Head-to-Foot Observation

1. Gait and Approach (Before the Patient Is Seated)

2. Head & Face

• Hair: Premature whitening → pernicious anaemia; thinning/coarseness → myxedema (hypothyroidism); patchy loss → alopecia areata or trichotillomania
• Face: Asymmetry of nasolabial fold or weakness on one side of face → contralateral cerebral hemisphere dysfunction or Bell palsy
• Eyelids: Ptosis (drooping lid) → early myasthenia gravis
• Pupils: Constriction → opioids; dilation → anticholinergics or hallucinogens; fixed dilated + dry skin → atropinism
• Conjunctivae: Injection/redness → alcohol abuse, cannabis, or superior vena cava obstruction
• Jaw/Skull: Large head and jaw → acromegaly
• Scalp wounds: Note and control bleeding (emergency context)
• Facial instability: Assess for potential airway compromise (trauma context)
• Tympanic membrane: Hemotympanum suggests basal skull fracture
• Nose: Epistaxis or septal hematoma
• Teeth/Jaw: Avulsed teeth, jaw instability

3. Neck & Trachea

• Tracheal deviation → tension pneumothorax
• Head tilt: may be adopted to avoid eye contact, but also indicates diplopia, visual field defect, or focal cerebellar dysfunction

4. Posture & Movements (Whole Body)

5. Grooming & Dress

• Unkempt hair, dirty nails, poor dental hygiene → depressive disorders, cognitive disorders
• Clothing mismatches (e.g., mismatched socks/shoes) → cognitive disorder
• Overall appropriateness of clothing to context and weather

6. General Appearance & Nutritional State

• Ill appearance / looseness of clothing → recent weight loss (depression, schizophrenia, GI disease, malignancy, Addison disease, hyperthyroidism)
• Obesity with moon facies, truncal obesity, buffalo hump → Cushing syndrome
• Puffy, bloated appearance → hypothyroidism
• Exophthalmos → hyperthyroidism
• Feminine fat distribution + absent secondary male sex characteristics → Klinefelter syndrome
• Short of breath / coughing → cardiopulmonary disease

7. Skin

8. Chest & Thorax

• Inspect, auscultate, and palpate for: deviated trachea, crepitus (pneumothorax), paradoxical chest wall movement (flail segment)
• Penetrating injuries to chest, back, or flank

9. Abdomen & Pelvis

• Distension and tenderness
• Penetrating abdominal wounds
• Pelvic stability (in trauma: consider pelvic wrap)
• Perineum: lacerations or haematoma
• Urethral meatus: blood (suggests urethral injury)
• Rectal examination: sphincter tone, gross blood

10. Extremities

• Peripheral pulses → vascular compromise
• Deformities, open/closed fractures, dislocations

11. Alertness & Responsiveness

• Drowsiness and inattention → more likely organic brain dysfunction (intrinsic disease or exogenous intoxication) than psychological cause

12. Auditory Observation (Listening)

13. Olfactory Observation (Smell)

Head-to-Foot Observation in Old Age

1. General First Impression

• Does the patient appear their stated age? Ill-health, chronic disease, or poor self-care makes a person appear older than their age.
• Frailty: Look for excess vulnerability — thin limbs, stooped posture, slow movement. Simple bedside tools include:
  • Gait speed (timed walk)
  • Get-up-and-go test (rise from chair, walk, return, sit)
  • Grip strength
  • Calf circumference (reduced = marker of sarcopenia)

2. Gait (Before the Patient Sits Down)

3. Head & Face

• Hair: Thinning and coarseness → hypothyroidism (myxedema); premature whitening → pernicious anaemia; patchy hair loss → alopecia areata or trichotillomania
• Face: Mask-like, expressionless facies → Parkinson disease; asymmetry of nasolabial fold → contralateral hemisphere lesion or Bell palsy
• Eyelids: Ptosis → myasthenia gravis; drooping also common with age
• Eyes: Exophthalmos → hyperthyroidism; sunken eyes → dehydration/malnutrition
• Pupils: Constriction → opioids; dilation → anticholinergics
• Lips/mouth: Lip-smacking and involuntary bucco-facial movements → tardive dyskinesia (prior antipsychotic exposure — important in elderly)
• Head tilt: Diplopia, visual field defect, or focal cerebellar dysfunction

