Delirium
Welcome to the Delirium module. This case study focuses on the recognition of delirium in an older Aboriginal person in the acute hospital setting, including the causes, treatment and evaluation to discharge of that person.
As the Australian population ages, there will be increasing demand for utilisation of health care resources by frail older people. Indigenous Australians have a high burden of illness and a life expectancy at birth that is 15-20 years less than non-indigenous Australians.
Delirium is an acute and fluctuating confusional state, involving altered levels of consciousness with reduced ability to focus, maintain and shift attention. It is a serious and common clinical syndrome that increases with age and is often caused by a complex interaction of multiple factors.
Module
- Interactive Case Study
- History
- Assessments
- Causes of Delirium
- Factors in Delirium
- Investigations
- Treatment Decisions
- Planning Ongoing Care
- Recommendation for Ongoing Care
- Family Meeting
- Module Summary
Mr Thomas is a 69 year old indigenous man who has been transferred to Royal Perth Hospital in respiratory distress.
Review Mr Thomas’ History through the links below, before progressing to his assessment.
Mr Thomas is an independent, cognitively intact 69-year-old Indigenous man living with his wife in the Kalumburu community of WA.
He presented to the community nurse with severe respiratory distress. The RFDS were called to transport Mr Thomas to Perth for urgent assessment and treatment. The transfer team noted Mr Thomas’ oxygen saturation of 91% and suspected right lower zone pneumonia. He was given high flow oxygen, IV ceftriaxone and merepenum and stabilised. His wife accompanied him because of Mr Thomas’ unfamiliarity with urban Australia.
As well as an accurate history of the current presentation it is vital to collect information regarding previous cognitive status, previous functional status, medication use, co-morbid conditions, pain levels, alcohol and drug use and environmental factors in any person presenting with altered mental state.
A diagnosis of CHANGE in mental state can only be made with a good assessment of BASELINE function.
Mr Thomas has partial blindness and diabetes mellitus. He had numerous minor fractures (all healed) when breaking brumbies in his teens and early 20’s. Bilateral cataracts were successfully removed 2 years ago. However, Mr Thomas’ vision is still limited and he wears glasses to compensate.
Metformin 850mg PO TDS
Paracetamol PRN – ‘when joints ache’.
Mr Thomas is a retired cattle roustabout. He is married with 5 children and 3 grandchildren who all live together in the same house. He smoked 2 packs (“Rollies”) a day for 35 years and quit 7 years ago. Has never drunk alcohol or used other drugs. Mr Thomas is an Elder in the community, is completely independent and continues to be active on the community council.
Detection of Altered Mental State
Mr Thomas arrived at the hospital overnight, was triaged in the ED and immediately admitted to the respiratory ward. IV ceftriaxone and merepenum were continued.
Admission staff noted that Mr Thomas appeared agitated and restless. He also had reduced attention span and trouble following conversations. Mr Thomas was repeatedly asking where he was. His speech was slow and at times, incoherent.
Since admission, he has been frequently pulling out the intravenous line.
Before you assess Mr Thomas, read the patient’s transfer letter from the remote area nurse.
Delirium is frequently misdiagnosed as depression or dementia. Delirium is a clinical diagnosis, based on history and observation of the patient at the bedside. If delirium is suspected, the first intervention should be a thorough assessment of the patient.
It is important to recognise delirium because it can be difficult for patients to reliably report their symptoms, even to those who know them well. The most effective treatment for delirium is early diagnosis and identification of the underlying cause/s. If the patient is an indigenous person, it might also be appropriate to request the assistance of the Aboriginal Health Worker (AHW), if available.
Some tips on effective communication
1. Approach the person slowly, calmly and from the front; respect personal space; address the person by name and introduce yourself; use eye contact; and speak clearly and simply.
2. When used appropriately, gentle touch and gestures as well as auditory, pictorial and visual cues may assist with communication.
3. Promote understanding by allowing time for the patient to process the information, paraphrase and/or repeat if nescessary.
Patient Interview
In order to assess Mr Thomas’ condition, you will need to ask him a series of questions - Click here
Mrs Thomas Interview
In order to assess Regarding Mr Thomas’ condition, you will need to ask Mrs Thomas a series of questions - Click here
Systems Interview
Continue to interview Mrs Thomas by Clicking here...
