Once seriousness is ruled out by observation, you have a good look at the “whole” patient. To a beginner, it is a good idea to observe from head to toe. A lot of information can be sought that guide where to focus further observation. Whatever is staring at you may not be missed but concentrate on areas that are not obvious. It is the only way to train our eyes for astute observation. In this article, we will see the importance and contribution of general observation. In this article, Dr. YK Amdekar stresses on obvious abnormalities and some that are often missed, but prudent in diagnosis.

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The first look

It is important to differentiate between acutely sick looking patients from chronically sick looking ones. Patients may also be very comfortable in spite of illness. It is more subjective, but to a trained eye, an acute sick look is easy to differentiate from a chronically sick one.

The entire process of thinking changes with such an observation. The chronically sick patient obviously has an existent disease though often silent or minimally disturbing for a long time, often not reported. A comfortable patient on presentation may suggest either a disease that does not disturb health in general, or it may indicate an acute disease that got controlled by itself or by intervention. An asthmatic attack or an epileptic seizure is a classic example as the patient may look normal once the episode ends.

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Abnormalities that stare at you

Growth

1. It is more relevant in children but also important in adults. A trained eye can judge weight and height within a range of 5-10% of actual measurements. Height once attained cannot go down and hence, a stunted adult signifies a long-standing abnormality. Short or excessively tall stature may lead further to focussed observations to guess the probable cause.
2. Weight is more affected than height in a child with a chronic progressive illness. Head size can also be judged by observation and small or large head size may signify abnormality and it can lead to further specific observation.

Development

This is a measure of functional maturity. Delayed development in a child or mental regression in an adult is obvious to an observer and again leads to further specific observation. Dysmorphic features may be obvious but subtle defects may need thoughtful observation.

Nutritional status

1. Loss of subcutaneous fat suggests calorie deficiency while poor muscle mass and oedema denote protein deficiency.
2. Pallor may be obvious only if severe but palmer creases can evaluate the degree of anaemia.
3. A close look at eyes may show dryness of conjunctiva and cornea along with Bitot’s spots that suggest vitamin A deficiency.
4. Vitamin D deficiency in young children is visible with enlarged epiphysis at wrists and beading of ribs with or without bony deformities.
5. Glossitis and stomatitis indicate vitamin B complex deficiency.

Such deficiency signs give a clue to the probable diagnosis. Morbid obesity is obvious but overweight may be observed with relation to weight for height and apparent waist circumference.

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The following examples would reiterate the importance of general observation.

Case 1

A 6-month-old infant is presented with fever, cold and cough. A general observation revealed a comfortable infant but had dysmorphic features suggestive of Down’s syndrome (Mongolism). There were defects in the child's organs and this observation would help the doctor to evaluate other defects if any, and counsel parents accordingly.

Such children are hypotonic – they have poor muscle tone, are slow to learn, and have cardiac defects that are known as well as other defects which are likely. In fact, such dysmorphic features are obvious to a trained eye at birth itself and parents could be informed about it without making them unduly worried.

Case 2

An 18-month-old child presented with an inability to walk. He started standing just a month ago, though he was able to sit by the age of 8 months. General observation revealed apparently a large head size with frontoparietal bossing, enlarged epiphysis at both the wrists with a protuberant abdomen. He looked otherwise comfortable and had normal mentation.

This suggested vitamin D deficiency. It prompted the doctor to ask detailed eating habits and it was found that this child was mainly consuming milk with very little solid food. He was addicted to drinking milk in a bottle. Thus, besides vitamin D supplements in therapeutic doses, it is important to counsel parents about the need to change feeding practices.

Case 3

A 4-year-old child presented with short stature. A general observation revealed a chronically sick-looking child with poor weight and height, moderately pale, puffy eyelids with normal mentation. It suggested chronic renal dysfunction. It led to measuring the child's blood pressure which was high.

Further, on direct questioning, parents reported recurrent fever episodes treated each time with antibiotics with temporary improvement. It indicated undiagnosed and poorly managed urinary tract infection as the cause of chronic renal dysfunction.

Case 4

An 18-month-old child presented with an inability to speak monosyllables. General observation revealed a hyperactive child moving around without purpose, unaware of the surrounding, would not look each time when called by his name, but occasionally when he would respond to his name, there would be no eye-to-eye contact and he would not sustain his attention.

The general observation indicated features of autism spectrum disorder- hyperactivity, inattention and poor social communication. The hearing must be tested in such a child to confirm normality before embarking on therapy.

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In summary, general observation offers a clue to further enquiry and focussed physical examination in the right direction. It can bring forth issues that parents may not have reported or ignored as not important. It thus paves the way for early diagnosis even before parents realise something is amiss.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.