1. Physical Assessment to Determine Nutritional Deficiencies
Sharolyn tsamoutales, Graduate student Intern
Bowling Green State University, 2012

2. Nutrition-focused Physical assessment
During initial patient (pt) evaluation an RD’s assessment can be further enhanced by performing a “head to toe” visual interpretation of a pt’s physical signs and symptoms in determining appropriate Medical Nutrition Therapy.
Throughout this process, it is important to exercise thoughtful consideration for pt’s comfort level.

3. Nutrition-focused Physical assessment
Seldom are nutrient deficiencies isolated, multiple deficiencies are most common
Physical signs of nutrient deficiencies are typically observed after prolonged diet inadequacy
Non-nutritional related symptoms may be observed

4. Clinical Assessment
Consideration of physical observations and interpretation of:
Hair Neurological
Eyes Additional
Oral health observations
Thyroid gland Hydration status
Nails
Skin

5. Hair Assessment Hair should have a shiny, normal to thick appearance that is not easily plucked.
Clinical Findings
Potential Deficiency
Thinning, sparse, Alopecia
Easily plucked, brittle
Dry
“Corkscrew”, coiled hair
Protein, Biotin, Zinc, Essential Fatty Acids (EFA), Iron
Zinc, Protein
Vitamin A, EFA, Zinc
Vitamin C

6. Hair Images
Alopecia
Corkscrew

7. Eye Assessment Eyes should appear bright and clear with healthy membranes and normal movement
Clinical Findings
Potential Deficiency
Nyctalopia,
Pale Conjunctiva
Ophthalmoplegia
Xerophthalmia
Fissuring in corners, redness
Vitamin A, E
Vitamin A, Iron
Thiamin (B1), Phosphorus
Vitamin A, Protein
Riboflavin (B2), Pyridoxine
Nyctalopia is night blindness.
Pale Conjunctiva presents in the eye lid as a pale, porcelain color.
Ophthalmoplegia is paralysis or impaired muscle function of the eye or slowing eye movement.
Xerophthalmia is dry eye, with decreased tear secretion.

8. Eye Images
Pale conjunctiva
Ophthalmoplegia

9. Oral health Assessment Mouth should appear free of sores and swelling, with normal pink/red gums and tongue. normal teeth, taste and smell.
Clinical Findings
Potential Deficiency
Cheilosis, Angular stomatitis, or Perlèche
Magenta glossitis
Pale, Sore tongue
Atrophic lingual papillae
Riboflavin, Pyridoxine, Niacin, Iron, Zinc
Riboflavin
Riboflavin, B12, Iron
Riboflavin, Niacin, Folate, B12, Protein, Iron
Cheilosis, Angular stomatitis, or Perlèche presents as bilateral fissuring and dry scaling of the vermilion surface of the lips and angles of the mouth.
Magenta glossitis presents as a deeply red-to-purple, smooth tongue.
Atrophic lingual papillae is a condition of the tongue. The small, red, raised area of the tongue is no longer visible and has a thin, shiny, smooth red appearance.

10. Atrophic lingual papillae
Oral Health images
Angular stomatitis
Atrophic lingual papillae

11. Oral health Assessment Mouth should appear free of sores and swelling, with normal pink/red gums and tongue. normal teeth, taste and smell.
Clinical Findings
Potential Deficiency
Swollen, retracted, bleeding gums
Loose teeth
Hypoguesia
Hyposmia
Vitamin C
Zinc
Hypoguesia is diminished or cessation of ability to taste.
Hyposmia is diminished or cessation of ability to smell.

12. Swollen, retracted, bleeding gums
Oral health Images
Swollen, retracted, bleeding gums
Loose teeth

13. Thyroid Gland Assessment Located on the front of the neck flanking the trachea, should not appear enlarged
Clincal Findings
Potential Deficiency
Hypothyroidism,
Goiter
Iodine
The thyroid gland is an endocrine gland made up of two lobes, one on either side of the trachea, joined by a narrow band of tissue. It produces the hormones thyroxine (T4)and triiodothyronine (T3), which require iodine. Iodine deficiency may be related to insufficient dietary intakes or malabsorption.
A goiter is visibly enlarged thyroid gland typically due to a deficiency of iodine.

14. Nail Assessment Nails should have a smooth appearance free of ridges and discoloration, with a normal, pale, crescent shaped, lunula
Clinical Findings
Potential Deficiency
Koilonychia
Longitudinal central ridges
Longitudinal nail beading
Absent Lunula
Brown-gray color
Transverse ridging, dry, brittle
Iron, Protein
Iron, Folic Acid, Protein
B complex (B1, 2, 3, 5, 6, 7, 9, 12), Protein
Protein, Iron,
B12
Protein, EFA
Koilonychia; spoon-shaped concave nails indicating an iron and protein deficiency, particularly sulfur-containing amino acids such as cysteine or methionine.

