Documenting Malnutrition. Part 5

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

The criteria for the physical findings in malnutrition in the setting of chronic illness are stricter than the ones of malnutrition in the setting of chronic illness. This means that the findings have to be more obvious to be considered positive. However, the signs and regions that are evaluated are essentially the same.

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. 

In order to diagnose severe malnutrition in the setting of chronic illness, the adipose tissue loss has to be “severe”, compared to severe malnutrition in the setting of acute illness in which the loss only has to be “moderate”.

When we evaluate the muscle tissue loss we have to look to the same regions of the body as described for severe malnutrition in the setting of acute illness.

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 severe malnutrition in the setting of chronic illness, the muscle tissue loss has to be “severe”.

So, a PE may read like this:

“Mr X is a 62 year old gentleman who presented to the primary care provider’s (PCP) office with a history of diarrhea for 3 months.”

HENT: Eyes look severely sunken in orbital cavity

Musculoskeletal: Severely hollow temporal areas, severe reduction of muscle mass of interosseous muscles of the hands. Severely reduced skin fold at the level of the triceps. Ribcage shows severely marked ribs. 

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement