General survey
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General Survey. Shelley Yeager Instructor DeSales University. Purposes of the General Survey. To give an overall impression, a "gestalt", of the patient. Techniques of Examination . Age. Technique: observe the patient from all angles. Age (cont.). Normal findings:

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General Survey

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General Survey

Shelley Yeager

Instructor

DeSales University


Purposes of the General Survey

  • To give an overall impression, a "gestalt", of the patient


Techniques of Examination


Age

  • Technique:

    • observe the patient from all angles


Age (cont.)

  • Normal findings:

    • patient appears his/her stated age


Age (cont.)

  • Deviations from normal findings:

    • patient's appears older than his/her stated age


Sexual Development

  • Technique:

    • observe the female patient's breast and pubic hair development from all angles and observe the male patient's penis, testes, scrotum, and pubic hair development from all angles


Sexual Development (cont.)

  • Normal findings:

    • Tanner’s stages of breast, penis and scrotum, and pubic hair development


Tanner 1: Breast Development

  • Preadolescent

    • only the nipple is raised above the level of the breast, as in the child


Tanner 2: Breast Development

  • Budding stage

  • Bud-shaped elevation of the areola

  • Areola increased in diameter and surrounding area slightly elevated


Tanner 3: Breast Development

  • Breast and areola enlarged

  • No contour separation


Tanner 4: Breast Development

  • Increasing fat deposits

  • The aerola forms secondary elevation above that of the breast

  • This secondary mound occurs in approximately half of all girls and in some cases persists in adulthood


Tanner 5: Breast Development

  • Adult stage

  • The areola is (usually) part of the general breast contour and is strongly pigmented

  • Nipple projects


Tanner 1: Female Pubic Hair Development

  • Preadolescent

  • No growth of pubic hair


Tanner 2: Female Pubic Hair Development

  • Initial, scarcely pigmented straight hair, especially along the medial border of the labia


Tanner 3: Female Pubic Hair Development

  • Sparse, dark, visibly pigmented curly pubic hair on the labia


Tanner 4: Female Pubic Hair Development

  • Hair coarse and curly

  • Abundant, but less than the adult


Tanner 5: Female Pubic Hair Development

  • Lateral spreading

  • Type and triangle spread of adult hair to medial surface of the thighs


Tanner 6: Female Pubic Hair Development

  • Further extension laterally, upward, or dispersed (occurs in only 10% of women)


Tanner 1: Penis and Scrotum Development

  • Testes, scrotum, and penis are the same size and shape as in the young child


Tanner 2: Penis and Scrotum Development

  • Enlargement of the scrotum and testes

  • The skin of the scrotum becomes redder, thinner, and wrinkled

  • Penis no larger or scarcely so


Tanner 3: Penis and Scrotum Development

  • Enlargement of the penis, especially in length

  • Further enlargement of the testes

  • Descent of the testes into the scrotum


Tanner 4: Penis and Scrotum Development

  • Continued enlargement of the penis and sculpturing of the glans penis

  • Increased pigmentation of the scrotum

  • This stage is sometimes best described as "not quite adult"


Tanner 5: Penis and Scrotum Development

  • Adult stage

  • Scrotum ample

  • Penis reaching nearly to the bottom of the scrotum


Tanner 1: Male Pubic Hair Development

  • Preadolescent

  • No growth of pubic hair

  • That is, hair in pubic area no different from that on the rest of the abdomen


Tanner 2: Male Pubic Hair Development

  • Slightly pigmented, longer, straight hair

  • Usually at the base of the penis

  • Sometimes on the scrotum


Tanner 3: Male Pubic Hair Development

  • Dark, definitely pigmented, curly pubic hair around the base of the penis


Tanner 4: Male Pubic Hair Development

  • Pubic hair definitely adult in type but not in extent (no further than the inguinal fold)


Tanner 5: Male Pubic Hair Development

  • Adult distribution

  • Hair spread to medial surface of thighs, but not upward


Sexual Development

  • Deviations from normal findings:

    • precocious puberty

    • delayed puberty


Level of Consciousness

  • Technique:

    • observe the patient's response to external stimuli


Level of Consciousness (cont.)

