Depression
Welcome to the Depression Module.
Depression is an important topic. It is common and is associated with a major burden of morbidity. This module will provide you with an interactive case study in which you will diagnose, treat and discharge a patient who has depression. Once you have completed the Pre-Module Test below you will be able to commence the Depression Module.
Module
- Interactive Case Study
- Patient Interview
- Presenting Symptoms
- Physical Assessment
- Cognitive Assessment
- Features of depression
- Investigations
- Differential Diagnosis
- Dementia or Depression?
- Mrs Wood's Diagnosis
- Predisposing and Precipitating Factors
- Communicating Diagnosis
- Treating Depression
- Treatment Plan
- Multi-disciplinary Care
- Family Care
- Care Plan
- Case Summary
Mrs Wood is a 79 year-old woman who presents with increased lethargy and progressive social withdrawal. Mrs Wood’s family have brought her in for assessment.
Review Mrs Wood’s history through the links below before moving on to her assessments.
- History of Presenting Complaint
- Medical History
- Medication History
- Social History
Mrs Amy Wood is a recently widowed, 79 year old woman. She is a retired seamstress, although until recently she continued to sew clothing for her grandchildren and do alterations for friends and family. Mrs Wood has previously been a positive and socially active woman, but over the last few months has become very withdrawn. Her children are concerned at her lack of interest in usual activities, social isolation and reduced level of personal care. Her mood is often low and she is frequently tearful.
Mrs Wood has a history of high blood pressure, chronic eczema and persistent back pain resulting from a car accident 15 years ago. She has had multiple operations, including a hysterectomy at age 57, right shoulder and knee re-constructions and removal of a benign breast lump.
It is also noted that Mrs Wood experienced post-natal depression after the birth of her second daughter, Judith. This was effectively treated with tricyclic anti-depressants.
Mrs Wood takes Hydrochlorothiazide 25mg for her high blood pressure, and does not report any negative side effects. She is in such a low mood that she has not taken this medication for several weeks.
She uses Betamethasone 0.05% cream to treat eczema and takes paracetamol as required for back pain.
Previous post-natal depression was effectively treated with Amitriptyline 50mg.
Mrs Wood is a retired, 79 year old widow. Her husband, Christopher, died from a heart attack 15 months ago. Mr and Mrs Wood have three daughters, 7 grandchildren and 3 great-grandchildren, all of whom live in neighbouring suburbs.
Until recently, Mrs Wood had been an active member of the community and enjoyed gardening, cooking, playing cards, and knitting. She has remained physically active throughout her life and has only in the last 6 months stopped attending seniors yoga and water aerobics classes at the local community centre.
Mrs Wood’s friends have been growing increasingly concerned that she has stopped attending all social activities and has even stopped inviting people over for afternoon tea, a ritual that she previously enjoyed very much. They have also noticed that she is unusually tearful.
Her children have also noticed this social withdrawal and note that their mother is reluctant to leave the house to participate in family gatherings, shows little interest in food, is often in poor spirits, tearful and takes no care in her personal appearance.
Family History
Mrs Wood was adopted and knows little about her family history. She is aware that her mother died young, but does not know what caused her death.
In order to assess Mrs Wood’s condition, you will need to ask her a series of questions. Please click on the questions below to obtain Mrs Wood’s answer.
- Tell me how things have been going lately?
- Is your back pain still troubling you?
- Do you always remember to take your medication for your blood pressure?
- Mrs Wood, do you live alone or with family?
- Do you often have visitors?
- Do you get lonely?
- Do you find it easy to get around your neighbourhood?
- Can you walk around OK? Do you need any walking aids or have you ever fallen?
- Do you do your own cooking and shopping?
- Are you able to perform all the usual daily activities, such as having a shower or bath, personal grooming, dressing and going to the toilet?
- Mrs Wood, why have you stopped going out and taking part in your usual activities?
- Are there any other aspects of your life at the moment that are particularly concerning to you?
What features of Mrs Wood’s present condition are consistent with both Dementia and Depression?
General Appearance:
Mrs Wood looks tired and withdrawn. Her affect is reactive but she is slow to respond to instructions, is tearful and has poor concentration.
Height: 150cms
Weight: 45kg (a reduction of 8kg in the last 12 months)
Please move your mouse cursor over Mrs Wood as if you were examining her. You must complete the examination before you go on.
Click on the tabs below to obtain the results of Mrs Wood's cognitive assessments.
