General Appearance
You can observe a lot by watching.
—YOGI BERRA (QUOTED BY DR BEN FRIEDMAN OF ALABAMA)
POINTS TO REMEMBER:
Your ability to do a good clinical examination increases with your medical knowledge.
The skilled clinician can often draw many diagnostic conclusions from his first look at the patient.
If you are not looking for something, chances are you won’t see it, even when it is present.
Before beginning the sequential physical examination, it is important to take a moment just to look at the patient. Unless one’s brain has been designed by nature to be like that of Arthur Conan Doyle’s medical school teacher, Dr Bell (see Chapter 26), one must systematically seek and record specific observations about the patient’s general appearance. I still suggest to medical students that they read the stories about Sherlock Holmes (who was modeled on Dr Bell) to learn the excitement of drawing inferences from precise observations, but the student will continue this practice only if reinforced by success. Unfortunately, he will not achieve that success unless he knows what to look for. As Goethe said, “Was man weiss, man sieht” (what one knows, one sees).
On a piece of scratch paper, write down what season of the year is referred to in the phrase in Fig. 5-1. If you wrote down the word “spring,” you are correct. No doubt, you read the sign as saying “Paris in the spring.” However, that is not what it says. Go back and read it again, and if you still see the same thing, read it aloud, word by word, pointing at each word on the sign with your finger.
Most students feel that this sign is only a trick. They see their patients everyday and cannot believe that something repeatedly exposed to their careful gaze would escape them. Accordingly, I suggest that you perform the following experiment on yourself, carefully following the steps in sequence.
Get a large piece of paper and a pen or pencil.
Take off your wristwatch and put it in your pocket or purse.
Draw the face of your wristwatch on the piece of paper. (If you have a digital watch, think of a clock face that you often see, such as your night table or kitchen clock.)
Now draw the hands, specifically indicating their shape and any markings on them.
Indicate the color of the hands and the color of the background.
Show the markings for the hours. What color are they? Are they Roman or Arabic numerals? Are any numerals omitted, and what kind of mark is used in their place, if any?
Mark exactly on your drawing any words printed on the face of your watch and any other outstanding marks.
Finally, take your watch out and compare its face with your drawing. How many false-positive memories did you have (i.e., markings on your sketch that do not actually exist on the face of the watch)? How many false-negative memories (i.e., markings on the face of the watch that you did not draw on your sketch)? How many thousands of times do you think you have glanced at this watch?
This exercise is intended to demonstrate that mere unstructured examination will not yield the most obvious of data, no matter how many times it is repeated, unless one is specifically looking for something. Although the outstanding diagnostician differs from the mediocre more in the way that he handles data than in the data that he collects, the importance of observation cannot be overemphasized: The superior clinician cannot gather too much information.
A Method
The principle of having a methodical search in mind before you begin the examination will be an underlying implicit emphasis of the remainder of this text. One sees what one looks for. Ironically, the general appearance section per se lends itself least to a methodical scheme. Take care to observe the following aspects of the general appearance when first meeting the patient (see Rodnan’s outline in Chapter 4): development, nutrition, apparent state of consciousness, apparent age, race, sex, posture or position in bed, comfort, attitude toward examination, degree of illness (acute or chronic), movements, habitus, and body proportions.
Morgan and Engel have stated that the general appearance section of the write-up should contain sufficient succinct material to permit a stranger, should he walk through the wards, to immediately identify the patient you are describing. It may include features of the patient that might also be included in a specific part of the physical examination, (especially the skin, facial appearance, or neurologic examination) but that are apparent to the methodical observer who is meeting the patient for the first time. Some syndromes, especially congenital ones, make the patient look unusual (i.e., “funny looking”). It is the observer’s job to describe just what is unusual about the patient’s looks.
This text will focus primarily on just three aspects of the general appearance for illustrative purposes: position and posture, movements, and habitus and body proportions. Additional illustrations are given in Chapter 9. This text will not follow the pattern of most other clinical diagnosis textbooks, that is, reciting a list of descriptions for the cousin diseases (so called because all the patients with the disease seem to have a family resemblance): hyperthyroidism,
hypothyroidism, Addison disease, Cushing disease, acromegaly, gargoylism, and so forth. First, the pictures of very advanced cases that appear in textbooks are obsolete in that we now usually make the diagnoses much earlier. Second, if you are experienced enough to be able to recognize these patients from their textbook photographs, you do not need a verbal description repeated here.
hypothyroidism, Addison disease, Cushing disease, acromegaly, gargoylism, and so forth. First, the pictures of very advanced cases that appear in textbooks are obsolete in that we now usually make the diagnoses much earlier. Second, if you are experienced enough to be able to recognize these patients from their textbook photographs, you do not need a verbal description repeated here.
