The patient’s behaviour may be influenced by the unaccustomed situation of being a patient, or the effect of their disease, particularly if they are in pain. The latter shows through their facial expression, the degree of eye contact, restlessness, sweating, anxiety, apathy, depression, lack of cooperation or aggression. Stress may be indicated by rapid respiration, but note whether the patient’s intelligence and personality equate to what one would expect from the history or whether this could have changed in relation to the disease.
Drugs, head injuries and other diseases of the central nervous system can effect the level of consciousness, varying through alert, slow and confused, lacking concentration, and reduced levels of response to spoken and physical stimuli. The patient’s orientation in time, place and person should be noted. The Glasgow Coma Scale (GCS – page 347) is a valuable way of documenting the level of consciousness for serial measurement. The patient’s speech may be impaired by disease of the central nervous system, producing dysphasia or dysarthria, and there may be voice changes, such as hoarseness in laryngeal infection or myxedema. Impairment of motor function can produce weakness or spasticity and these may affect speech.
The posture and gait should be noted, and other activities such as undressing. There may be added movements, such as the fine tremor of age, thyrotoxicosis, Parkinsonism and alcoholism, the flapping tremor of hepatic, respiratory, renal and cardiac failure, or more specific neurological abnormalities, producing lack of coordination and involuntary movements. If psychiatric abnormalities are present, or suspected, note the patient’s general behaviour, and disturbances of orientation. Record the emotional state, thought processes and content, hallucinations, delusions and compulsive phenomenon, and include an assessment of cognitive and intellectual function.