Assessment - General Survey

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Jarvis Chapter 9

GENERAL SURVEY

The general survey is a study of the whole person, covering the general health state and any

obvious physical characteristics. It is an introduction for the physical examination that will follow; it

should give an overall impression, a gestalt, of the person.

Begins during the interview or when you first meet the client.

Provides clues to guide the nurse during later assessment of body

regions and systems.

GENERAL SURVEY

Uses the following senses:

Vision

Hearing

Smell

GENERAL SURVEY COMPONENTS

Physical Appearance

Mental Status

Mobility

Behavior

Signs of Distress

Vital Signs

Height and Weight

GENERAL SURVEY: PHYSICAL PRESENCE

Stated Age versus Apparent Age


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Age- The person appears his or her stated age.

[Appears older than stated age, as with chronic illness, chronic alcoholism]

Sex- Sexual development is appropriate for gender and age.

[Delayed or precocious-(unusually low age) puberty]

General Appearance

Level of consciousness- The person is alert and oriented, attends to your questions and

responds appropriately.

[Confused, drowsy, lethargic]

Skin color- Color tone is even, pigmentation varying with genetic background, skin is intact

with no obvious lesions.

[Pallor, cyanosis, jaundice, erythema]

Facial features- Facial features are symmetric with movemement.

[Immobile, masklike, asymmetric, drooping]

No signs of acute distress are present.

[Cardiac or respiratory signs-diaphoresis, clutching the chest, shortness of breath, wheezing

/ Pain indicated by facial grimace, holding body part]

BODY STRUCTURE

Symmetry- Body parts look equal bilaterally and are in relative proportion to each other.

[Unilateral atrophy or hypertrophy. Asymmetric location of a body part]

Posture- The person stands comfortably erect as appropriate for age. Note the normal

plumb line through anterior ear, shoulder, hip, patella, ankle. Exceptions are the aging

person who may be stooped with kyphosis-(curvature in the thoracic spine).

[Rigid spine and neck; moves as one unit, e.g. arthritis]

[Shoulders slumped; looks deflated, e.g. depression]

Posistion- The person sits comfortably in a chair or examination table, arms relaxed at sides,

head turned to the examiner.


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[Tripod-leaning forward with arms braced on chair; occurs with chronic pulmonary disease]

[Sitting straight up and resists lying downs, e.g., congestive heart failure]

[Curled up in fetal position, e.g., acute abdominal pain]

Body build, contour- Proportions are:

1. Arm span (fingertip to fingertip) equals height.

2. Body length from crown to pubis roughly equal to length from pubis to sole.

Obvious physical deformities- not any congenital or acquired defects.

[Elongated arm span, arm span greater than height, e.g. Marfans syndrome hypogonadism]

[Missing any extremities or digits, webbed digits, shortened limb]

Body Fat

Nutrition- The weight appears within normal range for height and body build; body fat

distribution is even.

[Cachetric-(loss of weight), emaciated-(abnormally thin or weak). Simple obesity, with

even distribution]

[Centripetal (truncal) obesity- fat concentrated in face, neck, trunk, with thin extremities,

as in Cushs syndrome-(hyperadrenalism)]

Stature

Stature- The height appears within normal range for age, genetic heritage

[Excessively short or tall]

Motor activity

Gait- Normally, the base is as wide as the shoulder width; foot placement is accurate; the

walk is smooth, even, and well-balanced; and associated movements, such as symmetricarm swing are present.

[Exceptionally wide base. Staggered, stumbling]

[Shuffling, dragging, nonfunctional leg. Limping with injury]

[Propulsion- trouble stopping]


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Range of motion- Note full mobility for each joint and that movement is deliberate,

accurate, smooth, and coordinated.

[Limited joint range of motion]

[Paralysis- absent movement]

[Movement jerky, uncoordinated]

No involuntary movement.

[Tics, tremors, seizures]

Body and Breath odors

GENERAL SURVEY: PSYCHOLOGICAL PRESENCE

Dress, Grooming, and Personal Hygiene

Dress- Clothing is appropriate of weather, persons culture, & age. Clean & fits the body.