4. Dentition & Oral Hygiene

• Quality of dentition and moist mucous membranes = signs of health and hydration
• Dry mouth → dehydration (common and often under-recognised in elderly)
• Poor dentition → nutritional compromise, difficulty eating

5. Grooming & Hygiene

• Unkempt hair, dirty nails, unwashed appearance → depressive disorder or cognitive impairment (dementia)
• Note: In dementia, the patient may appear well-groomed because of caregiver effort — this does not rule out cognitive decline
• Clothing mismatches or inappropriate dress → cognitive disorder
• Hearing aids and glasses: Note whether present and in use — absence may cause misinterpreted behaviour or apparent "confusion"

6. Posture & Movements

7. Nutritional Status & Body Composition

• Weight loss / loose clothing → malignancy, GI disease, depression, dementia, hyperthyroidism, Addison disease
• Sarcopenia: Loss of muscle bulk, especially in limbs — visible wasting of thigh and calf muscles
• Moon facies + truncal obesity + buffalo hump → Cushing syndrome
• Puffy, bloated face → hypothyroidism
• Exophthalmos → hyperthyroidism (less commonly de novo in old age but may be chronic)

8. Skin

Elder abuse alert: Poor hygiene, unexplained bruising, nervous interaction with an accompanying caregiver, or social withdrawal warrant careful observation and inquiry. — Campbell Walsh Wein Urology

9. Chest & Breathing

• Is the patient breathless at rest or on speaking? → Cardiorespiratory disease
• Barrel chest → COPD (very common in elderly)
• Kyphosis → osteoporosis, vertebral fractures (visible spinal curvature)

10. Abdomen

• Distension → ascites, obstruction, malignancy
• Visible peristalsis in very thin elderly patients may be normal

11. Hands & Upper Limbs

• Grip strength → marker of frailty and sarcopenia
• Clubbing → lung/cardiac/GI disease
• Muscle wasting (thenar, interossei) → peripheral neuropathy, malnutrition
• Dupuytren contracture → common with ageing and alcohol

12. Lower Limbs & Feet (particularly important in geriatric assessment)

• Pedal oedema → heart failure, venous insufficiency, hypoalbuminaemia
• Foot deformities (bunions, hammer toes, calluses) → major cause of falling in the elderly
• Poorly trimmed or fungal-infected toenails → inability to self-care, no access to podiatry
• No socks worn → may indicate hip arthritis or reduced flexibility preventing dressing
• Skin between toes: Inspect for ulcers and poor hygiene, especially in diabetics
• Peripheral pulses: Absent/reduced → peripheral arterial disease (common in elderly)
• Leg ulcers: Venous (medial, shallow, sloughy) vs. arterial (punched-out, painful)

13. Alertness & Cognition (Observed Throughout)

• Drowsiness / inattentiveness → more likely organic (delirium, medication effect, metabolic) than psychological
• Fluctuating mental status → delirium until proven otherwise
• Memory lapses, perseveration, word-finding difficulty → dementia
• Paranoid ideation in elderly → occurs in schizophrenia but also dementia (especially Alzheimer), and delirium

14. Speech & Language

15. Smell

Key Geriatric-Specific Points to Always Check

1. Frailty markers — gait speed, grip strength, get-up-and-go test
2. Foot examination — deformities, ulcers, toenails (a major but overlooked cause of falls and disability)
3. Hearing aids and glasses — presence and use
4. Signs of elder abuse — unexplained injuries, fearfulness, poor hygiene disproportionate to apparent social support
5. Cognitive and affective status — always observe throughout the entire encounter