General survey and physical appearance

General Survey

• Involves the study of the whole person
• Includes general health state and any obvious physical characteristics
• Serves as an introduction for physical examination
• Gives an overall impression of the person
• Launch a general survey the moment you first encounter a patient

General Appearance

• Consists of assessing the apparent state of health
• Consider level of consciousness
• Note any signs of distress
• Skin color and any obvious lesions should be noted
• Dress, grooming and personal hygiene
• Observe Facial expressions
• Note any Odors of the body and breath
• Note posture, gait, and motor activity
• Measure height and weight
• Calculate the BMI

Physical Appearance

• Age: assess if the person appears to be their stated age
• Sex: assess the appropriateness of sexual development for gender and age

Apparent State of Health

• Can be described as frail, ill, fit or robust

Level of Consciousness

• A person is considered conscious when they are alert, oriented, attend to questions, and respond appropriately

Levels of Consciousness

• Alert: Awake and aware
• Verbal Stimuli: Responds to verbal cues
• Painful Stimuli: Only responds to painful stimuli
• Unresponsive: No response to any stimuli

Glasgow Coma Scale

• Used to asses level of consciousness with a score from 1-15, where 15 is best
• Eye opening is scored 1-4, with 4 being "spontaneously"
• Verbal response is scored 1-5, with 5 being "oriented"
• Motor response is scored 1-6, with 6 being "obeys commands"

Signs of Distress

• Includes evidence of cardiac or respiratory distress, pain, anxiety, or depression

Skin Color

• Color tone should be even
• Pigmentation varies according to the genetic background
• Skin is intact with no obvious lesions
• Pallor indicates paleness
• Cyanosis indicates blueish skin
• Jaundice indicates yellowing of the skin
• Bruises are injuries to skin capillaries
• Mottling refers to patchy skin

Dress, Grooming, & Personal Hygiene

• Consider how the patient is dressed
• Look at the hair, fingernails, & use of make-up for clues to patient’s personality, mood, & lifestyle
• Note any body piercings or tattoos

Facial Expression

• Should be observed at rest, during conversation, social interactions & during physical examination
• Changes can indicator health issues such as hyperthyroidism or depression

Odors of Body & Breath

• Can provide important diagnostic clues
• A fruity odor can indicate diabetes
• Can smell alcohol

Posture

• Person stands comfortably erect as appropriate for age
• Toddlers have a normally protuberant abdomen with toddler lordosis, which is normal
• Aging person may be stooped with kyphosis
• A typical posture of a patient with emphysema can be respiratory retractions

Gait

• Assess how the patient walks
• Includes: spastic gait, scissors gait, propulsive gait, steppage gait and waddling gait

Motor Activity

• Tremors
• Paralysis

Height

• Height appears within normal range for age and genetic heritage
• Ex. Turner Syndrome results in shorter than average height

Symmetry

• Body parts look equal bilaterally and are in relative proportion

Nutrition

• Weight appears within normal range for height & body build, body fat distribution even
• Evaluate the body build and contour noting proportions
• Arm span (fingertip to fingertip) equals height
• Body length from crown to pubis roughly equals length from pubis to sole
• Note and obvious physical deformities

Calculating the BMI

• BMI = [weight (lb) * 703] / [height² (in²)]
• OR
• BMI = [weight (kg)] / [height² (m²)]

BMI classifcation (kg/m²)

• Underweight: BMI <18.5
• Normal: BMI 18.5-24.9
• Overweight: BMI 25.0-29.9
• Obesity I: BMI 30.0-34.9
• Obesity II: BMI 35.0-39.9
• Extreme obesity III: BMI ≥40

Measurements

• Waist to hip ratio is used to assess fat distribution, which is an indicator of health risk
• Android obesity refers to obese persons with a greater proportion of fat in upper body, especially in abdomen
• Gynoid obesity refers to obese persons with most of fat in hips & thighs

Vital Signs

• Temperature
• Pulse Rate
• Respiratory Rate
• Blood Pressure

Temperature

• Normal oral temperature for a resting person is 37°C (98.6°F)
• Normal oral temperature ranges from 35.8°C to 37.3°C (96.4°F – 99.1°F)

Oral Temperature

• When using a glass thermometer, shake thermometer down to 35°C (96°F) or below
• Insert it under the tongue, instruct patient to close both lips, and wait 3 – 5 minutes
• Taking temperature can be altered by hot or cold liquids or smoking
• Best to delay measuring for 10 – 15 minutes after

Oral Temperature Contraindications

• Not recommended in patients who are:
  • Unconscious
  • Restless
  • Unable to close their mouths

Other routes to measure temperature

• Rectal temperature is typically 0.4°C – 0.5°C (0.7°F – 1°F) higher than oral temperature
• Axillary temperature is typically 1°C lower than oral
• Rectal temperature should have the patient lie on one side with hip flexed
• Insert rectal thermometer 3cm-4cm, or 1 1/2 inches into the anal canal , in a direction pointing to umbilicus. Remove it after 3 minutes, then read
• Quick, safe and reliable if performed tympanic membrane temperature measures core body temperature, whichis higher than normal oral temperature by 0.8°C (1.4°F)

Pulse Rate

• Stroke volume is the amount of blood every heart beat pumps into aorta
• Palpating peripheral pulse gives rate & rhythm of heartbeat
• With the pads of your index & middle fingers, compress radial artery until a maximal pulsation is detected
• If the rhythm is regular and rate seems normal, count the rate for 1 minute
• If the rate is unusually fast or slow, count it for 60 seconds

Heart Rate

• If the rhythm is irregular and rate should be further evaluated by cardiac auscultation
• Beats that occur earlier than others may not be detected peripherally & heart rate can be seriously underestimated
• Assess pulse for rate, rhythm, and volume
• Rate can be further defined as tachycardia or bradycardia
• Rhythm can be regular or irregular
• Volume can be weak or strong

Respiratory Rate

• Count the number of respirations in 1 minute either by: visual inspection, listening over the patient's trachea with stethoscope
• Normal is 14 – 20 breaths a minute
• Observe for rate, depth, rhythm and effort
• Rate can be normal, rapid, or slow
• Depth can be normal, shallow, or deep
• Rhythm can be regular, or irregular such as Cheyne-Stokes or Kussmaul
• Effort of breathing can be absent or present

Blood Pressure

• Different categories of blood pressure include normal Elevated, stage 1 hypertension, and stage 2 hypertension
• Normal is <120 systolic and <80 diastolic
• Elevated is 120-129 systolic and <80 diastolic
• Stage 1 hypertension is 130-139 systolic, or 80-89 diastolic
• Stage 2 hypertension is ≥140 systolic, or ≥90 diastolic