Thursday, March 16, 2017

Documenting Malnutrition. Part 4

The Physical Exam (PE) in Severe Malnutrition in the Setting of  Acute Illness

The presence of physical findings of malnutrition in the setting of acute illness is more difficult to find than in the typically malnourished chronically ill patient. Because of this, the criteria are less strict. In addition, there is the complication that most likely we do not know the premorbid condition of a patient so it would be difficult to assess the loss of muscle mass or the loss of adipose tissue. 

In order to assess the adipose tissue loss, we have to look for the following regions of the body:

- The periorbital region
- The triceps region for the triceps skin fold
- The ribcage region

When we assess the periorbital region we look for how sunken the eyes look in the orbital cavity. When we assess the tricipital fold, we see how much tissue can our fingers grab when we separate the triceps muscle from the skin and subcutaneous  tissue and when we examine the ribcage, we assess how prominent the rib bones look. 

The ASPEN criteria to determine severity of the malnutrition are very subjective. For example, in order to diagnose non-severe malnutrition in the setting of acute illness the adipose tissue loss in the mentioned regions has to be “mild”. In order to diagnose severe malnutrition in the setting of acute illness, the adipose tissue loss has to be at least “moderate”.


When we evaluate the muscle tissue loss we have to look to the following regions of the body:

- The temporal region (temples)
- The supraclavicular region (clavicles)
- The interosseous region in the hands
- The shoulder region
- The scapula region
- The thigh region.
- The calf region

Again, the ASPEN criteria are very subjective and in this case, what we are looking for is how depressed the hollow in the temporal region may be and how prominent the bony structures may look in all the other regions. The muscle size of the thighs and calves can also be assessed subjectively. In order to diagnose non-severe malnutrition in the setting of acute illness the muscle tissue loss in the mentioned regions has to be “mild”. In order to diagnose severe malnutrition in the setting of acute illness, the muscle tissue loss has to be at least “moderate”.


So, a PE may read like this:

“Mr A is a 58 year old gentleman who presented to the emergency department (ED) with a history of nausea, vomiting and abdominal pain for 5 days.

HENT: Eyes look moderately sunken in orbital cavity
Musculoskeletal: Moderately hollow temporal areas, moderately reduced muscle mass of interosseous muscles of the hands. Moderately reduced skin fold at the level of the triceps. Ribcage shows moderately marked ribs. 




Marco A. Ramos MD
Second Medical Opinions PLC
Physician Advisor in Clinical Documentation Improvement

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