Chapter 4
Beginning the
Physical Examination:
General Survey, Vital Signs,
and Pain
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The Health History
Common or Concerning Symptoms
•Fatigue and weakness
•Fever, chills, night sweats
•Weight change
•Pain
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Health History
• Fatigue and weakness
• Fatigue: a sense of weariness or loss of energy
• Weakness: a demonstrable loss of muscle power
• Medical vs. psychosocial causes
• Fever, chills, and night sweats
– Ask about exposure to illness or any recent travel
• Changes in weight
– Rapid or gradual (> 5% over six months).
o Rapid changes over a few days suggest changes in fluid,
not tissue
– Weight gain: nutrition vs. medical causes
– Weight loss: medical vs. psychosocial causes
– some medications may cause elevated temperature
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• Fatigue is a common symptom of depression and anxiety, but also
consider infections (such as hepatitis, infectious mononucleosis, and
tuberculosis); endocrine disorders (hypothyroidism, adrenal
insufficiency, diabetes mellitus); heart Failure; chronic disease of the
lungs, kidneys, or liver; electrolyte imbalance; moderate to severe
anaemia; malignancies; nutritional deficits; and medications.
• Weakness: Possible neuropathy or myopathy.
• Recurrent shaking chills suggest more extreme swings in temperature
and systemic bacteremia.
• Feeling hot and sweating also accompany menopause.
• Night sweats occur in tuberculosis and malignancy.
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• In immunocompromised patients with sepsis, Fever may be absent,
low-grade, or drop below normal (hypothermia).
• Edema from extravascular fluid retention is visible in heart failure,
nephrotic syndrome, liver failure, and venous stasis.
• Many drugs are associated with weight gain, such as: tricyclic antide-
pressants; insulin and sulfonylurea; contraceptives, glucocorticoids,
and progestational steroids; mirtazapine and paroxetine; gabapentin
and valproate; and propranolol.
• Causes of weight loss include gastrointestinal diseases; endocrine
disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency);
chronic infections, HIV/AIDS; malignancy
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• Weight loss with relatively high food intake suggests diabetes
mellitus, hyperthyroidism, or malabsorption. Consider also binge
eating (bulimia) with clandestine vomiting
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Pain
• Assess location, severity, associated features, attempted
treatments/medications, related illnesses, impact on daily activities
• Types of pain
– Nociceptive or somatic – related to tissue damage
– Neuropathic – resulting from direct trauma to the peripheral or
central nervous system
– Psychogenic – relates to factors that influence the patient’s
report of pain
o Psychiatric conditions
o Personality and coping style
o Cultural norms
o Social support systems
– Idiopathic – no identifiable etiology
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Components of General Survey
• General appearance
• Height and weight
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General Appearance - Description
• Apparent state of health • Dress, grooming, and
personal hygiene
– Acute or chronically ill, frail
– Appropriate to weather
• Level of consciousness and temperature
(hypothyroidism)
– Awake, alert, responsive or
lethargic, obtunded, – Clean, properly buttoned/zipped
comatose • Facial expression
• Signs of distress – Eye contact, appropriate
changes in facial expression
– Cardiac or respiratory; pain;
anxiety/depression • Odors of body and breath
• Skin color and obvious lesions • Posture, gait, and motor activity
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• Neglected appearance may appear in depression and
dementia, but should be compared with the patient’s
norm.
• Breath odors can reveal the presence of alcohol or
acetone (diabetes), pulmonary infections, uremia, or
liver failure.
• Patients often prefer sitting upright in left-sided heart
failure and leaning forward with arms braced in chronic
obstructive pulmonary disease.
• Anxious patients appear agitated and restless. Patients in
pain often avoid movement.
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Height and Weight
• Height
– Short or tall
– Build: slender and lanky, muscular, or stocky
– Body symmetry
– Note general body proportions and any deformities
• Weight
– Emaciated, slender, plump, obese
– If obese, is fat distributed evenly or concentrated over
trunk, upper torso, or around the hips?
– simple obesity or truncal fat with relatively thin limbs in
Cushing syndrome and metabolic syndrome.
• Calculating the body mass index (BMI)
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Body Mass Index
• A calculation based on height • Used to classify patients as:
and weight
Methods to Calculate Body Mass Index Classification of Overweight and
(BMI) Obesity by BMI
Unit of Method of Calculation Obesity BMI (kg/m2)
Measure Class
Weight in (1) Body Mass Index Chart
pounds, (see table on p. 91) Underweight <18.5
height in
(2) Weight (lbs) x 700* Normal 18.5-24.9
inches
Height (inches)
Height (inches) Overweight 25.0-29.9
Weight in (3) Weight (kg)
kilograms, Height (m2) I 30.0-34.9
Obesity
height in
II 35.0-39.9
meters
squared
Either (4) “BMI Calculator” at website Extreme
III >40
[Link]/bmibmical obesity
[Link]
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Waist Circumference.