  • Normal findings:

    • patient responds immediately to minimal external stimuli


Level of Consciousness (cont.)

  • Deviations from normal findings:

    • lethargic

    • obtunded

    • stuporous

    • comatose


Lethargic

  • Definition

    • patient appears drowsy, but opens his/her eyes and looks at you, respond to your questions, and then falls asleep


Obtunded

  • Definition

    • patient opens his/her eyes and looks at you, but responds slowly to your questions and is somewhat confused

    • alertness and interest in the environment are decreased


Stuporous

  • Definition

    • patient arouses from sleep only after painful stimulus

    • verbal responses are slow or even absent

    • lapses into a unarousable state when the stimuli ceases

    • minimal awareness of the self or the environment


Comatose

  • Definition

    • patient remains unarousable with eyes closed

    • there is no evident response to inner need or external stimuli


Signs of Distress

  • Technique:

    • observe the patient for signs of distress


Signs of Distress (cont.)

  • Normal findings:

    • no visible signs of distress


Signs of Distress (cont.)

  • Deviations from normal findings:

    • signs of distress, e.g.:

      • from cardiopulmonary insufficiency, e.g.:

        • labored breathing, shortness of breath, wheezing, cough

      • from pain, e.g.:

        • wincing, sweating, holding painful part, protectiveness of painful part

      • signs of anxiety, e.g.:

        • anxious face; fidgety movements; cold, moist palms


Stature

  • Technique:

    • observe the patient's stature from all angles


Stature (cont.)

  • Normal findings:

    • height appears within normal range for age, genetic heritage


Stature (cont.)

  • Deviations from normal findings:

    • height appears unusually tall for age, genetic heritage, e.g.:

      • giantism

      • acromegaly (hyerpituitarism)

      • Marfan's syndrome

    • height appears unusually short for age, genetic heritage, e.g.:

      • Turner's syndrome

      • achondroplastic dwarfism

      • hypopituitary dwarfism


Giantism

  • Description

    • excessive growth hormone secretion before closure of bone epiphyses in puberty causing overgrowth of all bones


Acromegaly (Hyerpituitarism)

  • Description

    • excessive growth hormone secretion after closure of bone epiphyses in puberty causing overgrowth of the bones in the face, hands, and feet


Marfan's Syndrome

  • Description

    • connective tissue disorder resulting in a tall, thin stature with long extremities and long, hyperextensible fingers


Turner's Syndrome

  • Description

    • a chromosonal abnormality seen in about 1 in 3000 live female births, characterized by the absence of one X chromosone, congenital ovarian failure, genital hypoplasia, cardiovascular anomalies, short stature, short metacarpals, shield chest, underdeveloped breasts, uterus, and vagina


Achondroplastic Dwarfism

  • Description

    • a genetic abnormality in the ability to convert cartilage to bone resulting in dwarfism characterized by a relatively large head, short stature, short limbs, thoracic kyphosis, prominent lumbar lordosis, and prominent abdominal protrusion


Hypopituitary Dwarfism

  • Description

    • deficiency in growth hormone secretion in childhood characterized by a short stature


Weight

  • Technique:

    • observe the patient's body weight from all angles


Weight (cont.)

  • Normal findings:

    • weight appears within range for height and body stature

    • body fat distribution is even


Weight (cont.)

  • Deviations from normal findings:

    • cachetic

    • exogenous obesity

    • excessive caloric intake

      • e.g., simple obesity

    • even body fat distribution

    • normal muscle strength

    • endogenous obesity

      • excessive secretion of or administration of adrenocorticotropic hormone (ACTH)

        • e.g., Cushing's syndrome

          • centripedal (truncal) obesity

          • fat concentrated in the face, neck, trunk

          • thin extremities

          • decreased muscle strength due to muscle atrophy

          • round (moon) face

          • hirsutism

          • purple abdominal striae (stretch marks)


Body Symmetry

  • Observe the patient's body symmetry from all angles


Body Symmetry (cont.)

