Clinical Corner: The General Appearance of Patients
Clinicians in training are told that their assessment of a patient should begin the moment they enter a room. In fact, if there are notable sounds or smells that can be appreciated from outside the patient’s room, this assessment can start even earlier.
It is often recommended that young clinicians go through a set checklist or fixed routine to ensure nothing is left out during data collection. Then, with all information gathered, one can go back, piece together a problem list, and try to think through all the possible explanations for these problems before narrowing down the most likely causes and deciding how to address them.
As clinicians gain experience, these processes happen simultaneously, allowing interviewers to move various disease processes up and down their mental lists, driving the next lines of questioning or examination. A patient’s general appearance is among the first things a clinician should observe, and this can help to guide the entire clinical encounter. This skill, like anything, takes practice.
Several pieces may contribute to an individual’s general appearance, including any signs of distress, such as sweating or labored breathing, level of consciousness or ability to interact, height, build, body odors, whether they appear different from their chronological age, any obvious wounds, or even unusual jewelry or tattoos, to name a few.
One remarkably tangible item I find useful is a description of a person’s apparent state of health. From across a room, we really can tell in a fraction of a second if someone looks well, and if not, we can describe them as appearing agitated, ill, in pain or frankly toxic.
Developing a rich vocabulary to describe people’s general appearance in just a few words is well worth the effort. I learned my favorite exercise for practicing this from a class I took in dental school that used art to hone students’ skills in physical diagnosis.
To do this exercise, go with a friend to your favorite museum, and venture into separate wings that have paintings, photographs or sculptures filled with people. On a notepad, describe seven or eight specific subjects in the works using just a few words.
Then find your friend, switch wings of the museum and notepads, and based on each other’s descriptions, find the people your friend picked out. Of course, you can do the same with real people from your social circles or celebrities, but I always enjoy a reason to get out and view some art.
Below are a few quick examples of patients I have seen:
1. Caucasian man in his 40s with leathery skin, smelling strongly of body odor and alcohol, devil horns tattooed on forehead. Lying in bed with eyes closed.
2. Pale, elderly Caucasian woman, looking unwell, lying in bed, trembling but alert. Blood splattered on her ankles and shoes.
3. Young Middle Eastern man of college age, appearing healthy, talkative and friendly but visibly anxious. Fidgets and paces occasionally.
4. Elderly Asian-American woman, finely dressed and neatly made up, quietly sitting in a chair, knitting.
5. Indian man in his 60s, lying in bed intubated, opens eyes to voice and makes eye contact before falling back asleep.
In the above examples, I might prioritize a mental status exam and a toxin screen in Patient 1 and a vascular exam and blood counts in Patient 2. Patient 3 may need reassurance before being interviewed, while Patient 4 may require close attention to detail with each recommendation. Patient 5 will likely not participate much in his examination, but he can hear and comprehend and will benefit from being told out loud what is happening.
When communicating about patients verbally, describing the general appearance allows listeners to get a mental picture of the patient as a whole before going into the system-by-system details.
In an ideal world, we ask every patient every question under the sun and closely examine every part of the body, but limited time and resources require clinicians to use their time with patients wisely.
Noting a patient’s general appearance allows a clinician to be thoughtful and directed about each encounter, and developing this skill can be fun and gratifying. Perhaps I’ll see you this coming weekend at the De Young’s David Hockney exhibit.