Question

Review how the general appearance assessment can give important clues to the patient’s needs.

Answer 1

The art of the practice of medicine is to be learned only by experience, it is not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become expert.

The physician is much like a detective, searching for clues in the history and physical examination, reserving judgment during the quest for conclusive data. General appearance demands less data collection than any of the other represented items of database content. Yet information gleaned from the patient appearance is particularly valuable, since it is usually the first bit of objective data. Examining the general appearance of the patient may be likened to surveying the forest before walking among the trees.

When you perform a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.

1. Inspection

Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Assess for color, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system.

2. Palpation

Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. Because your hands are your tools, keep your fingernails short and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last.

Types of palpation
Light palpation

    ▪ Use this technique to feel for surface abnormalities.
    ▪ Depress the skin ½ to ¾ inch (about 1 to 2 cm) with your finger pads, using the lightest touch possible.
    ▪ Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.

Deep palpation

    ▪ Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.
    ▪ Depress the skin 1½ to 2 inches (about 4 to 5 cm) with firm, deep pressure.
    ▪ Use one hand on top of the other to exert firmer pressure, if needed.

3. Percussion

Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient's body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas.

Types of percussion
Direct percussion

This technique reveals tenderness; it's commonly used to assess an adult's sinuses.

    ▪ Using one or two fingers, tap directly on the body part.
    ▪ Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort.

Indirect percussion

This technique elicits sounds that give clues to the makeup of the underlying tissue. Here's how to do it:

    ▪ Press the distal part of the middle finger of your nondominant hand firmly on the body part.
    ▪ Keep the rest of your hands off the body surface.
    ▪ Flex the wrist of your nondominant hand.
    ▪ Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient's skin.
    ▪ Listen to the sounds produced.

4. Auscultation

Auscultation involves listening for various lung, heart, and bowel sounds with a stethoscope.

Getting ready

    ▪ Provide a quiet environment.
    ▪ Make sure the area to be auscultated is exposed (a gown or bed linens can interfere with sounds.)
    ▪ Warm the stethoscope head in your hand.
    ▪ Close your eyes to help focus your attention.

How to auscultate

    ▪ Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient's skin, using enough pressure to leave a slight ring on the skin afterward.
    ▪ Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient's skin, just hard enough to form a seal. Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low-pitched sounds.
    ▪ Listen to and try to identify the characteristics of one sound at a time.

What can be learned by looking into a patient's face and eyes? The eyes have been called the windows of the soul, the face the mirror of the mind. Authors and poets have described the importance of such observation. Physicians will long remember some of their patients" faces, the pain, anger, or pleading that can be so vividly expressed by the human face. Clues to endocrine and physiologic abnormalities may also become apparent—the rounded facies of Cushing's disease, the prominent jaw and frontal bossing of acromegaly, or the exophthalmos of hyperthyroidism. Icteric sclera may tell more about a patient's alcohol problem than can be stated. Pallor may quickly explain shortness of breath. Lateral thinning of the eyebrows may suggest hypothyroidism; periorbital edema may represent the nephrotic syndrome; and a butterfly rash may predict lupus erythematosus.

A simple handshake may help assess the circulatory system, suggest active inflammation in the patient with arthritis, or differentiate the cold and moist hands of the anxious patient from the warm and moist ones of the thyrotoxic patient.

The patient's voice may suggest fear, depression, or mania. Speech can also be the first clue to dysarthria or aphasia. The thickened, low pitch of hypothyroidism or hoarseness of laryngeal carcinoma can be detected by a careful listener.

Observation of a shuffling gait will require a particular review of symptoms for signs of Parkinsons's disease and a physical examination particularly directed toward the assessment of mobility. Similarly, gait may suggest a mild hemiparesis secondary to stroke, or the ataxia of cerebellar disease.