General Physical

Assessment

C. Richard Finley, Ed.D, PA-CAssociate 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:

ColorTexture TurgorMoisture

Pigmentation

Lesions

Hair distribution

Warmth: use back of hand

Abnormal Findings

Color Pallor:

• Iron def. anemiaYellow:

• 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)

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

Asymmetry Unequal or asymmetric moles

are suspicious.

BorderIf the border is irregular or

indistinct, it is more likely to be cancerous (or precancerous)

ColorVariation of color (e.g., more

than one color or shade) within a mole is a suspicious finding

DiameterAny mole that has a diameter

larger than a pencil's eraser in size (> 6 mm) should be considered suspicious.

ElevationIf 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

Cervical Nodes

Exam of Lymph Nodes

Lymph nodes are part of immune system Lymphadenitis

FirmTenderEnlargedWarm

May remain enlarged after infectionLess than 1 cmNontender

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

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 cartilageEither 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

If enlarged, is it symmetricalUnilateral 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 glandConsistency of muscle tissueUnusual hardness

• Cancer or scarringSoftness, or sponginess

• Toxic goiterTenderness

• 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

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?

Auscultation

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 bea 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.

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

Light palpationAreas of tendernessMost sensitive indicator is patient’s facial

expression• Watch the patient’s face, not your hands

Voluntary or involuntary guarding may be present

Deep PalpationIdentify 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

Palpation of the AortaPress down deeply in the

midline above the umbilicusThe 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 SpleenUse the left hand (posteriorly) to lift the

lower rib cage and flank Press down just below the left costal

margin with the right handAsk the patient to take a deep breath

• The spleen is not normally palpable on most individual

Special

Tests

Rebound Tenderness

Test for peritoneal irritationWarn 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

Test for peritoneal fluid (ascites)Percuss the abdomen to outline areas of

dullness and tympanyHave 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

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

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

Discolored Urine

ColorlessLow concentration from excessive fluid

intake• Chronic glomerulonephritis• Diabetes mellitus• Diabetes insipidus

Cloudy White: Phosphates in an alkaline urineEpithelial cells from the lower GU tractBacteriaPus

Yellow: Highly concentrated normal urineTetracyclinePyridine

Orange: UrobilinogenSantonin (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)

Hematuria

Gross vs. Microscopic

KidneyTraumaNeoplasmsInfections

Stool Evaluation

Acute DiarrheaDefecation of watery or loose stoolsConsistency not frequency

Acute Nonbloody DiarrheaViral gastroenteritisFood intoleranceFecal impaction

Acute Bloody DiarrheaPosterior penetrating duodenal ulcerStaph food poisoningHeavy metal poisoningUlcerative colitis

Chronic Intermittent DiarrheaChronic pancreatitisIrritable colonFibrocystic disease

Chronic Constant DiarrheaUlcerative colitisRegional enteritis

Constipation Acute Constipation

Intestinal obstructionFecal impaction

Chronic ConstipationIrritable colonAtonic colonMegacolon

• 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 StoolsSite of hemorrhage is in the colon or belowCopious hemorrhage higher may pass

through undigested Occult Blood

Small volume from any site in the alimentary tract