Use here all the relevant observations made throughout the course of your history and examination. Include these areas:
Level of Consciousness. Is the patient awake and alert? Does the patient seem to understand your questions and respond appropriately and reasonably quickly, or is there a tendency to lose track of the topic and fall silent or even asleep?
If the patient does not respond to your questions, escalate the stimulus in steps:
■ Speak to the patient by name and in a loud voice.
■ Shake the patient gently, as if awakening a sleeper.
See the table on Level of Consciousness (Arousal), p. 595.
Lethargic patients are drowsy but open their eyes and look at you, respond to questions, and then fall asleep.
Obtunded patients open their eyes and look at you, but respond slowly and are somewhat confused.
If there is no response to these stimuli, promptly assess the patient for stupor or coma—severe reductions in the level of consciousness (see p. 595).
Posture and Motor Behavior. Does the patient lie in bed, or prefer to walk about? Note body posture and the patient's ability to relax. Observe the pace, range, and character of movements. Do they seem to be under voluntary control? Are certain parts immobile? Do posture and motor activity change with topics under discussion or with activities or people around the patient?
Tense posture, restlessness, and fidgetiness of anxiety; crying, pacing, and handwringing of agitated depression; hopeless, slumped posture and slowed movements of depression; singing, dancing, and expansive movements of a manic episode.
Dress, Grooming, and Personal Hygiene. How is the patient dressed? Is clothing clean, pressed, and properly fastened? How does it compare with clothing worn by people of comparable age and social group? Note the patient's hair, nails, teeth, skin, and, if present, beard. How are they groomed? How do the person's grooming and hygiene compare with those of other people of comparable age, lifestyle, and socioeconomic group? Compare one side of the body with the other.
Grooming and personal hygiene may deteriorate in depression, schizophrenia, and dementia. Excessive fastidiousness may be seen in an obsessive-compulsive disorder. One-sided neglect may result from a lesion in the opposite parietal cortex, usually the nondominant side.
Facial Expression. Observe the face, both at rest and when the patient is interacting with others. Watch for variations in expression with topics under discussion. Are they appropriate? Or is the face relatively immobile throughout?
Manner, Affect, and Relationship to Persons and Things. Using your observations of facial expressions, voice, and body movements, assess the patient's affect. Does it vary appropriately with topics under discussion, or is the affect labile, blunted, or flat? Does it seem inappropriate or extreme at certain points? If so, how? Note the patient's openness, approachability, and reactions to others and to the surroundings. Does the patient seem to hear or see things that you do not or seem to be conversing with someone who is not there?
Expressions of anxiety, depression, apathy, anger, elation. Facial immobility of parkinsonism
Anger, hostility, suspiciousness, or evasiveness of paranoid patients. Elation and euphoria of the manic syndrome. Flat affect and remoteness of schizophrenia. Apathy (dulled affect with detachment and indifference) in dementia. Anxiety, depression
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