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Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.

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Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.

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Chapter 217General Appearance

and .

Definition

"The art of the practice of medicine is to be learned only by experience, tis not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become expert." Osler (1919).

Technique

The general appearance of a patient may provide diagnostic clues to the illness, severity of disease, and the patient's values, social status, and personality. The astute physician will begin to gather this information immediately upon meeting the patient. By observing gait, facial features and expression, handshake, and quality of voice, the physician may begin to detect unique qualities and potential problems. Physicians who have the ability to remember a patient's name and face for many years are those who pay intense attention to the initial encounter.

No detail is unimportant. The following should be evaluated systematically:

  • Facies and expression (Table 217.1)
  • Clothing and paraphernalia (Table 217.3): Are clothes appropriate for the time of year? What does jewelry or makeup say about the patient? Is a particular scarf, hat, or patch covering an area of deformity or disease?
  • Stature and habitus (Table 217.4): Observe the patient's body build. Very short stature will be seen in dwarfism, pseudohypoparathyroidism, Turner's syndrome, or prepubertal steroid therapy. Tall and lanky individuals with long, thin extremities suggest Marfan's syndrome
  • Posture and decubitus (Table 217.5): The normal state of resting tone in muscle groups results in healthy, upright posture with tone greatest in antigravity muscles. Alteration in this tone may result in the characteristic postures of Parkinson's disease, stroke, or cerebellar abnormalities. Decubitus refers to the observed posture of the patient in bed. Does the patient prefer to lie on one side, such as occurs in the lateral decubitus position of a patient with abdominal disease? Is the patient lying very still in bed, as might occur in peritonitis, or is there flailing such as that seen with renal colic?
  • Odor of breath and body (Table 217.6): Does the breath suggest poor hygiene or anaerobic infection? Does the comatose patient have the fruity odor of diabetic ketoacidosis?
Table 217.1. Clues to Disease from Facies and Expression.

Table 217.1

Clues to Disease from Facies and Expression.

Table 217.2. Clues to Disease from Gait.

Table 217.2

Clues to Disease from Gait.

Table 217.3. Clues to Disease from Clothing and Paraphernalia.

Table 217.3

Clues to Disease from Clothing and Paraphernalia.

Table 217.4. Clues to Disease from Stature and Habitus.

Table 217.4

Clues to Disease from Stature and Habitus.

Table 217.5. Clues to Disease from Posture and Decubitus.

Table 217.5

Clues to Disease from Posture and Decubitus.

Table 217.6. Clues to Disease from Odor of Breath and Body.

Table 217.6

Clues to Disease from Odor of Breath and Body.

Basic Science

The physician is much like a detective, searching for clues in the history and physical examination, reserving judgment during the quest for conclusive data. Read, for example, the following passage that emphasizes Sherlock Holmes" powers of observation:

" "Pon my word Watson, you are coming along wonderfully. You have really done very well indeed. It is true that you have missed everything of importance, but you have hit upon the method, and you have a quick eye for colour. Never trust to general impressions, my boy, but concentrate yourself upon details. My first glance is always at a woman's sleeve. In a man it is perhaps better first to take the knee of the trouser. As you observe, this woman had plush upon her sleeves, which is a most useful material for showing traces. The double line a little above the wrist, where the typewritist presses against the table, was beautifully defined. The sewing machine, of the hand type, leaves a similar mark, but only on the left arm, and on the side of it farthest from the thumb, instead of being right across the broadest part, as this was. I then glanced at her face, and observing the dint of a pince-nez at either side of her nose, I ventured a remark upon short sight and typewriting which seemed to surprise her."

"It surprised me."

"But, surely it was obvious. I was then much surprised and interested on glancing down to observe that, though the boots which she was wearing were not unlike each other, they were really odd ones; the one having a slightly decorated toe-cap, and the other a plain one. One was buttoned only in the two lower buttons out of five, and the other at the first, third and fifth. Now, when you see that a young lady, otherwise neatly dressed, has come away from home with odd boots, half-buttoned, it is no great deduction to say that she came away in a hurry."