- MMSE
- Clock Drawing Test
- Geriatric Depression Scale
Mrs Wood scores 22/30 on the MMSE, losing two points on recall, three on orientation, one on language and two on serial 7’s.
Click here to see her completed MMSE
Mrs Wood's Clock Drawing Test result is normal.
Older patients may not present with the typical symptoms of depression, and often have more somatic complaints and less obvious affective symptoms. The GDS is widely recommended and has been validated using a variety of formats (15 and 30 item scales).
Mrs Wood’s GDS score is 11. A score of 5 or more suggests depression.
Click here to see the completed GDS form
At this point in time, what are the key features supporting a diagnosis of depression?
Please click on each feature to obtain further information.
- Loss of Interest and Pleasure in Usual Activities
- Low mood and/or tearful disposition
- Significant weight change or Change in appetite
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Loss of energy and motivation
- Feelings of worthlessness
- Decreased concentration
- Thoughts of death or suicide
People with severe depressive episodes often find it very difficult to continue with their work, domestic and social lives. They no longer find any pleasure (anhedonia).
Depression can make a person feel sad, hopeless, worthless, pessimistic or guilty. Crying is frequent, although some individuals are reluctant to admit this, and others feel as if they have 'gone beyond crying'.
Depression may cause physical symptoms such as anorexia (loss of appetite) and weight loss or, less commonly, weight gain.
Altered sleep is another common physical symptom of depression.
Major depression may also include features such as distress and agitation and/or slowed thought and movement (psychomotor retardation).
Also known as amotivation.
People with depression often feel they have nothing to offer, they are useless or a waste of time.
Depression is often accompanied by slowing of thought and difficulty in maintaining attention. This can also be in part due to lack of interest. This often leads to a misdiagnosis of dementia in the older person.
Many people with depression have suicidal ideas, and asking about these is a crucial aspect of their assessment. They often find it a relief to talk about these ideas. Asking about suicidal ideas is a sequential process, beginning with questions about the severity of the low mood. Then ask if the patient has ever felt that life is not worth living. A 'yes' could be followed by enquiring whether the patient has ever felt like ending their own life. Finally assess if the patient has any particular plans in mind.
In the older adult population, it is important to rule out any medications or medical conditions that may be the underlying cause of depression, especially if the patient does not have a history of this disorder. You should now request further laboratory tests to help determine the cause of Mrs Wood’s condition.
Blood Screening
Blood tests are often used in investigation of depressive symptoms, primarily to exclude other possible causes of a cognitive disorder. These include active infection (white cell count), hyperthyroidism, hypothyroidism, B12 deficiency, renal and liver disease. It is also useful to record folate, glucose, calcium and cholesterol levels. Review Mrs Wood's blood test results by clicking on the tabs below and review results before proceeding.
- FBC
- Vitamin B12
- Urea and Electrolytes
- Liver Function Tests
- Blood Glucose Level
- Thyroid Function Test
- Lipids
White cell count 7.5x109/L (normal range 4.0-11.0x109/L)
Neutrophil count 4.1x109/L (normal range 2.0-7.5x109/L)
Haemoglobin 135 g/l (normal range 115-160 g/l for adult females)
Mean cell volume 92 fl (normal range 80-100 fl)
Platelets 165x109/L (normal range 150-400x109/L)
Infection or blood dyscrasia may be a possible cause for the symptoms reported. Results are within normal range.
428 pmol/L (normal range 120-680pmol/L)
A vitamin-B12 level should be obtained to evaluate for a reversible cause of cognitive symptoms. Results are within normal range.
Na 143 mmol/L (normal range 134-146 mmol/L)
K+ 3.9 mmol/L (normal range 3.4-5.0 mmol/L)
Ca 2.3 mmol/L (normal range 2.15-2.60 mmol/L)
Creatinine 95 µmol/L (normal range 50-95 µmol/L for adult females)
Urea 5.7 mmol/L (normal range 134-3.0-8.0 mmol/L)
Renal function is assessed to rule out metabolic disturbance or kidney dysfunction. Results are within normal range.Electrolytes disturbance (eg hyponataemia) is a common cause of confusion. Results are within normal range.
AST 26 U/L (normal range <35 U/L for adult females)
ALT 17 U/L (normal range <30 U/L for adult females)
Bilirubin 17 µmol/L (normal range <20 µmol/L)
ALP 88 U/L (normal range 35-135 U/L)
GGT 32 U/L (normal range <40 U/L for adult females)
Albumin 39 g/L (normal range 35-50 g/L)
To assess liver disease as a possible cause of depressive symptoms. Mrs Wood’s results are normal.
