General Survey Flashcards by Enrique Castro

What must you do first when u see the patient

Observe and Assess

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It begins with the opening moments of patient encounter. First impression of your patient

General Survey

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What should we Assess?

Apparent Health Status
Signs of Consciousness
Facial Characteristics
Skin Color and Obvious Lesions
Dress, Grooming, and Personal Hygiene
Odors of Body and Breath
Body type, Posture, Gait, and Motor Activity
Speech
Cultural Considerations
Developmental Considerations

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Identify what factors during assessment these questions belong to:
- Is the patient acutely or chronically ill?
- Is the patient frail?
- Is the patient fit or robust?
- Is the patient overweight or underweight?

Apparent State of Health

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Identify what factors during assessment these questions belong to:
- Is the patient awake, alert, and responsive to you and others in the environment?
- Is the patient drowsy, lethargic, or stuporous
- Is the patient unconscious

Level Of Consciousness

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Identify Signs of Distress :
- clutching the chest
- has pallor, cyanosis, or diaphoresis
- labored breathing, wheezing, or coughing

Cardiac or Respiratory Distress

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Identify Signs of Distress :
- wincing, diaphoresis, protectiveness of painful area, unusual posture favoring one limb or region of body

Pain

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Identify Signs of Distress :
- anxious facial expressions, fidgety movements, cold moist palms, inexpressive or flat effect, poor eye contact, or psychomotor slowing

Anxiety of Depression

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Identify the Facial Characteristics:
- drooping of eyelid

Ptosis

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Identify what factors during assessment these questions belong to:
- do you see pain, fear, anxiety
- does patient maintain eye contact
- is his or her facial expression happy or sad
- is the facial features symmetrical

Facial Characteristics

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Identify the Facial Characteristics:
- indicates a transient ischemic attack or stroke

Drooping of one side of the face

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Identify the Facial Characteristics:
- bulging or protruding eyeballs
- may suggest hyperthyroidism

Exophthalmos

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Identify Skin color and Obvious Lesions:
- pale complexion or unusual lightness of skin color; may
indicate anemia, malnutrition, vitamin deficiency

Pallor

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Identify Skin color and Obvious Lesions:
- bluish discoloration of the skin or mucous membrane; may indicate poor oxygenation

Cyanosis

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Identify Skin color and Obvious Lesions:
- yellowish discoloration of the skin or mucous membranes
- may suggest underlying hepatobiliary tract disease

Jaundice

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Identify Skin color and Obvious Lesions:
- medical term for mole
- common benign skin lesion but some may be malignant

Nevus

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Identify what factors during assessment these questions belong to:
- how is patient dressed based on the environment
- how worn out is the patient’s shoes and clothing
- does patient have jewelry or tattoos
- does patients nails show signs of biting
- does the patient practice personal hygiene well

Dress, Grooming, and Personal Hygiene

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Identify what factors during assessment these questions or facts belong to:
- can be important diagnostic clues
- fruity odor/ acetone breath may suggest high level of ketones
- other breath odors may suggest alcohol, presence of pulmonary infections, uremia, or liver failure

Odors of Body and Breath

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Identify what factors during assessment these questions or facts belong to:
- the body type, posture, gait, and motor activity of the patient

Body type, posture, gait, and motor activity

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Identify what these statements identify:
- patient’s body size and build in respect of his or her gender and age
- is patient stocky, slender, or average build
- Does patient have abnormal fat distribution?
- Does patient’s hand have clubbing, edema, and deformities

Body Type

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A disorder where body makes to much cortisol. results in truncal obesity and buffalo hump

Cushing’s Syndrome

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Excessive Abdominal fat

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Truncal Obesity

Collection of excess fat behind the neck

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Buffalo Hump

May reflect cardiopulmonary problem. they are found when observing the hands

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Nail clubbing and edema

Athritic changes

Deformities

Identify the problem by the posture of the patient: - Sitting upright

Left sided heart failure

Identify the problem by the posture of the patient: - leans forward with arms braced

COPD

Identify the problem by the posture of the patient: - agitated and restless

anxious

Identify the problem by the posture of the patient: - often avoid movement

patients in pain

Identify the problem by the posture of the patient: - abnormal thoracic curve of spine

Kyphosis

Identify the problem by the posture of the patient: - abnormal Lumbar curve of spine

Lordosis

Manner of walking of a person. Has following questions - how patient enters room - are the patient's movement smooth and coordinated - does he or she need a cane or walker - do u see a wide base of support with short stride - It suggests musculoskeletal, or neurological problem

Gait

Identify what the questions and facts point to: - is there any involuntary motor activity - are some parts immobile - observe for tremors, involuntary movement, or paralysis - can bedridden patient move from side to side, sit up in bed, and change positions - how much assistance does the patient need to move

Motor activity

Rhythmic oscillatory movements and can be subdivided into 3 sub groups

Tremors

Identify which tremor sub group: - most prominent at rest and may decrease or disappear with voluntary movement

Resting or static tremors

Identify which tremor sub group: - appear when affected part is actively maintaining a posture

Postural Tremors

Identify which tremor sub group: - absent at rest, appear with movement and often gets worse as the target gets closer - causes include cerebellar disorders

Intention Tremors

Movement that is not done consciously

Involuntary Movement

They are arrhythmic, repetitive,bizarre movements that chiefly involve face, mouth, jaw, and tongue. Person does grimacing, pursing of lips, protrusions of tongue, and opening and closing of mouth.

Oral Facial Dyskinesias

These are brief repetitive, stereotyped, coordinated movements occurring at irregular intervals

Tics

Its similar to athetoid movements but involve larger parts of the body. Results in grotesque twisted postures of body

Dystonia

Causes more slower and more twisting and writhing that choreiform movements and have larger amplitude. Commonly involves face and the distal extremities

Athetosis

Choreiform movements are brief, rapid, jerky, irregular, and unpredictable. Occurs at rest or interrupt normal coordinated movements. Seldom repeats. Involves face, head, lower arms, and hands

Chorea

Identify what factors during assessment these questions or facts belong to: - what is your patient's speech pattern and pace - is your patient's response appropriate - Note the tone and quality of patient's voice - Patients vocabulary and sentence structure offer clues to his or her educational level

Speech

what can we conclude with from a patients speech: - pressured, inappropriate response, and illogical or incoherent

may be associated with psychiatric disorders

what can we conclude with from a patients speech: - pressured and hurried

may also be seen as hyperthyroidism

what can we conclude with from a patients speech: - changes in voice quality

Cranial nerve IX lesion may be present

what can we conclude with from a patients speech: - garbled - indicates problem on language centers of the brain

associated with strokes

Identify what factors during assessment these facts or questions belong to: - note down any cultural influences that affect physical characteristics, response to pain, dress, and grooming, and hygiene. - it also influences person's verbal and non verbal communication

Cultural Considerations

Identify what factors during assessment these questions belong to: - how we interact and assess patient must be appropriate with their condition, experience, or age

Developmental Considerations

Developmental Considerations - Children

* Behavior should correspond with the child’s developmental level * Children tend to regress when ill * Take note of the relationship between child and parent

Developmental Considerations - Pregnant

* General appearance should reflect gestational age * Look for normal changes that occur with pregnancy, such as wide base of support and lordosis * Look for swelling * Note patient’s affect and response to pregnancy

Developmental Considerations - OLDER ADULTS

* Look for normal changes that occur with aging * Look for clues of decreasing ability to function, especially dressing and grooming problems * Pay attention to affect * Note changes in mental status

General Survey Flashcards

(53 cards)