THE GENERAL SURVEY

The General Survey

The General Survey of the patient's appearance, height, and weight begins with the opening moments of the patient encounter, but you will find that your observations of the patient's appearance crystallize as you start the physical examination. Tre best clinicians continually sharpen their powers of observation and description. As you talk with and examine the patient, heighten your focus on the patient's mood, build, and behavior. These de­tails enrich and deepen your emerging clinical impression. A skilled observer describes the distinguishing features of the patient's appearance so well that colleagues can spot the patient in a crowd of strangers.

Many factors contribute to the patient's body habitus: socioeconomic status, nutrition, genetic makeup, degree of fitness, mood state, early illnesses, gender, geographic location, and age cohort. Recall that the patient's nutritional status affects many of the characteristics you scrutinize during the General Survey: height and weight, blood pressure, posture, mood and alertness, facial color­ation, dentition and condition of the tongue and gingiva, color of the nail beds, and muscle bulk, to name a few. Be sure to make the assessment of height, weight, BMI, and risk for obesity a routine part of your clinical practice.

Now is the time to recall the observations you have been making since the first moments of your interaction, refining them throughout your assess­ment. Does the patient hear you when greeted in the waiting room or ex­amination room? Rise with ease? Walk easily or stiffly? If hospitalized when you first meet, what is the patient doing-sitting up and enjoying televi-sion? . .. or lying in bed? ... What do you see on the bedside table-a maga-zine? ... a flock of "get well" cards? ... a Bible or a rosary? ... an emesis basin? ... or nothing at all? Each observation should raise questions or hy-potheses for you to consider as your assessment unfolds.

- GENERAL APPEARANCE

Apparent State of Health. Try to make a general judgment based on ob­servations throughout the encounter. Support it with the significant details.

Level of Consciousness. Is the patient awake, alert, and responsive to you and others in the environment? If not, promptly assess the level of consciousness.

Signs of Distress. Does tl1e patient show evidence of the problems listed below?

• Cardiac or respiratory distress

EXAMPLES OF ABNORMALITIES I

Is the patient acutely or chronically ill, frail, or fit and robust?

See Chapter 17, The Nervous System, Level of Consciousness, p.735

Is there clutching of the chest, pal­lor, diaphoresis, or labored breath­ing, wheezing, and coughing?

114 BATES' GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

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THE GENERAL SURVEY

• Pain

• Anxiety or depression

Skin Color and Obvious Lesions. Assess any changes in skin color, scars, plaques, or nevi.

Dress, Grooming, and Personal Hygiene. How is the patient dressed? Is the clothing appropriate for the temperature and weather? Is it clean and appropriate to the setting?

Glance at the patient's shoes. Are there cut-outs or holes? Are the shoes run-down?

Is the patient wearing unusual jewelry? Are there body piercings?

Note the patient's hair, fingernails, and use of cosmetics. They may be clues to the patient's personality, mood, lifestyle, and self-regard.

Do personal hygiene and grooming seem appropriate to the patient's age, lifestyle, occupation, and stage of life?

Facial Expression. Observe the facial expression at rest, during conversa­tion about specific topics, during the physical examination, and in interac­tion with others. Watch for eye contact. Is it natural? Sustained and unblinking? Averted quickly? Absent?

I EXAMPLES OF ABNORMALITIES

Is there wincing, sweating, protec­tiveness of a painful area, facial grimacing, or an unusual posture favoring one limb or body area?

Are there anxious facial expressions, fidgety movements, cold and moist palms, inexpressive or flat affect, poor eye contact, or psychomotor slowing. See Chapter 5, Behavior and Mental Status, pp. 141 - 169.

Pallor, cyanosis, jaundice, rashes, bruises should be pursued. See Chapter 6, The Skin, Hair, and Nails, pp. 171-203.

Excess clothing may reflect the cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences.

Cut-out holes or slippers may indi­cate gout, bunions, edema, or other painful foot conditions. Run-down shoes can contribute to foot and back pain, calluses, falls, and infection.

Copper bracelets are sometimes worn for arthritis. Piercing may appear on any part of the body.

"Grown-out" hair and nail polish can help you estimate the length of an illness. Fingernails chewed to the quick may reflect stress.

Unkempt appearance may be seen in depression and dementia, but this appearance must be compared with the patient's probable norm.

Watch for the stare of hyperthy­roidism; the immobile face of par­kinsonism; the flat or sad affect of depression. Decreased eye contact may be cultural or may suggest anxiety, fear, or sadness.

CHAPTER 4 I Beginning the Physi ca l Examination: General Survey, Vital Signs, and Pa in 115

THE GENERAL SURVEY

Odors of the Body and Breath. Odors can be important diagnostic clues, like the fruity odor of diabetes or the scent of alcohol.

Never assume that alcohol on a patient's breath explains changes in mental status or neurologic findings.

Posture, Gait, and Motor Activity. What is the patient's preferred pos­ture?

Is the patient restless or quiet? How often does the patient change position?

Is there any involuntary motor activity? Are some body parts immobile? Which ones?

