Physical examination

Structure

Emphasise signs relevant to both the patient's presenting and chronic problems and to differential diagnoses where applicable.

Note signs of long-term psychotropic drug use.

Also attempt to identify signs that indicate the presence/absence of conditions that may present with psychiatric complications (i.e. neurological and endocrine disorders, substance abuse).

Writing tips

You may use the past simple tense to describe the patient's state at the time of the Physical Examination, as in Example 12. This emphasises that the exam findings are specific to the time of conducting the Physical Examination, but suggests that they are probably subject to change if repeated.

Alternatively, you may use the present simple tense to report the findings of the Physical Examination. This would contribute toward a consistent reference point for the report by placing the activity of the Physical Examination at the same time as the interview, the findings of which are forming the basis of this report.

It would also grant the Physical Examination findings more immediate perspective. Both approaches to reporting the findings of the Physical Examination are acceptable. It is important to be consistent, though, in the approach you adopt.