Nutrition Focused Physical Exam

  

Name  ______________________________
Last                        First

 

  • OBJECTIVES:
  • Gain hands on experience performing a nutrition-focused physical exam
    • Video record your physical exam with your client and provide the link in this assignment where indicated.
  • Become familiar with diagnosis criteria for moderate (non-severe) malnutrition and severe malnutrition and use NFPE data to diagnosis nutrition status

 

Part 1: Conduct a Nutrition-Focused Physical Exam

Please find a “client” to practice completing a NFPE and fill out the checklist table below.  Please video record yourself conducting this exam on your “client”.  You can use the “head to toe” method presented in class or go in any order you would like.  Please offer comments on ALL sites even if your observation does not suggest malnourishment (describe what the well-nourished site looks like).  In other words, if you do not see any evidence of fat or muscle loss or other irregularities, please indicate that in your comment.

 

  Site Instructions/Tips Comments
  Subcutaneous Fat Exam    
Orbital Fat Pads Palpate (touch) for fat loss under eye; dark circles and loose skin  
Buccal fat Palpate below cheek bone for hollow/sunken appearance  
Triceps Bend arm to 90 degrees, pinch fat and roll between fingers (do not include muscle in pinch)  
Ribs Palpate lower back and mid-axillary line, grasp above iliac crest for fat stores, look for separation between ribs, instruct person to push against something  
  Muscle Exam    
Temples Look for thinning of muscle over temporal bone, palpate in scooping motion, ask person to chew  
Clavicle Observe for prominence, palpate for muscle just below clavicle, person sitting upright (not hunched)  
Shoulder Arm at side, look for squaring vs. round shape, feel shoulder to assess muscle, do both sides  
Scapula Observe for prominence, inspect for trapezius and latissimus dorsi muscle loss, instruct person to push against something, do both sides  
Interosseous Ask person to make “OK” sign and press pointer finger and thumb together. Inspect for indentation and palpate muscle. Do both sides.  
Quadriceps/Thigh Ask person to sit, prop leg and press heal into floor/bed. Palpate quadriceps to differentiate muscle from fat. Do both sides.  
Knee Prop leg, palpate for musculature around patella.  Do both sides.  
Calf Grasp calf to determine muscle. Do both sides.  

 

 
  Micronutrient Exam*    
Hair Not easily plucked, thick (no patches), smooth, shiny, no irregularity in color.  
Eyes Use penlight in “W” motion. Ask person to look L, then look R.  Examine for irregularities. Can focus on sclera (whites of eyes) – look for Bitot’s spots (“silvery” or translucent patches/areas on sclera). Ask person to pull down lower lids to look at conjunctiva.  
Mouth (Oral Mucosa) Use penlight to look for irregularities in mouth. Mucosa should be moist with pink hue.  
Lips Look for irregularities (dryness, angular stomatitis, fissures, etc,)  
Gums Ask person to pull down lower lip. Look for irregularities. Gums should be pink (not red, swollen or bloody).  
Tongue Ask person to stick out tongue.  Look for irregularities (glossitis, swelling, red/beefy, pale)  
Nails Examine all nails for irregularities. Test for capillary refill (squeeze fingertip and should turn from pale to pink within 2-3 seconds)  

 

 
Skin Assess skin turgor. Examine all exposed skin for irregularities (rashes, spots, dryness, wounds, etc.)  
  Fluid Accumulation Exam    
Upper Body Assess skin turgor. Look for generalized edema.  
Lower body/extremities Press with 1-2 fingers on top of foot, ankle and shin.  
Sacral (non-ambulatory) For those not walking, can examine sacral area for edema. Only examine if subject cannot walk
  Functional Status Exam**    
Hand grip strength Use dominant hand, arm at 90 degree angle with elbow close to body, grip with the space between knuckles flat and forward facing. Can adjust grip for different hand sizes. Encourage person to squeeze as hard as they can. May need to repeat. If person falls 2 standard deviations below the mean for their age and gender, can be used as an indicator for severe malnutrition.  

