General Physical Assessment


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General Physical Assessment

  1. 1. General Physical Assessment C. Richard Finley, Ed.D, PA-C Associate Professor Acting Department Chair Assistant Academic Director Physician Assistant Department College of Allied Health & Nursing
  2. 2. Examination of the Skin
  3. 3. Exam of the Skin <ul><li>Examine the patient in good lighting </li></ul><ul><li>Inspect and palpate skin for the following: </li></ul><ul><ul><li>Color </li></ul></ul><ul><ul><li>Texture </li></ul></ul><ul><ul><li>Turgor </li></ul></ul><ul><ul><li>Moisture </li></ul></ul><ul><ul><li>Pigmentation </li></ul></ul><ul><ul><li>Lesions </li></ul></ul><ul><ul><li>Hair distribution </li></ul></ul><ul><ul><li>Warmth: use back of hand </li></ul></ul>
  4. 4. Abnormal Findings <ul><li>Color </li></ul><ul><ul><li>Pallor: </li></ul></ul><ul><ul><ul><li>Iron def. anemia </li></ul></ul></ul><ul><ul><li>Yellow: </li></ul></ul><ul><ul><ul><li>Jaundice </li></ul></ul></ul><ul><ul><ul><li>Carotenemia </li></ul></ul></ul><ul><ul><ul><li>Hemolysis </li></ul></ul></ul><ul><ul><li>Red: </li></ul></ul><ul><ul><ul><li>Erythroderma </li></ul></ul></ul><ul><li>Pigmentation </li></ul><ul><ul><li>Hyper pigmentation </li></ul></ul><ul><ul><li>Localized : </li></ul></ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul><ul><ul><ul><li>BCP ingestion </li></ul></ul></ul><ul><ul><li>Generalized : </li></ul></ul><ul><ul><ul><li>Thyrotoxicosis </li></ul></ul></ul><ul><ul><ul><li>Liver disease </li></ul></ul></ul><ul><ul><ul><li>Renal disease </li></ul></ul></ul><ul><ul><li>De-pigmentation: </li></ul></ul><ul><ul><ul><li>Vitiligo </li></ul></ul></ul><ul><ul><ul><li>Injury </li></ul></ul></ul>
  5. 5. Abnormal Findings <ul><li>Texture </li></ul><ul><ul><li>Soft: (Thyrotoxicosis) </li></ul></ul><ul><ul><li>Tight: (Scleroderma) </li></ul></ul><ul><ul><li>Rough : (Hypothyroidism) </li></ul></ul><ul><li>Moisture </li></ul><ul><ul><li>Dry: (Vitamin A def, Myxedema) </li></ul></ul><ul><ul><li>Oily: (Acne) </li></ul></ul><ul><li>Turgor </li></ul><ul><ul><li>Decreased: (Dehydration) </li></ul></ul><ul><li>Warmth: </li></ul><ul><ul><li>Generalized warmth : (Fever, Hyperthyroidism) </li></ul></ul><ul><ul><li>Localized warmth : (Inflammation) </li></ul></ul><ul><ul><li>Coolness: (Hypothyroidism, Frostbite, Hypothermia, Shock, Low cardiac output) </li></ul></ul>
  6. 6. MOLE WARNING SIGNS The &quot;ABCD&quot; rule & Melanoma Danger Signs
  7. 7. <ul><li>A symmetry </li></ul><ul><ul><li>Unequal or asymmetric moles are suspicious. </li></ul></ul>
  8. 8. <ul><li>B order </li></ul><ul><ul><li>If the border is irregular or indistinct, it is more likely to be cancerous (or precancerous) </li></ul></ul>
  9. 9. <ul><li>C olor </li></ul><ul><ul><li>Variation of color (e.g., more than one color or shade) within a mole is a suspicious finding </li></ul></ul>
  10. 10. <ul><li>D iameter </li></ul><ul><ul><li>Any mole that has a diameter larger than a pencil's eraser in size (> 6 mm) should be considered suspicious. </li></ul></ul>
  11. 11. <ul><li>E levation </li></ul><ul><ul><li>If a mole is elevated, or raised from of the skin, it should be considered suspicious </li></ul></ul>
  12. 12. Examination of the Lymph Nodes
  13. 13. Lymph Node Palpation <ul><li>Palpate with pads of all four fingertips </li></ul><ul><li>Examine both sides simultaneously </li></ul><ul><li>Use steady gentle pressure </li></ul><ul><li>The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw </li></ul>
  14. 14. Cervical Nodes
  15. 17. Exam of Lymph Nodes <ul><li>Lymph nodes are part of immune system </li></ul><ul><li>Lymphadenitis </li></ul><ul><ul><li>Firm </li></ul></ul><ul><ul><li>Tender </li></ul></ul><ul><ul><li>Enlarged </li></ul></ul><ul><ul><li>Warm </li></ul></ul><ul><li>May remain enlarged after infection </li></ul><ul><ul><li>Less than 1 cm </li></ul></ul><ul><ul><li>Nontender </li></ul></ul>
