Skin Color and Obvious Lesions. See Chapter 4, The Skin, for details.

Anxious face, fidgety movements, cold moist palms; inexpressive or flat affect, poor eye contact, psychomotor slowing

Very short stature is seen in Turner's syndrome, childhood renal failure, achondroplastic and hypopituitary dwarfism. Long limbs in proportion to the trunk is seen in hypogonadism and Mar-fan's syndrome

Generalized fat in simple obesity; truncal fat with relatively thin limbs in Cushing's syndrome and syndrome X

Causes of weight loss include malignancy, diabetes mellitus, hyperthyroidism, chronic infection, depression, diuresis, and successful dieting

Pallor, cyanosis, jaundice, rashes, bruises iress, Grooming, and Personal Hygiene. How is the patient ressed? Is clothing appropriate to the temperature and weather? Is it clean, properly buttoned, and zipped? How does it compare with clothing worn ?y people of comparable age and social group?

Excess clothing may reflect the cold intolerance of hypo-thyroidism, hide skin rash or needle marks, or signal personal lifestyle preferences.

Glance at the patient's shoes. Have holes been cut in them? Are the laces tied? Or is the patient wearing slippers?

Cut-out holes or slippers may indicate gout, bunions, or other painful foot conditions. Untied laces or slippers also suggest edema.

Is the patient wearing any unusual jewelry? Where? Is there any body piercing?

Note the patient's hair, fingernails, and use of cosmetics. They may be clues to the patient's personality, mood, or lifestyle. Nail polish and hair coloring that have "grown out" may signify decreased interest in personal appearance.

Do personal hygiene and grooming seem appropriate to the patient's age, lifestyle, occupation, and socioeconomic group? These are norms that vary widely, of course.

Copper bracelets are sometimes worn for arthritis. Body piercing may appear on any part of the body.

"Grown-out" hair and nail polish can help you estimate the length of an illness if the patient cannot give a history. Fingernails chewed to the quick may reflect stress.

Unkempt appearance may be seen in depression and dementia, but this appearance must be compared with the patient's probable norm.

Facial Expression. Observe the facial expression at rest, during conversation about specific topics, during the physical examination, and in interaction with others. Watch for eye contact. Is it natural? Sustained and unblinking? Averted quickly? Absent?

The stare of hyperthyroidism; the immobile face of parkinsonism; the flat or sad affect of depression. Decreased eye contact may be cultural, or may suggest anxiety, fear, or sadness.

Odors of the Body and Breath. Odors can be important diagnostic clues, such as the fruity odor of diabetes or the scent of alcohol. (For the scent of alcohol, the CAGE questions, p.__, will help you determine possible misuse.)

Breath odors of alcohol, acetone (diabetes), pulmonary infections, uremia, or liver failure

Never assume that alcohol on a patient's breath explains changes in mental status or neurologic findings.

Posture, Gait and Motor Activity. What is the patient's preferred posture?

Is the patient restless or quiet? How often does the patient change position? How fast are the movements?

Alcoholics may have other serious and potentially correctable problems such as hypoglycemia, subdural hematoma, or post-ictal state

Preference for sitting up in left-sided heart failure, and for leaning forward with arms braced in chronic obstructive pulmonary disease

Fast, frequent movements of hyperthyroidism; slowed activity of hypothyroidism

Is there any apparent involuntary motor activity? Are some body parts immobile? Which ones?

Tremors or other involuntary movements; paralyses. See Table 16-8, Involuntary Movements, (pp. ___-___).

Does the patient walk smoothly, with comfort, self-confidence, and balance, or is there a limp or discomfort, fear of falling, loss of balance, or any movement disorder?

See Table 16-13, Abnormalities of Gait and Posture (pp. - ).

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