General

Physical Assessment

Haider Yousif
Assistant Professor
Clinical Oncologist
MD., Msc
2023
 Physical assessment / Examination
Is a systematic data collection method that uses the senses of :
Vision
Hearing
Smell
Touch

To detect health problems

There are four techniques used in physical assessment and these are:-
Inspection,
Palpation,
Percussion and
Auscultation.
Usually history taking is completed before
physical examination
 Preparation for Examination
Infection control:
If patient have any open skin lesions and any drainage.
Nurse has to maintained infection control and avoid
infection :
-Use apron (is an outer protective garment that
covers primarily the front of the body).
-Use gloves
-Use mask
-Use gown
 Equipment required for a full examination

• Stethoscope / Sphygmomanometer / Thermometer

• Torch
• Measuring tape / Weighing scales & a height measuring device
• Wooden spatula
• Magnifying glass
• Ophthalmoscope / Otoscope / Tuning fork
• Tendon hammer
• Cotton wool
• Disposable Neurotips (pins )
 Patient Preparation
 Prepare the patient physically and make the patient comfortable
throughout the physical assessment for successful exam.
 Explain to the patient everything to be done & clarify client doubt.

Physical preparation
Bladder and Bowel elimination
Draped properly
Dressed properly Psychological preparation
Positioning Should free from anxious feeling.
If both are opposite sex then third
person is necessary.
Observe facial expression
THE PATIENT
SETTING
Privacy: Is essential when you examine a patient.

Pulling the curtains around the bed in a ward obscures vision but
not sound.

Talk quietly but ensure good communication

The room should be warm and well light (mild jaundice).

Adjustable the examination couch or bed and back rest is essential

(dysponic patient)

Seek permission to expose the areas of the body to be examined &

cover the rest of the patient

Avoid unnecessary exposure and embarrassment (shame).

Tactfully (diplomatically) ask relatives to leave the room before
the physical examination except if :
-Child patient
-Opposite sex
-Patient is apprehensive
-If you need a translator
-If the patient requests it.
-For any intimate examination
 Principals of inspection
It’s the use of vision to distinguish the normal from the
abnormal findings.

In addition to previous points of patient setting

 Position and expose body part to view all surfaces
 Inspect each area for size, shape, color, symmetry, position and
abnormalities.
 If possible compare each area inspected with the same area on the
opposite side.
 If the emergency response was to the patient's home,
make a visual inspection for
 Cleanliness

 Prescription medicines

 Illegal drug

 Weapons

 Signs of alcohol use

NOTE: If there is a sign of acute distress , comprehensive health

assessment is deferred until when patient is stable.
 FIRST IMPRESSIONS

- Assess patients’ general behavior & external

appearance,

- Watch how they rise from their chair and walk

into the room.
 HEAD TO TOE ASSESSMENT

General examination: (GAD-5B-2P-GASA)

1.Gender and race:

[White, Black or African American, Indian or Asian]
Example –
Skin cancer is 20% higher in white than black people.
Prostate cancer is higher in African American than white American.

2. Age :
Old age people and children's are more prone to get infection.
3. Distress Signs :
Pain, Difficulty in breathing
4. Body type:
Thin, Fat
5. Body movement:
-Movement are purposefully.
-If any part is immobile.

6. Body Hygiene :
-Personal hygiene maintain or not.
-Cosmetic used or not
7. Body Dress:
Culture, life style, socio economic status.
It should be appropriate according to weather condition.
8. Body odor:
-Unpleasant odor -Poor hygiene
-Bad breath -Poor oral hygiene

9. Position & Posture: (static and dynemic)

Standing , upright position or Knee flexed
10. Gait:
Co-ordination proper or not, person normally walk with the arms
swinging freely at the sides, with the head and face leading the
body.

11. Affect and mood:

-Feeling's to other
-Emotionally expression
-Mood appropriate as per situation
12. Speech:
Pressure, tone, speed.

