General Appearance, Facies, and Body Habitus

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Chapter 1 General Appearance, Facies, and Body Habitus

General Appearance

A. Posture

3 What information can be obtained from observing the patient’s posture?

In abdominal pain the posture is often so typical as to localize the disease:

image Patients with pancreatitis usually lie in the fetal position: on one side, with knees and legs bent over.

image Patients with peritonitis are very still and avoid any movement that might worsen the pain.

image Patients with intestinal obstruction are instead quite restless.

image Patients with renal or perirenal abscesses bend toward the side of the lesion.

image Patients who lie supine, with one knee flexed and the hip externally rotated, are said to have the “psoas sign.” This reflects either a local abnormality around the iliopsoas muscle (such as an inflamed appendix, diverticulum, or terminal ileum from Crohn’s disease) or inflammation of the muscle itself. In the olden days, the latter was due to a tuberculous abscess, originating in the spine and spreading down along the muscle. Such processes were referred to as “cold abscesses” because they had neither warmth nor other signs of inflammation. Now, the most common cause of a “psoas sign” is intramuscular bleeding from anticoagulation.

image Patients with meningitis lie like patients with pancreatitis: on the side, with neck extended, thighs flexed at the hips, and legs bent at the knees—juxtaposed like the two bores of a double-barreled rifle.

image Patients with a large pleural effusion tend to lie on the affected side to maximize excursions of the unaffected side. This, however, worsens hypoxemia (see Chapter 13, questions 48–51).

image Patients with a small pleural effusion lie instead on the unaffected side (because direct pressure would otherwise worsen the pleuritic pain).

image Patients with a large pericardial effusion (especially tamponade) sit up in bed and lean forward, in a posture often referred to as “the praying Muslim position.” Neck veins are greatly distended.

image Patients with tetralogy of Fallot often assume a squatting position, especially when trying to resolve cyanotic spells—such as after exercise.

B. State of Hydration

C. State of Nutrition

38 How important is the distribution of body fat?

Very important, since it strongly determines the impact of obesity on health. Fat deposition may be central (mostly in the trunk) or peripheral (mostly in the extremities) (Fig. 1-1).

Men tend to have central obesity, whereas women have peripheral obesity. Upper and central body fat distribution (especially if intra-abdominal rather than subcutaneous) is a greater predictor of insulin resistance and cardiovascular risk than BMI alone. It also has higher association with hypertension, diabetes, atherosclerotic cardiovascular diseases, and other chronic metabolic conditions (metabolic syndrome). For example, a waist-to-hip ratio ≥1.0 is considered an “at risk” indicator for both men and women, confirming that an apple shape (extra weight around the stomach) is more dangerous than a pear shape (extra weight around hips or thighs). Subjects judged to be lean by BMI alone may be very insulin resistant if their body fat is centrally distributed.