general physical assessment

General Physical Assessment: 

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: 

Examination of the Skin

Exam 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

Abnormal Findings: 

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

Abnormal Findings: 

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)

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

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

Slide 7: 

A symmetry Unequal or asymmetric moles are suspicious.

Slide 8: 

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

Slide 9: 

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

Slide 10: 

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

Slide 11: 

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

Examination of the Lymph Nodes: 

Examination of the Lymph Nodes

Lymph Node Palpation: 

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

Cervical Nodes: 

Cervical Nodes

Exam of Lymph 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

Malignancies: 

Malignancies 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: 

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

Examination of the Thyroid: 

Examination of the Thyroid

Inspection: 

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 : 

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

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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: 

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

Examination of the Abdomen: 

Examination of the Abdomen

General Considerations: 

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

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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: 

Anatomical Locations

Inspection: 

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

Auscultation: 

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

Slide 32: 

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

Percussion: 

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

Liver Span: 

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.

Splenic Dullness: 

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.

General Palpation: 

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

Palpation of the Liver: 

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

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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.

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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: 

Special Tests

Rebound Tenderness: 

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

Slide 42: 

+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

Slide 43: 

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

Slide 44: 

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

Slide 45: 

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

Evaluation of Stool and Urine: 

Evaluation of Stool and Urine

Discolored Urine : 

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

Slide 48: 

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)

Slide 49: 

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: 

Hematuria Gross vs. Microscopic Kidney Trauma Neoplasms Infections

Stool Evaluation: 

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

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

Slide 53: 

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

Constipation : 

Constipation 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 : 

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