General Subjective Global Assessment of Nutritional Status Form
Taking a systematic approach and going from the patient’s head to their toes, note your observations for each of the following
|
Body Part |
Observation | Comments |
| Posture | Straight | Patient able to stand up straight |
| Stature | Tall | —- |
| Body Type | Slim and athletic | —- |
| Hair | Does not appear dry or brittle | Patient reports that it does not fall out easily when touched/no excessive hair loss |
| Head and Neck | No indentation of temples; no abnormalities | __ |
| Eyes | Slightly bulged fat pads; slightly dark circles; no sign of nutrient deficiencies | Patient reports eyes look the same, dark circles are normal |
| Nose | Some mucous present, appears clear | R/t allergies as per patient |
| Mouth | No inflammation, cracking, or sores present | __ |
| Lips | No dryness, cracking, or sores present; color appears normal | Patient reports no changes |
| Tongue | Normal pink color; no apparent sores | Patient reports no sores |
| Teeth and Gums | No missing teeth, all teeth appear healthy; gums are normal pink color; gums are not inflamed | Patient reports normal chewing ability |
| Upper Body | ||
| Clavicles | Rounded curves; visible but not prominent | Patient has not observed any changes in prominence of shoulder blades |
| Shoulders | Rounded curves | Patient has not observed any changes in appearance of shoulders |
| Scapula’s | Bones do not protrude; no significant depressions | __ |
| Deltoids | Rounded curves; bones not prominent | __ |
| Arms | Ample fat tissue between fingers | —- |
| Hands | Pads of thumb are flat when tip of forefinger and thumb touch | __ |
| Skin | Bounces back when pinched (good turgor) | No changes in skin (increased dryness or spots) as per patient |
| Nails | No cracking or splitting; color bounces back when pressed | Patient reports no changes in nail strength (no cracking or splitting) |
| Pulse | Normal | 60 bpm |
| Respiration | Normal breathing | Patient reports no difficulty breathing |
| Ribs | Full chest; no ribs visible; no protrusion of the iliac crest | __ |
| Abdomen | Flat and muscular | __ |
| Lower Body | ||
| Quadriceps | No bones prominent; does not curve inward | Patient reports no changes in thigh size or strength |
| Calves | Good curve; well-developed bulb of muscle | __ |
| Ankles | No swelling | Patient has not noticed any swelling in this area |
| Feet | No swelling | Patient has not noticed any swelling in this area |
| Toes | No cracking or splitting of toe nails and color bounces back when pressed; patient can wiggle toes |
Patient reports no changes in toe-nail strength (no cracking or splitting); Patient reports no loss of sensation in toes |
What have you observed re:
- Hydration status?
- Patient has good skin turgor and appears to be well hydrated. The patient states that she makes an effort to remain well hydrated by carrying a re-usable water bottle in her purse.
- Body composition?
- Patient has a healthy body composition – lean and muscular with a healthy amount of fat. Patient appears to carry more fat in the lower body than in the upper body.
- Indicators of Malnutrition?
- The patient does not show any signs of malnutrition.
- Indicators of Micronutrient Deficiency?
- Patient reports history of iron and vitamin D deficiency. However, there are no observable signs of any micronutrient deficiency.
What are your conclusions regarding this individual’s nutritional status?
Based on the nutrition-focused physical exam, the patient’s nutritional status is excellent. There were no signs of protein-calorie malnutrition (no fat or muscle loss), no signs indicative of a micronutrient deficiency, and there was no edema present and the patient appears well hydrated. The patient reports exercising for at least one hour 3-5 times per week (indoor cycling, Zumba, boot camps, Pilates, and other group exercise classes offered at the gym she belongs to) and following a general healthful diet with a focus on whole grains, healthy fats, lean protein sources, and a lot of fruits and vegetables.
CRDN 3.2: Conduct nutrition focused physical exams.