[Clothing too large and held up by belt suggests weight loss, as does the addition of new

holes in the belt. Clothing too tight may indicate obesity or ascites (excess fluid in the

membranes that line the abdomen and abdominal organs)]

[Consistent wear of certain clothing may provide clues; long sleeves may conceal needle

marks of drug abuse or thin arms of anorexia; Velcro fasteners instead of buttons may

indicate chronic motor dysfunction]

Grooming and Personal Hygiene- The person appears clean and groomed appropriately

for his or her age, occupation, and socioeconomic group.

Hair is groomed, brushed. Womens makeup is appropriate for age and culture.

(In a previously carefully groomed woman, unkempt hair and absent makeup may indicate

malaise or illness.]

Mood and Manner

Mood and Affect- The person is comfortable and cooperative with the examiner and

interacts pleasantly.

[Hostile, distrustful, suspicious, crying]

Speech


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Speech- Articulation (the ability to form words) is clear and understandable.

[Dysarthria (difficulty speaking) and dysphagia (difficulty swallowing)]

(Speech defect, monotone, garbled speech)

(Extremes of few words or of constant talking)

Facial Expressions

Facial Expression- The person maintains eye contact, expressions are appropriate to the

situation. (Note expressions but while the face is at rest and while the person is talking)

[Flat, depressed, angry, sad, anxious]

[However, anxiety is common in ill people. Also, some people smile when they are

anxious]

GENERAL SURVEY: DISTRESS

Labored breathing, wheezing or cough, or labored speech.

Painful facial expressions, sweating, or physical protection of painful

area.

Serious or life-threatening occurrences.

Signs of emotional distress or anxiety.

GENERAL SURVEY: Measurement

Weight

Weight-

[An unexplained weight loss may be a sign of a short-term illness, e.g., fever, infection,

disease of the mouth or throat, or a chronic illness e.g., endocrine disease, malignancy,

depression, anorexia nervosa, bulimia]

Balance scale that has been calibrated


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BMI

BMI:

[Weight gain usually is due to excessive caloric intake; occasionally it is due to endocrine

disorders, drug therapy (e.g., corticosteroids), or depression]

BMI CLASSIFICATIONS FOR ADULTS:

Underweight:


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production (from metabolism, exercise, food digestion, external factors) with heat loss

(through radiation, evaporation of sweat, convection, conduction).

[The thermostat function of the hypothalamus may become scrambled during illness or central

nervous system disorders]

Influences on temperature

Diurnal cycle- of 1 1.5F, with the trough occurring early in the morning hours

and the peak occurring late afternoon to early morning.

Menstrual cycle- Progesterone secretion, occurring with ovulation at midcycle

causes a 0.5 to 1.0 F rise in temperature that continues until menses.

Exercise- Moderate to hard exercise increases body temperature.

Age- Wider normal variation occur in the infant and yound child due to less

effective heat control mechanisms. In older adults, temperature is usually lower

than in other age-groups, with a mean of 36.2 C (97.2 F).

[Hyperthermia, or fever, is caused by pyrogens secreted by toxic bacteria during infections or

from tissue breakdown such as that following myocardial infarction, trauma, surgery, or

malignancy. Neurologic disorders (e.g., a cerebral vascular accident, or surgery) also can reset

brains thermostat at a higher level, resulting in heat production and conservation.]

[Hypothermia is usually due to accidental, prolonged exposure to cold. It also may be

purposefully induced to lower the bodys oxygen requirements during heart or peripheral

vascular surgery, neurosurgery, amputation, or gastrointestinal hemorrhage.]

Routes of temperature measurement

Oral- Accurate and convenient. The oral sublingual site has a rich blood supply

from the carotid arteries that quickly responds to changes in inner core

temperature.

Electronic thermometer- has advantages of swift and accurate measurement

as well as safe, unbreakable, disposable probe covers.

Axillary


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Rectal- take only when other routes are not practical.

[comatose or confused persons, for persons in shock, or for those who

cannot close the mouth bc of breathing or oxygen tubes, wired mandible,

or other facial dysfunction]

Wear gloves an insert a lubricated rectal probe cover on an electric thermometer

only 2-3cm (1 inch) into the adult rectum, directed toward the umbilicus. (For a

glass thermometer leave in for 2.5 min.) Disadvantages to the rectal route are

patient discomfort and the time-consuming and disruptive nature of the activity.

Tympanic membrane thermometer- senses infrared emissions of the

tympanic membrane (eardrum). The tympanic membrane shares the same

vascular supply as the hypothalamus (the internal carotid artery); thus it is an

accurate measurement of core temperature.

