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

Examination of the Skin

Exam of the Skin Examine the patient in good lighting Inspect and palpate skin for the following: Color Texture Turgor Moisture Pigmentation Lesions Hair distribution Warmth: use back of hand

Examine the patient in good lighting

Inspect and palpate skin for the following:

Color

Texture

Turgor

Moisture

Pigmentation

Lesions

Hair distribution

Warmth: use back of hand

Abnormal Findings Color Pallor: Iron def. anemia Yellow: Jaundice Carotenemia Hemolysis Red: Erythroderma Pigmentation Hyper pigmentation Localized : Pregnancy BCP ingestion Generalized : Thyrotoxicosis Liver disease Renal disease De-pigmentation: Vitiligo Injury

Color

Pallor:

Iron def. anemia

Yellow:

Jaundice

Carotenemia

Hemolysis

Red:

Erythroderma

Pigmentation

Hyper pigmentation

Localized :

Pregnancy

BCP ingestion

Generalized :

Thyrotoxicosis

Liver disease

Renal disease

De-pigmentation:

Vitiligo

Injury

Abnormal Findings Texture Soft: (Thyrotoxicosis) Tight: (Scleroderma) Rough : (Hypothyroidism) Moisture Dry: (Vitamin A def, Myxedema) Oily: (Acne) Turgor Decreased: (Dehydration) Warmth: Generalized warmth : (Fever, Hyperthyroidism) Localized warmth : (Inflammation) Coolness: (Hypothyroidism, Frostbite, Hypothermia, Shock, Low cardiac output)

Texture

Soft: (Thyrotoxicosis)

Tight: (Scleroderma)

Rough : (Hypothyroidism)

Moisture

Dry: (Vitamin A def, Myxedema)

Oily: (Acne)

Turgor

Decreased: (Dehydration)

Warmth:

Generalized warmth : (Fever, Hyperthyroidism)

Localized warmth : (Inflammation)

Coolness: (Hypothyroidism, Frostbite, Hypothermia, Shock, Low cardiac output)

MOLE WARNING SIGNS The "ABCD" rule & Melanoma Danger Signs

A symmetry Unequal or asymmetric moles are suspicious.

A symmetry

Unequal or asymmetric moles are suspicious.

B order If the border is irregular or indistinct, it is more likely to be cancerous (or precancerous)

B order

If the border is irregular or indistinct, it is more likely to be cancerous (or precancerous)

C olor Variation of color (e.g., more than one color or shade) within a mole is a suspicious finding

C olor

Variation of color (e.g., more than one color or shade) within a mole is a suspicious finding

D iameter Any mole that has a diameter larger than a pencil's eraser in size (> 6 mm) should be considered suspicious.

D iameter

Any mole that has a diameter larger than a pencil's eraser in size (> 6 mm) should be considered suspicious.

E levation If a mole is elevated, or raised from of the skin, it should be considered suspicious

E levation

If a mole is elevated, or raised from of the skin, it should be considered suspicious

Examination of the Lymph Nodes

Lymph Node Palpation Palpate with pads of all four fingertips Examine both sides simultaneously Use steady gentle pressure The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw

Palpate with pads of all four fingertips

Examine both sides simultaneously

Use steady gentle pressure

The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw

Cervical Nodes

Exam of Lymph Nodes Lymph nodes are part of immune system Lymphadenitis Firm Tender Enlarged Warm May remain enlarged after infection Less than 1 cm Nontender

Lymph nodes are part of immune system

Lymphadenitis

Firm

Tender

Enlarged

Warm

May remain enlarged after infection

Less than 1 cm

Nontender

Malignancies Firm Non-tender Matted (i.e. stuck to each other) Fixed (i.e. stuck to underlying tissue Increase in size over time

Firm

Non-tender

Matted (i.e. stuck to each other)

Fixed (i.e. stuck to underlying tissue

Increase in size over time

Common Causes of Lymphadenitis Pharyngitis or dental infections Diffuse upper airway infections Mononucleosis Systemic infections Tuberculosis Inflammatory processes Sarcoidosis

Pharyngitis or dental infections

Diffuse upper airway infections

Mononucleosis

Systemic infections

Tuberculosis

Inflammatory processes

Sarcoidosis

Examination of the Thyroid

Inspection Gland lies approximately 2-3 cm below the thyroid cartilage Either side of the tracheal rings, which may or may not be apparent on visual inspection.

Gland lies approximately 2-3 cm below the thyroid cartilage

Either side of the tracheal rings, which may or may not be apparent on visual inspection.

Palpation Stand behind the patient and place the middle three fingers of both hands along the mid-line of the neck, just below the chin identify and feel the structures from the front before performing the exam from behind Slide the three fingers of both hands to either side of the rings Have the patient drink water as you palpate

Stand behind the patient and place the middle three fingers of both hands along the mid-line of the neck, just below the chin

identify and feel the structures from the front before performing the exam from behind

Slide the three fingers of both hands to either side of the rings

Have the patient drink water as you palpate

If enlarged, is it symmetrical Unilateral vs. bilateral Discrete nodules within either lobe? Gland feels firm is it attached to the adjacent structures? (i.e. fixed to underlying tissue.. consistent with malignancy) freely mobile? (i.e. moves up and down with swallowing)

If enlarged, is it symmetrical

Unilateral vs. bilateral

Discrete nodules within either lobe?

