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Stack #106389

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
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Question
Answer
What should the physical examination include?   General impression and observations: hygiene, gait, posture, demeanor, speech. Evaluation of ht,wt, vs. Mental Status examination.  
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Observe physical examination: Gait   Movement, gait, posture.ie. gait is even, steady, strong, with normal balance.  
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Observe: Behavior,   overall appearance, speech and expressions  
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Document: Behavior   wringing of hands, questions must be repeated to pt; Responses are clear, but low voice, and very brief answers.  
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Mental status examination   Assess recent and remote memory.  
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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.  
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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.  
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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.  
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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.  
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Expert Documentation2 Physical Observation Gait:   Posture is erect, gait smooth, balance intact.  
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Expert Documentation 3 Appearance   Appearance is dishevelled but clothing is appropriate.  
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Expert Documentation 4 Oriented   Pt is orented to time, place and situation  
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5 : Speech   Speech is clear.  
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6: Eye contact   Reduced eye contact  
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7: Recall   Unable to recall four words or recent events; long term memory intact.  
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8: Document VS   VS: T - 35.7C, BP - 100/62, R - 18, P - 82.  
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9. Summary   Pt is in no apparent distress with no physical complaints.  
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Created by: tamiboren