-The tympanic membrane thermometer is a noninvasive, nontraumatic device that

is extremely quick and efficient.

-The probe tip has the shape of an otoscope.

-Gently place the covered probe tip in the persons ear canal and aim the infrared

beam at the tympanic membrane.

-Do not occlude the canal.

-Activate the device, read the temperature in 2 to 3 seconds.

-This thermometer is used with unconscious patients or with those in emergency

departments, recovery areas, and in labor and delivery units.

-Current evidence is conflicting; some studies do not support use of tympanic

membrane thermometry in critically ill patients. This device yields measures that

agree closely with core temperature, but accuracy can be affected by diaphoresis in

patients.

GENERAL SURVEY: Vital Signs

Pulse


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-With every beat, the heart pumps an amount of blood-the stroke volume- into the aorta.

This is about 70ml in the adult. The force flares the arterial walls and generates a pressure

wave, which is felt in the periphery as the pulse.

- Count for 30 seconds & multiply by 2.

-If rate is irregular, count for a full minute.

Assess the pulse, including:

(1) rate

(2) rhythm

(3) force

Stroke volume

- The amount of blood pumped by the left ventricle of the heart in one contraction.

(The stroke volume is not all the blood contained in the left ventricle; normally, only

about two-thirds of the blood in the ventricle is expelled with each beat.)

Technique of measurement

-Using the pads of your first 3 fingers, palpate the radial pulse at the flexor aspect

of the wrist laterally along the radius done. If rhythm is regular:

- Count for 30 seconds & multiply by 2.

-If rate is irregular, count for a full minute.

Rate

-In the adult at physical and mental rest, the normal resting heart range is 50 to 90

beats per minute (bpm). Normal rate for age group-The rate normally varies with age, being more rapid in infancy ad childhood and more

moderate during adult and older years.

-The rate also varies with gender; after puberty, females have a slightly faster rate than

males. Bradycardia/Tachycardia


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-In the adult, a resting heart rate less than 50 bpm is bradycardia.

Heart rates in the 50s/min occur normally in the well-trained athlete whose heart muscle

develops along with the skeletal muscles. The stronger, more efficient heart muscle

pushes out a larger stroke volume with each beat, thus requiring fewer bpm to maintain

a stable cardiac output.

-A more rapid resting heart rate, over 90 bpm, is tachycardia.

Rapid rates occur normally with anxiety or with increased exercise to match the bodys

demand for increased metabolism.

[Tachycardia occurs with fever, sepsis, and following myocardial infarction.]

Rhythm

- The rhythm of the pulse normally has an even tempo. Sinus arrhythmia- However, one irregularity that is commonly found in children and young adults is sinus

arrhythmia.(Usually not life threatening, referred to as a normal variation in the

beating of your heart; normal condition)

-Here the heart rate varies with the respiratory cycle, speeding up at the peak of

inspiration and slowing to normal with expiration. Inspiration momentarily causes a

decreased stroke volume from the left side of the heart; to compensate, the heart rate

increases.

Force

-The force of the pulse shows the strength of the hearts stroke volume.

-A weak, thread pulse reflects decreased stroke volume (e.g., as occurs with

hemorrhagic shock).

-A full, bounding pulse denotes an increased stroke volume (e.g., as with anxiety,

exercise, and some abnormal conditions).

-The pulse score is recorded using a 3-point scale:

3+ ->Full, bouding

2+ ->Normal


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1+ ->Weak, thread

0 ->Absent

Elasticity-?


Respirations

-Normally a persons breathing is relaxed, regular, automatic, and silent.

Technique of measurement

-Because most people are unaware of their breathing, do not mention that you willbe counting the respirations, bc sudden awareness may alter the normal pattern.

-Instead, maintain your position of counting the radial pulse and unobtrusively

count the respirations.

-Count for 30 seconds or a full minute if you suspect an abnormality.

Normal rate for age group

-Resp rates are normally more rapid in infants and children

-Neonate: 30-40 bmp

-1 yr: 20-40

2 yr: 25-32

8-10 yr: 20-26

12-14 yr: 18-22

16 yr: 12-20

Adult: 10-20

Ratio of pulse rate to respiratory rate should be approximately

4:1

-A fairly constant ratio of pulse rate to respiratory rate exists, which is about 4:1.


