CLINICAL ASSESSMENT

Prepared by: Assoc. Prof. Eleanor O. Sibug

CLINICAL ASSESSMENT
Clinical Assessment of nutritional status deals basically with the examination of changes that can be seen or felt in superficial tissues such as the skin, hair and eyes. This examination is usually coupled with medical history taking to identify nutrition related deficiencies or risks.

Protein Energy Malnutrition (PEM)

DYSPIGMENTATION OF HAIR AND SKIN Shows a distinct lightening of its normal color, most usually evident in a distance.

KWASHIORKOR
-was originally a Ghanaian

word meaning the evil spirit that infects the first child when the second child is born. It typically sets in between 18 months and 2 years. This condition is due to lack of protein in the diet.

KWASHIORKOR
-enlarged fatty liver -apathy, misery, irritability, sadness -Anorexia -hair is dry and brittle, easily pulled out, changes in color, becomes straight -skin develops lesions

KWASHIORKOR
-older infants and young children (1-3 years old) -some weight loss -some muscles wasting with retention of some body fat -growth is from 60 to 80% weight for age -Edema

KWASHIORKOR
-enlarged fatty liver -apathy, misery, irritability, sadness -Anorexia -hair is dry and brittle, easily pulled out, changes in color, becomes straight -skin develops lesions

MARASMUS
-occurs most commonly in children from 6 to 18 months of age in all the over-populated urban slums of the world. This is due to lack of total energy in the diet.

Menu

MARASMUS
-Infancy (less than 2 years) -Develops PEM slowly, chronic

-Severe muscle wasting with fat -Growth less than 60% weight for age -No detectable edema -No fatty liver

MARASMUS
-Anxiety, apathy

-Good appetite, possible

-Hair is sparce, thin and dry easily pulled out -Skin is dry thin and easily wrinkled

Syndromes of Malnutrition

Protein Energy Malnutrition (PEM)

MOON FACE Peculiar rounded prominence of the cheeks, which protrude over the general level of the nasolabial folds

Protein Energy Malnutrition (PEM)

FLAKY PAINT DERMATOSIS Extensive, bilateral hyper-pigmented patches of skin, which desquamate to leave superficial ulceration; resembles a seconddegree burn.

Protein Energy Malnutrition (PEM)

FLAKY PAINT DERMATOSIS Extensive, bilateral hyper-pigmented patches of skin, which desquamate to leave superficial ulceration; forearm resembles a second-degree burn.

Protein Energy Malnutrition (PEM)

FLAKY PAINT DERMATOSIS Extensive, bilateral hyper-pigmented patches of skin, which desquamate to leave superficial ulceration; resembles a seconddegree burn.
Back of legs

Protein Energy Malnutrition (PEM)

FLAKY PAINT DERMATOSIS Extensive, bilateral hyper-pigmented patches of skin, which desquamate to leave superficial ulceration; resembles a seconddegree burn.
Scrotal Dermatosis

Protein Energy Malnutrition (PEM)

Protein Energy Malnutrition (PEM)

Protein Energy Malnutrition (PEM)

Nutritional deficiency edema (right). Disappeared after adequate treatment (left)

Protein Energy Malnutrition (PEM)

Muscular and Skeletal System Good muscle tone; some fat under skin; can walk or run without pain Muscles have wasted appearance POSSIBLE DISORDER: Marasmus / Kwashiorkor Babys skull bones are thin and soft (craniotabes); round swelling of front and side of head (frontal and parietal); swelling of ends of bones (epiphyseal enlargement); small bumps on both legs. POSSIBLE DEFICIENCY: Vitamin D, Calcium or Phosphorus

PARTS OF AN EYE

VITAMIN A DEFICIENCY
KERATOMALACIA Softening of the entire thickness of part or the whole of the Cornea.

