Integrate the observations you have made throughout the history and physical examination, including the following.

Level of Consciousness. 

Is the patient awake and alert? Does the patient understand your questions and respond appropriately and reasonably quickly, or tend to lose track of the topic, grow silent, or even fall asleep?

If the patient does not respond to your questions, escalate the stimulus in steps:

■ Speak to the patient by name and in a loud voice.

■ Shake the patient gently, like wakening a sleeper.

If there is no response to these stimuli, promptly assess the patient for stupor or coma—severe reductions in level of consciousness.

Posture and Motor Behavior. 

Does the patient sit or lie quietly or prefer to walk around? Observe the patient's posture and ability to relax. Note the pace, range, and type of movement. Are movements voluntary and spontaneous? Are any limbs immobile? Are posture and motor activity affected by topics under discussion, type of activity, or who is in the room?

Dress, Grooming, and Personal Hygiene. 

How is the patient dressed? Is the clothing clean and presentable? Is it appropriate for the patient's age and social group? Note the grooming of the patient's hair, nails, teeth, skin, and, if present, beard. How do the grooming and hygiene compare with peers of comparable age, lifestyle, and socioeconomic group? Compare one side of the body with the other.

Facial Expression. 

Observe the face both at rest and during conversation. Watch for changes in expression. Are they appropriate for the topics being discussed? Or is the face relatively immobile throughout?

Manner, Affect, and Relationship to People and Things. 

Assess the patient's affect, or external expression of the inner emotional state. Is it appropriate to the topics being discussed? Or is the affect labile, blunted, or flat? Does it seem exaggerated at certain points? If so, how? Observe the patient's openness, approachability, and reactions to others and the surroundings. Does the patient hear or see things not present, or converse with someone who is not there?

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