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Introduction

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More mistakes, many more, are made by not looking than by not knowing.

Sir William Jenner (1815–98)

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GPs have an ideal opportunity to practise the art of careful observation and to notice all the signs and features characteristic of a patient from the time seen in the waiting room until the physical examination. We should be ‘like Sherlock Holmes’ in our analysis of the patient and accept the challenge of being astute diagnosticians and proud members of a noble profession.

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It is important to stand back (so to speak) and look at the patient's general appearance and demeanour. We should be assessing their mood and affect as much as their physical appearance. The first assessment to make is ‘Does the patient look sick?’.

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First impressions

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The first impression of the patient is always striking in some way and we should discipline ourselves to be as analytical as possible.

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A rapid inspection from a trained observer may be all that is necessary to allow the observer to pinpoint specific disorders, such as anaemia, hyperthyroidism, jaundice, acromegaly and alcohol abuse. Such ‘spot’ diagnosis is not justifiable unless the original signs are supported by further examination, which must be comprehensive.

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The following observations should therefore be made:

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  • facial characteristics

  • abnormalities of the head and neck

  • examination of the mouth

  • character and distribution of hair

  • examination of the skin (in general)

  • height and weight

  • posture and gait

  • genitalia

  • examination of extremities (hands, feet, nails, etc.)

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Physiognomy

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Physiognomy, from the Greek physiognomonia, meaning the judging of one's nature, is the art of judging character from the features of the face. It flourished during the Middle Ages. According to Addison1, ‘everyone is in some degree a master of that art which is physiognomy; and naturally forms to themselves the character of a stranger from the features of the face’. In reality, all doctors use a physiognomical approach to diagnose many medical conditions, although we may not be as expert at the art as we should be.

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The face is a person's most immediate means of communicating with others; it is a shield and banner, a mask and a mirror. It reveals mental faculties and emotional turmoil. It is the first perspective gained of patients as they walk into the consulting room.

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The face as a mirror of disease

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A fascinating aspect of the art of clinical medicine is the clinical interpretation of the patient's facies. Not only are specific skin lesions common on the face but the face may also mirror endocrine disorders and organ failure such as respiratory, cardiac, kidney and liver failure.

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Jaundice may be masked by the natural colour of the cheeks but the yellow conjunctivae will be ...

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