13. Client abuse: any problem during growing and serious health
problem during childhood.

14. Substance abuse: -Drugs / Alcohol & Smoking

 Variable type of patient position
STANDING
SUPINE AND PRONE
  Sitting/fowler’s Propped Up Position
Asthma & HF

0⁰
- 6
45

Fowler's position is a standard patient positioning which the patient is

seated in a semi-upright sitting position (45-60 degrees) and may have
knees either bent or straight. ... Fowler's position facilitates the relaxing
of tension of the abdominal muscles, allowing for improved breathing.
This position is also ideally suitable for implementation of oral and
gastric feeding in the patient’s body
Lateral decubitus position
Indicated for abdominal radiograph which
is used to identify free intraperitoneal
gas (pneumoperitoneum)

Supine position
Tripod
position
Curled Up Position
Mohammedian Prayer Position

Sitting and leaning forward Position

 DORSAL RECUMBENT

A position in which the patient lies on

the back with the lower extremities
moderately flexed

Used in pelvic and abdominal

examination
 LITHOTOMY
A position in which the patient lies on the back with
the lower extremities moderately flexed & rotated
outward

Used in vaginal examination,

application of obstetrical tools.
KNEE-CHEST
 Sim’s
Is usually used for rectal examination, treatments and enemas
Gait and posture : give clues about
Neurological disorder
Musculoskeletal disorder or
Patient’s emotions and overall function.

Disorders of gait occur because of :

- Pain,
- Fixed or immobile joints,
- Muscle weakness or
- Abnormal limb control .

If the patient is in bed, look at his posture.

Spastic hemiparesis
One arm held immobile and
close to the side with elbow,
wrist and fingers flexed.
Leg extended with plantar
flexion of the foot.
On walking, the foot is
dragged, scraping the toe
in a circle (circumduction).

Caused by upper motor

neuron lesion, stroke.
Steppage gait
Foot is dragged or lifted high
and slapped onto the floor due
to loss of dorsiflexion.
Unable to walk on the heels.

Caused by foot drop owing to

lower motor neuron lesion.
Sensory or cerebellar ataxia
Gait is unsteady and wide
based. Feet are thrown forward
and outward and brought down
on the heels.
In sensory ataxia, the patient
watches the ground.
With eyes closed, he cannot stand
steadily (positive Romberg sign).

In cerebellar ataxia, turns are

difficult and patients cannot
stand steadily with feet together
whether eyes open or closed.
Caused by polyneuropathy
or posterior column damage,
e.g. syphilis.
Parkinsonian gait
Posture is curved with head
and neck forwards.

Arms are flexed at elbows and

wrists with little arm swing.

Steps are short and shuffling and

patient is slow in getting started
(festinant gait).

Caused by lesion in the basal

ganglia.
 GAIT ABNORMALITIES

Caused by lesion in weakness of the

the basal ganglia. proximal muscles
of the pelvic girdle
as in pregnancy or
muscle atrophy

Caused by upper motor Spastic cerebral Caused by lower motor

neurone lesion, stroke. palsy &UMNL neurone lesion, stroke.
Clothing :
Gives clues about :
1) Personality,
2) State of mind and
3) Social circumstances.

Young wearing
dirty clothes due to
alcohol or drug -Elderly patients with
addiction
faecal or urinary soiling
(immobility, dementia or
other mental illness)
Anorectic patients
wear baggy clothing
to cover weight loss
 Odours
A distinctive smell, especially an unpleasant one .

Everybody has a natural smell, produced by bacteria acting on

apocrine sweat; this may be altered by deodorants and
perfume.

Excessive sweating and poor personal hygiene increase body

odour and may be compounded by dirty or soiled clothing and
stale urine.
Excessive body odor occurs in:
• Extreme old age or weakness
• Major mental illness
• Alcohol or drug misuse
• Physical disability preventing normal hygiene
• Severe learning difficulties.

Other Odors:
Tobacco’s characteristic remaining smell saturate skin, hair and
clothing.

Marijuana (cannabis) can also be identified by smell.