Glucose 5.3 mmol/L (normal range 3.0-5.4 mmol/L)
Hypo- and hyper-glycaemia can cloud cognitive function. Results are within normal range.
TSH 3.7 mU/L (normal range 0.40-4.0 mU/L)
Metabolic disturbances are a possible cause of depressive-like symptoms. Results are within normal range. Hypothyroidism in particular can cause depressive symptoms.
Cholesterol 4.6 mmol/L (normal range <5.5 mmol/L)
HDL 1.2 mmol/L (normal range <1.0 mmol/L)
LDL 1.7 mmol/L (normal range <3.0 mmol/L)
Triglyceride 1.8 mmol/L (normal range <2.0 mmol/L)
Normal result
Cranial Imaging
It is important that an underlying brain pathology is not contributing to Mrs Wood being so depressed. In particular subclinical vascular disease can contribute to cognitive slowing (although there is no risk factor history to suggest this in Mrs Woods case). A CT scan or MRI scan can also rule out intracranial bleeding and malignancies that may be impacting on her mood. Click here to review Mrs Wood's CT scan.
What are the major differential diagnoses for Mrs Wood’s presentation?
The following can also help distinguish a depressive illness from a dementing illness:
1. Symptoms worse in the morning (dementia has a progressive course)
2. Variable attention span (normal attention span in dementia)
3. Selective (rather than impaired recent and remote) memory impairment
4. Altered psychomotor behaviour (normal psychomotor behaviour in dementia).
Older people with depression may do poorly on cognitive tests, but in general they have more insight into their difficulties and make less effort during a cognitive examination than would a person with dementia. A person with depression may also recognise their memory problems, whereas a person with dementia may deny they have any memory decline.
Mrs Wood's case...
A MMSE score of 22/30 and reports of memory problems may lead you to suspect that Mrs Wood may have early dementia in addition to depression.
If Mrs Wood’s memory problems persist even when she has received effective treatment for her depression, it would be worth referring her for further cognitive assessment.
More information about the differential diagnosis of depression
Mrs Wood is experiencing a number of the symptoms outlined in the DSM IV criteria
for the diagnosis of depression and is therefore diagnosed with depression.
From the list below, what would you consider to be the most likely type of depression in Mrs Wood’s case?
Click on the tabs below to find out more about each sub-type before submitting your answer.
- Clinical/Major/Unipolar Depression
- Atypical Depression
- Major Depression with Psychotic Features
- Dysthymia
- Mixed depression and anxiety
- Bipolar Affective Disorder (formally known as manic depressive illness)
Major depression is also known as unipolar depression, clinical depression or major depressive episode. The person with major depression may seem to “walk around with the weight of the world on their shoulders”. There is low mood, accompanied by disinterest in regular activities and often hopelessness. There is often a loss of appetite and weight loss with typical sleep pattern changes. Characterised by a depressed mood that lasts for at least two weeks.
The person with atypical depression is sometimes able to experience happiness and moments of elation. Symptoms of atypical depression may have “reversed negative symptoms”, such as oversleeping, overeating and weight gain. People who suffer from atypical depression may believe that outside events control their mood (i.e. success, attention and praise). Episodes of atypical depression can last for months or be a chronic condition.
This is a very rare form of depression. The person with psychotic depression may have may have delusions or hallucinations The delusions and hallucinations are likely to be negative (“mood congruent”).
A syndrome of chronic depression, with similar but less severe features of major depression that may last for years. The person with dysthymia is sometimes seen as “chronically depressed” and may also have episodes of major depression.
A combination of symptoms of depression and anxiety but not severe enough to warrant a diagnosis of either major depression or a specific anxiety disorder.
An emotional disorder characterised by changing mood shifts from low (depression) to high (mania) or hypomania (Bipolar II).