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-Normally, both pulse and respiratory rates rise as a response to

exercise or anxiety.


BLOOD PRESSURE

-Blood pressure is the force of the blood pushing against the side of its container, the

vessel wall.

-The strength of the push changes with the event in the cardiac cycle.

-The systolic pressure is the maximum pressure felt on the artery during left ventricular

contraction, or systole.

-The diastolic pressure is the elastic recoil, or resting, pressure that the blood exertsconstantly between each contraction.

-The pulse pressure is the difference between the systolic and diastolic pressures and

reflects the stroke volume.

[-The mean arterial pressure (MAP) is the pressure forcing blood into the tissues,

averaged over the cardiac cycle.

-This is not an arithmetic average of systolic and diastolic pressures bc diastoliclasts longer. Rather, it is a value closer to diastolic pressure plus one-third the pulse

pressure.]


Influences on blood pressure

Age-Normally, a gradual rise occurs through childhood and into the adult years.

Race- In the US, an African American adults BP is often higher than that of a whiteperson of the same age. The incidence of hypertension is Twice as high in African

Americans as in whites.


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Weight- BP is higher in obese persons than in persons of normal weight of the same

age (including adolescents).

Emotions- The BP momentarily rises with fear, anger, and pain as a result of

stimulation of the sympathetic nervous system.

Sex- Before puberty, no difference exists between males and females. After puberty,

females usually show a lower BP reading than do male counterparts. After menopause,

BP in females is higher than in males.

Diurnal rhythm- A daily cycle of a peak and a trough occurs; the BP climbs to a high

in late afternoon or early evening and then declines to an early morning low.

Exercise- Increasing activity yields a proportionate increase in BP. Within 5 minutes of

terminating the exercise, the BP normally returns to baseline.

Stress- The BP is elevated in persons feeling continual tension bc of lifestyle,

occupational stress, or life problems.


Physiologic factors controlling blood pressure

-The level of BP is determined by 5 factors:

Cardiac output- If the heart pumps more blood into the container, (i.e., the bloodvessels), the pressure on the container walls increase.

Peripheral vascular resistance- Is the opposite to blood flow through the

arteries. When the container becomes smaller (e.g., with constricted vessels), the

pressure needed to push the contents becomes greater.

Volume of circulating blood- Refers to how tightly the blood is packed into the

arteries. Increasing the contents in the container increases the pressure.

Viscosity- The thickness of blood is determined by its formed elements, the blood

cells. When the contents are thicker, the pressure increases.

Elasticity of vessel walls- When the container walls are stiff and rigid, thepressure needed to push the contents increases.


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*Study p.137 Fig 9-5 for Factors Controlling BP Condition

The cuff size is important; using a cuff that is too narrow yields a falsely high BP bc it

takes extra pressure to compress the artery.

Arm Pressure

-A comfortable relaxed person yields a valid blood pressure. Many people are anxious at the

beginning of an examination; allow at least a 5-min rest before measuring the BP. Then take

two or more BP measurements separated by 2 min.

-For each person, verify BP in both arms once, either on admission or for the first complete

physical examination. It is not necessary to continue to check both arms for screening or

monitoring.

-Occasionally a 5- to 10-mm Hg difference may occur in BP in the two arms (if values are

different, use the higher value) and is due to artifact or to subtle differences in technique.

(A reproducible difference in the two arms of more than 10 to 15 mm Hg may indicate arterial

obstruction on the side with the lower reading.)

-The person may be lying or sitting, arm at heart level. Feet should be flat on floor bc BP has a

false high measurement when legs are crossed versus uncrossed!!!

--Palpate the brachial artery, which is located just above the antecubital fossa, medial to the

biceps tendon. With the cuff deflated, center it about 2.5 cm (1 inch) above the brachial artery

and wrap it evenly.

--Now palpate the brachial or radial artery. Inflate cuff until the artery pulsation is obliterated

and then 20 to 30 mm Hg beyond. This will avoid missing an auscultatory gap, which is a period

when Korotkoff sounds disappear during auscultation.

[An auscultatory gap occurs in about 5% of people, most often in hypertension caused by a

noncompliant arterial system.]