Alcohol smell on a patient’s breath, particularly in the morning,

may suggest an alcohol problem.
 Halitosis (bad breath)

Causes :
1) Decomposing food wedged between the teeth,
2) Gingivitis,
3) Stomatitis,
4) Atrophic rhinitis and
5) Tumors of the nasal passages.
Other characteristic odours include:
• Fetor hepaticus: breath of the dead in patients with liver failure

• Ketones: a sweet smell due to acetone in diabetic ketoacidosis or

starvation

• Uraemic fetor: fishy smell on the breath in uraemia

• Putrid or fetid smell of chronic anaerobic suppuration due to

bronchiectasis or lung abscess

• Foul­smelling belching in patients with gastric outlet obstruction

• Strong faecal smell in patients with gastrocolic fistula.

Facial expression

Ask yourself :
• ‘Does this patient look well?’
- Poverty of expression indicate parkinsonism
- Apathy , with poverty of expression & poor eye
contact indicate depression

- Startied expression indicate hyperthyroidism

- Apathy with pale and puffy

skin indicate hypothyroidism
- Lugubriuos (saddness) expression with
bilateral ptosis (droping of upper lid) with
frontal balding and delayed relaxation of
grip after a handshake indicate myotonic
dystrophy “progressive muscle wasting and
weakness “ and are not able to relax certain muscles
after use.

- Agitated (anxious) expression indicate

anxiety , or hypomania
 Skin Complexion :
Facial color depends on :
Oxyhaemoglobin (bright red)
- Reduced haemoglobin (paller)
- Melanin (brown) and Phenothiazines induce
slate grey pigmentation
- Carotene (orange)

Drug metabolites Diseases

Chronic kidney Sulphaemoglobin

Mepacrine Amiodarone disease or
(anti maliaria) (anti arrythemia) yellow­brownish methaemoglobin
yellow bluish­grey bluish tinge

Phenothiazines
(Antipsychotic)
(slate grey)
Abnormal pigmentation:
Melanin
Skin colour is greatly influenced by the deposition
of melanin

Vitiligo
This chronic condition produces bilateral symmetrical depigmentation,
commonly of the face, neck and extensor aspects of the limbs, resulting
in irregular pale patches of skin.
Causes of abnormal melanin production
Mechanism Condition
Underproduction
Autoimmune destruction of melanocytes - Vetiligo (patchy depigmentation)
Genetic deficiency of tyrosinase (is the key enzyme - Albinism (generlized depigmentation)
in melanin synthesis)
Reduced pituitary secretion of melanotrophic - Hypopituitrism
peptides
GH &sex steroids
Overproduction
Increase pituitary secretion of melanotrophic - Adrenal insuffiecincy (Addison's disease)
peptides
Ectopic release of melanotrophic peptides peptides - Nelsons syndrome due to ectopic
by dys-regulated tumors cells adrenocorticotrophic hormone secretion by
tumors as SCLC
Increase levels of sex hormones - Pregnancy (chloasma) and OCP*
[by amplifying the effects of UV on melanogenesis
via direct effects on melanocytes or indirect effects
via keratinocytes & on transfer of melanosomes

Iron deposition and stimulation of melanocytes - Haemochromatosis

*OCP : oral contraceptive pills

 Albinism
This is an inherited disorder in which patients have
little or no melanin in their skin or hair.

The amount of pigment in the iris varies; some

individuals have reddish eyes, but most have blue.

Pregnancy and oral contraceptives

These may produce chloasma (the mask of
pregnancy) , is splashes of darkened skin that may
appear on the forehead, nose, and cheeks

Iron
Haemochromatosis increases skin pigmentation due
to iron deposition and stimulation of melanocytes.
Sites seen of overproduction of melanin
It produces brown pigmentation, particularly
1)In skin creases,
2)Recent scars,
3)Sites overlying bony prominences,
4)Areas exposed to pressure, e.g. belts and bra straps,
5)The mucous membranes of the lips and mouth, where
it results in muddy (dirty) brown patches .
Carotene
Hypercarotenaemia :
A yellowish/orange discoloration is seen
on the face, palms and soles, but not the sclerae, and this
distinguishes it from jaundice .

Causes:
1) Eat large amounts of raw carrots and tomatoes
2) Hypothyroidism: [↓ in the conversion of carotene into vitamin A]
Bilirubin:
Jaundice is detectable when serum bilirubin
concentration is elevated and the sclera, mucous
membranes and skin become yellow .
(Sclera contain elastin fiber which have high affinity to
bilirubin)
In longstanding jaundice a green colour
develops in the sclerae and skin due to
biliverdin (green colour) which result from
heme-oxygenase.

