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Spotting subtle signs that point to big problems

Vol. 1, No. 7 / July 2002

When training residents to perform the mental status examination, I ask them such questions as “What color are the patient’s shoes?” Too often, in their haste to describe the patient’s ability to spell “world” backwards, they miss the obvious. Board certification examinees also tend to not see a patient’s well-healed wrist scars or facial droop.

Head-to-toe observation of a patient may uncover an undisclosed disorder, condition, or life situation that could affect treatment. Here’s what I look for at the first evaluation:

As the patient enters the room Observe the gait for a limp, shuffle, or other classic signs of illness or injury. Is there evidence of Parkinson’s disease (stooped posture, slow to get started, decreased arm swing, slow to turn)? Is the patient steady on his or her feet? (If not, sensory or cerebellar ataxia may be present.) Is there a foot drop (lower motor neuron disease)? Do the patient’s shoes drag or scrape (spastic hemiparesis from a prior stroke)?

The head Note the quantity and distribution of hair. Is it combed or brushed (ability to care for self, hemineglect)? Is there evidence of unusual hair loss (trichotillomania, hypothyroidism, lupus, side effects from medications)? Any scarring on the scalp (accidental or intentionally-inflicted trauma) or general skull deformities (enlarged in hydrocephalus, Paget’s disease)? Are the ears low-set (fragile X syndrome, other congenital diseases)? Any scarring on the ears (past trauma)?

The face Is there acne (Cushing’s syndrome, ovarian dysfunction, reaction to lithium), telangiectasias (acne rosacea, lupus), or hypopigmentation? Vitiligo may reveal an autoimmune disorder. Hyperpigmentation may point to metastatic melanoma, drug abuse, or endocrinopathies such as Addison’s disease or ectopic ACTH syndrome.

Are there facial scars or bruising (abuse)? Any evidence of characteristic facies (acromegaly, Parkinson’s or Cushing’s disease)? Are the parotid glands enlarged (eating disorders, diabetes, cirrhosis)? Any tics or stereotypies (drug abuse, Tourette’s syndrome)? Does the facial expression match what the patient is saying? Psychologic defense mechanisms may be at work or even malingering.

The mouth Any lip sores (sexually transmitted diseases), angular stomatitis (vitamin deficiencies), or bad dentition (drug abuse, age-related dementia, homelessness)?

The eyes Does the patient make normal eye contact? Is he or she wearing dark glasses (depression, posttraumatic stress disorder, drug abuse)? Is gaze palsy (head injuries, Wernicke’s syndrome) or icterus (hepatic disease) present? Are the sclera discolored or bloodshot (alcohol withdrawal, marijuana abuse)? Are the pupils dilated (atropine, mushroom abuse) or pinpoint (opioid use)?

The neck Any thyroid enlargement (goiter), tracheostomy scar (past trauma or suicide attempt), or inspiratory contraction of sternomastoid muscles (pulmonary disease)? Any evidence of dystonia (neuroleptic malignant syndrome or neuroleptic-induced dystonia)?

Hands and arms Are there overt scars (past trauma, self-mutilation, suicide attempts) or bruising (abuse)? Are the fingernails appropriately maintained? Any evidence of clubbing (cardiopulmonary disease, GI inflammation, cirrhosis) or tremor (alcohol or other drug withdrawal, Parkinsonism, cerebellar infarct)? Even the presence of tattoos, a wedding band, or other jewelry can speak volumes about the patient’s stability. A tattoo can be a form of self-mutilation, while pendants and charms may offer clues to the patient’s spiritual beliefs.

Clothing Is the clothing clean and well maintained, or are buttons and zippers inappropriately fastened (dementia)? Is the clothing not age-appropriate (personality disorders), overtly drab and dark (depression), or outlandish (mania)? Is it not seasonable (homelessness, dementia)?

Dr. Benzick is a staff psychiatrist, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas, and an associate professor of psychiatry, University of Texas Health Sciences Center at San Antonio.

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