General Survey
Shelley Yeager
Instructor
DeSales University
Purposes of the General Survey

To give an overall impression, a "gestalt", of the patient
Techniques of Examination
Age

Technique:

observe the patient from all
angles
Age (cont.)

Normal findings:

patient appears his/her stated age
Age (cont.)

Deviations from normal findings:

patient's appears older than his/her stated age
Sexual Development

Technique:

observe the female patient's
breast and pubic hair
development from all angles
and observe the male
patient's penis, testes,
scrotum, and pubic hair
development from all angles
Sexual Development (cont.)

Normal findings:

Tanner’s stages of breast, penis and scrotum, and pubic hair
development
Tanner 1: Breast Development

Preadolescent

only the nipple is raised
above the level of the
breast, as in the child
Tanner 2: Breast Development



Budding stage
Bud-shaped elevation of
the areola
Areola increased in
diameter and surrounding
area slightly elevated
Tanner 3: Breast Development


Breast and areola enlarged
No contour separation
Tanner 4: Breast Development



Increasing fat deposits
The aerola forms
secondary elevation above
that of the breast
This secondary mound
occurs in approximately
half of all girls and in some
cases persists in adulthood
Tanner 5: Breast Development



Adult stage
The areola is (usually) part
of the general breast
contour and is strongly
pigmented
Nipple projects
Tanner 1: Female Pubic Hair Development


Preadolescent
No growth of pubic hair
Tanner 2: Female Pubic Hair Development

Initial, scarcely pigmented
straight hair, especially
along the medial border of
the labia
Tanner 3: Female Pubic Hair Development

Sparse, dark, visibly
pigmented curly pubic hair
on the labia
Tanner 4: Female Pubic Hair Development


Hair coarse and curly
Abundant, but less than the
adult
Tanner 5: Female Pubic Hair Development


Lateral spreading
Type and triangle spread of
adult hair to medial surface
of the thighs
Tanner 6: Female Pubic Hair Development

Further extension laterally,
upward, or dispersed
(occurs in only 10% of
women)
Tanner 1: Penis and Scrotum
Development

Testes, scrotum, and penis
are the same size and
shape as in the young child
Tanner 2: Penis and Scrotum
Development



Enlargement of the
scrotum and testes
The skin of the scrotum
becomes redder, thinner,
and wrinkled
Penis no larger or scarcely
so
Tanner 3: Penis and Scrotum
Development



Enlargement of the penis,
especially in length
Further enlargement of the
testes
Descent of the testes into
the scrotum
Tanner 4: Penis and Scrotum
Development



Continued enlargement of
the penis and sculpturing
of the glans penis
Increased pigmentation of
the scrotum
This stage is sometimes
best described as "not
quite adult"
Tanner 5: Penis and Scrotum
Development



Adult stage
Scrotum ample
Penis reaching nearly to
the bottom of the scrotum
Tanner 1: Male Pubic Hair Development



Preadolescent
No growth of pubic hair
That is, hair in pubic area
no different from that on
the rest of the abdomen
Tanner 2: Male Pubic Hair Development



Slightly pigmented, longer,
straight hair
Usually at the base of the
penis
Sometimes on the scrotum
Tanner 3: Male Pubic Hair Development

Dark, definitely pigmented,
curly pubic hair around the
base of the penis
Tanner 4: Male Pubic Hair Development

Pubic hair definitely adult in
type but not in extent (no
further than the inguinal
fold)
Tanner 5: Male Pubic Hair Development


Adult distribution
Hair spread to medial
surface of thighs, but not
upward
Sexual Development

Deviations from normal findings:


precocious puberty
delayed puberty
Level of Consciousness

Technique:

observe the patient's
response to external stimuli
Level of Consciousness (cont.)

Normal findings:

patient responds immediately to minimal external stimuli
Level of Consciousness (cont.)

Deviations from normal findings:




lethargic
obtunded
stuporous
comatose
Lethargic

Definition

patient appears drowsy, but
opens his/her eyes and
looks at you, respond to
your questions, and then
falls asleep
Obtunded

Definition


patient opens his/her eyes
and looks at you, but
responds slowly to your
questions and is somewhat
confused
alertness and interest in the
environment are decreased
Stuporous

Definition




patient arouses from sleep
only after painful stimulus
verbal responses are slow
or even absent
lapses into a unarousable
state when the stimuli
ceases
minimal awareness of the
self or the environment
Comatose

Definition


patient remains unarousable
with eyes closed
there is no evident response
to inner need or external
stimuli
Signs of Distress

Technique:

observe the patient for signs
of distress
Signs of Distress (cont.)

Normal findings:

no visible signs of distress
Signs of Distress (cont.)

Deviations from normal findings:

signs of distress, e.g.:

from cardiopulmonary insufficiency, e.g.:


from pain, e.g.:


labored breathing, shortness of breath, wheezing, cough
wincing, sweating, holding painful part, protectiveness of painful part
signs of anxiety, e.g.:

anxious face; fidgety movements; cold, moist palms
Stature

Technique:

observe the patient's stature
from all angles
Stature (cont.)

