1. General Appearance

2. Objectives
List features to observe as part of the general appearance of patients
Describe some of the classic physical appearances of several diseases (ex. Marfan, Turner, Hyper- and Hypothyroidism)
Use body mass index to define extremes of weight
Identify a patient’s level of consciousness
List steps to properly take a blood pressure

3. Question…
An astute physician gathers as much information as possible in the history and physical before beginning to think about the differential diagnosis.
True or False?

4. Possible items to comment on for General appearance
General state of health
Level of comfort
Respiratory effort
Is there a disconnect between chronologic age and development?
Extremes of Height/Weight
Posture, motor activity, gait
Obvious deformities or distinguishing characteristics
-Amputee? Scars from trauma or surgery?
Characteristic facies?
Dress, grooming, personal hygiene
Odors
Level of awareness or consciousness
Skin color/hair distribution

5. Think of specific diseases
Genetic disorders
Turner
Down
Neurologic disease
Parkinson disease
Endocrine disorders
Acromegaly
Cushing syndrome
Hyperthyroidism
Hypothyroid - myxedema

6. 1. General state of health ?

10. 2. General level of comfort ?

14. 3. Abnormal Respiratory effort ?
Gasping for breath
Labored breathing
Coughing
Unable to speak in sentences
Using accessory muscles of respiration
Audible wheezing/stridor

15. Miller PE, Houston BA. N Engl J Med 2014;371:357-357.
Dahl's Sign
Miller PE, Houston BA. N Engl J Med 2014;371:

16. Question
A 25 year old male is at your office at 4 pm for a screening exam for his new job. He is obese, has no other known medical problems. On exam he has equal and symmetrical pulses of his radial, femoral and dorsalis pedis pulses. His blood pressure is slightly elevated.
What might be an explanation?
1. Probable coarction of the aorta
2. The 8 oz. cup of coffee he drank at 8 am
3. The width and length of the cuff is too small
4. The sprint to your office because he thought he was late (but he ended up being 45 minutes early)
5. He has high blood pressure

17. Vital Signs Blood Pressure Part of General Survey
Pick the right size cuff
Width about 40% of upper arm circumference
Length of inflatable cuff about 80% of upper arm circumference
Avoid smoking, caffeine, or exercise 30 minutes prior
Exam room s/b quiet and comfortable
Sit quietly for 5 minutes in a chair with feet on the floor
Arm is free of clothing, not with fistula, scars form brachial artery cut-down or lymphedema
Position arm so brachial artery, at the antecubital crease is at heart level (~4th ICS)
If seated, rest arm on table above patients waist; if standing, support arm at patient’s
mid-chest.

18. New Blood Pressure Guidelines
2017 American College of Cardiology and American Heart Association
Normal < 120/80 (mm Hg)
Elevated / <80
HTN
Stage or diastolic 80-89
Stage 2 >140 or diastolic >90
Based on the average of two or more readings, more than 2 occasions

19. 4. Disconnect between chronologic age and development ?
Appears younger than stated age
Appears older than stated age
Precocious puberty
Before age 7 females
Before age 9 males

20. 5. Extremes of Height ?

23. [[File:Marfan Patient.jpeg|Marfan Patient]]
By Mileny ES Colovati1, Luciana RJ da Silva1, Sylvia S Takeno1, Tatiane I Mancini1, Ana R N Dutra1,Roberta S Guilherme1, Cláudia B de Mello2, Maria I Melaragno1and Ana B A Perez1 - CC BY 2.0,

24. By Staufenbiel I, Hauschild C, Kahl-Nieke B, Vahle-Hinz E, von Kodolitsch Y, Berner M, Bauss O, Geurtsen W, Rahman A - CC BY-SA 2.0,

25. Original PNG by Goopsmirk, SVG version by TheAwesomeHwyh.

26. 6. Extremes of Weight ?

27. Underweight (BMI < 18) Cachectic, Malnourished, Emaciated
Too little weight
Underweight (BMI < 18)
Cachectic, Malnourished, Emaciated
?Eating disorder (anorexia)
?cancer

29. https://www. omicsonline

30. Body Mass Index

31. 6. Posture/motor activity?

33. 6. Gait?

