How to Describe a Patient's General Appearance
Begin by systematically documenting craniofacial features, age-appropriate responsiveness to the environment, vital signs, skin characteristics, and overall body habitus, as these elements provide critical diagnostic information and establish baseline clinical status. 1
Structured Approach to General Appearance Documentation
Initial Observational Elements
Document craniofacial abnormalities including mandible, maxilla, and nasal structures, as these may indicate underlying genetic or developmental conditions 1
Assess age-appropriate responsiveness to the environment—note whether the patient appears alert, engaged, and interactive versus lethargic or withdrawn 1
Record growth variables including length/height, weight, and occipitofrontal circumference (when age-appropriate) 1
Vital Signs and Physiologic Parameters
Measure and document temperature, pulse, respiratory rate, blood pressure, and oxygen saturation as objective markers of clinical status 1
Note whether heart rate is regular or irregular, as rhythm abnormalities may correlate with the patient's overall appearance of distress 1
Skin and Integumentary Assessment
Describe skin color, perfusion status, and presence of any injuries such as bruising or erythema 1
Document pallor or cyanosis, noting that visible central cyanosis requires ≥5 g/L unsaturated hemoglobin and may indicate serious cardiopulmonary pathology 2
Assess capillary refill time—normal is <2 seconds; prolonged refill suggests inadequate tissue perfusion 2
Facial Cues and Expression
Observe specific facial features including eye position (open versus closed), lip color and position (pale, parted, or droopy), and overall skin tone, as these provide important information about acute illness 3
Note facial expressions characterized by emotional valence—acutely ill patients often appear more sad, less happy, and less surprised 3
Be aware that obvious facial features are frequently missed even by experienced clinicians; systematic observation reduces this risk 4
Body Habitus and Mobility
Calculate and document BMI using the formula: weight in kilograms divided by height in meters squared 1
Assess mobility status: able to walk independently, requires assistive devices (cane, walker), requires wheelchair assistance, or bedridden 1
Document posture and body orientation, as these may reflect pain, respiratory distress, or neurologic impairment 1
Neurologic and Responsiveness Indicators
Evaluate alertness and responsiveness to sound and visual stimuli 1
Assess general muscle tone and symmetry of movement, strength, and reflexes 1
Note pupillary response to light and presence of symmetrical reflexes 1
Common Pitfalls to Avoid
Avoid vague descriptors like "appears well" or "no acute distress" without supporting objective findings—instead, document specific observable features 1, 3
Do not rely on gestalt impressions alone—systematic description reduces change blindness and missed diagnoses 4, 5
Recognize that contextual bias affects observation—clinicians report "seeing" more features when a diagnosis is suggested, which can lead to confirmation bias 4
Document whether the patient "looks older than stated age" only when supported by specific physical findings (skin changes, mobility limitations, cognitive function), as this assessment carries risk of negative bias but may indicate accelerated aging from chronic disease 6
Documentation Strategy
Follow a consistent anatomic sequence (head-to-toe or system-by-system) to ensure thoroughness and reduce the likelihood of overlooking key features 1, 7
Describe findings before interpreting them—this systematic narrative approach reflects methodical clinical reasoning and reduces premature diagnostic closure 7
Use objective, measurable terms whenever possible rather than subjective impressions 1, 3