Does the patient walk smoothly, with comfort, self-confidence, and balance, or is there a limp or discomfort, fear of falling, loss of balance, or any move­ment disorder?

Height and Weight. Measure the patient's height in stocking feet and weigh the patient to determine the BMI.

Is the patient unusually short or tall? Is the build slender, muscular, or stocky? Is the body symmetric? Note the general body proportions.

Is the patient emaciated, slender, overweight, or obese? If the patient is obese, is the fat distributed evenly or concentrated over the upper torso, or around the hips?

EXAMPLES OF ABNORMALITIES

Breath odors can indicate the pres­ence of alcohol, acetone (diabetes), pulmonary infections, uremia, or liver failure.

People with alcoholism may have other serious and potentially cor­rectable problems such as hypo­glycemia, subdural hematoma, or postictal state.

There is a preference for sitting upright in left-sided heart failure and for leaning forward with arms braced in chronic obstructive pulmonary disease.

Anxious patients appear agitated and restless. Patients in pain often avoid movement.

Look for tremors, other involuntary movements, or paralysis. See Table 17-5, Tremors and Involuntary Movements, pp. 752-753.

See Table 17-10, Abnormalities of Gait and Posture, p. 759. An impaired gait increases risk of falls.

Be aware of very short stature in Turner's syndrome, childhood renal failure, and achondroplastic and hypopituitary dwarfism; long limbs in proportion to the trunk in hypo­gonadism and Marfan's syndrome; height loss in osteoporosis and ver­tebral compression fractures.

There is generalized fat in simple obesity; truncal fat with relatively thin limbs in Cushing's syndrome and metabolic syndrome.

116 BA TES' GU I DE T 0 PHYS IC AL EXAM I NAT I 0 N AN D H IS T,O RY TAK I NG

THE GENERAL SURVEY

Weigh the patient with shoes off. Make note of any weight changes over time.

Calculating the BM/. Use your measurements of height and weight to calculate the body mass index) or BMI. Body fat consists primarily of adipose in the form of triglycerides and is stored in subcutaneous, inter-abdominal, and intramuscular fat deposits that are difficult to measure directly. The BMI incorporates estimated but more accurate measures of body fat than weight alone. The National Institutes. of Health caution that people who are very muscular can have a high BMI but still be healthy. Likewise, the BMI for older adults and those with low muscle mass may appear inappropriately "normal."

There are several ways to calculate the BMI, as shown in the accompanying table. Choose the method best suited to your practice. The electronic med­ical record software may do this automatically.

Waist Circumference. If the BMI is 35 or greater, measure the patient's waist circumference just above the hips. Risk for diabetes, hypertension, and cardiovascular disease increases significantly if the waist circumference is 35 inches or more in women and 40 inches or more in men.

Methods to Calculate Body Mass Index (BMI)

Unit of Measure

Weight in pounds, height in inches

Weight in kilograms, height in meters squared

Either

=====

Method of Calculation

(1) Body Mass Index Chart (see table on the next page)

(2) (Weight (lbs) x 700*) Height (inches)

Height (inches)

(3) Weight (kg)

Height (m2)

(4) "BMI Calculator" at Web site www.nhlbisupport.com/bmi

*Several organizations use 704.5, but the variation in BM! is negligible. Conversion formulas:

2.2lbs=1 kg; 1 inch= 2.54 cm; 100 cm= 1 meter.

Source: National Institutes of Health-National Heart, Lung, and Blood Institute: Calculate Your Body Mass Index. Available at: http://www.nhlbisupport.com/bmi. Accessed June 25, 2011 .

EXAMPLES OF ABNORMALITIES

Causes of weight loss include malignancy, diabetes mellitus, hyper­thyroidism, chronic infection, depres­sion, diuresis, and successful dieting.

See discussion of Optimal Weight, Nutrition and Diet, pp. 108-113.

CHAPTER 4 I Beginn ing the Physical Examination: General Survey, Vital Signs, and Pain 117

THE VITAL SIGNS EXAMPLES OF ABNORMALITIES

Body Mass Index Table

Normal Overweight Obese

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Height (inches) Body Weight (pounds)

58

59

60

61

62

63

64

65

66

91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181

94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188

97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194

100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201

104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207

107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214

110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221

114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228

118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235

186

193

199

206

213

220

227

234

241

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320

Source: National Institutes of Health-National Heart, Lung, and Blood Institute: Body Mass Index Table. Available at http://www.nhlbi.nih.gov i guidelines/obesity/bmi_tbl.pdf. Accessed June 25, 2011.

The Vital Signs Now you are ready to review or measure the Vital Signs: blood pressure, heart rate, respiratory rate, and temperature. The vital signs provide critical initial information that often influences the direction of your evaluation. Typically they are already recorded in the record by office staff. If they are abnormal, you will often retake them during the visit.

Begin by measuring the blood pressure and the heart rate. The heart rate can be assessed by counting the radial pulse with your fingers, or the apical pulse with your stethoscope at the cardiac apex . Continue either of these techniques as you count the respiratory rate without alerting the patient­breathing patterns can change if the patient knows breaths are being

See Table 9-3, Abnormalities of the Arterial Pulse and Pressure Waves,

p. 393. See Table 4-7, Abnormalities in Rate and Rhythm of Breathing, p.140.

