Bates’ Visual Guide to Physical Examination

Volume 5: 5.3 General Survey Video Transcript

Narrator: With the patient’s health history in mind, and after good hand hygiene, you are ready for the general survey. Through study and repetition, the examination will flow more smoothly and your technique will become more proficient.

Typically, the physical examination begins with the general survey of the patient. This includes:

Check for changes in skin color and any obvious lesions. Look for scars, plaques or nevi. Consider whether the patient’s personal hygiene and grooming seem appropriate to his or her lifestyle, age, occupation and stage of life. Keep in mind that these norms vary widely, but evaluate if the patient’s clothing is appropriate to the setting and for the weather. For example, are the shoes run down with cutouts or holes leading to painful feet? Note the patient’s hair, fingernails and use of cosmetics if any. They may be clues to the patient’s personality, mood and self regard.

Observe the patient’s facial expression at rest, during conversation and during the physical examination. Watch for eye contact and evaluate if it’s natural, sustained or unblinking or is the gaze averted quickly. Is the affect flat, suggesting depression? Odors, such as the fruity odors of diabetes or the smell of alcohol can be important diagnostic clues. However, never assume that alcohol is the sole or even the most important cause of changes in mental status or neurologic findings.

Does the patient walk smoothly with comfort, self-confidence and balance? Note the patient’s preferred posture and whether the patient is restless or quiet. How often does the patient change position? Is there any apparent in voluntary motor or are any limbs immobile? If possible, measure the patient’s height with the patient in stocking feet. Take this opportunity to note general body proportions and look for any deformities such as kyphosis or scoliosis.

Whenever possible, weigh your patience with their shoes off. Make note of any weight changes over time. Use your measurements of height and weight to determine the body mass index (or BMI). There are several ways to establish the BMI. Your electronic medical record software may do this automatically, or you may use a BMI table. The BMI is calculated by relating height in the column on the left to weight indicated in the corresponding rows to the right. If the BMI is 35 or greater, measure the patient’s waist circumference just above the hips. Risk for diabetes, hypertension and cardiovascular disease increases significantly if the waist circumference is 35 inches or more in women and 40 inches or more in men.

If the BMI is about 25, assess the patient for the additional risk factors noted here:

Patients with a BMI over 25 and two or more of these risk factors should pursue weight loss, especially if the waist circumference is elevated, seen in metabolic syndrome. Additionally, you should assess dietary intake by taking diet history and assessing the patient’s eating patterns. Assess the patient’s motivation to make lifestyle changes that promote weight loss. Be prepared to provide counseling about nutrition and exercise by being well informed about strategies that promote weight loss.

If the patient’s BMI falls below 18.5, investigate possible anorexia, bulimia or other serious medical conditions.

Throughout the general survey, you should strive to continually sharpen your observations and your ability to describe all of the distinguishing features of the patient’s general appearance. Your description should be so precise that a colleague should be able to identify the patient out of a crowd of strangers.