Chapter 2:	Patient Observation
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The RCPs observational skills are called upon to evaluate the patient’s general appearance, starting with looking for obvious abnormalities in the patient’s:

• Skin: Observation begins with the skin and mucus membrane color, which indicates oxygenation. If the lips or nail beds have orange, green, or yellow tints, the patient may have impaired liver function. Flushed skin indicates either a fever or high blood pressure. Anemic patients have very pale skin, and diaphoresis (sweating) can be caused by an increase in sympathetic discharge or increased workload of breathing.

The RCP should also look for evidence of cyanosis. Cyanosis is a bluish tint of the skin and mucus membranes due to reduced hemoglobin in the subpapillary venous plexus. The amount of reduced hemoglobin depends on the hemoglobin concentration and oxygen saturation. This nonspecific symptom is related to either hypoxemia or decreased perfusion. Detecting cyanosis is often made difficult by available lighting and the patient’s normal skin color. Cyanosis becomes visible to most observers when the amount of reduced hemoglobin in the capillary blood exceed 5 to 6 g/dL. This may be due to a reduction in either arterial or venous oxygen content or both. When the arterial hemoglobin saturation drops to 75% or less, most observers see cyanosis in the mucous membranes of the lips and mouth, as well as the fingers.

• Face, Head and Neck: See if the patient’s face pale is or flushed, scarred, swollen, or flabby. Patient distress (respiratory distress, cyanosis, or plethora) can be estimated from their facial expressions. Head size, shape, contour, and symmetry are all important to take note of. Also see if there seems to be any tenderness over sinuses or mastoids. Any bruits. Observe any rigidity or limitation of motion in the patient’s neck. Note abnormal pulsation, scars masses, enlarged salivary glands, or lymph nodes. Describe the thyroid gland, position of trachea, and note carotid and jugular pulses. Jugular venous distension is often due to congestive heart failure, and distention of the jugular veins during expiration can be due to severe obstructive lung disease.

• Ear, Nose, Mouth, and Throat: Check hearing acuity, noting any discharge from the ears, and briefly describe condition of ear drums. Note nasal airway obstructions, septal deviation, discharge, condition of mucosa, and polyps. Check breath odor, color and appearance of lips, tongue, gums condition of teeth, dentures, appearance of mucosa. Describe the palate, uvula, tonsils, and posterior pharynx when indicated, and record findings of examination of nasopharynx and larynx. Check for difficulty with a sore throat, hoarseness, speech defect, difficulty swallowing, or tonsillitis.

• Eyes: Respiratory distress can affect the patient’s pupils. Pupillary size can be affected by cerebral oxygenation, and indirectly by cardiac output.



• Hands and Ankles: Clubbing is a painless, uniform enlargement of the terminal segment of a finger or toe, and is indicative of dilating peripheral vessels and in increase in subcutaneous tissue as a compensatory mechanism for chronic, severe hypoxemia. In this condition a change in the angle between the nail and proximal skin to 180° or greater occurs. In the early stages it’s difficult to diagnose, but in its later stages diagnosis is relatively easy. The normal angle is 160° to 165° for fingers, and 175° for thumbs. Clubbing is said to be present if the hyponychial angle is increased more than 187° to 209° . Ankle edema is important to note because it indicates the possibility of venous return, peripheral vascular disease, fluid overload, and even heart disease.