How to assess built and nourishment in gpe in case taking
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how to assess built and nourishment in GPE general physical examination clinical case taking
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Assessing Built and Nourishment in GPE (General Physical Examination)
In Indian/South Asian clinical case-taking, Built and Nourishment are two of the first parameters recorded under GPE, right after the patient's introduction. They are assessed by inspection (primarily) supplemented by anthropometric measurements.
1. BUILT
Definition: Built refers to the overall body frame/skeletal structure and muscular development of the patient — essentially the physique relative to their age, sex, and height.
How to Assess:
- Observe the patient standing (or seated if unable to stand): look at overall skeletal frame, muscle mass, and body proportion
- Measure height and weight; calculate BMI (weight in kg / height in m²)
- Note waist circumference and waist-to-hip ratio (for cardiovascular risk)
Classification of Built:
| Category | Description |
|---|---|
| Well-built | Good muscular development, proportionate body frame for age and sex, normal BMI |
| Moderately built | Average frame and muscle development; neither robust nor wasted |
| Poorly built | Small frame, underdeveloped muscles, thin limbs, low BMI |
Clinical Clues to Record:
- Marfanoid habitus: Tall, long extremities, long fingers (arachnodactyly), high-arched palate → Marfan syndrome
- Short stature with stocky build → Hypothyroidism, achondroplasia
- Barrel chest (increased AP diameter) → COPD/emphysema
- Cachexia/emaciation → Malignancy, TB, chronic heart failure, HIV
- Obesity → Note central vs peripheral; increased waist-to-hip ratio = central obesity
2. NOURISHMENT
Definition: Nourishment refers to the nutritional status of the patient — adequacy of fat stores and muscle mass relative to expected normal.
How to Assess:
Nourishment is assessed by a combination of inspection, palpation, and anthropometrics:
(A) Subcutaneous Fat Stores (Adipose Tissue)
- Pinch test (skin fold): Pinch a fold of skin at:
- Triceps region (posterior upper arm)
- Subscapular region
- Orbital/periorbital area (sunken eyes = fat loss)
- Buccal fat pad (hollowed cheeks = significant fat loss)
- Well-nourished: Ample adipose tissue between fingers
- Poorly nourished: Fingers nearly touch; minimal fat; bony and venous outlines clearly visible
(B) Muscle Mass Assessment
- Temporalis muscle: Look from front, ask patient to turn head side-to-side
- Normal: Well-defined temporal fullness
- Wasted: Hollowing/scooping/depression in temporal fossa
- Deltoid/shoulder region: Look at shoulder contour
- Normal: Rounded, curved at shoulder-neck junction
- Wasted: Square-looking, acromion process protrudes prominently
- Clavicle region: Look for bony protrusion of clavicle and acromion
- Interosseous muscles of the hand: Look for wasting between metacarpals
- Quadriceps (anterior thigh): Grasp the quad — depression/thin line indicates wasting
- Calf (gastrocnemius): Grasp the calf — minimal tissue or poor definition = wasting
(C) Anthropometric Measurements
| Measurement | Normal Reference |
|---|---|
| BMI | 18.5–24.9 kg/m² (normal) |
| Mid-upper arm circumference (MUAC) | >23.5 cm (adults) |
| Triceps skinfold thickness | ~12–25 mm (varies by sex) |
Classification of Nourishment:
| Category | Description |
|---|---|
| Well-nourished | Normal subcutaneous fat, good muscle bulk, no signs of deficiency |
| Moderately nourished | Some fat/muscle loss; mild pallor, slight hollowing but not overt wasting |
| Poorly nourished | Obvious fat and muscle wasting; sunken eyes, hollow cheeks, prominent bones, cachexia |
Additional Signs That Reflect Nutritional Status:
| Sign | Suggests |
|---|---|
| Pallor of conjunctiva/palms | Iron/B12/folate deficiency (anaemia) |
| Angular stomatitis, glossitis | Riboflavin, B12, iron deficiency |
| Bitot's spots, night blindness | Vitamin A deficiency |
| Bleeding gums, perifollicular haemorrhage | Vitamin C deficiency (scurvy) |
| Pitting oedema (bilateral) | Protein deficiency (kwashiorkor) |
| Bowing of legs, craniotabes | Vitamin D deficiency (rickets) |
| Dermatitis (4 D's: Dermatitis, Diarrhoea, Dementia, Death) | Niacin/B3 deficiency (pellagra) |
| Xanthomas over tendons/extensor surfaces | Hyperlipidaemia |
How to Record in Case Sheet
Example of a well-nourished, well-built patient:
"Patient is a well-built, well-nourished adult male, aged approximately 30 years."
Example of a poorly nourished patient:
"Patient is moderately built and poorly nourished with temporal wasting, sunken eyes, hollow cheeks, prominent clavicles, and loss of subcutaneous fat on pinch testing."
Summary Table
| Parameter | What to Look For | Grading |
|---|---|---|
| Built | Frame, muscle bulk, height-weight proportionality, BMI | Well / Moderately / Poorly built |
| Nourishment | Subcutaneous fat (pinch test), muscle bulk (temporal, deltoid, interossei, quadriceps), signs of deficiency | Well / Moderately / Poorly nourished |
Key principle: Built reflects constitutional/skeletal frame and muscular development; Nourishment reflects current nutritional adequacy (fat + muscle stores). A patient can be well-built but poorly nourished (e.g., a previously muscular patient with recent illness-related wasting).
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