Nutrition 411: The Physical Assessment Revisited: Inclusion of the Nutrition-Focused Physical Exam

  Imagine the following scenario: You just completed the nutrition assessment of an elderly woman recently admitted to your facility. She is 5'0" tall and 85 lb; based on her dietary and medical histories, you deduce she has not been consuming enough total calories. However, her current serum albumin level is normal, suggesting she has adequate visceral protein status. Why the discrepancy? What you may not realize is that a large extravascular pool of albumin tends to equilibrate by entering the vascular system when plasma concentrations of albumin decrease, as would occur with total energy deprivation. Thus, while this woman may be malnourished, her serum albumin level does not reflect this fact. This is an example of why nutrition professionals cannot rely solely on one single indicator of nutritional status. They need to routinely look at the entire clinical picture, often by conducting a comprehensive nutrition assessment.

  Nutrition assessment is a comprehensive evaluation to define nutritional status using medical, social, nutritional, and medication histories; laboratory data; physical examination; and anthropometric measurements.¹ The history should include information about the timing and amount of weight changes, medical illnesses, medications, gastrointestinal symptoms (abdominal pain, constipation, diarrhea, dysphagia), dietary habits (eating fewer than two meals per day, alcohol consumption, dietary supplement intake, dental status), social habits (eating alone, needing assistance in self-care), economic status (having enough money for food), and mental status, particularly with regard to depressive symptoms.² Although most nutrition professionals are familiar with the components of a thorough nutrition assessment, developments in what is now understood about serum albumin and prealbumin values force us to revisit how much weight we place on these markers and to consider alternative clinical indicators of nutritional status, such as the physical exam.

Height and Weight, Tried-and-True

  Height and weight data are utilized in healthcare settings for the following reasons: 1) to calculate body mass index (BMI) for nutrition assessment; 2) to formulate an appropriate meal plan; 3) to monitor the appropriateness and/or effectiveness of nutritional interventions (eg, snacks and supplements); 4) to track the prevalence of significant weight changes; and 5) to satisfy regulatory requirements.

  Measures of height and weight are useful markers of nutritional status because changes in body weight over time may reflect a change in nutritional status. When working with older adults, usual body weight (rather than “ideal body weight” or BMI) is the preferred standard; achieving a stable weight for 6 months or more is the most important issue.3 Weight loss in excess of 10% of usual weight represents protein-energy malnutrition that will impair physiologic function, particularly muscle strength and endurance. Weight loss that exceeds 20% of usual weight should be considered severe protein-energy malnutrition that will substantially impair most organ systems.²

  However, using height and weight measures for evaluating nutritional status has some limitations. First, what appears to be a short-term weight change or initially relying on the patient’s recall or estimate of their own weight rather than a direct measurement (an unreliable practice) may actually reflect an inaccurate measurement.⁴ Second, short-term weight gain or loss may reflect changes in fluid status rather than nutritional well-being. For example, fluid retention is particularly problematic in patients with hypoalbuminemic malnutrition because aldosterone, antidiuretic hormone, and insulin stimulated by the stress response cause the retention of sodium and fluid.² Finally, it is impossible to determine from a simple weight change what exactly — fluid, muscle (lean body mass), or fat mass — was lost or gained. For example, excess body fat in obese individuals and/or older adults may mask a significant loss of lean body mass,⁵ which is not desired.

Serum Albumin and Prealbumin, Tried and Not-So-True

  Based on their extensive history and continued use in clinical practice, levels of serum albumin and more recently prealbumin have been the traditional markers for the nutritional assessment of protein-energy malnutrition. Albumin is a plasma protein produced by the liver that has traditionally been used as an indicator of visceral protein balance. With a serum half-life of 2 to 3 weeks, the serum albumin level reflects changes in protein status over a relatively long period of time. Low serum albumin is a strong predictor of risk for morbidity and mortality in both hospitalized and ambulatory patients. In contrast, prealbumin, with a half-life of only 2 days, is a transport protein synthesized by the liver that correlates strongly with visceral protein status and is believed to be a more sensitive indicator of protein deficiency than serum albumin.^5,6

  Using serum albumin and prealbumin as markers for protein nutrition status has some limitations. First, serum proteins are affected by a patient’s total body water status, liver function, and renal losses, which can lead to a misinterpretation of values. Also, both are negative acute-phase reactants that tend to decrease in concentration under conditions of inflammation, a state characteristic of many acutely ill and chronically ill patients. A serum albumin value of <3.5 g/dL is thought to indicate a mild systemic inflammatory response; a value <2.4 g/dL indicates a severe systemic inflammatory response, reflecting systemic inflammation that produces anorexia (limiting food intake) and increases protein catabolism, accelerating the development of protein-energy malnutrition. Adequate feeding in the presence of systemic inflammation will not increase the serum albumin concentration, although substantial nutritional benefit may be gained in terms of wound healing and immune function.2 Therefore, as long as inflammatory markers, such as C-reactive protein (CRP), are elevated, “albumin and prealbumin are useless as measures of nutrition status.”⁶ In addition, studies have indicated that serum album is a less sensitive indicator of a patient’s nutritional status than clinical judgment based on a patient’s medical history and physical examination.⁴ The time has come for nutritionists and other health professionals to become more comfortable with inspecting the patient from head to toe for clinical signs of nutrition inadequacies.