Type of Depression
Predisposing and Precipitating Factors for Depression in Older People
Psychological factors
- Unresolved traumatic experiences
- Previous history of depression
- Damage to body image
- Fear of death
- Frustration with memory loss
- Difficulty adjusting to stressful or changing conditions
- Substance use
Environmental factors
- Loneliness, isolation
- retirement
- Being unmarried
- Recent bereavement
- Lack of a supportive social network
- Decreased mobility doe to illness or loss of driving privileges
Physical factors, including genetics
- Inherited tendencies toward depression
- Co-occurring illness (e.g. stroke etc)
- cerebrovascular changes
- B-12 deficiency
- Chronic or severe pain
Personality characteristics
- Low self-esteem
- Extreme dependency
- pessimism
Medications
- Some pain medicines (eg codeine)
- Some drugs for high blood pressure (propanolol)
- Hormones (Oestrogen, progesterone, prednisone)
- Some heart medications (digoxin)
- Anticancer and immune suppressing agents (cyclosporin, tamoxifen)
- Some drugs for Parkinson’s disease (levodopa)
- Some drugs for arthritis (indomethacin)
- Some tranquilizers/anti-anxiety drugs (diazepam)
- Alcohol
Often health care workers will use an holistic approach, explicitly seeking to consider the biologic, psychologic and social predisposing and precipitating factors for the presentation.
1. Allow adequate time and ensure privacy
2. Let the patient decide how much they want to know
3. Allow feelings to be expressed
4. Frequently assess patient’s understanding
5. Be respectful, caring and empathetic
6. Use language that is easy to understand
Treatment of underlying medical conditions or the discontinuation of certain medications may alleviate symptoms.
Mrs Wood has no significant underlying medical conditions that may be causing her depression, however you might consider whether her back pain is a contributing factor. Some blood pressure medications have been linked to depression although Hydrochlorothiazide is not among them.
It is important to consider, however, that there is a risk of Syndrome of Inappropriate Anti-diuretic Hormone (SAIDH) when anti-depressants are prescribed in conjunction with Hydrochlorothiazide, so this should be closely monitored if Mrs Wood is prescribed an anti-depressant.
There are a number of treatments for depression, both pharmacological and non-pharmacological, and these can work well alone or in conjunction with each other.
The most common treatment plan for major depression is anti-depressant medication in conjunction with cognitive behavioral therapy (or similar psychological therapy).
- 1. Drug Therapy
- 2. Psychological Therapy
- 3. Electroconvulsive Therapy
Antidepressant drug therapy has been shown to increase quality of life in depressed older adults. These medications must be carefully monitored for side effects, and when prescribed for older adults, doses are usually lower and increased more slowly than in younger adults. This is because more side effects are often reported (eg. increased falls) and more drug interactions are seen in older adults.
Antidepressants work by changing the level of neurotransmitters (chemical messengers) in the brain. Several neurotransmitters are thought to be in low supply in depression, including noradrenaline (sometimes called norepinephrine) and serotonin. Tricyclics mainly increase the level of noradrenaline in the brain. The SSRIs work by increasing the supply of serotonin only. The SNRIs and RIMAs increase the supply of both serotonin and noradrenaline in the brain.
The treatment for major depression in older adults is the same as for younger patients. This most commonly prescribed first line treatments include selective serotonin reuptake inhibitors (SSRI's) and similar agents like serotonin and norepinephrine reuptake inhibitors (SNRI’s) and tetracyclic antidepressants.
Tricyclic antidepressants (TCA's), monoamine oxidase inhibitors (MAOIs) (not used commonly now), and ECT may be used if responses to other lines of therapy are limited.
Older people may require smaller doses to achieve therapeutic levels because of decreased metabolism and clearance. It is important to consider drug interactions if the person is taking numerous medications.
Most antidepressants are equally effective. But some pose a higher risk of serious side effects. See below for more details...
- SSRI's
- SNRI's
- Tetracyclic's
- TCA's
- Other medication strategies
Psychological or Cognitive Behavioural Therapy (CBT) is the second arm of treatment for depression. Cognitive therapy addresses the pessimistic ideas, unrealistic expectations, and overly critical self-evaluations that create depression and sustain it. Problem solving therapy addresses the areas of the person's life that are creating significant stress, and contributing to the depression.
Ideal treatment plans will vary from patient to patient and depends largely on patient preference. The doctor should therefore discuss each type of therapy in detail and take the patients wishes into account when recommending a treatment plan.
Research has not shown any particular therapy, or combination of therapies, to be any more effective than the other.
Some patients may prefer either pharmacologic or psychological therapy in isolation, while others may feel more comfortable with combined therapy.
Electroconvulsive Therapy (ECT) may be indicated for treatment of severely depressed older people if other measures are unsuccessful, or the episode is life threatening and an urgent treatment response is required.
ECT involves the induction of generalised seizuresECT is given under a general anaesthetic and with a muscular relaxant.