Physical assessment of Mr Thomas may be difficult depending on his level of agitation, although attention at the bedside to the following factors is often helpful:
- Level of consciousness
- Hydration
- Observations – temperature, oxygen saturations, urine dipstick
- Search for infection: lungs, urine, abdomen, skin
- Evidence of alcohol abuse or withdrawal (eg tremor)
- Cognitive function using a standardised screening tool
- Neurological examination (including assessment of speech) - note comprehensive examination may not be possible due to altered mental state.
- Rectal examination – if impaction suspected (again, may not be possible.)
- Residual urine by bladder scan
Physical examination should be thorough as precipitants for delirium might be relatively minor if a patient has numerous risk factors. Important considerations include:
- Pupillary response
- Respiratory examination
- Cardiovascular examination
- Abdominal examination
- Suprapubic tenderness or palpable bladder
- Hip tenderness (in case of neck of femur fracture which can be overlooked in frail elderly people)
- Neurological findings
Before progressing to the result of Mr Thomas’ cognitive screen, take a moment to consider which screening tools are most appropriate and answer the following questions:
Case update
Mr Thomas is an independent, previously cognitively intact 69-year-old Indigenous man transferred to RPH via RFDS and admitted with respiratory distress.
Following his admission, Mr Thomas’ condition was noted to be complicated by acute confusion and he was diagnosed with delirium. He is receiving IV antibiotics but has been frequently pulling out his intravenous line.
You have established that Mr Thomas has an altered mental state and should now proceed to investigate Mr Thomas’ physical and mental state further, to determine the cause of delirium.
Predisposing and Precipitating Factors in Delirium
Delirium is caused by an interplay between predisposing (risk) factors and precipitating (causative) factors. The more risk factors an individual has the more vulnerable the brain is to an insult that can precipitate a delirium. Relevant insults may appear minor, such as a new drug or constipation.
In principle, anyone can experience a delirium, just as anyone’s brain can have a seizure - the less vulnerable the person, the higher the insult required.
The most common risk factor for delirium is dementia. Others include advanced age, visual impairment and depression.
Given the vast differential of delirium, investigations should be guided by history and physical examination findings.
Based on Mr Thomas’ history and physical examination findings, the following tests are ordered.
Please click on each test to reveal the result and the rationale for ordering the investigation.
- FBC
- C Reactive Protein
- Urea and Electrolytes
- Calcium
- Liver Function Test
- Glucose
- Blood cultures
- Urinalysis - Dipstick
- ECG ± Troponin
- Pulse oximetry
- Chest X-ray
Hb (Haemoglobin) 160g/l (normal range 135-180g/l)
White cell count (WCC) 26x109/L (normal range 4.0-11.0x109/L)
Platelets (Plt) 349x109/L (normal range 150-400x109/L)
Infection is a possible cause of delirium. Mr Thomas is “dry” hence the high Hb
CRP 96 mg/L - elevated (normal range <5.0mg/L)
Monitoring CRP can be useful in setting of acute sepsis
Na 152 mmol/L - elevated (normal range 134-146 mmol/L)
K+ 4.6 mmol/L (normal range 3.4-5.0 mmol/L)
Cr 180 µmol/L - elevated (normal range 60-120 µmol/L for adult males)
Mr Thomas is dehydrated and probably has substantial renal dysfunction which has not been recorded up until now. This was worth checking!
Ca+ 2.33 mmol/L (normal range 2.15-2.60 mmol/L)
Hyper and hypo calcium should be excluded as a cause of delirium
Albumin 32 g/L (normal range 35-50 g/L)
ALT 42 U/L (normal range <40 U/L for adult males)
GGT 51 U/L (normal range <60 U/L for adult males)
ALP 68 U/L (normal range 35-135 U/L)
Bilirubin 24 µmol/L (normal range <20 µmol/L)
Hepatic encephalopathy is important to rule out. In patients with pneumonia it is also important to check for other organ failure as this increases the risk of mortality.
14.5 mmol/L - elevated (normal range 3.0-5.4 mmol/L)
Exclude very high or low blood glucose in all confused older people.
Growth of gram positive coccus (subsequently identified as S Pneumoniae).
Blood cultures confirm Mr Thomas has septicaemia, probably related to a bacterial pneumonia
2+ glucose
1+protein
To exclude urine infection.
Sinus Tachycardia, no evidence of ischaemic change.
Given Mr Thomas’ heart rate and presentation with shortness of breath, an ECG is important part of the initial investigations
O2 saturation 91% on room air.
Test used to include or exclude hypoxia.
Posterior-anterior and lateral films show right lower lobe consolidation consistent with pneumonia.