VITAMIN A DEFICIENCY
CONJUCTIVAL XEROSIS Dryness, thickening, pigmentation and lack of luster and transparency of the bulbar conjunctiva of the exposed part of the eyeball

VITAMIN A DEFICIENCY
CORNEAL ULCER The cornea looks dull and has a small crater, which called a Corneal Ulcer

VITAMIN A DEFICIENCY
BITOTS SPOT These are abnormalities of the conjuctiva of the eye. The conjunctiva has a white to silver/gray foamy area on it, very similar to soap bubbles

VITAMIN A DEFICIENCY
DERMATITIS

RETINOL (Vitamin A) Excess of Vitamin A can cause

sparse hair w/ alopecia

ASCORBIC ACID (VIT C)

Nails of a person with scurvy

ASCORBIC ACID (VIT C)

Gums
Healthy; red; do not bleed; not swollen Spongy and bleed easily; recession of gums POSSIBLE DEFICIENCY: Vitamin C

CHOLECALCIFEROL (VIT D)

Picture of a child with rickets

Pyridoxine (Vitamin B6)

Loss of pyridoxine results in:
Dermatitis around the eyes, mouth, on the nose and behind the ears.

OTHER CLINICAL SYMPTOMS

MOTTLED ENAMEL With brownish and white patches with or without erosion of the enamel; usually best seen in the upper incisors.

Excess: Fluorine

Dental Fluorosis Versus Dental Caries

Dental Fluorosis Dental Caries

1. In Dental Caries unlike Dental Fluorosis, the discoloration has no pattern

2. Cavities are formed as a result of acid production by bacteria breeding in unhygienic oral environment
3. Cavities are formed between two teeth or hidden crevices where food debris collects

1: Fluorosis in children

Jharkhand *

F = 7.0 14.0 mg/L

Assam

*F = 2.5 12.00 mg/L

Fluorosis and Iodine deficiency disorders [IDD] may coexist in children Fluoride poisoning may be the primary cause leading to thyroid gland malfunctioning and resulting IDD
Madhya Pradesh

* F = 2.0 10.3 mg/L

OTHER CLINICAL SYMPTOMS

ATHROPIC PAPPILAE Filform papillae disappears and the tongue is extremely smooth in appearance Deficiency: Riboflavin, Niacin Iron

or

OTHER CLINICAL SYMPTOMS

Deformities in rickets, showing curvature of the limbs, potbelly, and Harrison grove

OTHER CLINICAL SYMPTOMS

ANGULAR STOMATITIS Excoriated lesion associated with fissuring of the angles of the mouth.

Deficiency: Riboflavin
SWELLING, SCARLET and RAW TONGUE POSSIBLE DEFICIENCY: Folic acid / Niacin

Tongue
Deep red in appearance; not swollen or smooth Magenta (purplish color) tongue; swollen sores; hyperemic and hypertrophic papillae; and atrophic papillae POSSIBLE DEFICIENCY: Riboflavin POSSIBLE NON-NUTRITIONAL DISORDER: Leukoplakia

Swelling; scarlet and raw tongue POSSIBLE DEFICIENCY: Folic acid / Niacin

OTHER CLINICAL SYMPTOMS

LIPS Smooth, not chapped or swollen Redness and swelling of mouth or lips (cheilosis), especially at corners of mouth (angular fissures and scars) POSSIBLE DEFICIENCY: Riboflavin

OTHER CLINICAL SYMPTOMS

RICKETY ROSARY OR BEADING OF THE RIBS Symmetrical modular enlargement of the costochondral junction Deficiency: Vitamin C and D

OTHER CLINICAL SYMPTOMS

EPIPHYSEAL ENLARGEMENT Particularly affecting the radius and ulna at the level of the wrist and the tibia and fibula at the level of the ankle

Deficiency: Vitamin D

OTHER CLINICAL SYMPTOMS

NASOLABIAL DYSSOBACEA Lesion consists of dry greasy filform excrescences, grayish or yellowish or pale in color usually located in the nasolabial folds. NASOLABIAL SEBORRHEA Scaling of skin around nostrils RIBOFLAVIN DEFICIENCY

Seborrhea is thought to be caused by an inflammatory hypersensitivity to epidermal, bacterial, or yeast antigens. The most common precipitating factors are stress, immuno suppression, and cold weather.