15. Nail Images Koilonychia Absent lunula.
Longitudinal central ridge Longitudinal nail beading

16. Skin Assessment Skin should appear Normally smooth and free of discoloration
Clinical Findings
Potential deficiency
Purpura
Petechiae
Pellegra
Follicular hyperkeratosis
Nasolabial seborrhea, scaling, dry, goose bump
Pallor
Vitamin C, K, Folic acid
Vitamin C, K
Niacin, Tryptophan
Vitamin A, B, C, E, EFA
Vitamin A, Zinc, EFA, Riboflavin, Pyridoxine
Iron, B12, Folic acid, Vitamin E
Purpura are large bruise discolorations from bleeding under the skin approximately 3–10 mm in size.
Petechiae are tiny red, brown, or purple round spots, formed in clusters from bleeding under the skin approximately 1-3 mm insize. It may appear to be a rash and do not loose their color with applied pressure.
Follicular hyperkeratosis is a skin condition characterized by excessive development of keratin in hair follicles, resulting in rough, cone-shaped, elevated papules whose openings are often closed with a white plug of sebum.
Nasolabial seborrhea is a redness and scaling in the nasolabial creases of the body or “laugh lines” of the face typical of vitamin B deficiency.

17. Skin Images
Purpura
Petechiae

18. Skin Images
Nasolabial seborrhea
Dry, goose bump

19. Skin Assessment Skin should appear Normally smooth and free of discoloration
Clinical Findings
Potential Deficiency
Dermatitis
Cellophane appearance
Desquamation, Pigmentation
Zinc, Niacin
Protein
Niacin, Protein

20. Desquamation, Pigmentation
Skin Images
Desquamation, Pigmentation
Protein edema

21. Neurologic Assessment
Clinical Findings
Potential Deficiency
Dementia
Confabulation, Beri-beri
Peripheral Neuropathy, Paresthesias
Thiamin, Vitamin E Niacinamide, B12,
Thiamin
Thiamin, Pyridoxine, B12
Confabulation is a memory disturbance exhibited in subjects who unintentionally make verbal statements that are inaccurate and historically false. Typically, subjects are confident in their statements despite making contradicting remarks. This is a symptom often seen in patients with Korsakoff’s Syndrome, Alzheimer’s Disease, Schizophrenia, and traumatic brain injuries. Beri-beri is the more extreme manifestation of thiamin deficiency.
Paresthesias is a tingling, burning, pricking, or numbness of a person's skin which may be transient or chronic.

22. Neurologic Images
Beri-beri
Tetany

23. Neurologic Assessment
Clinical Findings
Potential Deficiency
Ataxia
Tetany
Thiamin, Pyridoxine, B12, Vitamin E
Thiamin, Niacin, B12, Calcium, Vitamin D, Vitamin E, Magnesium
Ataxia is a neurological sign exhibiting a lack of voluntary coordination of muscle movements. Movements such as tendon reflexes, fine tactile and positioning skills.
Tetany is a syndrome of sharp flexing motions of the wrist and ankle joints exhibited by muscle twitching, cramps, convulsions, and possible stridor as a result of hyper-excitability of nerves and muscles caused by decreased extracellular ionized calcium.

24. Additional Physical Assessments
Clinical Findings
Potential Deficiency
Parotid enlargement
Osteomalacia, Rickets
Persistant Cough
Dyspnea
Protein
Vitamin D
Thiamin
Folic Acid, B12,
Vitamin E
Parotid enlargement is the swelling of the salivary gland. Xerostomia is dryness of the mouth caused by diminished function of the salivary glands.
Osteomalacia and Rickets present as pains and muscle weakness due to a deficiency of vitamin D. Fractures are common.
Rickets is the name used when it occurs in children and osteomalacia is the term used for adults.

25. Additional physical image
Parotid swelling
Osteomalacia, Rickets

26. Additional Physical Assessments
Clinical Findings
Potential Deficiency
Marasmus
Kwashiorker
Macronutrients, micronutrients
Protein, Iron, Folic Acid, Vitamin C
Marasmus is a form of protein-energy malnutrition, not only due to protein deficiency but to prolonged severe caloric deficit. Typically occurring in the first year of life, exhibiting growth retardation and wasting of subcutaneous fat and muscle.
Kwashiorker is a protein-energy malnutrition (PEM) produced by severe protein deficiency. Symptoms include retarded growth, changes in skin and hair pigment, edema.