Patients with chronic pernicious anemia have

mild jaundice (due to liver dysfunction as
cirrhosis) with anemia give a lemon­yellow
complexion
 Anemia
Is defined as a decrease in the :
1) Amount of (RBCs)
2) Hemoglobin in the blood or
3) Ability of the blood to carry oxygen.

Vasoconstriction caused Pallor occurs during a faint

or fear.

Vasodilatation produce a pink complexion, even in

anemia.
The pallor of anemia is best seen in :
- Mucous membranes of the conjunctivae,
-Lips / tongue (The ventral surface is smooth ,shiny, pink or slightly
pale w/ visible veins )
-Palmer crease (hyper extension see lighter color than palm indicate
Hb. ≤ 8 gm/dL)
-Nail beds

Non anemic skin pallor:

1)Fair skinned individual
2) Hypopituitarism and
3)Hypogonadism
4) Cold weather
5) Racial skin
Polycythaemia
Is a facial plethora caused by raised haemoglobin
concentration with elevated haematocrit >55%
( is blood volume that is occupied by RBCs increases
also known as packed cell volume (PCV) or erythrocyte
volume fraction (EVF), it is normally 45% for men and
40% for women).
Causes :
1) Increase in the number of RBC (absolute
polycythemia)
2) Decrease in the volume of plasma (relative
polycythemia(

Erythrocytosis : refers to a documented increase of

red cell mass , not increase in RBC No.
Types of Polycythaemia
A)Primary : polycythemia rubra vera

B) Secondary Polycythaemia : caused by

1) Hypoxia due to:
chronic lung disease , cyanotic congenital heart disease and
altitude
2) Excess erythropoietin due to :
Adult polycystic kidney disease , renal cancer and ovarian
cancer
Cyanosis
It is a blue or purple discoloration of
the skin and mucous membranes due
to the tissues near the skin surface
having low oxygen saturation.

(i.e absolute concentration of deoxygenated

haemoglobin is increased) .

It can be difficult to detect, particularly in black and

Asian patients.
Cyanosis is divided into two main types:
1) Central :
Occur around the core, lips, and tongue

Causes:
Cardiac or pulmonary disease that leads to poor blood oxygenation
in the lungs. It develops when arterial oxygen saturation
(SpO2) drops to ≤90% (normal 95-100%).

Oxygen saturation ratio: is a term referring to the fraction of

oxygen-saturated hemoglobin relative to total hemoglobin
(unsaturated + saturated) in the blood.
Total Hb [saturated
&unsaturated]

Hb,O2
2) Peripheral cyanosis :
This occurs in the hands, feet or ears, usually
when they are cold due to prolonged peripheral
capillary flow allows greater oxygen extraction
and hence increased levels of deoxyhaemoglobin.

In combination with central cyanosis, it is most often seen with

poor peripheral circulation due to shock, heart failure, vascular
disease and venous obstruction, e.g. deep vein thrombosis.
 In which condition ,Anemic or polycythemia see
cyanosis more ?

In anemia or hypovolaemic rarely see central cyanosis :

because severe hypoxia is required to produce the necessary
concentration of deoxygenated haemoglobin.

Conversely in polycythaemia patient can become cyanosed

at normal arterial oxygen saturation.
 Spot diagnoses
Many disorders have characteristic facial
features .
Osteogenesis imperfecta :
Is an autosomal dominant condition
causing fragile and brittle bones with
blue sclerae due to abnormal collagen
formation.

Systemic sclerosis (scleroderma)

Thick and tight skin causing loss of
the normal wrinkles and skin folds,
‘beaking’ [prominent] of the nose,
and narrowing and wrinkling of the
mouth.
Hereditary haemorrhagic telangiectasia
Is an autosomal dominant condition associated
with small dilated capillaries or terminal arteries
(telangiectasia) on the lips and tongue.

Myotonica Dystrophia Is an autosomal

dominant condition with characteristic features
of frontal balding, bilateral ptosis and delayed
relaxation of grip after a handshake.
 GRATITUDE
FOR ATTENTION