  16. 18. Malignancies <ul><li>Firm </li></ul><ul><li>Non-tender </li></ul><ul><li>Matted (i.e. stuck to each other) </li></ul><ul><li>Fixed (i.e. stuck to underlying tissue </li></ul><ul><li>Increase in size over time </li></ul>
  17. 19. Common Causes of Lymphadenitis <ul><li>Pharyngitis or dental infections </li></ul><ul><li>Diffuse upper airway infections </li></ul><ul><ul><li>Mononucleosis </li></ul></ul><ul><li>Systemic infections </li></ul><ul><ul><li>Tuberculosis </li></ul></ul><ul><li>Inflammatory processes </li></ul><ul><ul><li>Sarcoidosis </li></ul></ul>
  18. 20. Examination of the Thyroid
  19. 21. Inspection <ul><li>Gland lies approximately 2-3 cm below the thyroid cartilage </li></ul><ul><ul><li>Either side of the tracheal rings, which may or may not be apparent on visual inspection. </li></ul></ul>
  20. 22. Palpation <ul><li>Stand behind the patient and place the middle three fingers of both hands along the mid-line of the neck, just below the chin </li></ul><ul><ul><li>identify and feel the structures from the front before performing the exam from behind </li></ul></ul><ul><li>Slide the three fingers of both hands to either side of the rings </li></ul><ul><li>Have the patient drink water as you palpate </li></ul>
  21. 23. <ul><li>If enlarged, is it symmetrical </li></ul><ul><ul><li>Unilateral vs. bilateral </li></ul></ul><ul><li>Discrete nodules within either lobe? </li></ul><ul><li>Gland feels firm </li></ul><ul><ul><li>is it attached to the adjacent structures? </li></ul></ul><ul><ul><ul><li>(i.e. fixed to underlying tissue.. consistent with malignancy) </li></ul></ul></ul><ul><ul><li>freely mobile? </li></ul></ul><ul><ul><ul><li>(i.e. moves up and down with swallowing) </li></ul></ul></ul>
  22. 24. Findings of Exam of Thyroid <ul><li>Consistency of gland </li></ul><ul><ul><li>Consistency of muscle tissue </li></ul></ul><ul><ul><li>Unusual hardness </li></ul></ul><ul><ul><ul><li>Cancer or scarring </li></ul></ul></ul><ul><ul><li>Softness, or sponginess </li></ul></ul><ul><ul><ul><li>Toxic goiter </li></ul></ul></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><ul><li>Acute infections </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage into the gland </li></ul></ul></ul>
  23. 25. Examination of the Abdomen
  24. 26. General Considerations <ul><li>Patient should have an empty bladder . </li></ul><ul><li>Supine on the exam table and appropriately draped. </li></ul><ul><li>Examination room must be quiet to perform adequate auscultation and percussion. </li></ul><ul><li>Watch the patient's face for signs of discomfort during the examination </li></ul>
  25. 27. <ul><li>Disorders in the chest will often manifest with abdominal symptoms </li></ul><ul><li>It is always wise to examine the chest when evaluating an abdominal complaint </li></ul><ul><li>Inguinal/rectal examination in males </li></ul><ul><li>Pelvic/rectal examination in females </li></ul>
  26. 28. Anatomical Locations
  27. 30. Inspection <ul><li>Scars, striae, hernias, vascular changes, lesions, or rashes </li></ul><ul><li>Movement associated with peristalsis or pulsations </li></ul><ul><ul><li>Abdominal contour </li></ul></ul><ul><ul><ul><li>Flat, scaphoid, or protuberant? </li></ul></ul></ul>
  28. 31. Auscultation <ul><li>Place the diaphragm of stethoscope lightly on the abdomen </li></ul><ul><li>Listen for bowel sounds </li></ul><ul><ul><li>normal </li></ul></ul><ul><ul><li>increased </li></ul></ul><ul><ul><li>decreased </li></ul></ul><ul><ul><li>absent </li></ul></ul>
  29. 32. Listen for bruits over the renal arteries, iliac arteries, and aorta