The Nutrition-Focused Physical Examination

  The patient’s external appearance and an evaluation of the skin, eyes, hair, mouth, abdomen, extremities, and nails often provide clues regarding the presence of nutritional deficiencies. A systematic physical exam is important in evaluating nutritional status. Although a general inspection may immediately reveal obvious over- or underweight, the body can reveal many other clues to a patient’s nutritional status. The registered dietitian (RD) may conduct a nutrition-focused physical examination of the patient. General guidelines on how to conduct such an exam follow. Select areas of particular importance to assess nutritional status are described. In addition, Table 1 summarizes additional clinical signs and symptoms of nutrient deficiencies. All findings should be thoroughly documented in the appropriate section of the medical record and communicated to the other health team members.

  A physical exam typically begins with a general inspection of the body and skin, then moves from the head downward. Upon overall inspection, a wasted, skinny appearance indicates an inadequate total energy intake. Protein-energy malnutrition is revealed in many areas of the body and may show up as the following: loss of appetite, flaking dermatitis, pigmentation changes in the skin, temporal muscle wasting, distended abdomen, hepatomegaly (enlarged liver), and muscle wasting and weakness of the extremities. A protein deficiency may be revealed by extremity edema and transverse lines on the nails.²

  Skin. The skin is examined using inspection and palpation; the practitioner’s eyes and powers of observation are the most important tools. Begin by inspecting the skin for color and uniform appearance, thickness, symmetry, hygiene, and the presence of any lesions, tears, bruising, edema, rashes, or flakiness. As you inspect, palpate the skin for moisture, temperature, texture, turgor, and mobility. Minimal perspiration or oiliness should be present, and the skin should range from cool to warm to the touch. The texture should be smooth, soft, and even. To assess turgor and mobility, gently pinch a small section of skin on the forearm or sternal area between the thumb and forefinger and then release the skin. The skin should feel resilient, move easily when pinched, and return to place immediately when released. Turgor will be altered if the patient is dehydrated or if edema is present. If you encounter any skin lesions (a catch-all term that collectively describes any pathologic skin change or occurrence), describe them according to the following characteristics: configuration (size, shape, color, texture, elevation, or depression); exudate (color, odor, amount, consistency); and location and distribution on the body.⁷

  Head. Starting at the top of the head, palpate the patient’s hair, which should be smooth, symmetrically distributed, and have no splitting or cracked ends. Coarse, dry, brittle hair is associated with hypothyroidism; fine, silky hair is associated with hyperthyroidism.⁷ Hair that is sparse, thin, and easy to pull out may be a sign of a protein deficiency.²

  Moving down, eyes that appear recessed in their sockets may indicate dehydration.⁸ The eyes are also a good place to spot particular nutrient deficiencies such as vitamin A, a crucial nutrient for the visual center of the body. A deficiency in vitamin A can show up as poor vision at night or in dim light (night blindness), impaired visual recovery after a glare, sensitivity to light, blurring, conjunctival inflammation, and excessive dryness, followed by progressive cloudiness and softening of the corneas (ie, keratomalacia).² With advancing vitamin A deficiency, dry, “foamy,” silver-gray deposits (Bitot spots) may appear on the delicate membranes covering the whites of the eyes.⁹ A lack of riboflavin also may play a role in some of these symptoms, including light sensitivity, blurring, and inflammation of the conjunctiva.²

  Mouth. A patient’s oral health is extremely important to the nutrition professional because this is the typical entry point for adequate nutrition and hydration. Abnormal conditions can contribute to pain when chewing or swallowing, which can lead to malnutrition. Signs of dehydration can also be detected in this area — most notably dry tongue, longitudinal tongue furrows, and dry mucous membranes.⁸ To conduct an oral exam, start by asking the patient to close his/her mouth. Inspect and palpate the lips for symmetry, color, edema, and any surface abnormalities. Dry, cracked lips (chelitis) may be caused by dehydration, wind chapping, dentures, or excessive lip licking. Painful cracking at the corners of the mouth and scaling of the lips (cheilosis and angular stomatitis) may indicate a riboflavin deficiency. The color of the lips is influenced by a variety of conditions. For example, pallor may be a sign of anemia.