Gland feels firm

is it attached to the adjacent structures?

(i.e. fixed to underlying tissue.. consistent with malignancy)

freely mobile?

(i.e. moves up and down with swallowing)

Findings of Exam of Thyroid Consistency of gland Consistency of muscle tissue Unusual hardness Cancer or scarring Softness, or sponginess Toxic goiter Tenderness Acute infections Hemorrhage into the gland

Consistency of gland

Consistency of muscle tissue

Unusual hardness

Cancer or scarring

Softness, or sponginess

Toxic goiter

Tenderness

Acute infections

Hemorrhage into the gland

Examination of the Abdomen

General Considerations Patient should have an empty bladder . Supine on the exam table and appropriately draped. Examination room must be quiet to perform adequate auscultation and percussion. Watch the patient's face for signs of discomfort during the examination

Patient should have an empty bladder .

Supine on the exam table and appropriately draped.

Examination room must be quiet to perform adequate auscultation and percussion.

Watch the patient's face for signs of discomfort during the examination

Disorders in the chest will often manifest with abdominal symptoms It is always wise to examine the chest when evaluating an abdominal complaint Inguinal/rectal examination in males Pelvic/rectal examination in females

Disorders in the chest will often manifest with abdominal symptoms

It is always wise to examine the chest when evaluating an abdominal complaint

Inguinal/rectal examination in males

Pelvic/rectal examination in females

Anatomical Locations

Inspection Scars, striae, hernias, vascular changes, lesions, or rashes Movement associated with peristalsis or pulsations Abdominal contour Flat, scaphoid, or protuberant?

Scars, striae, hernias, vascular changes, lesions, or rashes

Movement associated with peristalsis or pulsations

Abdominal contour

Flat, scaphoid, or protuberant?

Auscultation Place the diaphragm of stethoscope lightly on the abdomen Listen for bowel sounds normal increased decreased absent

Place the diaphragm of stethoscope lightly on the abdomen

Listen for bowel sounds

normal

increased

decreased

absent

Listen for bruits over the renal arteries, iliac arteries, and aorta

Percussion Percuss in all four quadrants Categorize what you hear as tympanic or dull. Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may be a clue to an underlying abdominal mass

Percuss in all four quadrants

Categorize what you hear as tympanic or dull.

Tympany is normally present over most of the abdomen in the supine position.

Unusual dullness may be a clue to an underlying abdominal mass

Liver Span Percuss downward from the chest in the right midclavicular line to detect the top edge of liver dullness. Percuss upward from the abdomen in the same line to detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult.

Percuss downward from the chest in the right midclavicular line to detect the top edge of liver dullness.

Percuss upward from the abdomen in the same line to detect the bottom edge of liver dullness.

Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult.

Splenic Dullness Percuss the lowest costal interspace in the left anterior axillary line This area is normally tympanic. Ask the patient to take a deep breath and percuss this area again Dullness in this area is a sign of splenic enlargement.

Percuss the lowest costal interspace in the left anterior axillary line

This area is normally tympanic.

Ask the patient to take a deep breath and percuss this area again

Dullness in this area is a sign of splenic enlargement.

General Palpation Light palpation Areas of tenderness Most sensitive indicator is patient’s facial expression Watch the patient’s face, not your hands Voluntary or involuntary guarding may be present Deep Palpation Identify abdominal masses or areas of deep tenderness

Light palpation

Areas of tenderness

Most sensitive indicator is patient’s facial expression

Watch the patient’s face, not your hands

Voluntary or involuntary guarding may be present

Deep Palpation

Identify abdominal masses or areas of deep tenderness

Palpation of the Liver Place the fingers just below the right costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers Or it may slide under your hand as the patient exhales. A normal liver is not tender

Place the fingers just below the right costal margin and press firmly.

Ask the patient to take a deep breath.

You may feel the edge of the liver press against your fingers

Or it may slide under your hand as the patient exhales.

A normal liver is not tender

Palpation of the Aorta Press down deeply in the midline above the umbilicus The aortic pulsation is easily felt on most individuals A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

Palpation of the Aorta

Press down deeply in the midline above the umbilicus

The aortic pulsation is easily felt on most individuals

A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

Palpation of the Spleen Use the left hand (posteriorly) to lift the lower rib cage and flank Press down just below the left costal margin with the right hand Ask the patient to take a deep breath The spleen is not normally palpable on most individual

Palpation of the Spleen

Use the left hand (posteriorly) to lift the lower rib cage and flank

Press down just below the left costal margin with the right hand

Ask the patient to take a deep breath

The spleen is not normally palpable on most individual

Special Tests

Rebound Tenderness Test for peritoneal irritation Warn the patient Press deeply on the abdomen After a moment, quickly release pressure If it hurts more upon release, the patient has rebound tenderness

