03 MRS – Physical examination 1: General observation

Main Scale

The doctor tends to fail to observe the patient ( and on home visits, the environment) as an essential part of acquiring objective data. Important clinical items are sometimes overlooked. The doctor shows that he or she has taken notes of the patient’s  appearance, behaviour and physical activity, where appropriate increasing the background knowledge by home visits, and shows that he or she can use this sort of information in understanding the patient.
1 2 3 4 5 6 7 8 9 10
Has little understanding of this. Attempts to do this but is not yet skilful and sometimes runs into difficulty. Attempts to do this and is usually successful but recognises his/her limitations. Perfect

Subscales

The doctor observes:

Rarely Occas
ionally
Fairly
frequently
Often Usually
(a) The patient’s build, posture and mobility, and colour. Co-ordination (as evidenced by manipulation of clothes, laces, buttons, etc). Alertness. Facial expressions.
(b) The home environment.

Notes for raters

This area of behaviour is best assessed by asking, in random or problem caseanalysis, “What do you think of that patient as a person?” and”What can you tell me about X now that you I’ve been to his/herhome?”.

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