Physical examination

Naturopathic physical examination should be systematic and precisely recorded, while relating particular signs to standardised definitions. Assessment of a patient begins as soon as the consultation starts. A person’s disposition, facial complexion and expression, body size and shape, mobility, gait and posture, as well as the way they conduct or hold themselves, may provide important clues in relation to their mental and physical states.¹ A general inspection of the whole body may reveal external evidence of a disease, for example obesity, wasting, arthritis, abnormal stature or development, presence of pain, jaundice, pallor or cyanosis.²

Warm, sweaty palms on the initial handshake may indicate an overactive thyroid due to increased circulation with blood vessel dilation. In contrast, an underactive thyroid may cause the hands to be cool and dry in texture.³ Persons with alcohol dependence may attempt to conceal their addiction; however, certain signs may provide indicators such as plethoric faces, rhinophymic noses and alcoholic aroma. Smokers may also be revealed by their scent or nicotine-stained fingers. A person’s facial expression may portray psychiatric illness such as depression, while conversation may alert to an anxiety disorder. In developing countries, malnutrition with subsequent wasting and loss of weight is a relatively common occurrence; however, when these signs appear in more developed populations, naturopaths should be alerted to potential underlying pathological conditions such as diabetes, thyrotoxicosis, malabsorption syndromes or chronic infections.⁴

Anthropometric data

To begin a regular physical examination, a person’s anthropometric data—including height, weight, waist and hip measures, as well as skin fold or bioelectrical impedance analysis (BIA) to give an estimation of body fat percentages and lean mass—can be collected. Next, a methodical inspection of the hands and nails, skin colour and texture, hair, face and mouth including the tongue, eyes, irises and sclera, concluding with gastrointestinal palpation.

Height and weight should be determined to assess if a person is over- or underweight. Waist to hip ratio (WHR) is the most useful predictor of cardiovascular disease mortality while body mass index (BMI = weight (kg)/height (m²)) may be a better predictor of increased mortality from raised blood pressure (see Table 2.1).⁵

Table 2.1 Data that predict increased mortality from cardiovascular disease and raised blood pressure⁵

Some form of body composition analysis, whether via skin fold or BIA, should also be performed to determine lean mass or protein sufficiency. Protein insufficiency may have widespread ramifications. Hypoproteinaemia can cause deviations in circulating levels of certain micronutrients, such as iron,⁶ zinc, copper⁷ and potentially selenium.⁸

Body signs and symptoms

Physical signs may be important aids in identifying nutritional dysfunction, though care should also be taken during case taking as particular signs may not be specific and may relate to non-biological factors (such as injury or excessive sun exposure). Signs may also differ between populations and may also vary over time periods within a population.⁹ Any findings suggesting an abnormality should be considered a clue rather than a diagnosis. Table 2.2 outlines a variety of signs and symptoms as documented in research literature.

Table 2.2 Body signs and symptoms in nutritional deficiency

Bioelectrical impedance analysis

Bioelectrical impedance analysis measures the impedance or opposition to the flow of an electric current (usually 50 kHz) through the body fluids contained mainly in the lean and fat tissue. This is generally low in lean tissue, where intracellular fluid and electrolytes are primarily contained, but high in fat tissue. In practice, a small constant current is passed between electrodes spanning the body and the voltage drop between electrodes provides a measure of impedance. The resulting impedance reading is proportional to the total body water volume. Prediction equations are used to convert impedance to a corresponding estimate of total body water.¹²⁷ Lean body mass is then calculated from this estimate using an assumed hydration fraction for lean tissue. Fat mass may then be calculated by subtracting lean mass from total body weight. Although commonly accepted as a measure of these markers many naturopathic practitioners adopt novel conclusions from this technique that are yet to build an evidentiary base.

Gastrointestinal palpation

Gastrointestinal palpation should be performed only by practitioners trained in this skill and when deemed appropriate through the case-taking process. In addition to its more generalised conventional application, it may also be a beneficial technique to alert a practitioner to an underlying digestive dysfunction in a naturopathic consult.

Palpitation of the abdominal area may reveal various underlying organ pathologies such as liver disease or gall bladder insufficiencies (see Figure 2.1a):

Figure 2.1 (a) Normally palpable abdominal structures (b) Palpating the liver

Source: Adapted from Jarvis 2007⁶⁴

Palpation may also locate a mass. If so, it must be distinguished from a normally palpable structure or enlarged organ and note must be taken of its location, size, shape, tenderness, consistency, surface, mobility, pulsatility and tenderness. Gastrointestinal palpation may also be used in conjunction with other abdominal physical examinations, such as auscultation and percussion, to elicit required information. An example of this is that a fluid wave indicates ascites, which may occur with heart failure, portal hypertension, cirrhosis of the liver, hepatitis, pancreatitis and cancer.⁶⁴

Prior to commencing palpation, the abdomen should be viewed for any intestinal bloating or asymmetry, prior to palpating each organ individually. On palpation look for any tenderness or muscular guarding, which may indicate potential issues in that region. When palpating, keep one hand flat; this will be in contact with the abdomen and the other on top to apply pressure for palpation. Initially, gentle pressure should be applied, then pressure more deeply.

Palpation should begin in the upper middle region below the ribcage where the stomach is located. To the right along the line of the ribs is the gallbladder and further to the right is the liver. Across on the far left of the stomach, the spleen is located somewhat deeper than the previous organs. If you roll the person onto their right side the pancreas may be felt if deep pressure is placed from near the side moving toward the midline and slightly upward. Next the area around the umbilicus is the small intestines, while slightly above and toward the right is the duodenum. Distal to the small intestine is the ascending colon with the appendix situated below the latter. The jejunum is located to the left of the small intestine; continuing in this direction the descending colon with the sigmoid is found below. From this position moving medially, above the pubic bone, is the rectal sheath (see Figure 2.1).