34. On line

35. 7. Obvious deformities or distinguishing characteristics ?
Amputee?
Prominent visible scars from surgery or trauma
Visible piercings or tattoos

36. 8. Characteristic Facies ?
Moon face of Cushings
Prognathism of acromegaly
Stare of thyrotoxicosis
Myxedema loss of lateral 1/3 of eyebrows, puffy face, dry skin and brittle hair
Parkinson – masked face (immobile face), hunched posture, resting tremor, paucity of movement, no arm swing with walking, minimal blinking
Color
slapped cheeks – fifth disease
Butterfly = malar rash of lupus
Decreased eye contact – cultural, fear, depression

37. Cushing syndrome [[File:CushingsFace.jpg|thumb|CushingsFace]]

39. As compared with the hand of a normal person (left), the hand of a patient with acromegaly (right) is enlarged, the fingers are widened, thickened and stubby, and the soft tissue is thickened (A). Facial aspect of a patient with acromegaly. The nose is widened and thickened, the cheekbones are obvious, the forehead bulges, the lips are thick and the facial lines are marked (B and C).
Acromegaly
Chanson, Philippe, MD, Best Practice & Research Clinical Endocrinology & Metabolism, Volume 23, Issue 5,
Copyright © Elsevier Ltd Note—description of hands reversed

40. Acromegaly showing the patient before development of the tumor (picture on the left) and after development of the tumor (picture on the right). Note the coarse facial features and enlargement of the jaw and lips. (From Damjanov I: Pathology for the Health-Related Professions, 2nd ed. Philadelphia, WB Saunders, 2000, p 407.)
(From Damjanov I: Pathology for the Health-Related Professions, 2nd ed. Philadelphia, WB Saunders, 2000, p 407.)
Endocrine Disorders
Goljan, Edward F., MD, Rapid Review Laboratory Testing in Clinical Medicine, CHAPTER 10,
Copyright © Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.

43. LUMEN

45. Copyright © 2014 McGraw-Hill Education. All rights reserved.
Date of download: 8/3/2014
Copyright © 2014 McGraw-Hill Education. All rights reserved.

46. Marks, James G., MD, Lookingbill and Marks' Principles of Dermatology, 14, 183-195
Copyright © Copyright © 2013, Elsevier Inc. All rights reserved.

47. (From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, 4th ed. St. Louis, Mosby, 2002.)

48. 9. Dress Grooming/ Hygiene/clothing?
Disheveled
Unkempt
Excessive fastidiousness
Is clothing clean, properly fastened?
How does clothing compare with clothing of comparable age and social group?
Is hair groomed, beard kempt?
Inappropriate dress for season

49. 9. Footwear ? Slippers? Untied shoes? Cut holes in shoes?
Think edema (CHF, nephrotic syndrome)
Cut holes in shoes?
Painful foot conditions like bunions or gout

50. hubpages.com/u/417164_f260.jpg

51. A , A 72-year-old woman presented with lymphedema of the left lower extremity after an extended hysterectomy with regional lymph node dissection performed 15 years previously because of uterine cancer. Severe lymphedema was evident (volume, 5413 mL). B , Two lymphaticovenous side-to-end anastomoses (LVSEAs) were performed for the dorsum of the foot, three were performed for the leg, and one for the thigh. C , Postoperative indocyanine green fluorescence lymphography shows patency of the LVSEA at the medial side of the dorsum of the foot, where a tree pattern was observed, and nonpatency at the other LVSEA of the foot ( star , anastomosis site; triangles , lymphatic vessel; arrow , subcutaneous vein). D , At 6 months after LVSEA, lymphedema of the left lower extremity has improved (volume, 4326 mL).
Outcomes of lymphaticovenous side-to-end anastomosis in peripheral lymphedema
Maegawa, Jiro, MD, Journal of Vascular Surgery, Volume 55, Issue 3,
Copyright © Society for Vascular Surgery

52. 10. Odors ?

53. 11. Level of awareness or consciousness
Confused – delirious (inpatients)
Anxious –fidgety
Manic - Hyper – expansive movements
Depressed (Slow, slumped posture, disinterested, gloomy)
Peds – inconsolable, crying, won’t play with favorite toys

54. Levels of consciousness
Stimulus needed for Response
Response
Level of Consciousness
Normal conversation
Normal response
Alert
Loud questioning
Drowsy, but responds
Lethargic
Gentle touch or movement
Opens eyes,
slow response,
may be confused
Obtunded
Painful stimulus
Ex. Sternal rub, pressure on fingernail
Minimal to no response
May exhibit posturing
Comatose

55. 12. Skin color/hair distribution
Color Changes
Yellow: Jaundice, Hypercarotenemia
Blue: Cyanosis - central vs peripheral Silver ingestion
Red: sunburn disease allergy toxin
Hair distribution
Hirsute females, normal variation vs. virilization
Alopecia – cancer treatment?
Diaphoretic, excessively dry, temperature…..