  • Normal findings:

    • symmetry in the size and shape of the body parts


Body Symmetry (cont.)

  • Deviations from normal findings:

    • asymmetry in the size and shape of the body parts


Posture

  • Technique:

    • observe the patient's posture from all angles


Posture (cont.)

  • Normal findings:

    • patient stands comfortably erect as appropriate to age

    • normal "plumb line" through anterior ear, shoulder, hip, patella, and ankle

    • lordosis (sway back) and protruberant abdomen in standing toddler

    • kyphosis (hunch back) in the aging person


Posture (cont.)

  • Deviations from normal findings:


Position

  • Technique:

    • observe the patient's position from all angles


Position (cont.)

  • Normal findings:

    • patient sits comfortably in a chair, on the bed, or on the examination table with arms relaxed at sides and head turned toward examiner


Position (cont.)

  • Deviations from normal findings:

    • leaning forward with arms braced on chair arms (tripod position)

      • e.g., chronic pulmonary disease

    • sitting straight up and resisting lying down

      • e.g., left-sided congestive heart failure

    • curled up in a fetal position

      • e.g., acute abdomen


Body Build

  • Technique:

    • observe the patient's body build from all angles


Body Build (cont.)

  • Normal findings:

    • arm span equals height

    • body length from crown to pubis roughly equal to length from pubis to sole

    • mesomorph

    • ectomorph

    • endomorph


Mesomorph

  • Description

    • body build characterized by a predominance of muscle, bone, and connective tissue


Ectomorph

  • Description

    • body build characterized by a slender and fragile physique


Edomorph

  • Description

    • body build characterized by a soft, round physique with a large trunk and thighs, tapering extremities, and an accumulation of fat throughout the body


Body Build (cont.)

  • Deviations from normal findings:

    • Marfan's syndrome


Marfan’s Syndrome

  • Description

    • connective tissue disorder resulting in tall, thin stature with long extremities and long, hyperextensible fingers and an arm span that exceeds height and a pubis to sole measurement that exceeds crown to pubic measurement


Gait

  • Technique:

    • observe the patient's gait from all angles


Gait (cont.)

  • Normal findings:

    • normal pattern of gait

    • gait of old age


Normal Pattern of Gait

  • Head is erect

  • Gaze is straight ahead

  • Vertebral column is upright

  • Feet are a shoulder's width apart

  • Heel strikes the ground before the toe

  • Feet are dorsiflexed in the swing phase


Normal Pattern of Gait

  • Arm opposite the swing-through foot moves forward at the same time

  • Gait is smooth, coordinated, and rhythmic with even weight borne on each foot


Gait (cont.)

  • Deviations from normal findings:

    • abnormal patterns of gait, e.g.:

      • spastic hemiparesis

      • scissors

      • steppage

      • sensory ataxia

      • cerebellar ataxia

      • Parkinsonian

      • gait of old age


Spastic Hemiparesis

  • Associated with corticospinal tract disease, such as with cerebral vascular accident (CVA)


Spastic Hemiparesis (cont.)

  • One arm is held immobile and close to the side, with elbow, wrist, and interphalangeal joints flexed; the leg is extended, with plantar flexion of the foot; on walking, the patient either drags the foot, often scraping the toe, or circles it stiffly outward and forward (circumduction)


Scissors

  • Associated with bilateral spastic paresis of the legs


Scissors (cont.)

  • The gait is stiff; each leg is advanced slowly, and the thighs tend to cross forward on each other at each step; the steps are short; the patient appears to be walking through water


Steppage

  • Associated with foot drop, usually secondary to lower motor neuron disease


Steppage (cont.)

  • The patient either drags his/her feet or lifts them high, with knees flexed, and brings them down with a slap onto the floor, thus appearing to the walking up stairs; the patient is unable to walk on his/her heels; the steppage gait may involve one or both sides


Sensory Ataxia

  • Associated with the loss of position sense in the legs, as from polyneuropathy or posterior column damage


Sensory Ataxia (cont.)

