General Survey:

Awake, conscious, not in respiratory distress,

Vital signs:
BP: 120/80 mmHg
PR: 78 bpm
RR: 20 cpm
Temp: 36.7 C

Physical Examination
Skin:
Brown, trimmed nails, hair is black in color, warm to
touch, good skin turgor, (+) 2
nd
degree burn at the
right dorsal hand
HEENT:
Anicteric sclerae, pinkish palpebral conjunctivae,
(-) ear discharge, nasal septum at midline , (-) tonsillar
enlargement , non erythematous,non exudative
Neck:
Trachea at midline, no palpable mass, (-)CLAD



Chest/Lungs:
Equal lung expansion, clear breath sounds
Heart:
Adynamic precordium, normal rate regular rhythm, no
murmur
Abdomen:
Flat, normoactive bowel sounds,tympanitic,nontender
Extremities
Full pulses, CRT<2sec, no edema, no cyanosis
Genitalia:
Not assessed
Rectal Exam:
Not assessed

Neurologic exam:
GCS 15
Eye Response: 4 (Spontaneous)
Verbal Response: 5 (Oriented)
Motor Response: 6 (Obeys to Command)

Cranial nerves
I - can smell
II, III Pupil are round and equally reactive to light and
accommodation.
IlI, IV, VI normal EOMS.
V Normal sensation of face
VII no facial asymmetry
VIII able to hear whispered voice
IX , X - Able to swallow w/o difficulty.
XI No shoulder lag
XII tongue is in the midline, able to move tongue in
different directions
Motor
No involuntary movements such as tics, tremors
or fasciculation's noted.
Strength is 5/5 on all extremities.
Sensory
Pain , temperature , light= intact



MENTAL STATUS EXAM
I. PRESENTATION

General appearance - patient was seen handcuffed
and agitated.He was poorly- groomed, wearing black
short pants without t-shirt.Hands and feet are dirty
covered with mud.Nails were not trimmed.
Behavior agitated
Doctor - patient interaction
initially uncooperative(doesnt answer questions ) but
became cooperative during the course of conversation.

II. EMOTIONAL STATE AND REACTION

Mood Anxious
Affect Appropriate

III. NEUROVEGETATIVE FUNCTION:

SLEEP: early insomnia
APPETITE: Normal
WEIGHT : No Change
DIURNAL VARIATION: None
ATTENTION: Poor
SPEECH
hesitant

IV: PERCEPTION
(+) audiovisual hallucinations
I saw a group of women and they told me to
kill someone



V. THOUGHT PROCESS :
(+) tangentiality

CONTENT :
(-) Ideas of reference
(-) suicidal ideation
(+) homicidal Ideation

VI.SENSORIUM & COGNITION
A. Oriented to person,but not to place and
time


B. MEMORY :
unimpaired immediate & recent memory
Impaired remote memory



C. CONCENTRATION & ATTENTION

serial subtraction : 20-3=17; 17-3= 14; 14-3=?
Spelling: w-o-r-l-d ;unable to spell backwards
abstract thought: Impaired
VII. JUDGMENT & INSIGHT

Impaired judgment
Insight level 1