Occasional mood instability/anxiety; being treated; no memory changes; no history of suicide attempts or suicidal or homicidal thoughtsGeneral Findings and Physical ExamGeneral ObservationsDoes patient appear to be their stated age?Patient appears stated age of 41 yearsLevel of consciousnessAlert and oriented x4Skin colorColor is uniform pink with no lesions or discolorations notedNutritional statusObesePosture and positionSitting upright; arms crossedObvious physical deformitiesNo obvious physical deformities, such as scoliosis, kyphosis, or amputationsMobility: gait, use of assistive devices, ROM of joints, no involuntarymovementFull mobility without assistance; gait stable and steady; no assistive devices; full ROM in joints; no involuntary movementsFacial expressionRelaxed; pleasantMood and affectMood appears calm and relaxed; affect pleasant, open,and appropriateSpeech: articulation, pattern, content and Speech is clear and distinct; articulation is clear with no slurring or disarticulation; content full and 6
appropriate, native languageappropriate for age and education; speaks native language (English) clearly and fluentlyHearingPatient responds appropriately to questions asked at a normal tone and volume.Personal hygieneAppears clean and appropriately groomed; no obvious odor or other hygiene deficitsMeasurements and Vital SignsWeightApprox. 400lbsHeight5’10”BMI57.4Radial pulse: raterhythm82 regular rate and rhythmRespirations: ratedepth16; regular; nonlabored; depth of breathing is normal with not gasping, shallowness, or undirected deep breathingBlood pressure (indicate if sitting or lying)132/72 sittingTemperature (if indicated)N/APain assessmentNo pain reportedSkinHands and nailsSkin on hands is uniform in color, unblemished, warm; nailbeds pink; capillary refill <3 seconds Color and pigmentationUniform in color; no areas of hyperpigmentation or hypopigmentationTemperatureWarm MoistureHeels and feet very dry; other skin areas appropriately dryTextureSmooth texture on majority of skin; skin rough on heels and feetTurgorSkin is taut with some movement; no excessive skin orlack of turgor notedPresence of lesions?No rashes, macules, papules, or vesicles notedHead and Face7
ScalpHairCraniumScalp is smooth with no lesions, excessive dryness, excessive oiliness, or dandruff; hair is thick, smooth, clean, and does not come out easily; cranium is rounded, normocephalic, and symmetricalFace (cranial nerve VII)Sensation is intact on different facial regions; cranial nerve VII intact as evidenced by symmetry and ability to move facial muscles at willTemporal artery and temporomandibular jointTemporal artery: pulses present, no nodules or tenderness noted. TMJ: no pain on palpation or movement; no clicks or abnormal shifting on palpationMaxillary sinuses and frontal sinusesNo tenderness or pain noted on palpation; no nodules or bogginess noted on palpationEyesVisual fields (cranial nerve II)Visual fields intact and full by confrontationExtraocular muscles,
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