56. Hypopigmentation
From Derm Atlas

57. Central cyanosis of the lips. The general examination
Douglas, Graham, Macleod's Clinical Examination, 3, 41-62Copyright © Copyright © 2013 Elsevier Ltd All rights reserved

58. peripheral cyanosis (with clubbing); (B) central cyanosis
peripheral cyanosis (with clubbing); (B) central cyanosis.CyanosisMcMullen, Sarah M., MD, American Journal of Medicine, The, Volume 126, Issue 3, Copyright © Elsevier Inc.

59. Cyanosis
From Derm Atlas

60. Bluish-silvery discoloration of the patient's face
Bluish-silvery discoloration of the patient's face. Note the color difference between the face, which was directly exposed to silver spray, and hand. The discoloration develops on exposure to sunlight. Argyria and Decreased Kidney Function: Are Silver Compounds Toxic to the Kidney?
Mayr, Michael, MD, American Journal of Kidney Diseases, Volume 53, Issue 5, Copyright © National Kidney Foundation, Inc.

61. Carotenemia, yellow palm shown next to normal palm
Carotenemia, yellow palm shown next to normal palm.Errors in Metabolism
James, William D, MD, Andrews' Diseases of the Skin Clinical Dermatology, 26, Copyright © © 2011, Elsevier Inc. All rights reserved.

62. Carotenemia. The patient's legs are noticeably orange when compared to the photographer's hand.Nutritional Diseases
McLeish Schaefer, Stephanie, Dermatology, 51, e1Copyright © © 2012, Elsevier Limited. All rights reserved.

63. Conjunctival icterus.Xanthoderma: A clinical review
Haught, Justin M., MD, Journal of the American Academy of Dermatology, Volume 57, Issue 6,
Copyright © American Academy of Dermatology, Inc.

64. Yellow-orange pigmentation characteristic of carotenemia
Yellow-orange pigmentation characteristic of carotenemia.Syndromes associated with nutritional deficiency and excess
Jen, Melinda, MD, Clinics in Dermatology, Volume 28, Issue 6, Copyright © 2010

65. Derm Atlas

67. Dramatic change in physical appearance before ( A ) and 1 month after ( B ) treatment with paclitaxel and carboplatin.
Chemotherapy-induced alopecia Chon, Susan Y., MD, Journal of the American Academy of Dermatology, Volume 67, Issue 1, e37-e47Copyright © American Academy of Dermatology, Inc.

68. Avoid the default to “WDWN male in NAD”
“Well developed, well nourished male in no apparent distress”

69. The eye does not see what the mind does not know

70. Reminders and Your “To Do” list:
Small group: sign in and introductions
lecture and questions reviewed
discuss photos provided in context of general appearance/use as rich a vocabulary as you can
Pick a small group representative! Let the course coordinator know today.
Fill out evaluation form as a group, small group rep return folder to the coordinator
Monday, August 12 at noon
IF Facilitator Absent in small groups-----
Let Alison know
Know your small group number/faculty names.
Tomorrow: August 7 , 2019 Radiology Lecture (Radiology Vertical Curriculum) 1 pm room 390
Thursday: August 8, :30am, Room 390 ENT
PEDS SHADOWING OPT OUT by Friday pm
Next week Tuesday lecture: Ophthalmology 1 pm
Small group: Lecture and question review for both the ENT and EYE lectures
Read the assignment, linked through the library
Bring your ophthalmoscope and otoscope----- fully charge equipment
See objective pages to prepare for each session ahead of time

