer
therapy, trauma• Edematous tongue
• Niacin
Neck• Enlarged Thyroid
• Iodine deficiency • Inflammatory process • Various cysts • Thyroiditis
• Enlarged parotid gland • Protein deficiency • Bulimia • Mumps
Nails• Normal Nails
• Adherent to nail bed, uniform in thickness and feels smooth
• Lackluster, dull • Protein
• Splinter hemorrhages: distal end of nails,• Vitamins A & C
• Flaky nails • Magnesium, Selenium
Area/System Symptom or Sign DeficiencyGeneral appearance Wasting Energy
SkinRash Many vitamins, zinc, essential fatty acidsRash in sun-exposed areas Niacin (pellagra)Easy bruising Vitamin C or K
Hair and nailsThinning or loss of hair ProteinPremature whitening of hair SeleniumSpooning (upcurling) of nails Iron
EyesImpaired night vision Vitamin A
Corneal keratomalacia (corneal drying and clouding) Vitamin A
MouthCheilosis and glossitis Riboflavin, niacin, pyridoxine, ironBleeding gums Vitamin C, riboflavin
Extremities Edema Protein
Neurologic
Paresthesias or numbness in a stocking-glove distribution Thiamin (beriberi)
Tetany Ca, MgCognitive and sensory deficits Thiamin, niacin, pyridoxine, vitamin B12
Dementia Thiamin, niacin, vitamin B12
Musculoskeletal
Wasting of muscle ProteinBone deformities (e.g., bowlegs, knocked knees, curved spine) Vitamin D, Ca
Bone tenderness Vitamin DJoint pain or swelling Vitamin C
GI
Diarrhea Protein, niacin, folate, vitamin B12
Diarrhea and dysgeusia ZincDysphagia or odynophagia (due to Plummer-Vinson syndrome) Iron
Endocrine Thyromegaly Iodine