General Survey

Question 1

physical appearance

Answer 1

AGE - patient appears stated age
SEX- sexual development is appropriate to sex
LOC- patient is alert and oriented responding to my prompts
SKIN COLOUR- skin colour is appropriate to genetic background
FACIAL FEATURES- facial features are symmetrical with movement
DISTRESS- there are no signs of distress

Question 2

Body Structure

Answer 2

STATURE- height is appropriate for age and gender
NOURISHMENT- patient is well nourished, a good weight for height and age, and shows no signs of dehydration
SYMMETRY- ask patient to extend their arms and note the symmetry bilaterally
POSTURE - Patient is sitting erect comfortably with no slouching or stiffness
POSITION - Patient is sitting comfortable in bed in high fowlers
BODY BUILD/CONTOUR - Patients body has normal proportions, patient has an Ectomorph build

Question 3

Mobility

Answer 3

GAIT - smooth, well balanced walk with a symmetrical arm swing
ROM - patient exhibits good mobility of joints, with smooth and coordinated movements.

Question 4

Behavior

Answer 4

FACIAL EXPRESSION - patient maintains good eye contact, her expressions are appropriate to the situation
MOOD AND AFFECT - patient is comfortable and cooperative and interacting pleasantly
SPEECH - patient has a clear and articulate speech. Ideas are easily conveyed and understood
DRESS - Patient is dressed appropriately for weather, age and cultural group.
ORIENTATION (neuro and resp) - Alert and oriented x3, responsive to questions