Normal findings:

height appears within normal range for age, genetic heritage
Stature (cont.)

Deviations from normal findings:

height appears unusually tall for age, genetic heritage, e.g.:




giantism
acromegaly (hyerpituitarism)
Marfan's syndrome
height appears unusually short for age, genetic heritage, e.g.:



Turner's syndrome
achondroplastic dwarfism
hypopituitary dwarfism
Giantism

Description

excessive growth hormone
secretion before closure of
bone epiphyses in puberty
causing overgrowth of all
bones
Acromegaly (Hyerpituitarism)

Description

excessive growth hormone
secretion after closure of
bone epiphyses in puberty
causing overgrowth of the
bones in the face, hands,
and feet
Marfan's Syndrome

Description

connective tissue disorder
resulting in a tall, thin stature
with long extremities and
long, hyperextensible fingers
Turner's Syndrome

Description

a chromosonal abnormality
seen in about 1 in 3000 live
female births, characterized
by the absence of one X
chromosone, congenital
ovarian failure, genital
hypoplasia, cardiovascular
anomalies, short stature,
short metacarpals, shield
chest, underdeveloped
breasts, uterus, and vagina
Achondroplastic Dwarfism

Description

a genetic abnormality in the
ability to convert cartilage to
bone resulting in dwarfism
characterized by a relatively
large head, short stature,
short limbs, thoracic
kyphosis, prominent lumbar
lordosis, and prominent
abdominal protrusion
Hypopituitary Dwarfism

Description

deficiency in growth
hormone secretion in
childhood characterized by a
short stature
Weight

Technique:

observe the patient's body
weight from all angles
Weight (cont.)

Normal findings:


weight appears within range for height and body stature
body fat distribution is even
Weight (cont.)

Deviations from normal findings:
•
•
•
cachetic
exogenous obesity
excessive caloric intake

•
•
•
e.g., simple obesity
even body fat distribution
normal muscle strength
endogenous obesity

excessive secretion of or administration of adrenocorticotropic hormone (ACTH)
•
e.g., Cushing's syndrome
•
•
•
•
•
•
•
centripedal (truncal) obesity
fat concentrated in the face, neck, trunk
thin extremities
decreased muscle strength due to muscle atrophy
round (moon) face
hirsutism
purple abdominal striae (stretch marks)
Body Symmetry

Observe the patient's body
symmetry from all angles
Body Symmetry (cont.)

Normal findings:

symmetry in the size and shape of the body parts
Body Symmetry (cont.)

Deviations from normal findings:

asymmetry in the size and shape of the body parts
Posture

Technique:

observe the patient's
posture from all angles
Posture (cont.)

Normal findings:




patient stands comfortably erect as appropriate to age
normal "plumb line" through anterior ear, shoulder, hip, patella, and
ankle
lordosis (sway back) and protruberant abdomen in standing toddler
kyphosis (hunch back) in the aging person
Posture (cont.)

Deviations from normal findings:
Position

Technique:

observe the patient's
position from all angles
Position (cont.)

Normal findings:

patient sits comfortably in a chair, on the bed, or on the examination
table with arms relaxed at sides and head turned toward examiner
Position (cont.)

Deviations from normal findings:

leaning forward with arms braced on chair arms (tripod position)


sitting straight up and resisting lying down


e.g., chronic pulmonary disease
e.g., left-sided congestive heart failure
curled up in a fetal position

e.g., acute abdomen
Body Build

Technique:

observe the patient's body
build from all angles
Body Build (cont.)

Normal findings:





arm span equals height
body length from crown to pubis roughly equal to length from pubis to
sole
mesomorph
ectomorph
endomorph
Mesomorph

Description

body build characterized by
a predominance of muscle,
bone, and connective tissue
Ectomorph

Description

body build characterized by
a slender and fragile
physique
Edomorph

Description

body build characterized by
a soft, round physique with a
large trunk and thighs,
tapering extremities, and an
accumulation of fat
throughout the body
Body Build (cont.)

Deviations from normal findings:

Marfan's syndrome
Marfan’s Syndrome

Description

connective tissue disorder
resulting in tall, thin stature
with long extremities and
long, hyperextensible fingers
and an arm span that
exceeds height and a pubis
to sole measurement that
exceeds crown to pubic
measurement
Gait

Technique:

observe the patient's gait
from all angles
Gait (cont.)

Normal findings:


normal pattern of gait
gait of old age
Normal Pattern of Gait






Head is erect
Gaze is straight ahead
Vertebral column is upright
Feet are a shoulder's width
apart
Heel strikes the ground
before the toe
Feet are dorsiflexed in the
swing phase
Normal Pattern of Gait


Arm opposite the swingthrough foot moves forward
at the same time
Gait is smooth,
coordinated, and rhythmic
with even weight borne on
each foot
Gait (cont.)

