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

General Survey

Shelley Yeager

Instructor

DeSales University


Purposes of the general survey

Purposes of the General Survey

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


Techniques of examination

Techniques of Examination


General survey

Age

  • Technique:

    • observe the patient from all angles


Age cont

Age (cont.)

  • Normal findings:

    • patient appears his/her stated age


Age cont1

Age (cont.)

  • Deviations from normal findings:

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


Sexual development

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

Sexual Development (cont.)

  • Normal findings:

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


Tanner 1 breast 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

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

Tanner 3: Breast Development

  • Breast and areola enlarged

  • No contour separation


Tanner 4 breast development

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

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

Tanner 1: Female Pubic Hair Development

  • Preadolescent

  • No growth of pubic hair


Tanner 2 female pubic hair development

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

Tanner 3: Female Pubic Hair Development

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


Tanner 4 female pubic hair development

Tanner 4: Female Pubic Hair Development

  • Hair coarse and curly

  • Abundant, but less than the adult


Tanner 5 female pubic hair development

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

Tanner 6: Female Pubic Hair Development

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


Tanner 1 penis and scrotum development

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

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

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

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

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

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

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

Tanner 3: Male Pubic Hair Development

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


Tanner 4 male pubic hair development

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

Tanner 5: Male Pubic Hair Development

  • Adult distribution

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


Sexual development1

Sexual Development

  • Deviations from normal findings:

    • precocious puberty

    • delayed puberty


Level of consciousness

Level of Consciousness

  • Technique:

    • observe the patient's response to external stimuli


Level of consciousness cont

Level of Consciousness (cont.)

  • Normal findings:

    • patient responds immediately to minimal external stimuli


Level of consciousness cont1

Level of Consciousness (cont.)

  • Deviations from normal findings:

    • lethargic

    • obtunded

    • stuporous

    • comatose


Lethargic

Lethargic

  • Definition

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


Obtunded

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

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

Comatose

  • Definition

    • patient remains unarousable with eyes closed

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


Signs of distress

Signs of Distress

  • Technique:

    • observe the patient for signs of distress


Signs of distress cont

Signs of Distress (cont.)

  • Normal findings:

    • no visible signs of distress


Signs of distress cont1

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

Stature

  • Technique:

    • observe the patient's stature from all angles


Stature cont

Stature (cont.)

  • Normal findings:

    • height appears within normal range for age, genetic heritage


Stature cont1

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

Giantism

  • Description

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


Acromegaly hyerpituitarism

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

Marfan's Syndrome

  • Description

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


Turner s syndrome

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

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


Hy popituitary dwarfism

Hypopituitary Dwarfism

  • Description

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


Weight

Weight

  • Technique:

    • observe the patient's body weight from all angles


Weight cont

Weight (cont.)

  • Normal findings:

    • weight appears within range for height and body stature

    • body fat distribution is even


Weight cont1

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

Body Symmetry

  • Observe the patient's body symmetry from all angles


Body symmetry cont

Body Symmetry (cont.)

  • Normal findings:

    • symmetry in the size and shape of the body parts


Body symmetry cont1

Body Symmetry (cont.)

  • Deviations from normal findings:

    • asymmetry in the size and shape of the body parts


Posture

Posture

  • Technique:

    • observe the patient's posture from all angles


Posture cont

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 cont1

Posture (cont.)

  • Deviations from normal findings:


Position

Position

  • Technique:

    • observe the patient's position from all angles


Position cont

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 cont1

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

Body Build

  • Technique:

    • observe the patient's body build from all angles


Body build cont

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

Mesomorph

  • Description

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


Ectomorph

Ectomorph

  • Description

    • body build characterized by a slender and fragile physique


Edomorph

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 cont1

Body Build (cont.)

  • Deviations from normal findings:

    • Marfan's syndrome


Marfan s syndrome1

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


General survey

Gait

  • Technique:

    • observe the patient's gait from all angles


Gait cont

Gait (cont.)

  • Normal findings:

    • normal pattern of gait

    • gait of old age


Normal pattern of gait

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 gait1

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 cont1

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

Spastic Hemiparesis

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


Spastic hemiparesis cont

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

Scissors

  • Associated with bilateral spastic paresis of the legs


Scissors cont

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

Steppage

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


Steppage cont

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

Sensory Ataxia

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


Sensory ataxia cont

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

Cerebellar Ataxia

  • Associated with disease of the cerebellum or associated tracts


Cerebellar ataxia cont

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

Parkinsonian

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


Parkinsonian cont

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

Gait of Old Age

  • The aging process


Gait of old age cont

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

Involuntary Movements

  • Technique:

    • observe the patient for involuntary movements from all angles


Involuntary movements cont

Normal findings:

absence of involuntary movements

Involuntary Movements (cont.)


Involuntary movements cont1

Involuntary Movements (cont.)

  • Deviations from normal findings:

    • tics

    • tremors

    • seizures


Facial expression

Facial Expression

  • Technique:

    • observe the patient's facial expression from all angles


Facial expression cont

Facial Expression (cont.)

  • Normal findings:

    • maintains eye contact (unless a cultural taboo)

    • expressions are appropriate to the situation


Facial expression cont1

Facial Expression (cont.)

  • Deviations from normal findings:

    • flat

    • depressed

    • angry

    • sad

    • anxious


Mood and affect

Mood and Affect

  • Technique:

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


Mood and affect cont

Mood and Affect (cont.)

  • Normal findings:

    • comfortable and cooperative with the examiner


Mood and affect cont1

Mood and Affect (cont.)

  • Deviations from normal findings:

    • hostile

    • distrustful

    • suspicious

    • crying


Speech

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

Speech (cont.)

  • Deviations from normal findings:

    • dysarthria

    • dysphagia

    • speech defect

    • monotone

    • garbled speech

    • extremes of few word or constant talking


Dress

Dress

  • Technique:

    • observe the patient's dress from all angles


Dress cont

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 cont1

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

Grooming and Personal Hygiene

  • Technique:

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


Grooming and personal hygiene cont

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 cont1

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

Odors of Body or Breath

  • Normal findings:

    • absence of odors of the body and breath


Odors of body or breath cont

Odors of Body or Breath (cont.)

  • Deviations from normal findings:

    • foul breath

    • alcohol on the breath

    • body odor


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