• If the BMI is ≥35 kg/m2, measure the patient’s waist
circumference just above the hips.
• Risk for diabetes, hypertension, and cardiovascular
disease increases signifcantly if the waist circumference
is 35 inches or more in women and 40 inches or more in
men.
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Vital Signs
• Blood pressure
• Heart rate and rhythm
• Respiratory rate and rhythm
• Temperature
• Pain
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Blood Pressure – Optimal Conditions
• Avoid smoking or drinking caffeinated beverages 30
minutes prior to measurement
• Ensure that the room is quiet and comfortably warm
• Patient should be seated quietly in a chair with feet on the
floor for at least 5 minutes
• Patient’s arm should be FREE of clothing
• Palpate the brachial artery
• Position the arm so that the brachial artery is at heart
level
• Rest the arm on a table a little above the patient’s waist,
or support the patient’s arm with your own at his mid-
chest level
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Measurement of Blood Pressure
• Center the inflatable cuff over the brachial artery with the lower
border 2.5 cm above the antecubital crease
• Secure the cuff snugly, not tightly, and position the patient’s arm
so that it is slightly flexed at the elbow
• With the fingers of your opposite hand, palpate the radial artery
and inflate the cuff until the radial pulse disappears; add 30 mm
Hg to this pressure
• Deflate the cuff promptly and completely and wait 15-30 seconds
• Place the bell of the stethoscope lightly over the brachial artery
• Inflate the cuff to the sum pressure previously determined and
deflate slowly
– The point at which you hear the first two consecutive beats is
the systolic pressure
– The disappearance point is the diastolic pressure
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Measurement of Blood Pressure (cont.)
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Blood Pressure
• Auscultatory gap
– A silent interval that may be present between the
systolic and diastolic blood pressures; i.e., the sound
disappears for a while, then reappears
• Orthostatic blood pressure
– Measure blood pressure and heart rate with the patient
supine; wait 3 minutes, then have the patient stand
up; now repeat the measurements
o Normal: systolic BP drops slightly or remains
unchanged; diastolic BP rises slightly
o Orthostasis: systolic BP drops >20 mm Hg or
diastolic BP drops >10 mm Hg
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Normal and Abnormal Blood Pressure
• Normal (adults older than 18 years)
– Systolic: <120 mm Hg
– Diastolic: <80 mm Hg
• If blood pressure is elevated:
– Repeat blood pressure and verify in the
contralateral arm
– Consider “White Coat Hypertension”
o Occurs in 10%–20% of all patients
o Try to relax the patient and retake BP later in
the visit
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Special Situations
• Weak or Inaudible Korotkoff Sounds.
• White Coat Hypertension.
• The Obese or Very Thin Patient.
• Arrhythmias.
• The Hypertensive Patient with Systolic Blood Pressure
Higher in the Arms than in the Legs
• Coarctation of the aorta arises from narrowing of the
thoracic aorta,
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Normal and Abnormal Blood Pressure
• Masked hypertension, defined as office blood pressure
<140/90, but an elevated daytime blood pressure of >135/85 on
home or ambulatory testing.
• Nocturnal hypertension: Physiologic blood pressure “dipping”
occurs in most patients at night as they shift from wakefulness to
sleep.
• A nocturnal fall of <10% of daytime values is associated with poor
cardiovascular outcomes and can only be identified on 24-hour
ambulatory blood pressure monitoring.
• Two other patterns have poor cardiovascular outcomes, a
nocturnal rising pattern and a marked nocturnal fall of >20% of
daytime values
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Heart Rate and Rhythm
• Radial pulse is commonly used to measure the heart
rate
– Use the pads of the index and middle fingers
– If the rate seems normal (50–90-100 bpm) and
the rhythm is regular, count the rate for 30
seconds and multiple by 2. If the rate is fast or
slow and/or the rhythm is irregular, count for a
full 60 seconds.
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Respiratory Rate
• Observe rate, rhythm, depth, and effort of breathing
– Normal rate: ~20 breaths/minute
o Count for 60 seconds
– Observe rhythm: regular, irregular
– Observe depth: shallow, gasping
– Observe effort: normal, labored
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Temperature
• Average oral Rectal 0.5°C (1°F) > oral
temperature: temperature
37°C or 98.6°F Axillary 0.5°C (1°F) < oral
• Diurnal variation: temperature
35.8°C (96.4°F) to
37.3°C (99.1°F)
Tympanic 0.8°C (1.4°F) >
oral temperature
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Recording Your Findings
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