Infection is a possible cause of delirium.
Other Investigations
Other investigations may be indicated according to the findings from the history and examination. These can include:
CT head
CT has been shown to be unhelpful on a routine basis in identifying a cause for delirium and should be reserved for those with
- Focal neurological signs
- Confusion developing after head injury
- Confusion developing after a fall
- Evidence of raised intracranial pressure
- Those on antocoagulants
EEG
Although the EEG is frequently abnormal in those with delirium, showing diffuse slowing, its routine use as a diagnostic tool has not been fully evaluated. EEG may be useful where there is difficulty in the following situations:
- Differentiating delirium from dementia
- Differentiating delirium from non‑convulsive status epilepticus and temporal lobe epilepsy
- Identifying those patients in whom the delirium is due to a focal intracranial lesion, rather than a global abnormality
B12 and folate
Arterial blood gases
Specific cultures eg sputum, wound swabs
Lumbar puncture
Although various abnormalities have been seen in the CSF of patients with delirium, routine LP is not helpful in identifying an underlying cause for the delirium. It should therefore be reserved where there is reason to suspect a cause such as meningitis. This might include patients with the following features:
- Meningism
- Headache and fever
AXR for faecal loading
In the absence of definitive historical and physical examination findings, investigations usually include the following:
- FBC
- Urea and Electrolytes
- Urinalysis
- Chest x-ray
- Drug levels (if relevant)
- ECG
- Arterial blood gas
- CT and/or MRI, lumbar puncture and EEG may be considered only if no aetiology is identified from preliminary tests
Review what you have learned regarding Mr Thomas’ predisposing and precipitating factors for delirium by answering the questions below.
Mr Thomas was recently admitted with community acquired pneumonia.
Following admission, his condition deteriorated and he became acutely confused.
Mr Thomas was reviewed and diagnosed with delirium.
Mr Thomas has been prescribed antibiotics, fluids and supplemental oxygen to treat his pneumonia and septicaemia.
As his condition begins to improve it is likely that his delirium will resolve. Supportive care should be provided in the meantime to ensure his safety and comfort.
Consider how this might be achieved in Mr Thomas’ case.
Identifying appropriate strategies to manage delirium
Care for a person with delirium is complex and needs to consider many factors.
It is important to work with Mr Thomas’ family, with the aid of the AHW if necessary, in order to engage them and encourage them to help implement care interventions.
Mr Thomas’ wife has not heard of delirium and wants to know more about it so that she can understand her husband’s condition.
Make some time to sit with Mrs Thomas in a quiet and comfortable environment and explain in simple terms what delirium is and answer any other questions she might have.
Treatment Options
Treatment for delirium includes pharmacological and non-pharmacological interventions, although pharmacological interventions should not be considered as first line treatment.
Mr Thomas' symptoms should be reviewed in order to decide upon appropriate treatment.
On re-examination, Mr Thomas appears more lucid, but is still quiet and withdrawn.
He displays occasional episodes of irritability, but no wandering or other potentially dangerous behaviours have been reported by Mrs Thomas or care staff. He is eating small amounts of food and taking liquids orally with assistance, to supplement the subcutaneous fluids. He is less agitated now that the IV line is not constantly connected.
As Mr Thomas is more responsive at this examination, you decide to administer the cognitive screening tests.
He scores: 20/39 on KICA and 17/30 on MMSE, indicating a moderately impaired cognitive state.
Click here to see the scoring sheet for MMSE
Based on your observations, and reports from Mrs Thomas and care staff, which of the following delirium treatment strategies are most appropriate for Mr Thomas?
Click here to answer the question
As part of Mr Thomas’ medical care, his wife was encouraged to stay with him, especially in the evening or overnight when he was most agitated. Environmental stimulation was minimised and a comforting environment was established by eliminating unexpected and irritating noises where possible. The environment was also modified to minimise risk of injury.
All care staff, as well as Mrs Thomas, provided meaningful orienting stimuli.
A range of observation/surveillance measures including more frequent nursing observation and prevention strategies were undertaken.
Restraints should be minimised or avoided as highly agitated patients often fight against them, resulting in injury and sometimes death.
Drug therapy is sometimes indicated in patients with delirium despite employing a complete range of non-pharmacologic interventions. Drug therapy may be used in order to:
- relieve distress in a highly agitated or hallucinating patient
- carry out essential investigations or treatment
- prevent the patient endangering themselves or others
Pharmacologic Management of Delirium
Even though pharmacological management was not indicated in Mr Thomas' case, it is important to know not only when drug intervention is warranted, but also the preferred medications and corresponding appropriate dosages.