-Deflate cuff quickly and completely; then wait 15 to 30 seconds before reinflating so that the

blood trapped in the veins can dissipate.


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-Place the bell of the stethoscope over the site of the brachial artery, making a light but airtight

seal.

-The diaphragm endpiece is usually adequate, but the bell is designed to pick up low-pitched

sounds such as the sounds of a blood pressure ready.

-Rapidly inflate the cuff to the maximal inflation level you determined.

-Then deflate the cuff slowly & evenly, about 2 mm Hg per heartbeat.

*Note the point at which you hear the first appearance of sound, the muffling of sounds, and

the final disappearance of sound.

These are phases I, IV, and V of Kortkoff sounds, which are the compenents of a BP

reading.

-Hypotension, abnormally low BP.

-Hypertension- abnormally high BP.

Orthostatic (or Postural) Vital Signs

Take serial measurements of pulse and BP when

(1) you suspect volume depletion

(2) when the person is known to have hypertension or is taking antihypertensive

meds

(3) when the person reports fainting , or- syncope

Have the person rest supine for 2 to 3 min, take baseline readings of pulse and BP, and then

repeat the measurements with the person sitting and then standing. For the person who is too

weak or dizzy to stand, assess supine and then sitting with legs dangling.

-When the position is changed from supine to standing, normally a slight descrease (less than

10 mm Hg) in systolic pressure may occur.


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[Orthostatic hypotension, a drop in systolic pressure of more than 20 mm Hg or orthostatic

pulse increases of 20 bpm or more occurs with a quick change to a standing position. These

changes are due to abrupt peripheral vasodilation without a compensatory increase in cardiac

output. Orthostatic changes also occur with prolonged bedrest, older age, hypovolemia-

(diminished volume of blood circulating in the body), and some drugs.]

-Record BP by using even numbers. Also record the persons position, the arm used, and the

cuff size if different from the standard adult cuff.

-Record the pulse rate and rhythm, noting whether the pulse is regular.

The Aging Adult

GENERAL SURVEY

Physical appearance- By the eighth and ninth decades, body contour is sharper, with more

angular facial features, and body proportions are redistributed.

Posture- A general flexion occurs by the eight or ninth decade.

Gait- Older adults often use a wider base to compensate for diminished balance, arms may be

held out to help balance, and steps may be shorter uneven.

MEASUREMENT

-Weight

The aging person appears sharper in contour with more prominent bony landmarks than the

younger adult. Body weight decreases during the 80s and 90s. This factor is more evident in

males, perhaps bc of greater muscle shrinkage. The distribution of fat also changes during the

80s and 90s. Even with good nutrition, subcutaneous fat is lost from the face and periphery (esp

the forearms), whereas additional fat is deposited on the abdomen and hips .


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This change in fat distribution and loss in muscle mass can affect the BMI interpretation

in the older adult. For any given BMI, an older adult has more fat tissue than lean tissue when

compared with a younger adult. As an aging person becomes shorter, the BMI reflecting the

shorter height may overestimate the body fat content.

However, these factors do not affect the validity of BMI classification in order to

monitor the persons weight status.

-Height

By their 80s & 90s, many people are shorter than they were in their 70s.

Bc long bones do not shorten with age, the overall body proportion looks different a shorter

trunk with relatively long extremities.

[This results from shortening in the spinal column from thinning of the vertebral disks and

shortening of the individual vertebrae and from the postural changes of kyphosis and slight

flexion in the knees and hips]

VITALS SIGNS (Aging Adult)

-Temperature

Changes in the bodys temperature regulatory mechanism leave the aging person less

likely to have fever but at a greater risk for hypothermia. Sweat gland activity is also

diminished.

-Pulse

The normal range of heart rate is 50 to 90bpm, but the rhythm may be slightly irregular.

The radial artery may feel stiff, rigid, and tortuous in an older person, but this condition doesnot necessarily imply vascular disease in the heart or brain.

The increasingly rigid arterial wall needs a faster upstroke of blood, so the pulse is actually

easier to palpate.


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-Respirations

Aging causes a decrease in vital capacity and a decreased inspiratory reserve volume.

May note a shallower inspiratory phase and an increased respiratory rate.

-Blood Pressure

The aorta and the major arteries tend to harden with age. As the heart pumps against a

stiffer aorta, the systolic pressure increases, leading to a widened pulse pressure.