 FIGURE 5-1 Self-study Exercise. Write down the season of the year referred to on this sign, and see text p.85. (Courtesy of Dr Campbell Moses, New York, with permission.) |
For the Attending. Look at the devices attached to and the medications flowing into the patient. Professor Ask-Upmark would inspect the patient’s bedside table for diagnostic clues and information about the patient’s personality, religious beliefs, and social support system. Look at the orderliness with which things are arranged. Look for the type of reading material that is present, if any. Inspect the clothing. Dr Bill Domm of Virginia inspected the shoes of patients he suspected of malingering to see whether the soles were worn in the pattern predicted from the abnormal gait that they displayed. There is no specific place in the record for such observations. They might be placed in the history or the physical examination, under general appearance, according to the taste of the individual.
Position and Posture
Patients with Abdominal Pain
In patients with abdominal pain, the position may be of particular value in the differential diagnosis. Patients with a perinephric abscess tend to bend toward the side of the lesion (see Chapter 20 and Fig. 20-7). Patients drawn up in the fetal position often have pancreatitis. Patients who are restless in their agony probably have some form of obstruction, whereas patients with peritonitis tend to hold themselves quite still (Silen, 1979).
A patient who is lying on his back with his knee flexed and his hip externally rotated is said to have the psoas sign (Fig. 5-2). Formerly considered a sign of peritoneal irritation (resulting, for example, from appendicitis or an abscess associated with regional ileitis or diverticulitis), in modern medicine, it is more frequently seen with disease inside the psoas muscle itself, such as an abscess or iatrogenic hemorrhage due to anticoagulation (see also the reverse psoas maneuver in Chapter 20).
Patients with Breathing Difficulty
Posture may also be a helpful clue for diagnosing conditions that cause breathing difficulties. Several positions, each with pathophysiologic significance, have been described.
 FIGURE 5-2 The psoas sign is usually elicited with the patient supine, not erect. (After Andrea del Castagno’s Saint Sebastian.) |
Orthopnea
Cardiac Orthopnea
Orthopnea (literally, “straight up breathing”) signifies left-sided congestive heart failure more than 95% of the time. The pathophysiology of orthopnea is rooted in the anatomic fact that in the erect posture, only the left heart remains centered in its (pulmonic) venous system, whereas the right heart becomes higher than most of the (systemic) venous system that supplies it. (In the supine posture, both the right and the left heart are centered in their respective venous systems.) In other words, when the patient is erect (standing or sitting), the right ventricle experiences a lowering in its filling pressure relative to the left ventricle. This may selectively decrease right ventricular output to the point that the fluid-filled lungs can now be cleared by the (weakened) left ventricle. This mechanism also explains why patients with pure right-sided heart failure do not experience orthopnea and why patients with left-sided heart failure experience some relief of their breathlessness when right-sided heart failure supervenes.
Patients with pulmonic stenosis may say that they can breathe better with their heads propped up on several pillows than when lying flat. There are also situations in which an increase in abdominal contents will make it easier for the patient to breathe when
sitting up. Whereas technically these are examples of orthopnea, they do not signify left ventricular failure and do not result from the pathophysiologic mechanism described above.
sitting up. Whereas technically these are examples of orthopnea, they do not signify left ventricular failure and do not result from the pathophysiologic mechanism described above.
Pulmonary Orthopnea
If there is severe bilateral apical disease with relative sparing of the bases of the lungs, the patient may have orthopnea, since assuming the recumbent position will increase perfusion to the unventilated part of the lung and decrease oxygenation. On sitting up, such patients will again preferentially perfuse the better ventilated bases of their lungs, increase oxygenation, and decrease the sensation of breathlessness, thus mimicking the orthopnea of congestive heart failure.
Patients with severe obstructive pulmonary disease may also sit up in order to brace themselves (see Fig. 7-1A) to immobilize the thorax proper and improve the efficiency of the accessory muscles of inspiration. Leaning forward also helps by compressing the abdomen. The increase in the intra-abdominal pressure pushes the flattened diaphragm of the emphysematous patient back up into a more rounded dome, increasing its efficiency as the piston of respiration (Sharp, 1986). Over a long period, this posture may lead to pigmented patches where the patient has braced his elbows on the thighs (see Fig. 7-1B).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
