nl_e17

GENERAL PHYSICAL EXAMINATION: MENTAL STATUS
GENERAL PHYSICAL EXAMINATION
HEIGHT WEIGHT
GENERAL SURVEY
MENTAL STATUS
PERTINENT PHYSICAL
FINDINGS/PHYSICAL
INJURIES
Include if possible:
� Nutritional status (optional)
� Ambulant/non-ambulant
� Respiratory distress/not in respiratory distress
� Other comments
Include if possible:
� Orientation as to time, place, person 5
� Consciousness, demeanor 6
� Developmental delay or mental retardation? 7
5. Orientation as to Time, Place, Person
Some children are obviously too young to be “oriented”; in these situations, simply describe the
patient’s level of awareness (e.g., awake, asleep but arousable, alert, etc.).
6. Consciousness, Demeanor
Describe what the patient is doing while under observation (e.g., playing, crying but consoled by
mother, sitting quietly, etc.). For older children and adolescents, note indicators of demeanor,
including blank staring or a depressed appearance.
7. Developmental Delay or Mental Retardation
Examining physicians who are not developmental specialists may still include general observations
concerning a patient’s mental status. In cases of suspected developmental delay or mental retardation,
physicians should indicate that their observations serve as estimations only and that the patient will be
referred to a psychiatrist, psychologist or developmental pediatrician for assessment.