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Patient Centered Medicine 2

General Appearance Myles Sheehan, S.J., M.D.

GENERAL APPEARANCE Moving from history to physical examination, Evaluating the patient's general appearance, and An introduction to functional assessment I. MAKING THE TRANSITION FROM HISTORY TO PHYSICAL A. The physical exam begins when you greet the patient. You look at your clinic schedule for the day and see a newpatient, Mr. Robinson, a 75 y.o. man, who is presenting for a complete history and physical. You go out to the waiting area to greet Mr. Robinson and find an older man accompanied by a younger woman. Mr. Robinson is dressed in a sweatshirt and baggy pants. His shoes appear somewhat scuffed and the tops of the shoes are worn and salt stained. As you introduce yourself, Mr. Robinson pushes himselfout of the chair, using the arms like parallel bars. His handshake is firm but you note that he appears pale. The woman accompanying Mr. Robinson introduces herself as his daughter and accompanies her father into the office. Robinson walks slowly, he swings his left leg out as he walks and his left arm is slightly flexed. He stops once to take a rest, leaning on his daughter's arm. B. It continuesas you observe him/her during the course of the interview. You ask Mr. Robinson what brought him to your office and how you might be of assistance. It takes a moment for him to answer, as he catches his breath. You notice that his ankles are swollen. During the interview, Mr. Robinson frequently looks to his daughter for answers to specific questions. C. Portions of the history may best be obtainedduring the physical examination.

The history obtained from Mr. Robinson, coupled with the observations you have made about his general appearance, have raised a number of questions in your mind. You have several preliminary diagnoses but realize that you need data to hone your diagnostic impressions, make certain you are not missing important historical information, and provide confirmatoryevidence on physical examination. As a consequence, you explain to Mr. Robinson that you would like to do a physical exam at this point. You ask Mr. Robinson's daughter if she has any questions or concerns, or anything she would particularly like you to pay attention to during the exam and then cordially invite her to step out of the room so you can examine her father in privacy. She admits herconcern that her father does not seem to be doing well in general and she is especially concerned about his breathing and forgetfulness. II. THE ELEMENTS OF GENERAL APPEARANCE A. Physical Characteristics Sex, race, body build, obvious deformities or distinguishing characteristics, state of development in relation to chronological age.

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Revised:06/24/05

Patient Centered Medicine 2

General Appearance Myles Sheehan, S.J., M.D.

Who cares? Sex: Influences your prior probability of certain diagnoses, helps differentiate findings during development. Race: Especially pertinent with certain diagnoses, e.g. sickle cell anemia, thalassemia. Be cautious, however, about confusing stereotypes with reality. Body build: Is the person very talland skinny? Are they short and squat? Height and weight are extremely useful pieces of data in following a person. First, it gives objective data to verify your clinical impression (e.g., 6' 1" and 140 pounds is quite thin and makes one wonder why the person does not weigh more). Second, serial measures of weight provide evidence for systemic illness or another problem that may need investigation(e.g., if the 6' 1" man now weighs 140 pounds but six months previously weighed 165, then you have objective verification of a 25-pound weight loss and, if the cause is not obvious, a need to determine a reason for the weight loss like depression, malignancy, severe illness, etc.). Obvious deformities and characteristics: Is there anything that catches your eye when you see this person?...