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Lecture Notes

General Survey

  1. purposes
    1. to give an overall impression, a "gestalt", of the patient
  2. techniques of examination
    1. age
      1. observe the patient from all angles
      2. normal findings
        1. patient's appears his/her stated age
      3. deviations from normal findings
        1. patient's appears older than his/her stated age
    2. sexual development
      1. 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
      2. normal findings:
        1. Tanner's scale of sexual maturity
          1. females
            1. breast development
              1. Tanner 1
                1. preadolescent
                2. only the nipple is raised above the level of the breast, as in the child
              2. Tanner 2
                1. budding stage
                2. bud-shaped elevation of the areola
                3. areola increased in diameter and surrounding area slightly elevated
              3. Tanner 3
                1. breast and areola enlarged
                2. no contour separation
              4. Tanner 4
                1. increasing fat deposits
                2. the aerola forms secondary elevation above that of the breast
                3. this secondary mound occurs in approximately half of all girls and in some cases persists in adulthood
              5. Tanner 5
                1. adult stage
                2. the areola is (usually) part of the general breast contour and is strongly pigmented
                3. nipple projects
            2. pubic hair development
              1. Tanner 1
                1. preadolescent
                2. no growth of pubic hair
              2. Tanner 2
                1. initial, scarcely pigmented straight hair, especially along the medial border of the labia
              3. Tanner 3
                1. sparse, dark, visibly pigmented curly pubic hair on the labia
              4. Tanner 4
                1. hair coarse and curly
                2. abundant, but less than the adult
              5. Tanner 5
                1. lateral spreading
                2. type and triangle spread of adult hair to medial surface of the thighs
              6. Tanner 6
                1. further extension laterally, upward, or dispersed (occurs in only 10% of women)
          2. males
            1. penis and scrotum development
              1. Tanner 1
                1. testes, scrotum, and penis are the same size and shape as in the young child
              2. Tanner 2
                1. enlargement of the scrotum and testes
                2. the skin of the scrotum becomes redder, thinner, and wrinkled
                3. penis no larger or scarcely so
              3. Tanner 3
                1. enlargement of the penis, especially in length
                2. further enlargement of the testes
                3. descent of the testes into the scrotum
              4. Tanner 4
                1. continued enlargement of the penis and sculpturing of the glans penis
                2. increased pigmentation of the scrotum
                3. this stage is sometimes best described as "not quite adult"
              5. Tanner 5
                1. adult stage
                2. scrotum ample
                3. penis reaching nearly to the bottom of the scrotum
            2. pubic hair development
              1. Tanner 1
                1. preadolescent
                2. no growth of pubic hair
                3. that is, hair in pubic area no different from that on the rest of the abdomen
              2. Tanner 2
                1. slightly pigmented, longer, straight hair
                2. usually at the base of the penis
                3. sometimes on the scrotum
              3. Tanner 3
                1. dark, definitely pigmented, curly pubic hair around the base of the penis
              4. Tanner 4
                1. pubic hair defintely adult in type but not in extent (no further than the inguinal fold)
              5. Tanner 5
                1. adult distribution
                2. hair spread to medial surface of thighs, but not upward
      3. deviations from normal findings:
        1. precocious puberty
        2. delayed puberty
    3. level of consciousness
      1. observe the patient's response to external stimuli
      2. normal findings:
        1. patient responds immediately to minimal external stimuli
      3. deviations from normal findings:
        1. lethargic
          1. patient appears drowsy, but opens his/her eyes and looks at you, respond to your questions, and then falls asleep
        2. obtunded
          1. patient opens his/her eyes and looks at you, but responds slowly to your questions and is somewhat confused
          2. alertness and interest in the environment are decreased
        3. stuporous
          1. patient arouses from sleep only after painful stimulus
          2. verbal responses are slow or even absent
          3. lapses into a unarousable state when the stimuli ceases
          4. minimal awareness of the self or the environment
        4. comatose
          1. patient remains unarousable with eyes closed
          2. there is no evident repsonse to inner need or external stimuli
    4. signs of distress
      1. observe the patient for signs of distress
      2. normal findings:
        1. no visible signs of distress
      3. deviations from normal findings:
        1. signs of distress, e.g.:
          1. from cardiopulmonary insufficiency
            1. e.g, labored breathing, shortness of breath, wheezing, cough
          2. from pain
            1. e.g, wincing, sweating, holding painful part, protectiveness of painful part
        2. signs of anxiety
          1. e.g., anxious face; fidgety movements; cold, moist palms
    5. stature
      1. observe the patient's stature from all angles
      2. normal findings:
        1. height appears within normal range for age, genetic heritage
      3. deviations from normal findings:
        1. height appears unusally tall for age, genetic heritage
          1. giantism
            1. excessive growth hormone secretion before closure of bone epiphyses in puberty causing overgrowth of all bones
          1. acromegaly (hyerpituitarism)
            1. excessive growth hormone secretion after closure of bone epiphyses in puberty causing overgrowth of the bones in the face, hands, and feet
          1. Marfan's syndrome
            1. connective tissue disorder resulting in a tall, thin stature with long extremities and long, hyperextensible fingers
        2. height appears unusually short for age, genetic heritage
          1. Turner's syndrome
            1. 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
          1. achondroplastic dwarfism
            1. 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
          2. hypopituitary dwarfism
            1. deficiency in growth hormone secretion in childhood characterized by a short stature
    6. weight
      1. observe the patient's body weight from all angles