General appearance demands less data collection than any of the other represented items of database content. Yet information gleaned from the patient appearance is particularly valuable, since it is usually the first bit of objective data. Examining the general appearance of the patient may be likened to surveying the forest before walking among the trees. Writings of 50 or more years ago contain the very-best descriptions relating patient appearance to disease. Osler's detailed description of the patient with typhoid fever is a classic example. The sensitivity and specificity of patient appearance have withstood the test of time. Excellent clinicians continue to use this technique with high yield.

Clinical Significance

What can be learned by looking into a patient's face and eyes? The eyes have been called the windows of the soul, the face the mirror of the mind. Authors and poets have described the importance of such observation. Physicians will long remember some of their patients" faces, the pain, anger, or pleading that can be so vividly expressed by the human face. Clues to endocrine and physiologic abnormalities may also become apparent—the rounded facies of Cushing's disease, the prominent jaw and frontal bossing of acromegaly, or the exophthalmos of hyperthyroidism. Icteric sclera may tell more about a patient's alcohol problem than can be stated. Pallor may quickly explain shortness of breath. Lateral thinning of the eyebrows may suggest hypothyroidism; periorbital edema may represent the nephrotic syndrome; and a butterfly rash may predict lupus erythematosus.

A simple handshake may help assess the circulatory system, suggest active inflammation in the patient with arthritis, or differentiate the cold and moist hands of the anxious patient from the warm and moist ones of the thyrotoxic patient.

The patient's voice may suggest fear, depression, or mania. Speech can also be the first clue to dysarthria or aphasia. The thickened, low pitch of hypothyroidism or hoarseness of laryngeal carcinoma can be detected by a careful listener.

Observation of a shuffling gait will require a particular review of symptoms for signs of Parkinsons's disease and a physical examination particularly directed toward the assessment of mobility. Similarly, gait may suggest a mild hemiparesis secondary to stroke, or the ataxia of cerebellar disease.

An illustration of what the patient's appearance can reveal is shown by the following case:

The patient is from a rural area, brought to the clinic by family members. He is cachectic and thin; his clothes fit loosely. His face shows great sadness and fear. His speech is difficult, his mouth dry, and a fecal odor is evident on his breath. He is pale, his sclera are icteric, and his head bobs and body jars with each heartbeat. On shaking hands, his skin is warm and his nails have subungual hemorrhages. A hole has been cut out of his shoe where the large toe protrudes.

This patient is extremely ill, and only a detailed history and physical examination will provide the necessary data for diagnosis and treatment. However, important information has already been collected and can be used to make hypotheses and chart a further course. The patient has a chronic debilitating disease. Perhaps his fears of medical care have delayed presentation and resulted in advanced disease. The odor of his breath suggests poor oral hygiene and the head bobbing suggests advanced aortic regurgitation. This presentation could be consistent with subacute endocarditis. Subungual hemorrhages provide further support for this hypothesis. His pale complexion and scleral icterus may be caused by a hemolytic anemia secondary to endocarditis; but a chronic hemolytic anemia might cause gout, requiring the modified shoe.

These hypotheses are generated by data obtained from the patient's general appearance. The possibilities will require confirmation by more detailed history (has there been fever, chills, weight loss, night sweats), physical examination (is there an aortic regurgitant murmur, splenomegaly or podagra), and laboratory data (blood cultures, complete blood count, peripheral smear, uric acid). But we have used the patient's general appearance to begin the scientific process that will eventually lead to accurate diagnosis.

References

  1. Cheraskin E, Ringsdorf WM Jr. Predictive medicine: a study in strategy. Mountain View, CA: Pacific Press Publishing, 1973.
  2. Feingold M, Gellis SS. Syndrome identification and consultation. Am J Dis Child. 1971;121:82–83. [PubMed: 5539824]
  3. Osler W. The principles and practice of medicine. New York: D Appleton, 1892;2–39.
  4. Osler W. The teacher. Johns Hopkins Hosp Bull 1919;30.
  5. Roberts HJ. Difficult diagnosis: a guide to the interpretation of obscure illness. Philadelphia: W.B. Saunders, 1959.
Copyright © 1990, Butterworth Publishers, a division of Reed Publishing.
Bookshelf ID: NBK330PMID: 21250172

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