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Stack #106389

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What should the physical examination include? General impression and observations: hygiene, gait, posture, demeanor, speech. Evaluation of ht,wt, vs. Mental Status examination.
Observe physical examination: Gait Movement, gait, posture.ie. gait is even, steady, strong, with normal balance.
Observe: Behavior, overall appearance, speech and expressions
Document: Behavior wringing of hands, questions must be repeated to pt; Responses are clear, but low voice, and very brief answers.
Mental status examination Assess recent and remote memory.
Assessment of recent and remote memory What did you eat for dinner last night? Pt. doesn't remember. What is your DOB? What are your parents' names? Pt is quick to answer. Husband confirms answers.
More recent and remote memory : Ask about time, place, and the situation. Recite 4 words to pt , instruct to repeat in a few minutes. Conclude with VS.
Family member: Please describe the things that you have noticed about the Pt's behavior that concern you the most. Finally, ask Pt. to recall the 4 words. Pt is able/unable to recall any.
Expert Documentation 1 General survey Pt's Name is Ht, and wt. Client reports feeling anxious and fearful. Recent behavior changes reported; reduced interest in maintaining appearance, household chores not completed, fatigued and depressed often.
Expert Documentation2 Physical Observation Gait: Posture is erect, gait smooth, balance intact.
Expert Documentation 3 Appearance Appearance is dishevelled but clothing is appropriate.
Expert Documentation 4 Oriented Pt is orented to time, place and situation
5 : Speech Speech is clear.
6: Eye contact Reduced eye contact
7: Recall Unable to recall four words or recent events; long term memory intact.
8: Document VS VS: T - 35.7C, BP - 100/62, R - 18, P - 82.
9. Summary Pt is in no apparent distress with no physical complaints.
Created by: tamiboren
 

 



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