Click here to review the RPH Pharmacological flow chart that details the acute pharmacological management guidelines for older inpatients.
Click on the specialties below to reveal assessment results and recommendations
- Physical Therapy
- Speech and Language; Dietetics
- Medical
- Psychiatry
The physiotherapist has been asked to see Mr Thomas regarding his respiratory secretions. They also spoke to Mrs Thomas to assess Mr Thomas’ level of physical activity before he got sick. Prior to his illness Mr Thomas was an active member of his household and community and would walk most places as he did not trust his eyesight to drive.
Since the onset of his current illness he has not been able to maintain his normal level of activity.
At present he is not agitated and a treatment plan is drawn up to include:
- Getting out of bed and into a chair
- Progress to walking short distances with supervision
- Progress to longer distances with supervision
- Progress to walk increasing distances without supervision
- Chest physiotherapy
It is noted that compliance may be an issue if he becomes agitated again.
The speech pathologist assessed this patient’s speech and ability to swallow along-side the dietician, who assessed his usual dietary pattern.
Mr Thomas’ swallow was intact, and his speech is slow and sometimes incoherent. However, this is likely to improve once delirium abates. The speech pathologist will continue to monitor Mr Thomas during his admission.
The dietitian spoke with Mrs Thomas and confirmed that Mr Thomas’ usual diet is appropriate for his diabetes. They generally eat a very natural, traditional diet with very few processed foods or refined foods. However, Mr Thomas’ future health risks could be reduced with weight loss and the dietitian will speak to Mr Thomas about how this might be achieved prior to discharge.
A treatment plan is drawn up to include:
- Daily mouth washes
- Ensure teeth are brushed after each meal
- Start patient eating light but high caloric diet (diabetes appropriate)
- Progress to full meal – solids
- Encourage drinking – juice and/or water
- Maintain record of bowel and bladder movements and volume
The medical team will work with nursing staff to support physiologic homeostasis (symptomatic management of fever, hypoxaemia and rehydration) monitor appropriate antibiotic therapy, and try to anticipate any complications while the infection resolves.
Should not be required in Mr Thomas’ case, although people with complex differential diagnoses, co-morbid psychiatric problems or very difficult behaviours may warrant psychiatric review
After 72 hours of hydration, oxygen, and antibiotic therapy, Mr Thomas’ respiratory distress has begun to improve. He is more consistently responding to questions, conversing with his wife, sleeping better and appears more oriented. There are no signs of agitation. Mr Thomas is now taking his antibiotics orally.
A family meeting with Mr Thomas, his wife, the AHW, social worker, discharge nurse, clinical nurse specialist, physiotherapist and attending physician will be held to discuss Mr Thomas’ discharge plan.
The following components of Mr Thomas’ discharge plan need to be considered as part of the family meeting:
- Ensure that he is fit for discharge/transfer
- Ensure that he and his wife understand what has happened
- Discuss the possibility for recurrence of the delirium and what can be done to prevent it.
- Ensure follow up with the remote area nurse.
- Finalise any prescriptions and confirm that Mr Thomas is aware of how to take his medications correctly. Reinforce the importance of completing the full course of antibiotics, even if he starts to feel better.
It is essential to re-evaluate Mr Thomas’ physical health and cognitive function to ensure that he is returning to baseline. Mrs Thomas, and nursing staff who have had frequent contact, are in a good position to monitor Mr Thomas’ recovery.
They report that Mr Thomas is now experiencing no breathing difficulties and is interacting much more normally. He isn’t agitated and is oriented to time and place. He is desperate to return closer to home, as he finds Perth cold, and doesn’t feel comfortable amongst so many people.
Physical Assessment
Investigations
Please click on each test to reveal the result and rationale
- Basic Laboratory
- Imaging
- Pulse Oximetry
FBC, Electrolytes, Kidney and Liver Function Tests, Glucose, CRP: all normal
These results have all normalised.
It is reasonable to document improvement
Chest X-ray was not repeated at this stage.
The patient has experienced significant clinical improvement and radiological changes usually lag behind. A repeat CXR at six weeks would be reasonable. You make a note to check where Mr Thomas could get a follow up chest x-ray.
O2 saturation 97% on room air
In the absence of respiratory distress, the test may not be required.