71. ENT

72. Access Medicine, Part 2. Specialty Areas from The Atlas of Emergency Medicine, 3e 2010; Failure to Thrive. This infant has not been able to maintain a normal growth pattern and appears cachectic. (Photo contributor: Kevin J. Knoop, MD, MS.)
dbbEWJo0wM&imgurl=
122&dur=8841&hovh=200&hovw=252&tx=145&ty=137&page=1&tbnh=139&tbnw=181&start=0&ndsp=41&ved=1t:429,r:5,s:0,i:96 2.
From the following article: Hormonal therapy in a patient with a delayed diagnosis of Turner's syndrome Aneta Gawlik and Ewa Malecka-Tendera Nature Clinical Practice Endocrinology & Metabolism (2008) 4, doi: /ncpendmet0747
(This image can be viewed in full color online at ExpertConsult )
Turner syndrome
Saenger, Paul, MD, Pediatric Endocrinology, CHAPTER 16, e1
Copyright © Copyright © 2014, 2008, 2002, 1996 by Saunders, an imprint of Elsevier Inc.
External phenotype of patients with Marfan syndrome, showing long extremities and digits, tall stature, and pectus carinatum. (“Used with permission from Mediscan, Medical-On-Line-Ltd, London.”From Libby P: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. Philadelphia, Saunders, 2007.)(Used with permission from Mediscan, Medical-On-Line-Ltd, London. From Libby P: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. Philadelphia, Saunders, 2007.)Marfan SyndromeParvizi, Javad, MD, FRCS, High-Yield Orthopaedics, Chapter 140, Copyright © Copyright © 2010 by Saunders, an imprint of Elsevier Inc.
Clinical features in a 12-year-old boy with Marfan syndrome. Note the pectus excavatum and long bone overgrowth (A); a beginning scoliosis at the onset of growth acceleration (B); and arachnodactyly and hypermobility of the small joints (C).Ehlers-Danlos syndromes and Marfan syndromeCallewaert, Bert, MD, Best Practice & Research: Clinical Rheumatology, Volume 22, Issue 1, Copyright © Elsevier Ltd
(From McBride ART, Gargan M: Marfan syndrome, Curr Orthop 20:418–423, 2006.)
Marfan SyndromeDoyle, Jefferson, Nelson Textbook of Pediatrics, Chapter 693, e1Copyright © Copyright © 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983, 1979, 1975, 1969, 1964, 1959 by Saunders, an imprint of Elsevier Inc.
Wrist sign. When the wrist is grasped by the contralateral hand, the thumb overlaps the terminal phalanx of the 5th digit. (From McBride ART, Gargan M: Marfan syndrome, Curr Orthop 20:418–423, 2006.)(From McBride ART, Gargan M: Marfan syndrome, Curr Orthop 20:418–423, 2006.)Marfan Syndrome
Doyle, Jefferson, Nelson Textbook of Pediatrics, Chapter 693, e1
Copyright © Copyright © 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983, 1979, 1975, 1969, 1964, 1959 by Saunders, an imprint of Elsevier Inc.
In Buckwalter JA, Ehrlich MG, Sandell LJ, et al, editors: Skeletal and growth development: clinical issues and basic science advances , Rosemont, Ill, 1998, American Academy of Orthopaedic Surgeons, p 585.)
( B, D, and F, From Richards BS: The effects of growth on the scoliotic spine following posterior spinal fusion. In Buckwalter JA, Ehrlich MG, Sandell LJ, et al, editors: Skeletal and growth development: clinical issues and basic science advances , Rosemont, Ill, 1998, American Academy of Orthopaedic Surgeons, p 585.)
ScoliosisRichards, B. Stephens, Tachdjian's Pediatric Orthopaedics, Chapter 12, Copyright © Copyright © 2014, 2008, 2002, 1990, 1972 by Saunders, an imprint of Elsevier Inc.
Kyphosis
Johnston, Charles E., Tachdjian's Pediatric Orthopaedics, Chapter 13, e3
Copyright © Copyright © 2014, 2008, 2002, 1990, 1972 by Saunders, an imprint of Elsevier Inc.
Hyperthyroidism
Gaw, Allan, MD PhD FRCPath FFPM PGCertMedEd, Clinical Biochemistry: An Illustrated Colour Text, 46, 92-93
Copyright © , Elsevier Ltd. All rights reserved.
(From Larsen PR, Kronenberg HM, Melmed S, Polonsky KS: Williams Textbook of Endocrinology, 10th ed. Philadelphia, WB Saunders, 2003.)
Psoriatic erythroderma. A The disease flare correlated with the administration of lithium. B Nail findings (subungual hyperkeratosis, nail plate thickening, and oil-drop changes) point to the diagnosis of psoriasis. There is also soft tissue swelling of the forefinger due to psoriatic arthritis. A, Courtesy, Jean L. Bolognia, MD; B, Courtesy, Wolfram Sterry, MD.
A, Courtesy, Jean L. Bolognia, MD; B, Courtesy, Wolfram Sterry, MD.
ErythrodermaBolognia, Jean L., MD, Dermatology Essentials, 8, 76-83
Copyright © © 2014, Elsevier Inc. All rights reserved.