clinical assessment

• Clinical assessment


  Examines those 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


  • It should not be used as the only method of assessment
  • Biochemical or laboratory results should be used as an adjunct to clinical assessment
• Medical history


  Past and present medical information, including the duration of the current illness, relevant symptoms, diagnostic tests and therapies (e.g., chemotherapy, radiation), and medications
• Physical examination


  Those 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)
• Signs


  Observations made by a qualified examiner
• Symptoms


  Manifestations reported by the patient
• Signs and symptoms of nutritional depletion are often non-specific and only develop during the advanced stages of nutritional depletion
• Non-specificity of the physical signs


  May be related to non-nutritional factors such as environment (such as excessive heat or sun, wind or cold air), lack of general personal hygiene, and cultural factors which can cause or contribute to the physical signs also associated with malnutrition
• Multiple physical signs


  May be exhibited by subjects with coexisting nutrient deficiencies confusing diagnosis
• Signs may be two-directional

  May occur during the development of a deficiency or the recovery
• Examiner inconsistencies or bias


  Can be minimized by standardizing the criteria used to define the physical signs and by training the examiners
• Variations in the pattern of physical signs


  Can be due to genetic factors, activity level, environment, dietary patterns, age, and degree, duration, and speed of onset of malnutrition
• Methods Used to Detect Signs

  1. Medical History

  2. Physical Examination
• Medical History


  • Can be obtained through interview or from records
  • Description of the patient and relevant environmental, social and family factors
• Types of Medical History

  • Source-Oriented Medical Record (SOMR)
  • Problem-Oriented Medical Record (POMR)
• Physical Examination


  • Validates findings from medical history
  • Gives information on the etiology of malnutrition
  • Includes functional tests for immune function, muscle strength, mobility, and cognitive function
• Information from Medical History

  • End-organ effects: edema, ascites, weight changes, obesity, muscle mass relative to exercise status
  • Miscellaneous: catabolic medications, immunosuppressive agents, genetic background, other medications, food allergies/intolerances
• Implementing clinical assessment


  • Should be carried out by a person with medical training
  • Auxiliary health workers can be trained in nutritional diagnosis so that they may be alerted to the major signs of clinical deficiencies
• Implementing clinical assessment


  • The clinical examination should be systematic
  • Examinations should start at the head (i.e., hair, eyes, mouth), move down the body and end at the feet
• The greater the numbers of signs present within a specific group, the larger the probability that the individual has a specific nutrient deficiency
• WHO Expert Committee on Medical Assessment of Nutritional Status (1963) classified the physical signs most often associated with malnutrition into three groups:


  • Group One - signs that are considered to be of value in nutritional assessment
  • Group Two - signs that need further investigation
  • Group Three - signs that have no relation to malnutrition
• Physical Signs Indicative or Suggestive of Malnutrition per Body Area

  • Hair
  • Face
  • Eyes
  • Lips
  • Tongue
  • Teeth
  • Gums
  • Glands
  • Skin
  • Nails
  • Muscular and skeletal systems
  • Internal Systems: Cardiovascular, Gastrointestinal, Nervous
• Physical Signs Indicative or Suggestive of Malnutrition per Body Area

  • Normal Appearance
  • Signs Associated with Malnutrition
• Internal Systems: Cardiovascular


  • Normal heart rate and rhythm; no murmurs or abnormal rhythms; normal blood pressure for age
  • Rapid heart rate (above 100 tachycardia); enlarged heart; abnormal rhythm; elevated blood pressure
• Internal Systems: Gastrointestinal


  • No palpable organs or masses (in children, however, liver edge may be palpable)
  • Liver enlargement; enlargement of spleen (usually indicates other associated diseases)
• Internal Systems: Nervous


  • Psychological stability; normal reflexes
  • Mental irritability and confusion; burning and tingling of hands and feet (paresthesia); loss of position and vibratory sense; weakness and tenderness of muscles (may result in inability to walk); decreases and loss of ankle and knee reflexes
• Latham, M.C., 1997
• Summary: Clinical Signs and Overt Pathology of Deficiency According to Age Group


  • Infant and Young Children
  • Adults
• Nutrient


  • A
  • D
  • E
  • K
  • Vitamin C
  • Thiamin
  • Riboflavin
  • Niacin
  • B6
  • B12
  • Folate
  • Biotin
  • Panthothenic acid
• TERMS ASSOCIATED WITH MALNUTRITION, PHYSICAL SIGNS & GUIDE IN INTERPRETATION

  • Apathy
  • Clinical marasmus
  • Irritability
  • Kwashiorkor
  • Pallor
  • Prekwashiorkor
• Protein and Energy Malnutrition

  • PEM is used to describe a broad array of clinical conditions ranging from the mild to the serious
  • Mild PEM manifests as poor physical growth in children
  • Kwashiorkor (characterized by the presence of edema) and nutritional marasmus (characterized by severe wasting) have high case fatality rates
  • Severe forms of PEM - kwashiorkor, marasmus and marasmic kwashiorkor
• 1930s Cicely Williams, working in Ghana, described in detail the condition she termed "kwashiorkor" (using the local Ga word meaning "the disease of the displaced child")
• ACUTE MALNUTRITION: Marasmus and Kwashiorkor

  • Marasmus: Wasting of body tissues – marasmic children are extremely thin; weight-for-height Z-score of less than -3
  • Kwashiorkor: Bi-lateral edema and weight-for-height of greater than or equal to -2 SD
  • Marasmic-Kwashiorkor: Bi-lateral edema and weight-for-height of less than -2 SD
• Marasmus


  • Affects 6-18 months, exacerbated by infectious disease due to lower immune system
  • Loss of adipose tissue and muscle mass due to lack of energy resulting from caloric deficit with protein deficiency
  • Signs: old man face, skin and bone appearance, no muscle/muscle atrophy, no subcutaneous fat, baggy pants, dermatosis/depigmentation of the skin
• Kwashiorkor


  • Affects 1-4 years old children and with younger sibling
  • Acute protein loss and hyper metabolism occurs, resulting in depleted visceral protein pool, hypoalbuminemia, and edema
  • Signs: moon face, muscle wasting, loss of subcutaneous fat, dermatosis/flaky pavement, depigmentation, pale due to anemia, easily pluckable hair, flag sign of hair or blond/discoloration of hair, non-lustrous hair, with edema, liver enlargement
• Characteristics of kwashiorkor


  • Skin
  • Face
  • Hair
• Source: D.B. Jelliffe, 1996, Switzerland
• Comparison of the Features of Kwashiorkor and Marasmus

  • Feature
  • Kwashiorkor
  • Marasmus
• Checking for Oedema


  Extent of edema is measured by the depth of indentation and how long it takes for the skin to rebound back to original position
• Moderate acute malnutrition


  • Also known as wasting
  • Defined by a weight-for-height indicator between -3 and -2 z-scores (standard deviations) of the international standard or by a mid-upper arm circumference (MUAC) between 115 mm and <125 mm (WHO, 2012)