With many older people the systolic & diastolic pressures increase, making it difficult to

distinguish normal aging values from abnormal hypertension.

PROMOTING HEALTH & SELF-CARE (p152)

Teaching an individual to keep these physical signs (lifestyle modifications) within normal

limits:

Lose weight if you are more than 10% above ideal weight.

Limit alcohol intake to no more than 1 oz of ethanol, 24 oz of beer, 10 oz of wine, or 2 oz

of 100-proof whiskey per day for men,

OR 0.5 oz of ethanol per day for women and lighter-weight people

Get regular aerobic exercise (30-45min brisk walk) most days of the week

Cut sodium intake from average 150 mmol/L to less than 100 mmol/L per day (less than

2.3 g of sodium per day)

Include recommended daily allowances of potassium, calcium, and magnesium in diet


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Stop smoking

Reduce dietary saturated fat and cholesterol

ABNORMAL FINDINGS

Abnormalities in Body Height and Proportion:

Hypopituitary Dwarfism

Deficiency in growth hormone in childhood results in retardation of growth below the 3rd

percentile, delayed puberty, hypothyroidism, and adrenal insufficiency.

(Ex: 9-year-old girl- appears short & much younger than her chronological age, w/

infantile facial features and chubbiness)

Gigantism

Excessive secretion of growth hormone by the anterior pituitary resulting in overgrowth of

entire body. When this occurs during childhood, before closure of bone epiphyses in puberty, it

causes an increased height and weight and delayed sexual development.

Acromegaly (Hyperpituitarism)

Excessive secretion of growth hormone in adulthood, after normal completion of body growth,

causes overgrowth of bone in face, head, hands, & feet but no change in height. Internal organs

also enlarge (e.g., cardiomegaly), and metabolic disorders (e.g., diabetes mellitus) may be

present.


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Marfans Syndrome

An inherited connective tissue disorder, characterized by tall, thin stature (greater than 95th

percentile), arachnodactyly (long, thin fingers), hyperextensible joints, arm span greater thanheight, pubis-to-sole measurement exceeding crown-to-pubis measurement, sternal deformity,

high-arched narrow palate, and pes planus-(flatfoot). Early morbidity and mortality occur as a

result of cardiovascular complications such as mitral regurgitation and aortic dissection.

[Mitral regurgitation- a disorder of the heart in which the mitral valve does not close properly

when the heart pumps out blood. It is the abnormal leaking of blood from the left ventricle,

through the mitral valve, and into the left atrium, when the left ventricle contracts, i.e. there is

regurgitation of blood back into the left atrium.]

[Aortic dissection- occurs when a tear in the inner wall of the aorta causes blood to flow betweenthe layers of the wall of the aorta, forcing the layers apart.]

Achondroplastic Dwarfism

A genetic disorder in converting cartilage to bone results in normal trunk size, short arms and

legs, and short stature. It is charachterized by a relatively large head with frontal bossing-

(prominent forehead) and midplace hypoplasia and, often, thoracic kyphosis-(humpback),

prominent lumbar lordosis-(an inward curvature of the lower backthe lumbar and cervical

vertebrae-), and abdominal protrusion.

Anorexia Nervosa

A serious psychological disorder characterized by severe & life-threatening weight loss and

amenorrhea-(absence of a menstrual cycle) in an otherwise healthy adolescent or young

woman. Behavior is characterized by fanatic concern about weight, aversion to food, distorted

body image (perceives self as fat despite skeletal appearance), starvation diets, frenetic

exercise patterns, & striving for perfection.

Endogenous Obesity-Cushing Syndrome


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Either administration of ACTH or excessive production of ACTH by the pituitary gland will

stimulate the adrenal cortex to secrete excess cortisol. This causes Cushing syndrome,

characterized by weight gain & edema with central trunk & cervical obesity (buffalo hump) and

round, plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin

arms & legs; reduced height; & thin, fragile skin w/ purple abdominal striae, bruising, and acne.Not the obesity here is markedly different from exogenous obesitydue to excessive caloric

intake, in which body fat is evenly distributed and muscle strength is intact.

Abnormalities in Blood Pressure

Hypotension

In normotensive adults:


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Hypertension

This occurs from no known cause but is responsible for about 95% of cases of hypertension.

Normal:

Assessment - General Survey

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