Deviations from normal findings:

abnormal patterns of gait, e.g.:







spastic hemiparesis
scissors
steppage
sensory ataxia
cerebellar ataxia
Parkinsonian
gait of old age
Spastic Hemiparesis

Associated with
corticospinal tract disease,
such as with cerebral
vascular accident (CVA)
Spastic Hemiparesis (cont.)

One arm is held immobile
and close to the side, with
elbow, wrist, and
interphalangeal joints
flexed; the leg is extended,
with plantar flexion of the
foot; on walking, the patient
either drags the foot, often
scraping the toe, or circles
it stiffly outward and
forward (circumduction)
Scissors

Associated with bilateral
spastic paresis of the legs
Scissors (cont.)

The gait is stiff; each leg is
advanced slowly, and the
thighs tend to cross
forward on each other at
each step; the steps are
short; the patient appears
to be walking through
water
Steppage

Associated with foot drop,
usually secondary to lower
motor neuron disease
Steppage (cont.)

The patient either drags
his/her feet or lifts them
high, with knees flexed,
and brings them down with
a slap onto the floor, thus
appearing to the walking
up stairs; the patient is
unable to walk on his/her
heels; the steppage gait
may involve one or both
sides
Sensory Ataxia

Associated with the loss of
position sense in the legs,
as from polyneuropathy or
posterior column damage
Sensory Ataxia (cont.)

The gait is unsteady and wide
based (with feet wide apart); the
patient throws his/her feet
forward and outward and brings
them down, first on the heels
and then on the toes, with a
double tapping sound; the
patient watches the ground for
guidance while walking; with the
eyes closed, the patient cannot
stand steadily with feet together
(a positive Romberg sign) and
the staggering gait worsens
Cerebellar Ataxia

Associated with disease of
the cerebellum or
associated tracts
Cerebellar Ataxia (cont.)

The gait is staggering,
unsteady, and wide based,
with exaggerated difficulty
on turns; these patients
cannot stand steadily with
their feet together, whether
their eyes are open or
closed
Parkinsonian

Associated with the basal
ganglia defects of
Parkinson's disease
Parkinsonian (cont.)

The posture is stooped,
with the head and neck
forward and hips and
knees slightly flexed; the
arms are flexed at the
elbows and wrists; the
patient is slow getting
started; steps are short and
often shuffling; arm swings
are decreased and the
patient turns around stiffly "all in one piece"
Gait of Old Age

The aging process
Gait of Old Age (cont.)

Speed, balance, and grace
decrease with aging; steps
become short, uncertain,
and even shuffling; the legs
may be flexed at the hips
and knees; a cane may
bolster lost confidence
Involuntary Movements

Technique:

observe the patient for
involuntary movements from
all angles
Involuntary Movements (cont.)

Normal findings:

absence of involuntary movements
Involuntary Movements (cont.)

Deviations from normal findings:



tics
tremors
seizures
Facial Expression

Technique:

observe the patient's facial
expression from all angles
Facial Expression (cont.)

Normal findings:


maintains eye contact (unless a cultural taboo)
expressions are appropriate to the situation
Facial Expression (cont.)

Deviations from normal findings:





flat
depressed
angry
sad
anxious
Mood and Affect

Technique:

observe the patient's mood
and affect from all angles
Mood and Affect (cont.)

Normal findings:

comfortable and cooperative with the examiner
Mood and Affect (cont.)

Deviations from normal findings:




hostile
distrustful
suspicious
crying
Speech

Normal findings:





articulation is clear and understandable
stream of talking is fluent with an even pace
conveys ideas clearly
word choice is appropriate to culture and education
communicates in prevailing language easily by him/herself or with an
interpreter
Speech (cont.)

Deviations from normal findings:
•
•
•
•
•
•
dysarthria
dysphagia
speech defect
monotone
garbled speech
extremes of few word or constant talking
Dress

Technique:

observe the patient's dress
from all angles
Dress (cont.)

Normal findings:




well fitting clothes
clothes look clean
clothes are appropriate for the season and temperature
clothes are appropriate to the person's culture and age group
Dress (cont.)

Deviations from normal findings:




ill fitting clothes
clothes look unclean
clothes are inappropriate for the season and temperature
consistent wearing of certain clothes, e.g.:

long sleeves to cover needle marks of drug abuse
Grooming and Personal Hygiene

Technique:

observe the patient's
grooming and personal
hygiene from all angles
Grooming and Personal Hygiene (cont.)

Normal findings:

clothes



shoes




intact
laces tied
clothes are appropriate for age, occupation, and socioeconomic group
hair



clothes look clean
clothes are properly buttoned and zipped
clean
groomed
nails


clean
groomed
Grooming and Personal Hygiene (cont.)

Deviations from normal findings:

clothes



shoes





have holes
laces untied
wearing slippers
clothes are inappropriate for age, occupation, and socioeconomic group
hair



clothes look unclean
clothes are improperly buttoned and zipped
unclean
poorly groomed
nails


unclean
poorly groomed
Odors of Body or Breath

Normal findings:
•
absence of odors of the body and breath
Odors of Body or Breath (cont.)

Deviations from normal findings:
•
•
•
foul breath
alcohol on the breath
body odor