118 BATES' GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

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BIBLIOGRAPHY EXAMPLES OF ABNORMALITIES

Recording Your Findings Your write-up of the physical examination begins with a general description of the patient 's appearance, based on the General Survey. Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups.

Recording the Physical Examination-The General Survey and Vital Signs

Choose vivid and graphic adjectives, as if you are painting a picture in words. Avoid cl iches such as "well-developed" or "well -nourished" or "in no acute distress," because they could apply to any patient and do not convey the spe­cial features of the patient before you.

Record the vital signs taken at the time of your examination. They are pref­erable to those taken earlier in the day by other providers. (Common abbrevia­tions for blood pressure, heart rate, and respi ratory rate are self-explanatory.)

"Mrs. Scott is a young, healthy-appearing woman, well -groomed, fit , and cheerful. Height is 5' 4" , weight 135 lbs, BMI 24, BP 120/80, right and left arms, HR 72 and regular, RR 16, temperature 37.5°C." OR "Mr. Jones is an elderly man who looks pale and chronically ill. He is alert, with good eye contact but unable to speak more than two or three words at a t ime due to shortness of breath. He has intercostal muscle retraction when breathing and sits upright in bed. He is thin , with diffuse muscle wasting. Height is 61

211

, weight 175 lbs, BP 160/95, right arm, HR 108 and irregular, RR 32 and labored, t emperature 101.2° F."

Suggests exacerbation of chronic obstructive pulmonary disease.

Bibliography Citations

1. Bray GA, Wilson JF. In the clinic . Obesity. Ann Intern Med 2008 ;154 :ITC4- l - ITC4- l 6.

5. National Center for Health Statistics, Centers for Disease Prevention and Control. New report finds pain affects millions of Americans . 2006, updated 12.29.09 . Available at http://www.cdc.gov/nchs/pressroom/06facts/hus06 .htm. Accessed June 18, 2011 .

2. American Medical Association. Pain Management: The Online Series. Pathophysiology of pain and pain assessment. Module 1-Pathophysiology of pain and pain assessment. Module 3 - Pain management: Barriers to Pain Management & Pain in Special Populations. Module 7 Assessing and Treating Persistent Non­malignant Pain: An Overview. September 2007. Available at http://www.ama-cmeonline.com/ pain_mgmt/. Accessed July 1, 2011.

3. Upshur CC, Ludemann RS, Savageau JA. Primary care pro­vider concerns about management of chronic pain in commu­nity clinic populations. J Gen Int Med 2006;21:652-655 .

4. Sinatra R. Opioid analgesics in primary care: challenges and new advances in the management of noncancer pain. J Am Board Fam Med 2006;19:165- 167.

6. Roger VL, Go AS, Lloyd-Jones DM et al. Heart disease and stroke statistics-2011 update: a report from the American Heart Association. Data source: National Health and Nutrition Survey (NHANES) 2005-2008; National Heart, Lung, blood Institute, and unpublished data. Circulation 2011;123:e18-e209. Available at http:// circ.ahajournals .org/cgijreprint/ CIR.Ob013e3182009701. Accessed April 13, 2011.

7 . Flegal KM, Carroll MD, Ogden CL et al. Pn:valence and trends in obesity among US adults,, 1999- 2008 . JAMA 2010;303:235- 241. •

8. Adams KF, Schatzkin A, Harris TB et al. Overweight, obesity and morality in a large prospective cohort of persons 50 to

71 years old . N Engl J Med 2006;335:763-778. 9 . Kenchaiah S, Evans JC, Levy D et al. Obesity and the risk of

heart failure. N Engl J Med 2002;347:305-313.

CHAPTER 4 I Beginning the Physical Examination : General Survey, Vital Signs , and Pain 131

;

I I

BATES'

Eleventh Edition

Lynn s. Bickley, MD, FACP Clinical Professor of Internal Medicine

School of Medicine University of New Mexico

Albuquerque, New Mexico

Peter G. Szilagyi, MD, MPH Professor of Pediatrics Chief, Division of General Pediatrics University of Rochester School of Medicine and Dentistry

Rochester, New York

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Library of Congress Cataloging-in-Publication Data

Bickley, Lynn S. Bates' guide to physical examination and history-taking.-11 th ed./Lynn S. Bickley, Peter G. Szilagyi .

p .; cm. Guide to physical examination and history-taking Includes bibliographical references and index. ISBN 978-1-60913-762-5 (hardback : alk. paper) I. Szilagyi, Peter G. II. Bates, Barbara, 1928-2002. Guide to physical examination and history-taking.

III. Title. IV. Title: Guide to physical examination and history-taking. [DNLM: 1. Physical Examination-methods. 2. Medical History Taking-methods. WB 205] 616.07'54-dc23

2012029587

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from appli­cation of the information in this book and make no warranty, expressed or implied, with respect to tl1e currency, complete­ness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.

The authors, editors, and publisher have exerted every effort to ensure tlut drug selection and dosage set fortl1 in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow ofinformation relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

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