General Survey

1
General Survey

• Shelley Yeager
• Instructor
• DeSales University

2
Purposes of the General Survey

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

3
Techniques of Examination
4
Age

• Technique
• observe the patient from all angles

5
Age (cont.)

• Normal findings
• patient appears his/her stated age

6
Age (cont.)

• Deviations from normal findings
• patient's appears older than his/her stated age

7
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

8
Sexual Development (cont.)

• Normal findings
• Tanners stages of breast, penis and scrotum, and
  pubic hair development

9
Tanner 1 Breast Development

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

10
Tanner 2 Breast Development

• Budding stage
• Bud-shaped elevation of the areola
• Areola increased in diameter and surrounding area
  slightly elevated

11
Tanner 3 Breast Development

• Breast and areola enlarged
• No contour separation

12
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

13
Tanner 5 Breast Development

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

14
Tanner 1 Female Pubic Hair Development

• Preadolescent
• No growth of pubic hair

15
Tanner 2 Female Pubic Hair Development

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

16
Tanner 3 Female Pubic Hair Development

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

17
Tanner 4 Female Pubic Hair Development

• Hair coarse and curly
• Abundant, but less than the adult

18
Tanner 5 Female Pubic Hair Development

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

19
Tanner 6 Female Pubic Hair Development

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

20
Tanner 1 Penis and Scrotum Development

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

21
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

22
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

23
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"

24
Tanner 5 Penis and Scrotum Development

• Adult stage
• Scrotum ample
• Penis reaching nearly to the bottom of the
  scrotum

25
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

26
Tanner 2 Male Pubic Hair Development

• Slightly pigmented, longer, straight hair
• Usually at the base of the penis
• Sometimes on the scrotum

27
Tanner 3 Male Pubic Hair Development

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

28
Tanner 4 Male Pubic Hair Development

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

29
Tanner 5 Male Pubic Hair Development

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

30
Sexual Development

• Deviations from normal findings
• precocious puberty
• delayed puberty

31
Level of Consciousness

• Technique
• observe the patient's response to external
  stimuli

32
Level of Consciousness (cont.)

• Normal findings
• patient responds immediately to minimal external
  stimuli

33
Level of Consciousness (cont.)

• Deviations from normal findings
• lethargic
• obtunded
• stuporous
• comatose

34
Lethargic

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

35
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

36
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

37
Comatose

• Definition
• patient remains unarousable with eyes closed
• there is no evident response to inner need or
  external stimuli

38
Signs of Distress

• Technique
• observe the patient for signs of distress

39
Signs of Distress (cont.)

• Normal findings
• no visible signs of distress

40
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

41
Stature

• Technique
• observe the patient's stature from all angles

42
Stature (cont.)

• Normal findings
• height appears within normal range for age,
  genetic heritage

43
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

44
Giantism

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

45
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

46
Marfan's Syndrome

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

47
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

48
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

49
Hypopituitary Dwarfism

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

50
Weight

• Technique
• observe the patient's body weight from all angles

51
Weight (cont.)

• Normal findings
• weight appears within range for height and body
  stature
• body fat distribution is even

52
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)

53
Body Symmetry

• Observe the patient's body symmetry from all
  angles

54
Body Symmetry (cont.)

• Normal findings
• symmetry in the size and shape of the body parts

55
Body Symmetry (cont.)

• Deviations from normal findings
• asymmetry in the size and shape of the body parts

56
Posture

• Technique
• observe the patient's posture from all angles

57
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

58
Posture (cont.)

• Deviations from normal findings

59
Position

• Technique
• observe the patient's position from all angles

60
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

61
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

62
Body Build

• Technique
• observe the patient's body build from all angles

63
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

64
Mesomorph

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

65
Ectomorph

• Description
• body build characterized by a slender and fragile
  physique

66
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

67
Body Build (cont.)

• Deviations from normal findings
• Marfan's syndrome

68
Marfans 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

69
Gait

• Technique
• observe the patient's gait from all angles

70
Gait (cont.)

• Normal findings
• normal pattern of gait
• gait of old age

71
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

72
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

73
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

74
Spastic Hemiparesis

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

75
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)

76
Scissors

• Associated with bilateral spastic paresis of the
  legs

77
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

78
Steppage

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

79
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

80
Sensory Ataxia

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

81
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

82
Cerebellar Ataxia

• Associated with disease of the cerebellum or
  associated tracts

83
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

84
Parkinsonian

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

85
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"

86
Gait of Old Age

• The aging process

87
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

88
Involuntary Movements

• Technique
• observe the patient for involuntary movements
  from all angles

89
Involuntary Movements (cont.)

• Normal findings
• absence of involuntary movements

90
Involuntary Movements (cont.)

• Deviations from normal findings
• tics
• tremors
• seizures

91
Facial Expression

• Technique
• observe the patient's facial expression from all
  angles

92
Facial Expression (cont.)

• Normal findings
• maintains eye contact (unless a cultural taboo)
• expressions are appropriate to the situation

93
Facial Expression (cont.)

• Deviations from normal findings
• flat
• depressed
• angry
• sad
• anxious

94
Mood and Affect

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

95
Mood and Affect (cont.)

• Normal findings
• comfortable and cooperative with the examiner

96
Mood and Affect (cont.)

• Deviations from normal findings
• hostile
• distrustful
• suspicious
• crying

97
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

98
Speech (cont.)

• Deviations from normal findings
• dysarthria
• dysphagia
• speech defect
• monotone
• garbled speech
• extremes of few word or constant talking

99
Dress

• Technique
• observe the patient's dress from all angles

100
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

101
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

102
Grooming and Personal Hygiene

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

103
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

104
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

105
Odors of Body or Breath

• Normal findings
• absence of odors of the body and breath

106
Odors of Body or Breath (cont.)

• Deviations from normal findings
• foul breath
• alcohol on the breath
• body odor