Test for peritoneal irritation

Warn the patient

Press deeply on the abdomen

After a moment, quickly release pressure

If it hurts more upon release, the patient has rebound tenderness

+CVA is associated with renal disease Warn the patient what you are about to do Have the patient sit up on the exam table Use heel of your closed fist to strike the patient firmly over costovertebral angles Compare the left and right sides Costovertebral Tenderness

+CVA is associated with renal disease

Warn the patient what you are about to do

Have the patient sit up on the exam table

Use heel of your closed fist to strike the patient firmly over costovertebral angles

Compare the left and right sides

Test for peritoneal fluid (ascites) Percuss the abdomen to outline areas of dullness and tympany Have the patient roll away from you Percuss again If dullness has shifted to areas of prior tympany, patient may have excess peritoneal fluid Shifting Dullness

Test for peritoneal fluid (ascites)

Percuss the abdomen to outline areas of dullness and tympany

Have the patient roll away from you

Percuss again

If dullness has shifted to areas of prior tympany, patient may have excess peritoneal fluid

Have patient lie on left side Place your left hand on patient’s right hip Extend the right thigh while applying counter resistance Increased abdominal pain indicates a positive psoas sign Psoas Sign

Have patient lie on left side

Place your left hand on patient’s right hip

Extend the right thigh while applying counter resistance

Increased abdominal pain indicates a positive psoas sign

Raise the patient's right leg with the knee flexed Rotate the leg internally at the hip Increased abdominal pain indicates a positive obturator sign Obturator Sign

Raise the patient's right leg with the knee flexed

Rotate the leg internally at the hip

Increased abdominal pain indicates a positive obturator sign

Evaluation of Stool and Urine

Discolored Urine Colorless Low concentration from excessive fluid intake Chronic glomerulonephritis Diabetes mellitus Diabetes insipidus

Colorless

Low concentration from excessive fluid intake

Chronic glomerulonephritis

Diabetes mellitus

Diabetes insipidus

Cloudy White : Phosphates in an alkaline urine Epithelial cells from the lower GU tract Bacteria Pus Yellow : Highly concentrated normal urine Tetracycline Pyridine Orange : Urobilinogen Santonin (anthelminthic) Phenindione (anticoagulant)

Cloudy White : Phosphates in an alkaline urine

Epithelial cells from the lower GU tract

Bacteria

Pus

Yellow : Highly concentrated normal urine

Tetracycline

Pyridine

Orange : Urobilinogen

Santonin (anthelminthic)

Phenindione (anticoagulant)

Orange in Acid/ Red in Alkaline: Rhubarb (food and purgative) Senna (cathartic) Aloes (cathartic) Red : Beets, blackberries, aniline dyes from candy Brown-Black : Highly concentrated normal urine Bilirubin (with yellow froth)

Orange in Acid/ Red in Alkaline:

Rhubarb (food and purgative)

Senna (cathartic)

Aloes (cathartic)

Red :

Beets, blackberries, aniline dyes from candy

Brown-Black :

Highly concentrated normal urine

Bilirubin (with yellow froth)

Hematuria Gross vs. Microscopic Kidney Trauma Neoplasms Infections

Gross vs. Microscopic

Kidney

Trauma

Neoplasms

Infections

Stool Evaluation Acute Diarrhea Defecation of watery or loose stools Consistency not frequency

Acute Diarrhea

Defecation of watery or loose stools

Consistency not frequency

Acute Nonbloody Diarrhea Viral gastroenteritis Food intolerance Fecal impaction Acute Bloody Diarrhea Posterior penetrating duodenal ulcer Staph food poisoning Heavy metal poisoning Ulcerative colitis

Acute Nonbloody Diarrhea

Viral gastroenteritis

Food intolerance

Fecal impaction

Acute Bloody Diarrhea

Posterior penetrating duodenal ulcer

Staph food poisoning

Heavy metal poisoning

Ulcerative colitis

Chronic Intermittent Diarrhea Chronic pancreatitis Irritable colon Fibrocystic disease Chronic Constant Diarrhea Ulcerative colitis Regional enteritis

Chronic Intermittent Diarrhea

Chronic pancreatitis

Irritable colon

Fibrocystic disease

Chronic Constant Diarrhea

Ulcerative colitis

Regional enteritis

Constipation Acute Constipation Intestinal obstruction Fecal impaction Chronic Constipation Irritable colon Atonic colon Megacolon Congenital or acquired defects in innervation Carcinoma of descending colon

Acute Constipation

Intestinal obstruction

Fecal impaction

Chronic Constipation

Irritable colon

Atonic colon

Megacolon

Congenital or acquired defects in innervation

Carcinoma of descending colon

Blood in the Feces Black or Tarry Stools (digestive enzymes convert Hgb to black pigment) Bloody Red Stools Site of hemorrhage is in the colon or below Copious hemorrhage higher may pass through undigested Occult Blood Small volume from any site in the alimentary tract

Black or Tarry Stools (digestive enzymes convert Hgb to black pigment)

Bloody Red Stools

Site of hemorrhage is in the colon or below

Copious hemorrhage higher may pass through undigested

Occult Blood

Small volume from any site in the alimentary tract