It is not known exactly how ECT works, but one of the theories is that it is believed to increase the level of certain neurotransmitters (chemical messengers) in the brain. These neurotransmitters are in short supply in depression.
Disadvantages
ECT can produce memory problems. These often improve after a couple of months.
In addition, a general anaesthetic involves a small risk of adverse effects.
Therapy for Mrs Wood
The treatment options for major depression in older adults are the same as for younger patients, although the doses of medication used are smaller and the side effects greater.
Finding the right anti-depressant medication can sometimes take time and may involve trying a few different options until an effective drug and optimal dose can be found.
Mrs Wood will commence Citalopram 10mg daily for two weeks, before increasing to 20mg.
Her condition will be monitored and if no improvement is shown within 6 weeks of combined therapy, a change in dosage or drug will be considered.
Mrs Wood is referred to a local Psychologist who has a lot of experience is treating older people with mood disorders.
Physical Activity and Depression
Regular exercise has been shown to help prevent and treat depression.
Research shows regular aerobic and strength-training activities of light or moderate intensity can result in up to a 50 per cent reduction in symptoms of depression and anxiety, especially for women and older people.
Keeping active can help in a number of ways, including:
- lifting mood
- helping people get a good night's sleep
- helping people feel more energetic and less tired
- blocking negative thoughts and/or distracting people from daily worries
- increasing social contact.
Maintaining physical activity can aid in overcoming the vicious cycle of inactivity and depression. Even though exercise can help prevent and manage depression, depressed people often have no energy or motivation. As a result, they often become less active and in turn, more depressed. The following were recommended to help Mrs Wood to stay active,
- Council recreation centres - many offer free or cheap sport and recreation facilities.
- Gyms - often offer a range of classes including aerobics in addition to gym equipment and swimming pools.
- Neighbourhood centres - offer a large range of low-cost group activities, many of which focus on staying active. These may include aerobics, yoga, dancing and walking groups. Information can be obtained through local government councils.
- Family and Friends - people with depression often feel like spending less time around people, increasing their sense of isolation and making it harder for them to recover from depression. It's important for people with depression to continue to take part in activities with family and close friends and to accept social invitations, even though they may not feel like it. Planning to do things with other people can also help someone with depression to stay motivated.
Please click on the specialties below for further information on the role they played in Mrs Wood’s on-going care.
- Physiotherapist
- Social Worker
Walking is one of the best forms of exercise for helping depression, but research has found that other exercise also helps.
Mrs Wood is encouraged to return to her yoga and water aerobics classes. The physiotherapist also shows Mrs Wood some specific exercises and stretches to help reduce her back and neck pain.
Sometimes depression can be alleviated by social interventions to help with isolation or loneliness such as group outings, volunteer work, or regular visits from concerned people.
The social worker visited Mrs Wood and her family to talk to them about depression, care-giving, and local resources. They are given advice regarding community groups and services that may be of assistance during Mrs Wood’s recovery, including available support services.
Mrs Wood’s family will assist their mother in every way possible. They draw up a roster system to ensure she has regular social contact, maintains participation in physical and social activities, takes her medications and attends all check-up visits.
It is important to assess carer and family stress and support. Your on-going assessment of the needs of the carer and level of support required is an essential component in your role of the management of the person with depression. Carer support is as important as patient support.
Further support and information can be accessed through ‘Blackdog’ or ‘Beyondblue’
Depression is a disorder in which both relapse (the early return of symptoms) and recurrence (the later return of symptoms after a period of remission) are common. It is reported that the majority (77.5%) of patients with a major depressive episode will relapse or have a chronic course. Thus goal setting is often a useful component of care.
Mrs Wood responded well to combined pharmacologic and cognitive therapy and within four months is feeling much more like herself again. A repeat MMSE was conducted and Mrs Wood’s score had improved to 28/30. Repeat GDS score was 7/15 – a substantial improvement.
She will remain on 20mg of Citalopram for the next 12 months and which time she will be reviewed and consideration will be given to lowering the dose to 10mg for a further 6-12 months.
Mrs Wood will continue to see her Psychologist regularly over the next 12 months to ensure her progressive improvement.
It is also important that she maintain participation in social and physical activities and Mrs Wood is fortunate to have a close circle of friends and family who will help her to achieve this. A strong social support network is very important in living with depression, especially for older people.
She will be closely monitored by her family and GP for any signs of relapse.
Depression 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.
