Clinical Assessment

• Clinical assessment


  Routine medical history and physical examination to detect physical signs (observations made by a qualified examiner) and symptoms (manifestations reported by the patient)
• Medical history


  Description of the patient and relevant environmental, social and family factors, and specific data on the medical history of the patient and his/her family
• Physical examination


  Examines changes, believed to be related to inadequate nutrition, that can be seen or felt in superficial epithelial tissue, especially the skin, eyes, hair, and buccal mucosa, or in organs near the surface of the body, e.g. parotid and thyroid glands
• Clinical assessment


  Examination of changes that can be seen or felt in superficial tissues, such as skin, eyes and hair, among others
• Advantages of clinical assessment


  • Can cover more clients in a short time
  • Inexpensive, no need for sophisticated equipment
• Disadvantages of clinical assessment


  • Non-specificity of signs (signs may be due to non-nutritional causes)
  • Overlapping of deficiency states (dietary deficiencies are not restricted to an isolated nutrient)
  • Bias of the observer (observations of two examiners are most often not consistent with each other)
• Classification of physical signs most often associated with malnutrition according to World Health Organization (WHO)


  • Group 1: signs that are considered of value in nutritional assessment or signs indicating a probable deficiency of one or more nutrients often associated with nutritional deficiency status
  • Group 2: signs that indicate probable long-term malnutrition in combination with other factors
  • Group 3: signs that have no relation to malnutrition, although they may be similar to physical signs found in persons with malnutrition and must be carefully delineated from them
• Major problems encountered in the clinical assessment of nutritional status


  • Their low general prevalence in developed countries in high-risk groups
  • The non-specificity of clinical signs in most populations, particularly developed countries
  • The substantial differences in the prevalence of physical signs recorded by different examiners
• Reasons for including physical examinations in nutrition surveys


  • It may reveal evidence of certain nutritional deficiencies that will not be detected by dietary or laboratory methods
  • The identification of even a few cases of clear-cut nutritional deficiency may be particularly revealing and provide a clue to other pockets of malnutrition in a community
  • The nutritional examination may reveal signs of a host of other diseases that merit diagnosis and treatment
• Limitations of the physical examination


  • Non-specificity of the physical signs
  • Presence of multiple physical signs
  • Signs may be two-directional
  • Examiner inconsistencies
  • Variation in the pattern of physical signs
• Apathy


  Unreactive, unresponsive, disinterested and inattentive to surroundings
• Clinical Marasmus


  Pronounced wasting of subcutaneous fat without edema, apathy may be present, face and eyes of the child may appear unusually bright due to the combination of wasting and prominence of the eyes
• Irritability


  Excessive or overreaction to minor stimuli, particularly manifest through crying or unusual indication of fear as a result of minor or relatively insignificant happenings
• Kwashiorkor


  Pitting edema on the pretibial region, underweight, undersize and underdeveloped for age, muscular wasting may be present or masked by edema, hair becomes thin, easily pluckable with flag sign, and change in texture to silken sparse hair
• Pallor


  Paleness and loss of color skin, nail buds, mucosa, and lips
• Pre-kwashiorkor


  An underweight, undersized, underdeveloped child without the evident pronounced wasting present in marasmus
• Dry hair


  Wire-like, unkempt, stiff hair, often brittle, sometimes may exhibit some leaching of the normal color
• Dispigmentation


  Definite change from normal pigment of the hair, includes both change of pigment, usually lightening of color and depigmentation
• Easily Pluckable hair


  Hair shafts are readily removed with minimum tug when a few strands are grasped between the finger and thumb, and gently pulled
• Other hair signs associated with malnutrition


  • Lack of luster, hair dull and dry, thin and sparse, hair fine, silky and straight, color changes (flag sign)
• Angular Lesions


  Present bilaterally when mouth is held open, may appear as pink or moist, whitish, macerated, angular lesions that blur the mucocutaneous junction
• Angular Scars


  Scars at the angles, which if recent may be pink, if old, may appear blanched
• Cheilosis


  Lips are swollen, tense or puffy, and the buccal mucosa extends out onto the lips, vertical fissuring of the lips
• Nasolabial seborrhea


  Greasy yellowish scaling or filiform excrescenses in the nasolabial area that become more pronounced on slight scratching with the fingernail or a tongue blade, scaling of skin around nostrils
• Depigmentation


  Skin color loss
• Malar and supraorbital pigmentation


  Over cheeks and under eyes
• Lumpiness or flakiness of skin of nose and mouth


  Dry white flakes in the eyebrows and then may spread to the skin between your brows, around the nose you may develop itchy red skin with a greasy scale
• Swollen face


  Facial swelling is the buildup of fluid in the tissues of the face, swelling may also affect the neck and upper arms
• Enlarged parotid glands


  Dry mouth, drooling, swelling, and pain are essentially the only symptoms caused by dysfunction of the salivary glands
• Bitot's spots


  Plague or patch or small circumscibed grayish or yellowish gray, dull, dry, foamy superficial lesions on the conjuctiva
• Blepharitis


  Inflammation of the eyelids
• Keratomalacia


  Softening of the cornea, partial or complete loss of vision, softening of a part or the entire thickening of the cornea, deformation and destruction of the eyeball
• Thickened opaque bulbar conjuctivae


  Results in a glazed, porcelain-like appearance obscuring the vascolarity
• Conjuctivae xerosis


  Dryness of the conjuctiva (clear transparent membrane covering the inner lids and white portion of the eyes)
• Pale conjuctiva


  Eye membranes are pale
• Conjuctival infection


  Redness of membranes
• Angular palpebritis


  Redness and fissuring of eyelid corners
• Corneal xerosis


  Dryness of the cornea (clear glass-like round part of the eye), dry, rough, in advanced stage, hazy bluish, milky appearance most marked in the lower central part, cornea had dull appearance
• Keratomalacia


  Cornea is soft
• Circumcorneal infection


  Ring of fine blood vessels around cornea