Mr Thomas' delirium appears to have resolved but he will require ongoing antibiotic therapy and inpatient physiotherapy before he can return to Kalumburu community. He has expressed a wish to be closer to home and transfer to Derby hospital will therefore be arranged.
It is important to remember that not all deliriums will resolve in the acute setting (especially if the patient has a pre-existing cognitive impairment), but confusion may resolve once they return to a familiar environment.
Acknowledging Aboriginal peoples' relationship rules demonstrates respect for Indigenous cultural processes of information sharing. Sometimes there is a need to "share the story" broadly with appropriate people in the extended family and community network through family meetings.
In Mr Thomas’ case, this may be organised through the community health nurse at Kalumburu, as only his wife is present with him in Perth.
Family Meeting at RPH
The primary goals of the family meeting held at RPH will be to:
- Review Mr Thomas’ medical condition and ensure that he and Mrs Thomas understand what has happened. One way to do this is to ask opened ended questions, such as ‘tell us about your understanding of what has made you unwell recently
- The discharge team should respond to Mr and Mrs Thomas’ concerns and questions. Provide additional education as necessary.
- Organise follow-up care (transport, support, medications, therapy, food, information/education, follow-up visit)
- Organise transfer letter, scripts and referrals.
Family Meeting Summary
Following Mr Thomas’ hospital stay during which he received IV antibiotics, subcutaneous fluids and oxygen, his breathing improved, the infection is responding well to treatment, and the delirium abated. Mr Thomas was prepared for transfer by holding a Family Meeting. Click below to see each of the outcomes...
- Information for Mr and Mrs Thomas
- Follow-up physiotherapy
- Consult with social worker and AHCW
- Transfer to Derby Hospital
Mr and Mrs Thomas received information on delirium. Their understanding of the conditions and its implications were clarified. They were also given realistic information regarding recovery and what can be done to prevent recurrence.
Recommendations for follow up physiotherapy at Derby hospital were given. The physiotherapist case notes and referral letter will be faxed directly to Derby hospital. Mr Thomas will need on-going inpatient physiotherapy, to aid in his functional recovery. Here's what the physio recommends...
Recommended In-Hospital Plan
Mr Thomas has been working with exercises to regain his strength and endurance. He is currently able to walk for short distances without assistance.
On discharge it is recommended that he be able to walk no less than 50 m without assistance and without shortness of breath.
He currently can only walk for 10m.
Physiotherapy is especially crucial when the patient has suffered functional impairment due to the delirium/illness and/or the hospitalisation.
The social worker and AHCW talked with Mr and Mrs Thomas about their experience, organised support services and arranged their transport to Derby Hospital. Further assistance in transport and support services will be given when they are ready to return to Kalumburu and other care needs will be assessed at that time by the AHCW at Derby Hospital. A follow up appointment will be made with the Remote Area Nurse from Kalumburu upon discharge from Derby Hospital.
The AHCW also arranges for the PATS forms to be completed, finalises the accommodation for Mrs Thomas in Perth and arranges further accommodation for her in Derby.
Mr Thomas is likely to spend another 3-4 days in Derby hospital, so that antibiotic therapy can be administered and his medical condition monitored. He will require a repeat chest x-ray in 6 weeks to ensure that the pneumonia has resolved. Given the difficulties in obtaining a remote medical review and organisation of a chest x-ray, the team arrange for Mr Thomas to have an overnight admission to Derby Hospital in 6 weeks time. The x-ray will be taken and reviewed by a medical officer (likely RFDS) at that time. The 1 hour flight will be paid for by PATS.
An episode of delirium indicates that a patient is in a high-risk population and needs special attention. Many patients have persistent cognitive or functional deficits subsequent to an episode of delirium, and are at a higher risk of re-occurrence. An appropriate treatment plan, prompt follow-up, screening for underlying dementia, and a focus on family education are essential components of patient care following the acute delirium episode.
Understanding the cultural barriers that may be experienced when caring for the Aboriginal patient is important.
These include:
- Medication adherence – instruction and access to supply.
- Discomfort and embarrassment when accessing mainstream health services.
- Traditional healing remedies – bush medicine.
- Literacy and the ability to understand instructions.
- When faced with medical terminology and complex language, the aboriginal patient may feel embarrassed or uncomfortable asking for clarification.
- Answers such as – ‘yes’ and ‘no’ while looking straight ahead may not mean an understanding of what they have just been asked or told.