27. Additional Physical Assessments
Marasmus
Kwashiorker

28. Hydration Status Assessment Clinical Physical Findings
Underhydration
Overhyration
Imput < output
Decrease in weight
Sunken, dry eyes
Oliguria, dark urine
Sticky salvia, dry membranes
Poor skin turgor
Cool, pale clammy skin
Imput > output
Increase in weight
Puffy, swollen eyes
Light colored urine
Moist skin
Anasarca, edema
Dyspnea, lung crackles

29. Nutrient specific Symptoms of deficiency
Vitamin A
Syndromes
Nyctalopia
- Xeropthalmia
Follicular hyperkeratosis
Signs and symptoms
Poor Vision
Corneal ulceration
Dry Hair
Dry Skin
Itchy Skin
Weak fingernails

30. Nutrient specific Symptoms of deficiency
Vitamin B1, Thiamin
Syndromes
Beri-beri
Wernicke’s encephalopathy
Korsakoff syndrome
Signs and symptoms
Muscle cramping
Hyporeflexia
Paresthesia
Poor Memory
Chest pain
Tachycardia
Dyspnea

31. Nutrient specific Symptoms of deficiency
Vitamin B2, Riboflavin
Related Syndrome
Ariboflavinosis,
Pellagra
Cheilosis
Edema
Seborrheic dermatitis
Growth retardation
Signs and Symptoms
red, scaly, oily skin rash
Mouth sores
Swollen tongue
Fissures of the mouth and lips
Itchy eyes

32. Nutrient specific Symptoms of deficiency
Vitamin B3,
Niacin/Nicotinamide
Related Syndrome
- Pellagra
Signs and Symptoms
Dermatitis
Diarrhea
- Depression
Dementia
Dysphagia/hypersalivation
- Abdominal/nausea

33. Nutrient specific Symptoms of deficiency
Vitamin B6,Pyridoxine
Related Syndrome
-Polyneuropathy
Signs and symptoms
Numbness, tingling, weakness of the limb
Diarrhea
Swollen tongue
Seizures
Nausea
- Depression
Impaired mental faculties
Itchy, red skin rash
Vomiting

34. Nutrient specific Symptoms of deficiency
Vitamin B9,
Folic Acid/Folate
Related Syndrome
- Macrocytic anemia
Increased risk of heart
disease, dementia,
and cancer
Signs and Symptoms
Pallor
Depression
Diarrhea
Swollen tongue
Fissures of mouth, lips
Dyspnea upon exertion

35. Nutrient specific Symptoms of deficiency
Vitamin B12
Related Syndrome
-Neuropathy
-Macrocytic Anemia
Signs and Symptoms
- Pallor
Sore, Red, swollen
tongue
Numbness or tingling in upper & lower limbs progressing to the trunk
Dyspnea
Depression
Memory loss
Low energy, weak muscles,
light-headedness
Increased risk over age 51

36. Nutrient specific Symptoms of deficiency
Vitamin C
Related Syndrome
- Scurvy
Signs and Symptoms
- Bleeding gums
Loose teeth
Halitosis
Nosebleed
Poor wound healing
Purpura
Corkscrew hair
Anemia
Painful joints, muscles
Numbness in extremities
Skin rash or spots

37. Nutrient specific Symptoms of deficiency
Vitamin D
Related Syndrome
- Osteomalacia
Rickets
Signs and Symptoms
Tingling, numbness, burning of lips, tongue, hands
Weak bones
Bone protusions
Bone pain
Bowing in legs
Muscle weakness
Muscle pain

38. Nutrient specific Symptoms of deficiency
Vitamin E
Related Syndrome
Hemolytic anemia
Neurologic problems
Signs and Symptoms
Pallor
Demetia
Night blindness
Dyspnea
Ataxia
Tetany
Muscle weakness
Follicular hyperkeratosis

39. Nutrient specific Symptoms of deficiency
Vitamin K
Related Syndrome
Bleeding disorders
Birth Defects
Signs and Symptoms
Purpura
Petechiae
Nosebleeds
Menorrhagia
Poor wound clotting
Gastrointestinal bleeding

40. Nutrient specific Symptoms of deficiency
Iron
Related Syndrome
Pica
Restless Led Syndrome
Signs and Symptoms
- Fatigue
- Alopecia
- Pale Conjunctiva
Pale, Sore tongue
Atrophic lingual papillae
Koilonychia
Longitudinal central ridges
Absent Lunula in nail
Pallor
Cold extremities
Pica is a condition in which a patient exhibits an extreme craving for the consumption of unusual non-food items, such as a craving for paint, cement, sand, or starch. Compulsive ice consumption is known to be one of the leading signs and symptoms of iron deficiency.
Restless Leg Syndrome (RLS), as the name suggests, patient’s have a strong urge to move their legs. This urge to move often occurs with strange and unpleasant feelings in the legs, resulting in difficulty with sleeping.

41. References
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