      2. normal findings:
        1. weight appears within range for height and body stature
        2. body fat distribution is even
      3. deviations from normal findings:
        1. cachetic
        2. exogenous obesity
          1. excessive caloric intake
            1. e.g., simple obesity
              1. even body fat distribution
              2. normal muscle strength
        3. endogenous obesity
          1. excessive secretion of or administration of adrenocorticotropic hormone (ACTH)
            1. e.g., Cushing's syndrome
              1. centripedal (truncal) obesity
                1. fat concentrated in the face, neck, trunk
                2. thin extremities
                3. decreased muscle strength due to muscle atrophy
                4. round (moon) face
                5. hirsutism
                6. purple abdominal striae (stretch marks)
    7. body symmetry
      1. observe the patient's body symmetry from all angles
      2. normal findings:
        1. symmetry in the size and shape of the body parts
      3. deviations from normal findings:
        1. asymmetry in the size and shape of the body parts
    8. posture
      1. observe the patient's posture from all angles
      2. normal findings:
        1. patient stands comfortably erect as appropriate to age
        2. normal "plumb line" through anterior ear, shoulder, hip, patella, and ankle
        3. lordosis (sway back) and protruberant abdomen in standing toddler
        4. kyphosis (hunch back) in the aging person
      3. deviations from normal findings:
    9. position
      1. observe the patient's position from all angles
      2. normal findings:
        1. patient sits comfortably in a chair, on the bed, or on the examination table with arms relaxed at sides and head turned toward examiner
      3. deviations from normal findings:
        1. leaning forward with arms braced on chair arms (tripod position)
          1. e.g, chronic pulmonary disease
        2. sitting straight up and resisting lying down
          1. e.g., left-sided congestive heart failure
        3. curled up in a fetal position
          1. e.g, acute abdomen
    10. body build
      1. observe the patient's body build from all angles
      2. normal findings:
        1. arm span equals height
        2. body length from crown to pubis roughly equal to length from pubis to sole
        3. mesomorph
          1. body build characterized by a predominance of muscle, bone, and connective tissue
        4. ectomorph
          1. body build characterized by a slender and fragile physique
        5. edomorph
          1. body build characterized by a soft, round physique with a large trunk and thighs, tapering extremities, and an accumulation of fat throughout the body
      3. deviations from normal findings:
        1. Marfan's syndrome
          1. 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
    11. gait
      1. observe the patient's gait from all angles
      2. normal findings:
        1. normal pattern of gait:
          1. head is erect
          2. gaze is straight ahead
          3. vertebral column is upright
          4. feet are a shoulder's width apart
          5. heel strikes the ground before the toe
          6. feet are dorsiflexed in the swing phase
          7. arm opposite the swing-through foot moves forward at the same time
          8. gait is smooth, coordinated, and rhythmic with even weight borne on each foot
        2. gait of old age
      3. deviations from normal findings:
        1. abnormal patterns of gait, e.g.:
          1. spastic hemiparesis
          2. scissors
          3. steppage
          4. sensory ataxia
          5. cerebellar ataxia
          6. Parkinsonian
          7. gait of old age
    12. involuntary movments
      1. observe the patient for involuntary movements from all angles
      2. normal findings:
        1. absence of involuntary movements
      3. deviations from normal findings:
        1. tics
        2. tremors
        3. seizures
    13. facial expression
      1. observe the patient's facial expression from all angles
      2. normal findings:
        1. maintains eye contact (unless a cultural taboo)
        2. expressions are appropriate to the situation
      3. deviations from normal findings:
        1. flat
        2. depressed
        3. angry
        4. sad
        5. anxious
    14. mood and affect
      1. observe the patient's mood and affect from all angles
      2. normal findings:
        1. comfortable and cooperative with the examiner
      3. deviations from normal findings:
        1. hostile
        2. distrustful
        3. suspicious
        4. crying
    15. speech
      1. normal findings:
        1. articulation is clear and understandable
        2. stream of talking is fluent with an even pace
        3. conveys ideas clearly
        4. word choice is appropriate to culture and education
        5. communiates in prevailing language easily by him/herself or with an interpreter
      2. deviations from normal findings:
        1. dysarthria
        2. dysphagia
        3. speech defect
        4. monotone
        5. garbled speech
        6. extremes of few word or constant talking
    16. dress
      1. observe the patient's dress from all angles
      2. normal findings:
        1. well fitting clothes
        2. clothes look clean
        3. clothes are appropriate for the season and temperature
        4. clothes are appropriate to the person's culture and age group
      3. deviations from normal findings
        1. ill fitting clothes
        2. clothes look unclean
        3. clothes are inappropriate for the season and temperature
        4. consistent wearing of certain clothes
          1. e.g., long sleeves to cover needle marks of drug abuse
    17. grooming and personal hygeine
      1. observe the patient's grooming and personal hygeine from all angles
      2. normal findings:
        1. clothes
          1. clothes look clean
          2. clothes are properly buttoned and zipped
          3. shoes
            1. intact
            2. laces tied
          4. clothes are appropriate for age, occupation, and socioeconomic group
        2. hair
          1. clean
          2. groomed
        1. nails
          1. clean
          2. groomed
      3. deviations from normal findings:
        1. clothes
          1. clothes look unclean
          2. clothes are improperly buttoned and zipped
          3. shoes
            1. have holes
            2. laces untied
            3. wearing slipper
          4. clothes are inappropriate for age, occupation, and socioeconomic group
        2. hair
          1. unclean
          2. poorly groomed
        1. nails
          1. unclean
          2. poorly groomed
    18. odors of body or breath
      1. normal findings:
        1. absence of odors of the body and breath
      2. deviations from normal findings:
        1. foul breath
        2. alcohol on the breath
        3. body ordor

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This page was last modified on 1/1/02