Sichtbefund

Sichtbefund is a term used in medical language to describe the objective findings that are visible to the clinician during a physical examination. It represents what can be observed by sight and simple inspection without invasive procedures, aided by lighting and basic examination tools. The Sichtbefund forms part of the clinical assessment and provides a snapshot of the patient’s current condition.

During the Sichtbefund, the clinician observes several areas, including general appearance (level of distress, nutrition, hydration), skin and integument (color, moisture, lesions, scars), head and neck (symmetry, edema, lymph nodes), and other visible signs such as posture, gait, or signs of pain. The examination may also note observable abnormalities in the eyes, respiratory effort, or other externally detectable cues. The findings are documented as objective data that can be verified by others.

The Sichtbefund is intended to complement other components of the physical examination, such as palpation, percussion, and auscultation, which assess internal structures and functions. It is particularly important in rapid assessments, triage, and initial rounds, where visible signs can guide further diagnostic steps and urgent management. However, it has limitations: it only captures what is observable, is influenced by lighting and observer experience, and cannot reveal deeper pathology that requires instruments, imaging, or laboratory tests.

Documentation typically uses concise, standardized language (for example, “appears well,” “skin warm and dry,” “pupils equal and reactive”). In German medical practice, the Sichtbefund is often reported as part of the overall Klinischer Befund and contrasted with findings obtained by palpation, auscultation, and additional tests.