The General Appearance assessment, often called the General Survey, is the immediate, non-invasive observation a healthcare professional makes upon first encountering a patient. This assessment begins the moment the patient is seen, providing an instantaneous impression of their overall health status, functional capacity, and level of comfort. This initial evaluation is the first step in the physical examination, setting the stage for subsequent assessments. Though based on the clinician’s observation, the process is systematic and relies on standardized categories to ensure consistent communication across the healthcare team.
Key Domains of Observation
A systematic review involves observing several distinct categories to build a comprehensive picture of the patient’s current state.
The apparent state of health is a primary consideration, where the clinician quickly judges if the patient appears well, acutely ill, or chronically ill. This domain includes noting if the patient looks their stated age or appears significantly older, which can suggest chronic disease.
The level of consciousness and mental status is also assessed, noting if the patient is awake, responsive, and engaging appropriately. The clinician observes facial expression, eye contact, and overall demeanor, looking for signs of confusion or inattentiveness.
Posture, gait, and motor activity are observed, assessing how the patient sits, stands, and moves. Findings here can include a shuffling gait, stiffness, or involuntary movements like tremors.
Signs of distress are immediately noted, which can manifest as physical discomfort, anxiety, or difficulty breathing. Obvious signs of pain, such as wincing or a protective body position, are recorded.
Finally, body habitus and nutritional status are assessed through a visual estimation of the patient’s build and weight relative to their height. This indicates whether the patient is well-nourished, underweight, or obese.
Standardized Terminology for Documentation
Translating initial observations into medical documentation requires using specific, standardized terminology that conveys precise meaning to other healthcare providers.
For describing mental status, a common phrase is “Alert and Oriented to Person, Place, and Time” (A&O x3), meaning the patient knows who they are, where they are, and the approximate time. When a patient is not fully alert, specific terms denote decreased consciousness:
- Lethargic: The patient is overly drowsy but can be aroused by moderate verbal or physical stimuli.
- Obtunded: The patient requires repeated, vigorous stimulation to awaken and remains minimally interactive.
- Stuporous: The patient is only briefly aroused by intense, painful stimuli before lapsing back into unresponsiveness.
Signs of physical distress are also described using clear terms. Diaphoresis refers to profuse sweating, suggesting physiological stress or shock. Grimacing or a guarded posture are non-verbal indicators of pain. Respiratory distress is described by visible signs like dyspnea (the sensation of breathlessness) or the use of accessory muscles to assist with breathing.
Terms also describe specific aspects of appearance that suggest underlying conditions:
- Pallor: An unusual paleness of the skin and mucous membranes, often caused by decreased blood flow or low red blood cell count.
- Cyanosis: A bluish discoloration of the skin, lips, or nail beds, signifying insufficient oxygenation.
- Jaundice: A yellowing of the skin and the whites of the eyes (sclera) due to a buildup of bilirubin.
- Cachectic: A state of severe physical wasting and malnutrition, typically seen in patients with terminal illnesses.
Guiding the Clinical Assessment
The description of the patient’s general appearance serves a distinct functional purpose, acting as a roadmap for the subsequent clinical assessment.
The documented observations allow the clinician to prioritize and focus the physical examination. For example, noting respiratory distress directs the clinician to immediately perform a detailed pulmonary and cardiac examination, rather than starting with a general head-to-toe assessment.
This initial impression also establishes a baseline for the patient’s status. Documenting a patient as “well-nourished and in no acute distress” provides a point of comparison for future changes. If the patient is later described as pale and lethargic, the baseline highlights a significant deterioration.
The General Appearance description further assists in formulating the initial differential diagnosis—the list of possible conditions causing the patient’s symptoms. A patient who appears jaundiced suggests conditions affecting the liver or blood, while a distinctive shuffling gait points toward neurological possibilities. This observational summary guides hypothesis generation and directs the diagnostic process.