General Appearance Flashcards
General appearance (def)
The initial evaluation or assessment of a patients overall health
Things to look for during GA (7)
- Gender
- Stage of life
- Presenting appearance (level of sickness)
- Mental status
- body development
- ethnic/racial background (when appropriate)
- State of comfort/discomfort
Level of toxicity
- how sick the pt looks
2. is it acute or chronic
How is state of comfort reported
NAD
What to look for when distressed
- posture/writhing, body language
- Difficulty breathing
- Emotional distress
Where is GA included in the SOAP note
In the objective section
Descriptors of body habitus (too much)
- overweight
- obese
- Morbidly obese - can only use if specific measurements are taken
Descriptors of body habitus (too little)
- Thin
- Slender
- Anorexic appearing
- Frail
- Cachetic
Cachetic
Wasted away - usually terminally ill patients
Development
- Overdeveloped = a lot of muscle
2. Underdeveloped =very little muscle, malnourished
Mental status
The patients affect
not how the patient says they feel
Things to observe with mental status
- LOC
- Orientation - neurologic
- Behavior- calm, agitated, lethargic
- Eye contact
- Physical appearance
- Speech - does it make sense, slurred,
Facies
Presentation of a disease that you can diagnose based on the pts face alone - “classic presentation” (hyperthyroidism). Usually endocrine related!
Types of facies
- hypo/hyperthyroid
- Cushinoid
- Leonine
- Depressed
