A Patient's General Appearance (Strong Exam)

A discussion of what can be inferred from a patient's general appearance, including the appearance of being acutely and/or chronically ill, abnormal skin tone (e.g. jaundice, cyanosis), stature, clothing, and unusual odors.
0:00 Introduction
0:57 Acute Appearance
1:32 Chronic Appearance
3:40 Abnormal Stature
4:01 Clothing
4:58 Odor
6:46 Skin tone
9:43 Documentation
#PhysicalExam

[@StrongMed]

The general appearance isn't the most evidence-based or world-rocking part of the exam, but the vital sign videos will begin challenging assumptions & common beliefs tomorrow!

[@waelfadlallah8939]

I am so loving this

[@t.k.touchdown6050]

6 years of med school, 1st year of internship, and it’s always refreshing to brush up my basics on physical examination. Thank you Dr Strong for the amazing content. Looking forward to future videos from this series, and I’ll be sure to pass along to other med students together with my rotations.

[@maryamthefairy]

A palatable, masterly described narration 👌

[@SctsceDuwn]

The refresher is refreshing. I will come back everyday and finish the course.

[@canas_fe4815]

Great video. Thanks as always for clarifying terminology and giving recs for clear and concise documentation phrasing.

[@minhashyder]

Thank you Dr Strong & Team. Great content as always 🥰

[@Fxhealth]

Great video editing and presentation as always Dr. Strong

[@ahmedosman889]

Thank you Dr. Eric, it was really useful

[@1Itsyasr]

Great series ❤

[@yasiraslam7490]

Great work ❤

[@damir611]

I work at outpatient ER so I just can't write that a patient looks older than his age 😀. great video

[@sueyun375]

Thank you !!!

[@SludgeMan90]

What if I'm really weak? Can you please make a "weak exam" version for us less physically capable?

[@tinystudent]

Great 😍

[@simena1]

Great video! You refer to icterus meaning specifically yellow discoloration of the sclera, which I believe is wrong? Doesn’t icterus and jaundice mean the exact same thing?

[@StrongMed]

Yes, icterus is technically a synonym for jaundice, and the proper term for what I was referring to is "icteric sclera" or "scleral icterus". I've never heard someone use "icterus" or "icteric" to refer to anything other than sclera; I think that biased me to be a little imprecise with the terminology. Thanks for pointing it out!

[@knh5116]

How do you go about documentation of appearance in a way that is cognizant of the fact that most patients can read their chart now?

[@StrongMed]

There is a spectrum of opinions on "open notes" documentation style (i.e. writing notes as if the patient was equally important as a potential reader). Personally, I make relatively few adjustments, though I probably have a different threshold for writing "patient appears older than stated age..." than I previously did. If the clothes are the wrong size or for the wrong climate, that doesn't seem problematic to me. If there is a pathologic odor present, you'll be talking to them about it anyway. I suppose "disheveled clothing" or "disheveled appearance" can be seen as judgmental and could be insulting, but from a practical standpoint, the patients who are arriving in that condition are the ones least likely to be reading their notes in the EMR. Regarding the rest of the exam and open notes - medical terminology means something more specific than what the layperson translation would be. If we write everything in a way that laypersons will fully understand, we will necessarily lose meaning in it, or we need to write out everything twice. (e.g. "CV: Regular rhythm, 2/6 systolic crescendo-decrescendo murmur at LUSB radiating to carotids, JVP 10cm; sound of turbulent blood heard both at the upper breastbone and the neck suggesting possible disease of the aortic valve, the pressure in the jugular vein was slightly elevated above normal"). This is just too time-consuming and cumbersome. I can see a near-future in which AI solves this problem by translating or interpreting medical notes for laypersons in real-time within the patient portal of the EMR with a click of button, but we aren't there yet.

[@NinjaSheepa]

[@arthurmabeejr8752]

This is a great narrative program but, why don't doctors follow protocol when someone has true pain and, suffering when laboratory findings, X-Ray, CT imaging have found: The reason for bone pain, Hypercalcemia, bone loss due to known origins, frequent urination excessively, anemia in lab markers, kidney discrepancies in labs? I am one of those patients: I also have a doctor that tried to diagnose me with Osteoporosis instead of finding out what the root cause is because of my age of 61? Even though I exercise more than most 20 year olds, I'm 6' tall and weigh 175 pounds with an excellent BMI. I have visible abs as a 6 pack with about 6% bodyfat composition. I eat healthy and, do not eat sweets or junk foods, I weight train 3 times a week and, between that I do cardio 45 minutes 3 times a week. My labs show my calcium as high as 13.9, my MCHC is L=31.8, RDW-CV is H=14.8, MPV is H=11.4, my testosterone stays low average=180. How does a doctor say I have Osteoporosis? My sleep suffers, I have constant bone pain in my lower back, arms and legs, I'm constantly fatigue, feeling like I just ran 100 miles when I just walked from my car to my garage? How can doctors justify in evaluating a patient or diagnosing a patient when things are being ignored?

[@5omethingsBetterThanNothing]

second to none

[@hunnybadger442]

I bet you aren't even aware that you can be fat and malnourished... Or that you can be anorexic and fat as well...

[@StrongMed]

Yep, of course this is possible, and thank you for pointing it out. However, as with cachexia, it is very difficult if not impossible to identify it only with the physical exam. In short, you need some history +/- blood tests to identify malnourishment in an obese patient.