  • The gait is unsteady and wide based (with feet wide apart); the patient throws his/her feet forward and outward and brings them down, first on the heels and then on the toes, with a double tapping sound; the patient watches the ground for guidance while walking; with the eyes closed, the patient cannot stand steadily with feet together (a positive Romberg sign) and the staggering gait worsens


Cerebellar Ataxia

  • Associated with disease of the cerebellum or associated tracts


Cerebellar Ataxia (cont.)

  • The gait is staggering, unsteady, and wide based, with exaggerated difficulty on turns; these patients cannot stand steadily with their feet together, whether their eyes are open or closed


Parkinsonian

  • Associated with the basal ganglia defects of Parkinson's disease


Parkinsonian (cont.)

  • The posture is stooped, with the head and neck forward and hips and knees slightly flexed; the arms are flexed at the elbows and wrists; the patient is slow getting started; steps are short and often shuffling; arm swings are decreased and the patient turns around stiffly - "all in one piece"


Gait of Old Age

  • The aging process


Gait of Old Age (cont.)

  • Speed, balance, and grace decrease with aging; steps become short, uncertain, and even shuffling; the legs may be flexed at the hips and knees; a cane may bolster lost confidence


Involuntary Movements

  • Technique:

    • observe the patient for involuntary movements from all angles


Normal findings:

absence of involuntary movements

Involuntary Movements (cont.)


Involuntary Movements (cont.)

  • Deviations from normal findings:

    • tics

    • tremors

    • seizures


Facial Expression

  • Technique:

    • observe the patient's facial expression from all angles


Facial Expression (cont.)

  • Normal findings:

    • maintains eye contact (unless a cultural taboo)

    • expressions are appropriate to the situation


Facial Expression (cont.)

  • Deviations from normal findings:

    • flat

    • depressed

    • angry

    • sad

    • anxious


Mood and Affect

  • Technique:

    • observe the patient's mood and affect from all angles


Mood and Affect (cont.)

  • Normal findings:

    • comfortable and cooperative with the examiner


Mood and Affect (cont.)

  • Deviations from normal findings:

    • hostile

    • distrustful

    • suspicious

    • crying


Speech

  • Normal findings:

    • articulation is clear and understandable

    • stream of talking is fluent with an even pace

    • conveys ideas clearly

    • word choice is appropriate to culture and education

    • communicates in prevailing language easily by him/herself or with an interpreter


Speech (cont.)

  • Deviations from normal findings:

    • dysarthria

    • dysphagia

    • speech defect

    • monotone

    • garbled speech

    • extremes of few word or constant talking


Dress

  • Technique:

    • observe the patient's dress from all angles


Normal findings:

well fitting clothes

clothes look clean

clothes are appropriate for the season and temperature

clothes are appropriate to the person's culture and age group

Dress (cont.)


Dress (cont.)

  • Deviations from normal findings:

    • ill fitting clothes

    • clothes look unclean

    • clothes are inappropriate for the season and temperature

    • consistent wearing of certain clothes, e.g.:

      • long sleeves to cover needle marks of drug abuse


Grooming and Personal Hygiene

  • Technique:

    • observe the patient's grooming and personal hygiene from all angles


Grooming and Personal Hygiene (cont.)

  • Normal findings:

    • clothes

      • clothes look clean

      • clothes are properly buttoned and zipped

    • shoes

      • intact

      • laces tied

    • clothes are appropriate for age, occupation, and socioeconomic group

    • hair

      • clean

      • groomed

    • nails

      • clean

      • groomed


Grooming and Personal Hygiene (cont.)

  • Deviations from normal findings:

    • clothes

      • clothes look unclean

      • clothes are improperly buttoned and zipped

    • shoes

      • have holes

      • laces untied

      • wearing slippers

    • clothes are inappropriate for age, occupation, and socioeconomic group

    • hair

      • unclean

      • poorly groomed

    • nails

      • unclean

      • poorly groomed


Odors of Body or Breath

  • Normal findings:

    • absence of odors of the body and breath


Odors of Body or Breath (cont.)

  • Deviations from normal findings:

    • foul breath

    • alcohol on the breath

    • body odor


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