This document provides guidance on assessing nutrition and performing a physical examination. It discusses evaluating body mass index, waist circumference, waist-hip ratio to assess macronutrient status. It also describes clinical signs of various micronutrient deficiencies. Key aspects of the physical exam covered include assessing pallor, icterus, cyanosis, clubbing, lymphadenopathy, and edema. Sites of the body are identified to examine for each of these signs. Common causes associated with abnormal physical findings are also outlined.

1. GENERAL PHYSICAL
EXAMINATION

2. ASSESSMENT OF NUTRITION
Macronutrient assessment
1) Body Mass Index (Quetelet Index)
It is calculated by the formula weight/ height2 (Kg/m2)
However the disadvantage is it doesn’t describe the
distribution of body fat.
BMI non Asian BMI Asian
Underweight <18.5 <18.5
Normal 18.5-24.9 18.5-22.9
Overweight 25-29.9 23-24.9
Obese 30-39.9 25-29.9
Morbidly obese >40 >30

3. 2) Waist Circumference:
Normal <94 cm in men and <80 cm in women
3) Waist:Hip ratio:
<0.8 in females <0.9 in males
inceased waist hip ratio has increased risk of coronary
artery disease

4. Micronutrient assessment
Clinical findings in Vitamin deficiencies
 Thiamine: Beri beri, neuropathy,muscle weakness
and wasting, cardiomyopathy
 Riboflavin: Angular stomatitis, Magenta tongue
 Niacin: Pellagra- dermatitis diarrhea dementia
 Vitamin B6: Glossitis, confusion, microcytic anemia
 Folate: Megaloblastic anemia
 Vitamin B12: Megaloblastic anemia, neuropathy
 Vitamin C: Scurvy, imflamed and bleeding gums

5.  Vitamin A: Xerophthalmia, night blindness, Bitot
spots, follicular hyperkeratosis
 Vitamin D: Rickets, osteomalacia
 Vitamin E:Peripheral neuropathy, spino cerebellar
ataxia
 Vitamin K: Bleeding Disorder
 Iron: Koilonychia, pica, anemia
 Calcium: Reduced bone mass
 Fluoride: Increased dental caries

6. Atrophic glossitis (bald tongue)
Angular cheilitis

7. Fissured tongue in Vitamin B
deficiency
Bitot spots seen in Vitamin A deficiency

8. Koilonychia seen in iron deficiency anemia

9. PALLOR
Sites of examination
 Examined in the areas where blood vessels are near
to the surface.
 Lower palpebral conjunctiva, Tongue, Nails, Palmar
crease
 Seen in Anemia.
 On hyperextension of the palm, if palmar creases are
light in colour than the surrounding skin then the
concentration of hemoglobin is usually less than
8g/dl.
Non anemic causes of pale skin: Fair skinned
individuals, hypopituitarism, hypogonadism

10. Pale lower palpebral conjuctiva
Pale palms compared with normal

11. ICTERUS
 Yellowish discolouration of skin,mucous membrane
and sclera.
 Due to increased bilirubin.
 Yellowish discolouration of sclera is due to the high
elastin content in the sclera
Sites to examine icterus
 Upper bulbar conjunctiva, lower surface of tongue
 It denotes the concentration of serum bilirubin of
atleast 3mg/dL

13. Differential diagnosis of yellowish discolouration of
skin
 Carotenoderma ( increased intake of carrots, oranges
and leafy vegetables): here there is no yellowish
discolouration of sclera
 Quinacrine
 Chronic exposure to phenols
 Long standing anemia

14. CYANOSIS
Cyanosis is the bluish discolouration of skin and mucous
membrane.
It results from the increased amount of reduced hemoglobin
the the blood.
Manifests when the reduced hemoglobin is >4g/dL
Cyanosis may be masked in severe anemia
Types:
1) Central cyanosis: Due to the decreased SaO2
Respiratory cause: High altitude, Alveolar
hypoventillation, pulmonary A-V shunts & fistula,
Cardiac causes: Congenital heart diseases
Sites: Skin, lips, tongue

15.  Other causes: Methemoglobinemia,
sulfhemoglobinemia
2) Peripheral cyanosis
Exposure to cold, arterial obstruction, reduced
cardiac output, venous obstruction.
Sites to be examined: tip of the nose, ear lobule, nails

16. CLUBBING
 Bulbous enlargement of the distal part of the fingers
and toes due to proliferation of connective tissue
Theories:
1) Platelet derived growth factor theory: This is the
most accepted theory. There is release of PDGF
from the platelets in response to imflammation or
hypoxia leading to vasodilation and proliferation of
soft tissues
2) Neurogenic theory: Vagal mediated stimulation
causing vasodilation

17. 3) Humoural theory: GH, PTH, estrogen,PG, bradykinin
causes vasodilation and clubbing
4) Ferritin theory
5) Hypoxic theory
Normal angle between the nail bed and and nail is known as
Lovibond angle and is about 160.
Causes:
Hereditary
Idiopathic
Respiratory: Bronchogenic carcinoma,
bronchiectasis, cystic fibrosis
Cardiac: Cyanotic heart disease, infective endocarditis

18. GIT causes: Liver cirrhosis,Imflammatory bowel
disease
Hypertrophic osteoarthropathy: Clubbing along with
subperiosteal distal diaphyseal new bone formation
with symmetric arthritis like changes in shoulders,
elbow, knee, ankle seen in lung cancers,
mesothelioma, bronchiectasis, hepatic cirrhosis.

19. Cyanosis in the nails with Clubbing

21. LYMPHADENOPATHY
 Check for the number, size, site consistency and
tenderness.
 Some important lymph node involvement in certain
diseases.
 Jugulodigastric nodes: URTI, tonsillitis
 Virchow’s node (Troisier sign): enlargement of left
supraclavicular node due to GIT or testicular
malignancies.
 Right supraclavicular nodes: malignancy of right lung
and left lower lobe
 Axillary lymph nodes: Carcinoma breast, Lymphoma
 Epitrochlear nodes: Secondary syphilis. Non hodgkin’s
lymphoma
 Periumbilical nodes ( Sister Mary Joseph’s nodule)
abdominal malignancy

22. EDEMA
Accumulation of fluid in interstitial space.
Types:
 Pitting type: Apply firm pressure on the shin of
tibia or 2cm above the medial malleolus for 20-30 s
and see for pitting.
Causes: Congestive cardiac failure, nephrotic
syndrome, liver cirrhosis, hypoproteinemia
 Non pitting type: Graves disease (non pitting due to
deposition of hyaluronic acid), filariasis (lymphatic
obstruction)

23. Pitting seen in the left limb