Post-Module Test
Module Feedback
Select the appropriate user group to ensure that your feedback is delivered appropriately:
- WACHS Users
- ECU Nursing
- All other users
The physiotherapy consult finds her Berg balance scale is 27/56. She has difficulty transferring, turning, reaching and balancing on one foot. The physio recommends some lower limb strengthening and gait exercises and some mild exercises to help rebuild her wasted quadriceps. It is important that Mrs Scott maintains participation in physical activity, in order to maintain muscle strength and joint range of movement and to improve her balance.
The physiotherapist prescribed specific mobility exercises (including stretches in prone lying) and specific strengthening exercises for hands and her leg extensors (which can be performed as a home program).
The physiotherapist uses models of anatomy to explain the physiology of voiding and bladder control problems. To help reduce stress incontinence, Mrs Scott’s pelvic floor muscles are assessed and found to be lax. Mrs Scott has been performing the exercises prescribed by the NCA, so the physiotherapist checks her technique to ensure she is doing them correctly. Further advice was needed to refine technique. Mrs Scott is aware that she needs to do these exercises at least 5 times per day, every day in order to recondition her pelvic floor.
To further address urge incontinence Mrs Scott will perform timed voiding, as advised by the NCA.
Fortunately, Mrs Wood has a normal CT scan.
CT is a relatively inexpensive, quick and non-invasive scan that produces images of brain structures such as the grey matter, white matter, cerebrospinal fluid cavities and blood vessels. These images may also reveal abnormalities such as tumours, strokes, and head injuries. The role of CT imaging in the diagnosis of dementia is primarily one of exclusion. Evidence based guidelines suggest that structural neuro-imaging with either CT or MRI scan is appropriate in the routine initial evaluation of patients with dementia.
MRI is a structural neuro-imaging method that provides images of the brain and other anatomical structures. Some studies using MRI have demonstrated that medial temporal lobe (MTL) atrophy can be predictive of Dementia Alzheimer’s Type (DAT) and that has been associated with neuropsychological and post-mortem data. MRI may assist in the diagnosis of DAT.
An MRI may be obtained if it is suspected that the patient has dementia, however MRI is not required to make a diagnosis of dementia
Dr Zheng’s brain MRI is provided below:
Brain imaging indicates volume loss, consistent with dementia. No evidence of masses or vascular disease.
General Appearance:
Mr Thomas is sweating and looks short of breath. His legs are constantly moving and he appears confused and agitated. His skin is moist and tribal scarring is noted on left and right upper arms, midline of chest and left and right thighs. His eyes are wandering and he appears to have trouble maintaining attention, although this does fluctuate. Admission staff report that his speech was slow and at times, incoherent. Mr Thomas also exhibited impaired orientation. His wife reports that he had trouble sleeping last night.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 28 shallow
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Observations:
Patient answered greeting when approached. He is sitting in a chair with no evidence of agitation or distress. Mr Thomas is now eating a full diet, opens bowels daily and urine output is in keeping with fluid intake. His mouth is moist and mucosa intact. The IV access is removed.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 18 even
Cognitive Testing
MMSE – 25/30 – may indicate resolution of delirium
KICA – 35/39 –Improvement in KICA score supports diagnosis of delirium.
Mrs Thomas does not think Mr Thomas is quite back to baseline, but is improving day by day.
General Appearance:
Mr Scott looks well. His affect is reactive but be appears to be slightly anxious.
Height: 184cms
Weight: 98kg (which has remained constant)
Please move your cursor over Mr Scott as if you were examining him. You must complete the examination before you go on.
General Appearance:
Mrs Scott looks well. She is reactive but has restricted mobility.
Height: 164cms
Weight: 76kg (which has remained constant)
Please move your cursor over Mrs Scott as if you were examining her. You must complete the examination before you go on.
Please move your cursor over Dr Zheng as if you were examining him. You must complete the examination before you go on.
General Appearance:
No tremor is observed. He is well groomed and does not appear anxious. He has normal attention and affect.
Height: 160cms
Weight: 70kgs
Temperature: 37.1
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Appearance:
General Appearance: Mrs Browning looks well. Her affect is reactive and she doesn’t appear to be distressed or anxious.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning looks happy and healthy.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning appears well. She is well presented, and is in high spirits.
Height: 178cms
Weight: 66kg (an increase of 1 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Your general observation is that Mrs Browning appears to be a very alert, independent and capable elderly woman. She is cheery, well presented and easily mobile.
Height: 178cms
Weight: 67.5kg (an increase of 1.5 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