  30. 33. Percussion <ul><li>Percuss in all four quadrants </li></ul><ul><li>Categorize what you hear as tympanic or dull. </li></ul><ul><ul><li>Tympany is normally present over most of the abdomen in the supine position. </li></ul></ul><ul><ul><li>Unusual dullness may be a clue to an underlying abdominal mass </li></ul></ul>
  31. 34. Liver Span <ul><li>Percuss downward from the chest in the right midclavicular line to detect the top edge of liver dullness. </li></ul><ul><li>Percuss upward from the abdomen in the same line to detect the bottom edge of liver dullness. </li></ul><ul><li>Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult. </li></ul>
  32. 35. Splenic Dullness <ul><li>Percuss the lowest costal interspace in the left anterior axillary line </li></ul><ul><ul><li>This area is normally tympanic. </li></ul></ul><ul><li>Ask the patient to take a deep breath and percuss this area again </li></ul><ul><ul><li>Dullness in this area is a sign of splenic enlargement. </li></ul></ul>
  33. 36. General Palpation <ul><li>Light palpation </li></ul><ul><ul><li>Areas of tenderness </li></ul></ul><ul><ul><li>Most sensitive indicator is patient’s facial expression </li></ul></ul><ul><ul><ul><li>Watch the patient’s face, not your hands </li></ul></ul></ul><ul><ul><li>Voluntary or involuntary guarding may be present </li></ul></ul><ul><li>Deep Palpation </li></ul><ul><ul><li>Identify abdominal masses or areas of deep tenderness </li></ul></ul>
  34. 37. Palpation of the Liver <ul><li>Place the fingers just below the right costal margin and press firmly. </li></ul><ul><li>Ask the patient to take a deep breath. </li></ul><ul><li>You may feel the edge of the liver press against your fingers </li></ul><ul><ul><li>Or it may slide under your hand as the patient exhales. </li></ul></ul><ul><li>A normal liver is not tender </li></ul>
  35. 38. <ul><li>Palpation of the Aorta </li></ul><ul><ul><li>Press down deeply in the midline above the umbilicus </li></ul></ul><ul><ul><li>The aortic pulsation is easily felt on most individuals </li></ul></ul><ul><ul><li>A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm. </li></ul></ul>
  36. 39. <ul><li>Palpation of the Spleen </li></ul><ul><ul><li>Use the left hand (posteriorly) to lift the lower rib cage and flank </li></ul></ul><ul><ul><li>Press down just below the left costal margin with the right hand </li></ul></ul><ul><ul><li>Ask the patient to take a deep breath </li></ul></ul><ul><ul><ul><li>The spleen is not normally palpable on most individual </li></ul></ul></ul>
  37. 40. Special Tests
  38. 41. Rebound Tenderness <ul><ul><li>Test for peritoneal irritation </li></ul></ul><ul><ul><li>Warn the patient </li></ul></ul><ul><ul><li>Press deeply on the abdomen </li></ul></ul><ul><ul><ul><ul><ul><li>After a moment, quickly release pressure </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If it hurts more upon release, the patient has rebound tenderness </li></ul></ul></ul></ul></ul>
  39. 42. <ul><ul><li>+CVA is associated with renal disease </li></ul></ul><ul><ul><li>Warn the patient what you are about to do </li></ul></ul><ul><ul><li>Have the patient sit up on the exam table </li></ul></ul><ul><ul><li>Use heel of your closed fist to strike the patient firmly over costovertebral angles </li></ul></ul><ul><ul><li>Compare the left and right sides </li></ul></ul>Costovertebral Tenderness
  40. 43. <ul><ul><li>Test for peritoneal fluid (ascites) </li></ul></ul><ul><ul><li>Percuss the abdomen to outline areas of dullness and tympany </li></ul></ul><ul><ul><li>Have the patient roll away from you </li></ul></ul><ul><ul><ul><ul><li>Percuss again </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If dullness has shifted to areas of prior tympany, patient may have excess peritoneal fluid </li></ul></ul></ul></ul>Shifting Dullness
