Although you are verbally quiet during the brief Step 3, you should be very mentally active, thinking about what the information means. Observe the patient for nonverbal cues, reviewed in Chapter 7; for example, depressed facial expressions, arms folded across the chest, toes tapping nervously. Observe also for clues in the following areas that will give additional information about the patient:34,35 (1) Physical characteristics: general health, skin and hair color, odor, deformities, habitus (eg, emaciated and disheveled, “uremic” breath, jaundice, amputated leg, kyphoscoliosis). (2) Autonomic changes: heart rate, skin color, pupil size, skin moisture, skin temperature (eg, rapid pulsation of the carotid artery observed in the neck, handshake reveals cold and moist palms, pupils constricted but then dilate when relaxed, sweating at outset of interview). (3) Accoutrements or accessories: clothing, jewelry, eyeglasses, makeup (eg, expensive suit and jewelry, thick eyeglasses, no makeup or poorly applied makeup). (4) Environment: in the hospital setting, items such as greeting cards, flowers, photographs (eg, several paintings by a grandchild, photograph of spouse, or their absence. (5) Self: becoming aware of your own emotions and reactions to patients in real time is an important clinical skill.36 We cover this topic in detail in Chapter 8 (also see doc.com Module 237).