OTHER CLINICAL SYMPTOMS

Rachitic spinal curvature, well marked when the child is sitting

OTHER CLINICAL SYMPTOMS

Bow-legs Harrisons Sulcus

IRON DEFICIENCY ANEMIA (IDA)

Chief Functions in the Body: 1. Part of the protein hemoglobin which carries oxygen from place to place in the body.

2. Part of the protein myoglobin in muscles, which makes oxygen available for muscle contraction.
3. Necessary for the utilization of energy as part of the cells' metabolic machinery. Significant Sources: red meats, fish, poultry, shell fish, Eggs, legumes, dried fruits.

IRON DEFICIENCY ANEMIA (IDA)

Deficiency Symptoms: 1. Blue sclera 2. Reduced resistance to infection 3. Reduced work productivity 4. Reduced physical fitness, weakness, fatigue 5. Impaired cognitive function (among children) 6.Reduce learning ability and increase distractibility 7. Impaired visual discrimination 8. Impaired reactivity and coordination in infants.

IRON DEFICIENCY ANEMIA (IDA)

Toxicity Symptoms: 1. Infections 2. Lethargy, joint disease 3. Pigmentation and loss of hair

IRON DEFICIENCY ANEMIA (IDA)

Deficiency Symptoms: 1. Itching, pale nail beds, eye membranes, and palm creases, concave nails, impaired wound healing.

2. Reduced resistance to cold, inability to regulate body temperature, pica (clay eating)

Nails
Firm, pink

Nails are spoon-shape (koilonychia); brittle, ridged nails POSSIBLE DEFICIENCY: Iron

SYMPTOMS OF IRON DEFICIENCY ANEMIA (IDA)

Weakness Insomnia Easily become tired Lack of appetite Lack of concentration Paleness
Source: RDA for Filipinos, 1989

SYMPTOMS OF IRON DEFICIENCY ANEMIA (IDA)

IODINE DEFICIENCY DISORDERS

STEPS IN EXAMINING THE THYROID GLAND 1. Stand in front of the patient in normal position 2. Look at the patient's lower part of the neck. Note any mass or enlargement. 3. Ask the patient to swallow. An enlargement in this area which moves up and down as the patient swallows is a visible goiter. 4. Stand behind the patient in normal position. 5. Use the tips of the index and middle fingers to feel the lower front part of the neck just above the notch of the breastbone.

IODINE DEFICIENCY DISORDERS

STEPS IN EXAMINING THE THYROID GLAND 6. Feel for the horizontal rings of the trachea or windpipe through a thin ribbon of tissue. This fleshy mass that can hardly be felt is the thyroid gland. The thyroid has lobes which extend to either side of the trachea. 7. Ask the patient to swallow while your fingers gently palpate the thyroid, If the mass on the neck is a goiter, it will go up and down while swallowing.

IODINE DEFICIENCY DISORDERS

NORMAL THYROID Thyroid Cartila Right lobe of thyroid gland Tracheal Ring

HOW TO PALPATE .
IN THE FRONT AT THE BACK

IODINE DEFICIENCY DISORDERS

GOITER

IODINE DEFICIENCY DISORDERS

GOITER

IODINE DEFICIENCY DISORDERS

GOITER

IODINE DEFICIENCY DISORDERS

GOITER

Physical Signs of Dehydration

Dehydration is the loss of water from the body that occurs when water output exceeds water input. The symptoms progress rapidly from thirst, to weakness, to exhaustion and delirium and end in death if not corrected.

Physical Signs of Dehydration

sunken eyes hollow cheekbones dry mucous membranes loss of skin turgor (elasticity) weak cry depression of the anterior fontanel deep, gasping respirations weak, rapid pulse thirst reduced urinary output weight loss

TEN SIGNS OF GOOD NUTRITON 1. Well developed body with proper height and weight. 2. Firm, well developed muscles 3. Good posture 4. Clear, blemish free skin. 5. Smooth and shiny hair 6. Clear eyes 7. Alert expression and good disposition 8. Sound sleep 9. Good digestion and bowel movement 10. Good appetite. Developed by: NDAP Foundation