  41. 44. <ul><ul><li>Have patient lie on left side </li></ul></ul><ul><ul><li>Place your left hand on patient’s right hip </li></ul></ul><ul><ul><li>Extend the right thigh while applying counter resistance </li></ul></ul><ul><ul><li>Increased abdominal pain indicates a positive psoas sign </li></ul></ul>Psoas Sign                                                 
  42. 45. <ul><ul><li>Raise the patient's right leg with the knee flexed </li></ul></ul><ul><ul><li>Rotate the leg internally at the hip </li></ul></ul><ul><ul><li>Increased abdominal pain indicates a positive obturator sign </li></ul></ul>Obturator Sign                  
  43. 46. Evaluation of Stool and Urine
  44. 47. Discolored Urine <ul><li>Colorless </li></ul><ul><ul><li>Low concentration from excessive fluid intake </li></ul></ul><ul><ul><ul><li>Chronic glomerulonephritis </li></ul></ul></ul><ul><ul><ul><li>Diabetes mellitus </li></ul></ul></ul><ul><ul><ul><li>Diabetes insipidus </li></ul></ul></ul>
  45. 48. <ul><li>Cloudy White : Phosphates in an alkaline urine </li></ul><ul><ul><li>Epithelial cells from the lower GU tract </li></ul></ul><ul><ul><li>Bacteria </li></ul></ul><ul><ul><li>Pus </li></ul></ul><ul><li>Yellow : Highly concentrated normal urine </li></ul><ul><ul><li>Tetracycline </li></ul></ul><ul><ul><li>Pyridine </li></ul></ul><ul><li>Orange : Urobilinogen </li></ul><ul><ul><li>Santonin (anthelminthic) </li></ul></ul><ul><ul><li>Phenindione (anticoagulant) </li></ul></ul>
  46. 49. <ul><li>Orange in Acid/ Red in Alkaline: </li></ul><ul><ul><li>Rhubarb (food and purgative) </li></ul></ul><ul><ul><li>Senna (cathartic) </li></ul></ul><ul><ul><li>Aloes (cathartic) </li></ul></ul><ul><li>Red : </li></ul><ul><ul><li>Beets, blackberries, aniline dyes from candy </li></ul></ul><ul><li>Brown-Black : </li></ul><ul><ul><li>Highly concentrated normal urine </li></ul></ul><ul><ul><ul><li>Bilirubin (with yellow froth) </li></ul></ul></ul>
  47. 50. Hematuria <ul><li>Gross vs. Microscopic </li></ul><ul><li>Kidney </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Neoplasms </li></ul></ul><ul><ul><li>Infections </li></ul></ul>
  48. 51. Stool Evaluation <ul><li>Acute Diarrhea </li></ul><ul><ul><li>Defecation of watery or loose stools </li></ul></ul><ul><ul><li>Consistency not frequency </li></ul></ul>
  49. 52. <ul><li>Acute Nonbloody Diarrhea </li></ul><ul><ul><li>Viral gastroenteritis </li></ul></ul><ul><ul><li>Food intolerance </li></ul></ul><ul><ul><li>Fecal impaction </li></ul></ul><ul><li>Acute Bloody Diarrhea </li></ul><ul><ul><li>Posterior penetrating duodenal ulcer </li></ul></ul><ul><ul><li>Staph food poisoning </li></ul></ul><ul><ul><li>Heavy metal poisoning </li></ul></ul><ul><ul><li>Ulcerative colitis </li></ul></ul>
  50. 53. <ul><li>Chronic Intermittent Diarrhea </li></ul><ul><ul><li>Chronic pancreatitis </li></ul></ul><ul><ul><li>Irritable colon </li></ul></ul><ul><ul><li>Fibrocystic disease </li></ul></ul><ul><li>Chronic Constant Diarrhea </li></ul><ul><ul><li>Ulcerative colitis </li></ul></ul><ul><ul><li>Regional enteritis </li></ul></ul>
  51. 54. Constipation <ul><li>Acute Constipation </li></ul><ul><ul><li>Intestinal obstruction </li></ul></ul><ul><ul><li>Fecal impaction </li></ul></ul><ul><li>Chronic Constipation </li></ul><ul><ul><li>Irritable colon </li></ul></ul><ul><ul><li>Atonic colon </li></ul></ul><ul><ul><li>Megacolon </li></ul></ul><ul><ul><ul><li>Congenital or acquired defects in innervation </li></ul></ul></ul><ul><ul><li>Carcinoma of descending colon </li></ul></ul>
  52. 55. Blood in the Feces <ul><li>Black or Tarry Stools (digestive enzymes convert Hgb to black pigment) </li></ul><ul><li>Bloody Red Stools </li></ul><ul><ul><li>Site of hemorrhage is in the colon or below </li></ul></ul><ul><ul><li>Copious hemorrhage higher may pass through undigested </li></ul></ul><ul><li>Occult Blood </li></ul><ul><ul><li>Small volume from any site in the alimentary tract </li></ul></ul>