16. DPR | General Assessment: General Observations-Distress, Morphologic Changes, Obesity & How to Describe Findings

A 45-year-old man presents to the clinic with vague complaints of “not feeling right.” On entry, you observe he is slumped in his chair, avoids eye contact, and is slow to respond. When asked how he is feeling, he says, “I just feel off… I don't care much anymore.” On exam, his speech is slow but intelligible. Based on these findings, what is the most appropriate documentation of both his mood and affect?

A. Mood: apathetic; Affect: flat
B. Mood: depressed; Affect: labile
C. Mood: anxious; Affect: broad
D. Mood: hostile; Affect: constricted
E. Mood: euthymic; Affect: appropriate

A

• A. ✅ Correct. "I don’t care anymore" = apathy (subjective mood). Flat tone/low response = flat affect.

• B. ❌ Labile = rapid shifts in emotional expression (e.g., crying, laughing suddenly)—not seen here.

• C. He did not express anxiety; “broad” affect implies emotional range.

• D. No aggression or irritability; "constricted" is too mild.

• E. “Euthymic” is a normal mood—not applicable here.

A 60-year-old woman with a history of uncontrolled diabetes and poor access to healthcare presents with fatigue. She appears older than her stated age, has sunken cheeks, dry skin, and is wearing a soiled sweatshirt in warm weather. Vitals are normal. What is the most appropriate placement and purpose of your visual findings in the SOAP note?

A. Subjective section; used to justify patient’s reported symptoms
B. Objective section; documents your observations as part of the general survey
C. Assessment section; guides differential diagnosis
D. Plan section; indicates the need for referrals
E. Vital signs section; as they pertain to the patient’s nutrition and temperature regulation

B

• A. ❌ Subjective = what the patient reports, not what you see.

• B. ✅ This is classic general survey data—appearance, hygiene, nutrition, state of health—all belong in the O (Objective) section.

• C. Assessment interprets—not describes—findings.

• D. Plan comes later. Observation precedes management.

• E. Vital signs are separate from general appearance.

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