* pen light needed to complete exam.  If you do not have one, in a pinch, a flashlight or phone light can work when doing this for practice and not professionally.

**dynamometer needed to complete exam.  Points will not be deducted if proper equipment is not available as long as you indicate this in the comment section.

 

How long did the NFPE take? Did you have any difficulties performing the exam?  Where there any findings to support a diagnosis of malnutrition?  If so, what?

 

 

Zoom link to video: _ (also copy and paste it to assignment submission comments in Canvas)

(see next page for Part 2)

 

 

Part 2: Case Study

Resources:

Muscle wasting and fat loss pictures to give you an example of what mild, moderate and severe loss looks like can be found under “Additional Readings & Resources” section of the this week’s module on Canvas (entitled “NFPE Tools and Resources”).

 Diagnostic criteria for moderate (non-severe) malnutrition and severe malnutrition in all 3 scenarios (acute, chronic or environmental/social) can be found:

-Slide 18 of notes (In our case study, our patient would fall under the acute category, so just compare the left columns of both the moderate and severe malnutrition criteria to see which she meets more of)

-NFPE diagnostic criteria file uploaded to Canvas

Micronutrient deficiencies can be found:

-Slides 20-25 of notes

-Micronutrient exam – clinical interpretations file uploaded to Canvas

-Pgs. 17-19 of the NFPE resource from Utah AND meeting file uploaded to Canvas

 

Patient Information:

read the following case study and answer the questions below.

A 32-year-old female patient was admitted to the hospital for exacerbation of her Crohn’s disease.  It has been well controlled since approximately 3 weeks ago (hint: acute inflammation present).

You have been consulted because of the patient’s decreased oral intake and severe weight loss.

 

Ht: 5’4”

Usual body weight: 120#

Wt one month ago: 120#

Current body weight: 114#

 

The dietitian asks the patient for more details in a diet history/recall and finds that patient has been eating maybe 1 meal per day (usually eats 3 meals with 1 snack) for the past 6 days, reports her clothes are not fitting the same, has diarrhea episodes 5+ per day and reports being weak, not moving around very much except to go to the bathroom (you can take this to mean decreased functional status).

NPFE observations/pictures: Ask yourself – is the loss mild, moderate or severe by comparing these pictures with those found in the “NFPE Tools and Resources” page on Canvas.

 

 

Subcutaneous fat loss Muscle wasting
 

Orbital

  

Temple
 

Buccal

 

  

Clavicle
 

Triceps

  

Shoulder
 

Ribs

  

Interosseous
   

Thigh
   

Calf

 

 

Additional findings: No edema, but pale conjunctiva, pallor (pale), and a pale/sore tongue.

 

Questions (1-7):

 

  • Which statement best reflects the patient’s current food intake (circle/highlight)?

 

≤ 50% total estimated energy requirement ≥ 5 days

< 75% total estimated energy requirement > 7 days

 

 

  • Which statement best reflects the patient’s unintentional weight loss (circle/highlight)?

 

5% in 1 month

> 5% in 1 month

 

 

  • Which category best reflects the patient’s level of subcutaneous fat loss (circle/highlight)? Look for observations (if offered) at orbital, buccal, triceps, and rib sites.  If examination of sites support both mild and moderate loss, select the category that is reflected in the majority of sites.

 

Mild loss

Moderate loss

 

  • Which category best reflects the patient’s level of muscle loss (circle/highlight)? Look for observations at temples, clavicle, shoulder, interosseous, thigh, and calf sites. If examination of sites support both mild and moderate loss, select the category that is reflected in the majority of sites.

 

Mild loss

Moderate loss

 

  • Which category best reflects the patient’s edema (circle/highlight)?

 

None

Mild

Moderate to severe

 

  • Given the diagnostic criteria below, find your answers from Q 1-5 on the colored chart (below). What would this patient be classified as (highlight/circle below)? (Remember: need to meet at least 2 of the criteria to be considered either moderate or severely malnourished)

Moderately (non-severe) malnourished

Severely malnourished

  • What do the findings of the patient’s mouth, eyes and overall skin suggest as possible micronutrient deficiency/deficiencies?