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