  After having the patient remove any dental appliances, use a tongue blade and bright light to inspect the buccal mucosa, gums, and teeth. The mucous membrane should be pinkish red, smooth, and moist. Be sure to note any lesions or inflammation present. The gums should have a slightly stippled, pink appearance with a clearly defined, tight margin at each tooth. The surface of the gums beneath dentures should be free of inflammation, swelling, or bleeding. Bleeding gums may be the result of ill-fitting dentures or indicative of a vitamin C or riboflavin deficiency. Inspect the mouth for any teeth that are loose, cracked, or in otherwise poor condition. Ask the patient to extend the tongue and inspect for any swelling and variation in size or color, coating, or ulcerations. The tongue should appear dull red, moist, and glistening with an anterior surface that is smooth, yet roughened with papillae and small fissures. Of particular note is a smooth red tongue with a slick appearance since this may indicate a niacin or vitamin B12 deficiency. Ask the patient to tilt their head back for you to inspect the palate. The whitish hard palate should be dome-shaped, while the pinker soft palate should be contiguous with the hard palate. Observe the palate for any abnormal nodules, redness, or inflammation.⁷

  Neck. Inspect the neck for any obvious abnormalities. For example, a mass that fills the base of the neck or visible thyroid tissue that glides upward when the patient swallows (you can ask them to swallow a sip of water) may indicate an enlarged thyroid, or goiter, which may be caused by an iodine deficiency. Marked edema of the neck may be associated with a local infection.⁷

  Abdomen. On the surface, the abdomen may be observed for skin color and surface characteristics. The skin of the abdomen is expected to have the same color variations and surface characteristics of the rest of the body. Generalized color changes such as jaundice, cyanosis, redness, or bruising should be noted; a glistening, taut surface appearance suggests ascites. Inspect the symmetry and contour of the abdomen from a seated position at the patient’s side, then move to a standing position behind the patient’s head. Generalized symmetric distention may occur as a result of obesity, enlarged organs, fluid (eg, ascites), or gas; asymmetric distention or bulging may indicate bowel obstruction, hernia, cysts, or other conditions. Once inspection has been completed, the next step is to evaluate bowel motility. This can be accomplished by placing the diaphragm of a warmed stethoscope on the abdomen and holding it in place with very light pressure. The idea is to listen for sounds and note their frequency and character. Audible clicks and gurgles that occur irregularly and range from 5 to 35 per minute are considered normal. Of course, prolonged gurgles called borborygmi commonly known as “stomach growling” may be heard. Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger, while decreased bowel sounds occur with peritonitis and paralytic ileus. If no sounds are discerned after 5 minutes of continuous listening, an “absence of bowel sounds” can be established. However, it is important to listen to all four quadrants of the abdomen to ensure no sounds are missed and to localize specific sounds.⁷

  Bones and joints. Finally, with regard to the extremities other than the condition of the skin, softening of the bone and bone tenderness may be related to vitamin D deficiency; bone ache and joint pain may indicate an inadequate intake of vitamin C. Muscle tenderness and muscle pain may be related to a lack of thiamine; spooning of the nails may indicate an iron deficiency.²

The Bottom Line

  Serum albumin and prealbumin have fallen out of favor as markers of visceral protein status because systemic inflammatory response commonly observed in critical care and prolonged illness can affect these measures. Therefore, it is imperative that nutrition and health professionals get a better physical snapshot of the patient, looking beyond a patient’s height and weight and gaining the knowledge, confidence, and experience necessary to conduct a nutrition-focused physical examination. This can provide valuable clues in planning individualized nutrition interventions for each patient.

Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Cristen Harris, PhD, RD, CSSD, CES, is an Assistant Professor and Core Faculty Member in the Department of Nutrition and Exercise Science, Bastyr University, Kenmore, WA. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.

1. Hammond K. Assessment: dietary and clinical data. In: Mahan LK, Escott-Stump S, eds. Krause’s Food & Nutrition Therapy, 12th ed. Philadelphia, PA: Saunders Elsevier;2008.

2. Bistrian BR. Clinical nutritional assessment. In: Goldman L, Ausiello D, eds. Cecil Medicine, 23rd ed. Philadelphia, PA: Saunders Elsevier;2008.

3. Neidert K, Dorner B. Consultant Dietitians in Health Care Facilities Dietetic Practice Group: Nutrition Care of the Older Adult: A Handbook for Dietetics Professionals Working Throughout the Continuum of Care. Chicago, IL: American Dietetic Association;2005.

4. DeLegge MH. Nutritional assessment. Gastroenterol Clin. 2007;36(1):1–22.

5. Noel MB, Thompson M, Wadland WC, Holtrop JS. Nutrition and family medicine. In: Rakel RE, ed. Textbook of Family Medicine, 7th ed. Philadelphia, PA: Saunders Elsevier;2007.

6. Litchford MD. Assessment: laboratory data. In: Mahan LK, Escott-Stump S, eds. Krause’s Food & Nutrition Therapy, 12th ed. Philadelphia, PA: Saunders Elsevier;2008.

7. Seidel HM, Dains JE, Ball JW, Benedict GW. Mosby’s Guide to Physical Examination, 5th ed. St. Louis, MO: Mosby, Inc;2003.

8. Gross CR, Lindquist RD, Woolley AC, Granieri R, Allard K, Webster B. Clinical indicators of dehydration severity in elderly patients. J Emerg Med. 1992;10(3):267–274.

9. National Organization for Rare Disorders, Inc. Keratomalacia. Available at: www.everettclinic.com/kbase/nord/nord762.htm. Accessed July 15, 2009.